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Expert opinions at the 11th Annual Meeting
of the “European Society for Photodynamic Therapy”
Paris, May 2011
Actinic keratosis in view of immune modulation
“Consistent light protection is the most
effective prophylactic method”, emphas -
Sequence therapy optimizes
ized Dirschka. This also applies for people
sustained therapeutic success
developing new lesions can be reduced.
Actinic keratosis has become endemic, with a constant upward trend.
New innovative prophylactic and therapeutic approaches are needed since the
transformation rates are constantly increasing with manifestations of squamous
cell carcinoma and pronounced recurrence rates. According to expert opinions
during the 11th Annual Meeting of the European Society for Photodynamic
Therapy, new pathophysiological findings as well as current clinical trial data
suggest the use of a sequential combination approach composed of photodynamic
therapy (PDT) followed by topical immune modulation.
The prevalence of actinic keratosis varies
Australia, for example, has a prevalence of
carcinomas depends on lesions. In patients
year and 11–26% in northern countries.
with untreated single lesions, the 10-year
risk is between 6 – 16%, and 10 – 20%
Incidence of actinic ceratosis* in Germany
developing actinic keratosis“, emphasized
Fig. 1: Incidence of actinic keratosis increases steadily
O N K O D E R M E . V . –
the incidence rate sky rockets in the over
A N O U T S T A N D I N G
■■ Selective surface therapy
■■ Not simply a cosmetic
Generally, carcinoma in situ due to actinic
baga telle but carcinoma
onkoderm e.V., established in 2009
Dermato-Oncologists. The goal is to
curettage and lasers as well as cytotoxic
Actinic keratosis is, by definition, a UV-
establish and to strengthen derma -
dependent, early, squamous cell carcinoma
tology as an integral part of medicine
lesions, but do not affect the underlying
(in situ), limited to the epidermal layer.
and to optimize the quality of patient
care. The 20 onkoderm centres with
high relapse rate following the application
over 40 specialists cover an area
with well over 6 million residents.
subclinical lesions, which occur in close
as well as UV-induced suppression of cell-
effect. Further treatment is necessary if
and the destruction of neoplastic cells via
is a vital process within the carcinogenic
*Expert opinions during the 11th Annual Conference of the “Euro -
pean Society for Photodynamic Therapy” on 10 March 2011 in Paris.
they are clinically manifest. In general, this
Diagram: Combination therapy PDT and imiquimod
leads to an unsatisfactory cosmetic result.
According to the Guideline for “Actinic
Keratosis“, published by the DDG (AWMF,
cycles. The cosmetic result is better than
Sequence therapy followed by PDT and imiquimod: a reasonable pathophysiological approach
■■ Sequential therapy
for sustained therapeutic
This data is consistent with results from a
sign that imiquimod is effective; a specific
explanation prior to the start of treatment
sensible therapeutic strategy. “Follow-up
lesions. The sustained treatment effect of
■■ Immune modulator deprives
actinic keratosis of its base
■■ Prior use of PDT increases
“Immune Response Modifiers” (IRM). The
comparative clinical trial presented at the
substance binds to the toll-like receptors 7
ably alleviated when PDT is given prior to
Nagore, Valencia, Spain, suggest the same
findings. The prospective, random clinical
identified receptors (TLR 1–10), which can
keratosis on facial areas or bald patches.
medical practice. For patients this implies
which are expressed on antigen presenting
treatment that is far more comfortable. In
cells. Dendritic cells establish the link to
best clinical and histological results were
sequential method. In addition, imiquimod
should become well established in medical
the Spanish study, the optimal strategy for
New 4-tiered light protection concept for individual sun protection
Safe in the sun
An individualized sun protection concept offers the safest protection against
sun damage and skin cancer. Such an innovative, standardized concept for sun
protection advice available at dermatology practices has recently been developed by
the sun protection group of experts within the national network of practicing
The practical aspects of sun protection are
Central America is photo protective.
melanocytic skin cancer has doubled every
ten years. In 2009, this alarming increase
● Rules of conduct
● Textile sun protection:
● Usage of sun protection cream and
sun protection factors:
The UV protec -
■■ Education in the hand
of the dermatologists
increased risk profile, even with short UV
● Oral sun protection:
Oral sun protec -
■■ Sun protection starts
crown of the head. Scientific examinations
As a matter of principle, the 4-tiered UV
sunny regions outdoor activities should be
oncologists in private practice (onkoderm
terms of geographic location is often not
e.V.) has developed a 4-tiered UV protec -
tion model, which will for the first time
central, western and southern Europe high
noon is noticeably after 12 o’clock. The
Recommended Sun Protection
Skin type and intensity of UV exposure are
classed into four different risk levels (from
normal to highly elevated). The combina -
tion thus provides levels of different sun
Table 1: The importance, i.e. of your individual skin
type, particular environment and codes of conduct,
pivotal point for sun protection advice is
where your employment is concerned, increases in line
in an easy to understand patient brochure.
dermatologist in terms of individual risk
SPF = sun protection factor in sun creams
PLE = Polypodium Leucotomos Extract as an example
of additional oral sun protection
UPF = Standardized UV protection factor for textiles
Innovative treatment for actinic keratosis
Combination therapy combines
improved effectiveness and superior tolerability
The advantages of sequence combination therapy with photodynamic therapy (PDT) followed by imiquimod is explained
in the following interview with Prof. Dr. Thomas Dirschka, Düsseldorf, and Prof. Dr. Uwe Reinhold, Bonn.
Why is the combination of imiquimod
Which patients do you prefer to treat
and PDT recommended for the
with this method?
treatment of actinic keratosis?
Combination treatment is
The marked advantage of this
extensive surface cancerification, which I
effects occur and that the side effects of
Will this treatment be used
Prof. Dr. Thomas Dirschka, Düsseldorf (left)
in the future?
target structures, i.e. the pathologically
and Prof. Dr. Uwe Reinhold, Bonn (right).
That would be preferable. In
How is the combination tolerated?
transformed tissue, which is subsequently
Prior PDT treatment markedly
recurrence, and can reinforce the level of
thus causing a decrease in the imiquimod-
Which treatment schedule do you
patients, especially those with pronounced
choose for this combination?
How can the increased effectiveness of
field cancerification, also experience pain
these therapies be explained?
We start with two cycles of
The phototoxic reaction during
How should patients be informed?
Two weeks later we start with Aldara, e.g.
three applications per week, for a total
apoptosis of tumour cells and activates a
Pronounced actinic keratosis
cellular immune response. However, not all
Why is PDT treatment administered
during surface cancerification. Sub sequent
local therapy with imiquimod can activate
additional effector T-cells, which kill the
The number of cells damaged
by actinic keratosis is significantly initially
What is the recurrence rate compared
What is the marked advantage of
to conventional treatment options?
using such a combination?
Due to the currently limited
The cumulative effect prolongs
clinical trial data this question cannot, as
the so called time-to relapse. Furthermore,
yet be accurately answered. Moreover, the
term relapse is not clearly defined. Does
when using this combination is excellent.
this include a time period of three, six or
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