Part 1 - What is Photodynamic Therapy?

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1 PDT Information for patients Part 1 - What is Photodynamic Therapy? Photodynamic therapy is an intelligent method in treating aging and sun-damaged skin. It involves the application of a solution on the skin. After a prescribed incubation period, this solution is preferentially taken up by sun damaged cells and converted to a photosensitizing agent inside these cells. This photosensitizing agent is then activated by lights of specific wavelengths. This produces a form of oxygen in the tissues that causes the sun damaged cells to die immediately. The strength of reaction in PDT is the result of skin preparation, incubation time, concentration and localization of the agent, light energy, location, individual skin characteristics, and degree of sun damage. We may adjust our treatment accordingly to find the right balance. There are a number of photosensitising agents that can be used. At Skin Check WA, we have access to two agents: Metvix and 5-ALA Metvix is a proprietary drug produced by a pharmaceutical company. It uses a cream and a narrow focused light (Aktilite). Aktilite can only be used for a small area at a time. Due to the cost of the drug, Metvix PDT for large area is costly. 5-ALA is a non-toxic, naturally occurring agent, produced by specialised compounding chemists. 5-ALA PDT is illuminated with a larger, broader light source. This makes it ideal for field or large area treatment such as the face, chest, arms or back. For treating large sun damaged areas, we recommend 5-ALA PDT due to the cost of Metvix. In the United States, 5-ALA is the most common PDT agent used in skin treatment.

2 Advantages of PDT Treatment performed in one day, even for a large area. Much shorter down time. Most people can return to daily activities after 1 week. Side effects are minimal. PDT treatment to the whole area can lead to more uniform colour, texture and tone; compared to spot treating with liquid nitrogen, electrocautery or surgery. Disadvantages of PDT It is more costly compared to freezing, Efudix and Aldara. There is no Medicare rebate or PBS subsidy for 5-ALA PDT. In those with very severely sun damaged skin, PDT may cause very strong reactions as these pre-cancerous cells come away. Darker pigmented patches called liver spots or lentigines can become temporarily darker and then peel off leaving normal skin. This usually occurs over 7-10 days. The exact result for each individual will vary, due to different skin type, degree of sun damage and response to treatment. In approximately 10% of people, repeat treatment may be necessary to achieve the best result. What other treatments are available for actinic keratoses? There are many other traditional methods we use at Skin Check WA: 1. Freezing this is effective but can only be used for spots or small areas 2. Electro-dessication electrical ablation for very small lesion. 3. Efudix (5-fluoruracil) a chemotherapy drug that is very effective. Active treatment lasts 3 weeks with inflammed skin, peeling and crusting with another 7-10 days of healing. Active, working individuals may have difficulty finding 3 4 weeks to complete treatment. 4. Aldara (imiquimod) a drug that stimulates the immune system to attack the sun damaged cells. Treatment is for 4 weeks and a number of people have to stop due to immune system induced muscle aches and tiredness. Only a small area can be treated at one time. It will take 3 separate treatments to treat the face. Similar to Efudix, active individuals may find it difficult to find 4 weeks to finish treatment. 5. Solaraze a medication that needs to be applied for 3 months. In our experience the effect is very mild and only useful for very mild sun damage. 6. Picato a new drug that has potential as it is applied over 3 days, with another 7-10 days of healing. However, only a small area (5cm x 5cm) can be treated at a time. It will take at least 3 treatments to complete the face.

3 How much improvement can I expect from PDT? Patients with moderate to severe sun damaged skin with sun spots, texture and tone changes including mottled pigmentation should generally see excellent results. You may also see improvement of large pores and pitted acne scars. How many treatments will I need to see the best results? To achieve maximum improvement of pre-cancerous areas (actinic keratosis), mildly damaged skin may require one or two treatments whereas moderately to severely damaged skin may require up to three treatments. Who is PDT ideal for? It is ideal for people who have large areas of sun damaged skin who prefers a short treatment duration, or those who find the longer treatment like Efudix sore and tiring.

4 Part 2 - PDT treatment at Skin Check WA To obtain the best result, PDT is a multi-step treatment: 1. Two (2) weeks of simple daily skin preparation to maximise the agent absorption into the sun damaged skin cells. 2. On treatment day, a solution is applied to the affected area(s). We allow the cream to absorb over an incubation time of 2-3 hours protected from light. 3. The solution is activated using a specialized light source. 4. Sun damaged cells begin to die and shed from the skin. This process begins immediately and can take 7-10 days to complete. 5. New healthier skin cells start to grow to replace the dead skin cells. 6. Continuing skin care and sun protection after PDT, to protect the new skin cells. Cost (1 st Jan 2016): 1 Region 2 Regions $750 Face + lateral cheeks $520 Face + hands/arms, Hands and arms $520 Face + Neck Upper chest $520 Face + Upper chest Front of Face + Scalp $520 2 nd or 3 rd treatment of same area(s) within 3 months $ = 50% of above What is included: 5-ALA agent, local anaesthetic cream, post-pdt lotion supplied to use after treatment, antihistamine tablets and Legionnaires type hat with face cover. What is not included: 1. ph balanced Allmedic Active Face and Body cleanser (use twice daily) 2. Skin Repair Cream exfoliation with 10-15% AHAs. (use twice daily 3. Cold Sores prevention (only for those prone to cold sores)

5 Part 3 - What to do before, during, and after PDT treatment Before committing to PDT Doctor and/or Nurse pre-pdt consultation to ask questions, preferably face to face. If this is difficult, our nurse can provide information over a phone consultation. Please contact our Leeming clinic on (option 3) 2 weeks before your PDT treatment Day Purchase and begin the 2-week skin preparation. Use the cleanser to wash the treatment area. Pat dry and apply a thin layer of the Skin Repair cream. Rub until it is absorbed into the skin. It is normal to have a slight stinging sensation. Do this in the morning and at night. Before your PDT treatment day If you are prone to cold sores and you are having facial PDT you should consider purchasing cold sores tablets (eg. EZOVIR from chemists). Use if you feel cold sores starting. Do not wear makeup, sunscreen or any other product on the day. Cease the skin repair cream from the day before. Before leaving home, wash the proposed treatment area thoroughly with warm water. Remember to bring or wear protective clothing that covers the treatment area. (e.g. sunglasses, gloves, long sleeve shirts or pants.) We will supply a hat. Organize shopping, exercise, gardening, mowing etc. before the day of treatment as you will have to stay indoors for two days after treatment. If you are staying at the clinic for your full treatment time, please remember to bring a good book, magazine or some paperwork to keep you occupied during the incubation phase. You may also wish to bring some lunch or snacks. On treatment day Take one antihistamine tablet (eg. Telfast). It will be supplied to you by the nurse. We will prepare the treatment area and apply a photosensitizing lotion onto the skin. The area is left to incubate for the recommended time. Protective gear is worn to stop the photosensitizing lotion reacting with any light until the incubation time has expired.

6 The area is then illuminated for 10 minutes under a very bright red light and another 10 minutes under a blue light. Skin soothing spray is applied by nurse during light activation. Local anaesthetic cream is applied post-activation. You will experience some tingling, stinging or discomfort during the illumination period. Our staff or doctor will be in attendance and will use a special cooling spray and fan to control these symptoms. After your PDT Treatment Make an appointment to see your doctor on day 3 7. It will help us if you can take a daily photo of your treated skin from day 3 onwards to show the doctor at the appointment. Cover up on your way home. Protect the treated area from any light exposure. Days 1-2 (first 48hr) You will be extremely sensitive to light. Avoid bright indoor lights and windows. Stay at least 3 meters away from TV. Turn Ipad and computer screen brightness down. Only go outside if absolutely unavoidable and protect the treated area from the light. Exposure to day light or bright indoor lights during the first 48 hours may cause a secondary photo-activation, which causes much pain and discomfort. The treated skin will be red and tender. Apply post PDT soothing lotion 4 times a day for two days, reducing to 2 times a day. Once the skin starts to peel and form dry scabs, use Vaseline instead of the soothing lotion. Keep all scabs greasy. It will speed up healing. Keep a 2 litre jug of cold water in the fridge. If the treated area stings or feels hot, soak a cloth with the cold water and use as a cold compress on the treated area as many times a day as needed. If there is further pain or discomfort take Panadol, Nurofen or stronger pain reliever such as Panadeine or Digesic. Use air conditioning or a fan to ease heat. Do not do vigorous exercise for five days post treatment. (if it causes you to feel flushed in the treatment area) Attend follow up appointments as scheduled. Days 3-4 The skin will continue to look red and flushed. Early peeling may occur. If the reaction is strong, refer to exuberant reaction information sheet. Continue using Post PDT soothing lotion 2-3 times a day until finished.

7 Start using Vaseline for scaly skin areas to keep the skin cells moist. Days 5-7 The skin will start to peel, scab and flake off. This means the treatment has worked by destroying the damaged skin cells. Continue with Vaseline for dry areas. DO NOT peel off soft, crusty skin or scabs. Use Vaseline in these areas and they will be peel off naturally. Days 8-9 The redness will start to disappear. The skin may feel itchy and somewhat tight. You must use daily sunscreen from now on, once the skin surface has recovered. Days In 99% of cases, by now your skin should be healed and feeling healthy. There could be some residual pinkness of the skin, which will settle with time. Days 14 and beyond Use daily sunscreen to protect your new skin cells. For those who wishes to pursue further rejuvenation of the skin, you can resume ph balanced Cleanser and AHA based Skin Repair cream. Protecting your new skin after your PDT Treatment Please note that new skin cells have formed after PDT treatment, replacing some of the sun damaged cells. These new skin cells are delicate and require protection from further UV radiation. Otherwise pigmentation and other signs of sun damage may reappear. Please use a high quality UVA + UVB daily sunscreen.

8 EXUBERANT REACTION If the reaction is exuberant, this is due to the large amount of sun damaged cells that have responded to the treatment, and are now shedding. The skin may weep with clear fluid. Follow these steps 1. To prevent infections use vinegar soaks as below. 2. Reduce fluid loss and drying out by applying petroleum jelly (eg. Vaseline) liberally. Keep the skin greasy. 3. Use Nurofen or other anti-inflammatory medications. 4. Topical steroid cream and occasionally oral steroids may be used short term to reduce the reaction. 5. Medical review with our doctors so we can monitor the progress closely. Vinegar Soaks Mix up a large container of boiled or distilled water with vinegar and leave in fridge to cool down. Mixture is: 1 cup boiled/distilled water: 1 teaspoon of white vinegar 1. Place 3-4 cloths in the container with the cool water in the fridge 2. When you get home from your PDT treatment, immediately squeeze out cold cloths and place on the treated area (e.g. face), changing cloths as necessary to keep area cool for 10 minutes 3. Repeat above every 1-2 hours or as needed. (Note: you can t over treat the area!) 4. In between vinegar soaks, apply post soothing lotion 5. Before bed and in the morning, remember to also apply the post soothing lotion 6. DO NOT let the area dry out! Use Vaseline in areas that are still dry after Post Soothing lotion has been applied.