Photodynamic Therapy for sBCC Shows Predictable Clearance and High In-Office Adherence

In a recent Dermatology Times Expert Perspectives custom video series, Todd Schlesinger, MD, a dermatologist, Mohs surgeon, and clinical trialist at Epiphany Dermatology in South Carolina, discussed the role of photodynamic therapy (PDT) in the management of superficial basal cell carcinoma (sBCC), with a focus on treatment structure, tolerability, and positioning relative to topical therapies.

Schlesinger highlighted data supporting red light–activated PDT with 10% aminolevulinic acid (ALA) gel, noting that clinical trial protocols allowed for up to 4 treatment cycles. Each cycle consists of 2 treatments, delivered with a 3-hour occluded incubation followed by 10 minutes of red light exposure. “It’s typically structured as at least 2 cycles. Can be 4,” he explained, emphasizing that while excision was performed after clinical clearance in the study setting, in routine practice clinicians may rely on established clinical and histologic clearance rates without mandatory surgical confirmation.¹

Tolerability remains a key consideration. In clinical trials, pain scores ranged from 2 to 5 on a numeric rating scale during active treatment, generally improving with subsequent sessions.¹ “The discomfort will be localized just to that area, and it would be typically only while they’re receiving light and a short time after,” Schlesinger said, describing the procedure as “typically tolerable.” He identified cooling as a preferred first-line strategy for mitigating discomfort, with optional use of topical or injected anesthesia and pre-treatment with acetaminophen or a nonsteroidal anti-inflammatory drug. Although some speculate that cooling could theoretically reduce efficacy by limiting photochemical activation, he noted that patient comfort remains a practical priority in office-based care.

When comparing PDT with 5-fluorouracil or imiquimod, Schlesinger highlighted the growing body of controlled data supporting PDT in sBCC. “Now that we have the pivotal paper, [with] PDT, at least you have a little bit of reliable data,” he said. He contrasted the more predictable, physician-directed in-office protocol of PDT with the variable inflammatory responses and adherence challenges associated with patient-applied topical therapies.

Although PDT is not yet approved specifically for sBCC and reimbursement remains a barrier, Schlesinger suggested its high adherence rates and procedural control position it as a compelling non-surgical option. Ongoing studies may further clarify its role not only in basal cell carcinoma but also in broader keratinocyte carcinoma management.

“Hopefully photodynamic therapy will rise further up in the management of not only basal cell carcinoma, but also for squamous cell carcinoma. All kinds of studies are being done around the country and around the world to try to make better use of this treatment, which I think is a very good thing for patients and physicians as well. So, hopefully we'll see good things coming,” Schlesinger concluded.

Reference

1. Schlesinger T, Chapman MS, Tu JH, et al. Red light photodynamic therapy with 10% aminolevulinic acid gel showed efficacy for treatment of superficial basal cell carcinoma in a randomized, vehicle controlled, double-blind, multicenter phase III study. J Am Acad Dermatol. 2025;93(6):1489-1498. doi:10.1016/j.jaad.2025.08.031

Watch more from the series here.