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5-ALA, PDT offer option for cystic acne


Aventura, Fla. — Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA, Levulan, Dusa Pharmaceuticals) and activation by pulsed dye laser energy, blue light or the sequential combination is an effective and safe treatment for moderate to severe cystic acne.

"We've come up with treatment algorithms that are more and more effective, require minimal patient downtime, and have virtually no risk for systemic side effects," says Mark Nestor, M.D., Ph.D. "The Levulan incubation time is 30 to 60 minutes, and we see long-term (two year) clearing in 60 percent of our patients."

Dr. Nestor described the ALA-PDT technique at the Masters of Pediatrics Conference in Miami. He is in private practice in Aventura, Fla., and is clinical associate professor of dermatology and cutaneous surgery, University of Miami School of Medicine, Miami.

"We use ALA-PDT primarily in patients with significant acne," he says. "We perform a series of three treatments, two to three weeks apart, and we start seeing results within the first two to three weeks. Some patients need more than three treatments. Those who get better but not clear can be treated again and with other light sources. We've had success with Levulan in these cases."

Levulan with blue light can be used successfully in patients with all skin types, he adds.

When treating cystic acne by ALA-PDT, Dr. Nestor uses the PhotoGenica V-Star Pulsed Dye Laser (Cynosure) at 595 nm followed by blue light.

"The pulsed dye laser has innate activity with acne," he says. "The effect is augmented by adding Levulan to the treated sites first. The short pulses activate the protoporphyrin IX, the photosensitive product that forms when Levulan is absorbed." Dr. Nestor recently obtained excellent results when he used the GentleWave LED photomodulation device run in the continuous mode for activation.

"People can also use blue light, intense pulsed light or other light sources," he says. "The least expensive is the blue light."

Beware of generics Dr. Nestor says Levulan is approved by the U.S. Food and Drug Administration (for actinic keratoses, not specifically for acne) and has an "incredible" safety profile.

"Levulan is not the same as the generic 5-aminolevulinic acid that is advertised and sold by compounding pharmacies," he says. "Using compounded products is very risky because we don't know the activity or percentage concentration of 5-aminolevulinic acid," he says. "And these preparations have not been evaluated by the FDA."

Dr. Nestor says that patients usually pay out of pocket for acne treatments with ALA-PDT.

"Cost (to the patient) can range from $300 to $400 per treatment up to $1,000, depending on which device or combination of devices is used," he says. "Most dermatologists use microdermabrasion before putting on Levulan, and if we use microdermabrasion, Levulan, pulsed dye laser, then blue light, one treatment costs $1,000."

New uses loom Dr. Nestor sees many new uses for ALA-PDT on the horizon.

"We are seeing some very promising ALA-PDT data for skin conditions as diverse as skin cancer and actinic damage, keratosis pilaris, hidradenitis suppurativa, morphea, mycosis fungoides, possibly onychomycosis and white hair removal, as well as cosmetic enhancement," he says. "Considering that many of these conditions have no treatments that work well, this is exciting."

Disclosure: Dr. Nestor is a member of Dusa Pharmaceuticals' physician advisory board. His presentation was not funded by any organization.

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