Optimizing treatment of acne with photodynamic therapy (PDT) to achieve long-term remission and reduce side effects. A prospective randomized controlled trial.

Photodynamic therapy with methyl aminolevulinate (MAL-PDT) is an effective treatment of acne vulgaris, but is associated with side effects. We performed a prospective randomized split-face study aimed at optimizing MAL-PDT treatment. Patients (n = 33) were randomized to two or four treatments of PDT with MAL on one cheek and placebo vehicle on the other cheek, 1-2 weeks apart. A 1.5-h pre-treatment with the MAL cream was followed by illumination with red light (20 J/cm2). Assessments were performed before treatment and 4, 10, and 20 weeks after the last treatment. In comparison to baseline, the number of inflammatory lesions at 20 weeks on cheeks treated with MAL-PDT showed a relative decrease of 74% in the group with two treatments and 85% in the group with four treatments. This new treatment regimen for both MAL-PDT and red-light-only PDT, with shortened pre-treatment and reduced light dose, could be an effective modality.

Cutaneous malignant melanoma show geographic and socioeconomic disparities in stage at diagnosis and excess mortality.

Background Preventive measures are needed to counteract the increasing burden of cutaneous malignant melanoma (CMM). As a basis for rational melanoma prevention, we investigated geographic differences and impact from socioeconomic factors related to incidence, clinical stage at diagnosis and outcome. Material and methods All patients with primary invasive CMM diagnosed in 2004-2013 in the southern and the western Swedish health care regions with a population of 2.9 million adults were eligible for the study. Population-based data were obtained from the national Cancer Register and the national Melanoma Quality Register. Geographic and socioeconomic differences in incidence per stage at diagnosis were mapped and correlated to excess mortality. Results Disease mapping based on 9743 cases in 99 municipalities and 20 metropolitan districts showed marked, regional disparities in stage-specific incidence of CMM. The incidence of stage I-II tumors was higher in the western health care region, whereas the incidence of stage III-IV CMMs was higher in the southern region. The divergent incidence patterns per stage at diagnosis were consistent across population strata based on educational level. The geographic disparities in CMM stage influenced relative survival with an excess five-year mortality ratio in the southern region versus the western region of 1.49 (95% confidence interval 1.22-1.82). The excess mortality ratio for patients with low versus high educational level was 1.81 (1.37-2.40). Conclusion Residential region and educational level influenced CMM stage and, thereby, excess mortality. These observations suggest that geographic as well as socioeconomic data should be considered in prevention of CMM.

Smartphone teledermoscopy referrals: a novel process for improved triage of skin cancer patients.

In this open, controlled, multicentre and prospective observational study, smartphone teledermoscopy referrals were sent from 20 primary healthcare centres to 2 dermatology departments for triage of skin lesions of concern using a smartphone application and a compatible digital dermoscope. The outcome for 816 patients referred via smartphone teledermoscopy was compared with 746 patients referred via the traditional paper-based system. When surgical treatment was required, the waiting time was significantly shorter using teledermoscopy for patients with melanoma, melanoma in situ, squamous cell carcinoma, squamous cell carcinoma in situ and basal cell carcinoma. Triage decisions were also more reliable with teledermoscopy and over 40% of the teledermoscopy patients could potentially have avoided face-to-face visits. Only 4 teledermoscopy referrals (0.4%) had to be excluded due to poor image quality. Smartphone teledermoscopy referrals allow for faster and more efficient management of patients with skin cancer as compared to traditional paper referrals.

Mobile teledermoscopy-there's an app for that!

BACKGROUND: The introduction of the smartphone with high-quality, built-in digital cameras and easy-to-install software may make it more convenient to perform teledermatology. In this study we looked at the feasibility of using a smartphone (iPhone 4(®)) with an installed application especially developed for teledermatology (iDoc24(®)) and a dermoscope (FotoFinder Handyscope(®)) that is customized to attach to the smartphone to be able to carry out mobile teledermoscopy. OBJECTIVES: To study the diagnostic accuracy of this mobile teledermoscopy solution, to determine the interobserver concordance between teledermoscopists (TDs) and a dermatologist meeting the patient face-to-face (FTF), and to assess the adequacy of the TDs' management decisions and to evaluate the image quality obtained. PATIENTS/METHODS: During a 16-week period, patients with one or more suspicious skin lesions deemed to need a biopsy or excision were included. The smartphone app was used to send a clinical image, a dermoscopy image and relevant clinical information to a secure Internet platform (Tele-Dermis(®)). Two TDs assessed the incoming cases, providing a specific primary diagnosis and a management decision. They also graded the image quality. The histopathological diagnosis was used as the gold standard. RESULTS: Sixty-nine lesions were included. The FTF dermatologist's diagnostic accuracy was 66.7%, which was statistically higher than TD 1 (50.7%, P=0.04) but similar to TD 2 (60.9%, P=0.52). The interobserver concordances between the FTF dermatologist and the two TDs and between the respective TDs showed moderate to substantial agreement. The TDs provided adequate management decisions for 68 (98.6%) and 69 (100%) lesions, respectively. The image quality was rated as excellent or sufficient in 94% and 84% of the cases by the respective TDs. CONCLUSION: This novel mobile teledermoscopy solution may be useful as a triage tool for patients referred to dermatologists for suspicious skin lesions.

Fluorescence diagnostics of basal cell carcinomas comparing methyl-aminolaevulinate and aminolaevulinic acid and correlation with visual clinical tumour size.

Fluorescence diagnostics based on aminolaevulinic acid (ALA) fluorescence has been suggested as an in vivo pre-surgical tool for tumour demarcation. We performed fluorescence diagnostics of 35 basal cell carcinomas (BCCs) undergoing photodynamic therapy (PDT) using methyl-aminolaevulinate (MAL). In addition, a semi-automated thresholding algorithm was implemented to detect the potential tumour region. The mean tumour fluorescence contrast was found to be 1.65 ± 0.06 during the first MAL-PDT session, and increased to 1.84 ± 0.07 at the second treatment (p < 0.01). This could imply that disruption of the skin barrier and inflammatory responses after the first session of PDT led to higher accumulation of proto-porphyrin IX during the second session of PDT. The tumour areas detected based on fluorescence in small BCCs (< 1 cm(2)) were in general (n = 18/23) larger than the visual clinical tumour size. In addition, the fluorescence contrast using MAL (1.65 ± 0.06) was found to be significantly higher (p<10(-4)) than the contrast (data from previous study) after application of ALA (1.20 ± 0.06). Thus, MAL generally provides higher tumour contrast than ALA in BCCs, and should be preferred for use in fluorescence diagnostics. Correlation between fluorescence, lack of treatment response and/or pain was not observed.

Important factors for pain during photodynamic therapy for actinic keratosis.

Photodynamic therapy (PDT) is an efficient treatment for actinic keratosis. A common problem, however, is pain. The aim of this study was to investigate pain during PDT for actinic keratosis. The possibility of using capsaicin cream for pain relief was also assessed. Pain was investigated during aminolaevulinic acid PDT in 91 patients. Size, redness, scaling and induration of the lesions were recorded. Maximum pain during treatment was registered, using a visual analogue scale (0-10). The pain-reducing efficacy of capsaicin was tested in a pilot study in six patients (10 lesions). These patients were pre-treated with capsaicin cream for one week before commencing PDT. Pain was found to be normally distributed around a mean value of visual analogue scale 4.6. Larger lesions gave more pain (p=0.001). The redness of the actinic lesions was found to be related to PDT-induced pain (p=0.01), the reduction of actinic area (p=0.007), and the cure rate (p=0.01). The redder the actinic area, the better the treatment outcome and the more pain experienced. Patients with the largest reduction in the actinic area experienced more pain (p=0.053). The most important factors for presence of pain seem to be the size and the redness of the lesion. No significant pain relief was experienced after pre-treatment with capsaicin.

Fluorescence contrast and threshold limit: implications for photodynamic diagnosis of basal cell carcinoma.

This study was designed to evaluate what application time of delta-5-aminolaevulinic acid (ALA) results in highest contrast between tumour and normal skin, in the interval 1-4 h, when using photodynamic diagnosis (PDD) of basal cell carcinomas (BCC) located on the face. Moreover, a value of the demarcation limit has been derived based on the fluorescence variation in normal skin adjacent to the tumour. Forty patients were included in the study, randomly allocated to four different groups with varying ALA application time in the range 1-4 h. The contrast, defined as the ratio between the fluorescence intensity in ALA-treated tumour tissue and normal skin, was calculated for each patient, and the mean values in each group were evaluated as a function of ALA application time. In addition, the fluorescence intensity variation in ALA-treated normal skin adjacent to the tumour was assessed. The results from this study show a peak of the mean contrast values after 3 h ALA application, but due to large interpatient variation, the mean contrast did not differ significantly in the interval 2-4 h. After 2 h ALA application, the fluorescence intensity variation in the normal ALA-treated skin was found to be at a maximum, which suggests that 2 h ALA application is not preferable when using PDD. Based on data of the fluorescence variation in ALA-treated normal skin after 3 and 4 h ALA application, a tolerance interval was calculated implying that values above 1.4 times the mean normal fluorescence indicate an abnormal condition. This tolerance limit agrees well with results obtained in a former study.