Skin and Medical Topics

The Skin Center

26081 Merit Circle Suite #109
Laguna Hills, CA 92653
(949- 582-7699
(949) 582-SKIN
Fax (949) 582-7691

 
Medical Information
 
Expert Medical Dermatologic Care
As experienced and professional physicians, our doctors enjoy taking care of all skin problems such acne, eczema, psoriasis, skin cancer, abnormal moles, rashes, warts, as well as hair and nail problems. Our Mohs surgeons perform Mohs micrographic surgeries, excisions, and other state-of-the-art laser and cosmetic procedures.
 
 
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Mohs Surgery
• What is Mohs micrographic Surgery (MMS)?
• Where can I have Mohs Surgery?
• How long does the surgery take?
• What kind of physician can perform Mohs Surgery?
• Where can I find a doctor board certified in Mohs?
• Is Mohs only for skin cancer?
• Can I remove my moles using Mohs?
• Am I a good candidate for Mohs Surgery?
• What if I have artificial joints or other health issues?
• What areas are treatable by Mohs Surgery?
• What are possible complications of Mohs?
• Is there scarring from surgery?
• What are alternatives for Mohs Surgery?
• What about plastic surgery?
• What about insurance coverage and costs?
• How do I prepare for my surgery?
• Can I smoke and drink alcohol before surgery?
• How is recovery?
• Can I return to work or school?
• Is there pain after surgery?
• What is the chance that my cancer will recur?
• Can I go out in the sun after surgery?
• How are skin cancers treated?
• Why is it called Mohs?
• What is Mohs micrographic Surgery (MMS)?
Mohs micrographic surgery is a minor surgical procedure and special method of removing skin cancers using local anesthesia (numbing). The majority of cases are performed right in the physician’s office. Mohs is a very precise, highly detailed technique whereby small layers of skin are removed and immediately examined under the microscope to make sure the skin cancer is completely removed.

The procedure uses frozen sections of skin which are then stained with special dyes. The dyed frozen pieces of skin are further examined under the microscope and a tumor map is drawn by the Mohs surgeon. The freezing process allows an immediate examination of the entire tumor margin and tissue histology (microscopic examination of cells).

If more cancer cells or “roots” are seen under the microscope, then another skin layer is removed and again examined. Each time that a skin level is removed, it is called a “level”. If no more cancer roots are seen, then it is called “clear” (no more tumor) and no additional levels are needed.

By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with good preservation of normal skin. Once the cancer has been fully removed, the Mohs surgeon looks at the wound to determine the way to get the best wound repair and cosmetic result for you.

Mohs is special because the entire edge and under-surface of each skin cancer layer is carefully examined under the microscope for the presence of very small cancer cells. With regular or traditional surgery only about 1 to 3% of the tumor margins are actually examined thereby increasing the chances that a small tumor root would be missed and left behind. Mohs allows for examination of 100% of the tumor margins thereby reducing the chance that tumor cells will be left behind.

Mohs is usually scheduled only on certain days in the doctor’s office because of the required equipment, tissue stains (dye), Mohs technologists, and microscopes. Most of these procedures are generally performed with the patient waiting in the office for the tissue to be “read” or interpreted by the Mohs surgeon.

• Where can I have Mohs Surgery?
Mohs micrographic surgery is usually performed in an outpatient setting like a doctor’s office and under local anesthetic (lidocaine). Sometimes the procedure may be performed in an outpatient surgical center with the assistance of an anesthesiologist. Rarely, it is performed in an inpatient hospital setting.

• How long does the surgery take?
You are generally in the medical office for several hours( average 2-7 hours) on the day of your Mohs procedure. Depending on how large or difficult your skin cancer is, different numbers of levels may be required to achieve clearance. Mohs requires your patience and your doctor’s careful effort and skill. It is not always possible to predict ahead of time how many hours your specific procedure will take. Most patients leave their day’s schedule open to allow for adequate time to complete their Mohs.
• What kind of physician can perform Mohs Surgery?
Most Mohs surgeons are specially trained dermatologists. There are also some plastic surgery, or Ear , Nose and Throat ( ENT) surgeons who are trained and may also perform Mohs.
• Where can I find a doctor board certified in Mohs?
There is no current Board Certification for Mohs Surgery. There are two nationally recognized and respected national Mohs specialty groups called the American College of Mohs Surgery and the American Society for Mohs Surgery (ASMS).Both of these medical groups have specialty training and certification exams for their members. Members of The American College of Mohs Surgery usually have completed an additional 1 to 2 years of Mohs training. Members of the American Society for Mohs Surgery are also trained and required to actively participate in an annual quality control Mohs slide peer review.
• Is Mohs only for skin cancer?
Yes, Mohs is a widely used method of surgically removing the most common types of skin cancers including basal cell carcinoma and squamous cell carcinoma. It is currently not used to remove non-cancerous growths.
Less frequently, Mohs may also be used for other malignant tumors. In special cases, Mohs may be used to surgically treat malignant melanoma, lentigo maligna, dermatofirosarcoma protuberans, merkel cell tumor, microcystic adnexal carcinoma, malignant trichoepithelioma, angiosarcoma, atypical fibroxanthoma and other cancerous tumors. However, most Mohs surgeons treat primarily basal and squamous cell cancers by this technique.
 
• Can I remove my moles using Mohs?
No, Mohs is usually not for mole removal. It is primarily designed for removing skin cancers. Moles are usually removed by standard or traditional surgery.
• Am I a good candidate for Mohs Surgery?
You may not be a good candidate for Mohs if you are unable to tolerate local anesthesia, have extreme anxiety, have a surgical phobia, or are in very poor health.Your decision on the best treatment choice may depend on different factors such as the location and type of skin cancer, your past treatments, your overall health, and level of comfort. Your physician can help you sort through the different treatments and assist in your shared decision making process. However, the right decision for you is always yours and your doctor’s to make.
• What if I have artificial joints or other health issues?
Your Mohs surgeon needs to know of any other medical conditions that may affect your surgery or wound healing. You would want to make sure to tell your surgeon beforehand if you have any artificial parts (implants) like knees or hips , a pacemaker or defibrillator, or need to take antibiotics before dental procedures because of a heart condition or murmur.Your Mohs surgeon needs to know if you have had a history of “Staph” or other skin infections in the recent past. You may be asked to wash with a special antibiotic soap or wash like Hibiclens ( Chlorhexidine) the night or morning before surgery to help reduce the number of bacteria on your skin.

Patients need to also advise their surgeon of any drug allergies such as to anesthetics like lidocaine, xylocaine, epinephrine, or novacaine. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, Hepatitis, HIV/ AIDS, or pregnancy.

• What areas are treatable by Mohs Surgery?
Mohs is used primarily for the treatment of head and neck basal and squamous cell skin cancers. It is particularly useful for skin cancers in difficult areas such as nose, lips, ears, and genitals.

It is also used on hands and feet where there is not a lot of extra tissue for bigger surgical removals. Mohs is very effective for the treatment of recurrent tumors (tumors that were previously removed and have re-grown at the same site). However, depending on the specific patient and tumor type, any area of the body may be treated by Mohs surgery.

• What are possible complications of Mohs?
As with any surgery or procedure , Mohs is associated with some possible risks and complications. While it is overall a very safe and effective minor surgical treatment, there are some possible uncommon complications. Since a scar usually forms anytime you cut the skin, most patients understand and expect some type of a scar after skin cancer removal.

Possible risks and complications of Mohs include (but are not limited to) bleeding, bruising, wound infection, pain, unsightly scar, keloid ( raised, thick scar), cosmetic disfigurement, skin discoloration, nerve damage, allergic reactions, pain, reaction to local anesthesia, widened or sunken in( depressed) scar, wound opening ( dehiscence) and spitting or retained stitches, cancer recurrence, need for further surgery or treatment including radiation or plastic surgery, and rarely death.

Minor, serious, or life threatening reactions can occur with the use of anesthetics or with medications given before, after or during surgery. Nerves controlling muscle movement, sensation, or other functions may be damaged. This nerve damage may be permanent.
Overall, most patients tolerate the minor surgery very well without any complications.

• What is reconstruction?
Reconstruction is repair
ing or fixing the wound.

Repairing or closing the wound may involve having your surgeon stitch the wound closed side by side. Sometime an area may heal better by letting the wound heal in by itself naturally without stitches. Additional reconstruction options include using a skin graft, moving a flap of skin, and plastic surgery closure.

Shared decision making is very important in this part and you are involved in how you prefer to repair the wound. Your Mohs surgeon may make some recommendations on how to close your wound.

The main goal with Mohs surgery is to remove the skin cancer first. Once the cancer is cleared out, then your Mohs surgeon will look at how to best fix the area. The goal of Mohs is to clear skin cancer, achieve the smallest scar, and preserve normal tissue.

• Is there scarring from Mohs surgery?
Yes, all human beings heal by permanent scar formation. In general, when you cut the skin, there will be some type of scar. Some people heal better than others. Some scars are more noticeable depending on the location and skin type.

There are many options for treatment of surgical scars including lasers, scar creams and gels, cortisone injections, and many other choices depending on the scar. You may want to discuss ways to help minimize scarring with your doctor at your stitch removal appointment.

• What are alternatives for Mohs Surgery?
It is important to understand that there are alternative treatments and options to Mohs. Additional treatment choices include (but are not limited to) local radiation, prescription topical creams, plastic surgery, curettage and desiccation (scrape and burn), regular surgery, chemotherapy creams or injections, cryosurgery ( deep freezing), photodynamic therapy ( uses a type of light and a light activated chemical called a photosensitizer).

• What about insurance coverage and costs?
Mohs surgery is generally considered a medical service and is not considered cosmetic. Currently, most insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling surgery and confirm your eligibility and benefits.

Mohs, like any surgical procedure, will result in additional procedure charges above the routine office visit fees. These surgical fees may range from one to two thousand dollars depending on the area, number of Mohs levels, and the type of closure or repair required. The more number of levels required, the higher the cost. Surgical centers and hospitals usually have a much greater costs associated with a facility fee in addition to the surgery fee.

Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally covers 80% of Mohs cancer surgery. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare.

Commercial or non-Medicare insurances currently generally cover a large percentage of your surgery unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or hospital for an approximate estimate of your charges before scheduling the procedure.

• What about plastic surgery?
You may decide to have regular surgery with a plastic surgeon instead of having Mohs.

Alternatively, you may also choose a hybrid option where your Mohs surgeon removes the tumor and clears it for you and then you have the plastic surgeon fix up the wound and stitch it up for you.

If you prefer to have your plastic surgeon repair the wound, you will want to let your plastic surgeon and dermatologist know ahead of time and plan that into your Mohs schedule.

• How do I prepare for my surgery?
Your personal physician will let you know the pre-operative instructions specific for your condition.For many typical outpatient Mohs surgeries in a physician’s office, most patients are advised to eat a good breakfast on the day of surgery and take all of their regular daily medications. Patients are advised to wear comfortable casual clothes and bring a sweater or small blanket.In most cases, patients are usually able to drive after most procedures and do not necessarily need a driver unless they feel uncomfortable. Diabetic patients may need to be more cautious about maintaining good blood sugars and avoiding dangerous lows in their sugars from fasting.Since you will be in the office for several hours, you may want to bring some personal snacks, drinks, and reading or knitting material. Personal music headsets or Ipods may also provide relaxation and help pass time between Mohs levels.For surgery center or hospital based procedures requiring any type of sedation or general anesthesia, patients may be required to not eat or drink anything past midnight the night before surgery. Your plastic surgeon or anesthesiologist will advise you of specific instructions before surgery.Most patients continue all doctor prescribed medications including aspirin and any blood thinners unless specifically advised otherwise only by the primary physician, or plastic or Mohs surgeon. Patients with a significant history of stroke, heart attacks, or even chest pain (angina) under a doctor’s care must discuss their medications with their doctor before making any changes. It is important to not discontinue blood thinners without a doctor’s specific instructions because of a potential greater risk of a heart attack and/or stroke.For otherwise healthy (non-cardiac and non-stroke patients) non-essential, non-medically prescribed, blood thinners such as Advil (ibuprofen), Motrin, Aspirin, Vitamin E, garlic supplements, Alka-seltzer, Peptobismol , other aspirin containing medications , etc. can be stopped at least 7-14 days before undergoing Mohs surgery to minimize bleeding and bruising.. These medications can thin your blood and make you more prone to bleed during and after surgery. Again, it is important to not discontinue or start any medication without a doctor’s specific instruction.• Can I smoke and drink alcohol before surgery?Smoking is discouraged for at least 1-2 weeks before surgery. Smoking can slow down wound healing and cause more wound infections.

Heavy alcohol use is not advised at least one week before surgery. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding. Your physician will want to know of any factors that may affect your surgery or wound healing.

• How is recovery?
Recovery is usually very easy and uneventful. Overall, resting as much as possible the first few days after surgery is generally helpful.

Stitches (sutures) are usually removed at the surgeon’s office anywhere from 4-14 days from the date of surgery. Your physician will let you know what date to return for stitch removal .

• Can I return to work or school?
Most patients are able to return to work or school the same day or next day after Mohs. Avoiding heavy lifting, straining, or strenuous exercise for 7-21 days may be required depending on the area of surgery. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure.

• Is there pain after surgery?
Most patient report no or minimal discomfort after surgery and require no pain medication.

If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take Tylenol (Acetaminophen) or another pain reliever over the counter. Aspirin or Aspirin containing pain relievers may cause increased bleeding. Rarely, prescription pain medications may be required for severe pain.

Your physician will let you know what pain medications are recommended for your specific condition.

• How do I take care of my surgical area after Mohs?
It is generally required to check with your surgeon for their specific wound care instructions just after surgery.
Often, you will be asked to go home and take it east for the rest of the day “couch potato day”. A few patients like to return to work and resume their work day after surgery.

It may be advisable to avoid heavy lifting and exercise especially the first 24-48 hours after surgery. Your physician will usually give you more detailed instructions depending on the area and size of the surgery.
You will have usually have a bulky “pressure” dressing on the surgery area for 1 day. You may be asked to keep the area dry until 24 hours. Swimming pools, oceans, and jaccuzi’s are usually off limits while the stitches are in. These may increase your chance of infection. Many physicians allow you to shower the next day after surgery. Wound care may require cleaning the wound with soap or hydrogen peroxide 2-3 times a day and applying an over the counter antibiotic ointment to the area.
Mild swelling is not uncommon the 1st day or two after surgery and can be lessened by use of an ice bag, ice cubes or chips in a small Ziplock baggie, or frozen peas in their bag. Leaving the dressing in place, ice use every 5-15 minutes every hour for the first 8-24 hours after surgery. Swelling is more common around for surgeries around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after surgery of the head and face area.The surgical area may ooze a little blood or clear liquid especially in the first few hours after surgery; activity may aggravate this. Hot drinks or bending over at the waist can also initiate or worsen bleeding of face wounds. If bleeding occurs, firm pressure applied directly to for ten to fifteen minutes to the site may be helpful. Most bleeding will stop if you apply enough pressure. Your surgeon should be notified of non-stopping bleeding. Rarely, a visit to the hospital emergency room may be necessary for severe bleeding.Your surgeon will need to know if pain is increasing after 1-2 days after your surgery or you are having fever or other concerning symptoms. In such cases, you may need to be seen at the surgeon’s office. The surgical area may need to be promptly checked for bleeding or infection.
Limiting hot foods, hot drinks, and heavy chewing for 48 hours may help decrease the chances of postoperative bleeding for wounds around the mouth or cheek areas.
Your physician will let you know their recommended wound care.
• What about makeup?
Most patients are advised to try to avoid applying makeup or powder directly on a fresh wound unless the surface is fully healed. Skin colored tape strips called steristrips are available to minimize and help cover-up a visible wound.
It is important to follow your own physician’s instructions for wound care.
• What is the chance that my cancer will recur?
There is a very low chance that your skin cancer will recur after Mohs surgery. Mohs cure rates have been reported as high as 96-99%.It is important to understand that no cancer treatment or surgery has a 100% cure rate. A skin cancer may recur or a new cancer may arise in the same or adjacent area even after Mohs or other surgery. Some skin cancers are more aggressive than others and need additional treatment and closer follow up.
Skin cancers frequently need additional follow up and possible further treatment. Although Mohs surgery tends to have the highest cure rate compared to other treatments, Mohs may not be necessarily curative in advanced skin cancer ( rare cases) and may need one or more procedures such as radiation or further surgery to fully treat the lesion.
Good follow up appointments with your physician are very important, especially in the first few years after Mohs. Many patients are seen every 4-6 months after their diagnosis of a skin cancer. Self skin examinations monthly are good practice for patients with a history of skin cancer. Any changing or new growth should be promptly checked by your physician. More regular follow up appointments may be needed for those with more aggressive tumors or tumors in high risk areas.
Your physician will recommend the proper follow up for your specific condition.
• How many “levels” of Mohs will I need?
On average, most patients may only need 1 or 2 levels before clearing the tumor roots. Depending on the skin cancer type and location, a patient may need anywhere from 1 to 10 or more levels of Mohs to clear a tumor.There is no way to predict ahead of time how many levels your cancer will require for cure. The number of Mohs levels needed to completely remove the skin cancer depends on how big your cancer is and where the “roots” are. Mohs surgeons alway strive to remove your cancer in as few levels as possible.There is also very little way to predict beforehand how large a skin cancer is because often there are invisible portions “roots” which can be seen only with the help of a microscope. Sometimes, more than one surgical procedure may be required to remove very large or invasive tumors, cancers in small areas or difficult areas, or to obtain the best medical and cosmetic result.
• Can I go out in the sun after surgery?
There are no specific strict sun restrictions after Mohs surgery. You may go out in the sun with sunscreen and protective hats and clothing. Overall, the sun is not your friend and should be avoided in excess. Excess sun exposure has been linked to possible skin cancer.
Use of sunscreen or other cover up on the scar is very helpful for at least 6 months after surgery to help minimize scarring. It is important to follow your own physician’s instructions for wound care and sun protection.
• How are skin cancers treated?
There are many good and effective ways to treat skin cancers. Options include local radiation (X-ray) treatments, curettage and desiccation “C&D” ( scrape and burn), cryosurgery ( specialized deep freezing), photodynamic therapy using Levulan and laser and or blue light, regular surgical excision, plastic surgery treatment, interferon injections, laser removal and surgery, Mohs surgery, and several prescription creams including Aldara ( imiquimod) and Efudex ( flurouracil).
• Why is it called Mohs?
Mohs is named after its inventor Dr. Frederic Mohs who first described the technique in 1941.








Photodynamic Therapy

What is Photodynamic Therapy?
Photodynamic Therapy (PDT) is a special medical treatment that uses a photosensitizing drug and a light source to activate the applied drug. The result is an activated oxygen molecule that can destroy specific cells, including pre-cancerous or certain types of cancer cells. The procedure is generally minor and performed in a physician’s office or outpatient setting.

PDT essentially has three steps. First, a light sensitizing liquid, cream, or intravenous drug (photosensitizer) is applied or administered. Second, there is an incubation period of minutes to days. Finally, the target tissue is then exposed to a specific wavelength of light which then helps activate the photosensitizing medication.

Steps:
• 1. Application of photosensitizer drug
• 2. Incubation period
• 3. Light activation

Although first discovered around 1913, PDT in the modern sense is a fairly new, evolving science whereby varying incubation times of a light sensitizing drug are used in combination with varying types of available light sources depending on the target tissue. The basic premise of PDT is selective tissue destruction. Although the photosensitizer may be absorbed all over by many cells, atypical or cancerous cells preferentially take up more of the drug and also may retain the drug for longer duration than normal tissues.

At present, the primary limitation of available PDT techniques is the depth of penetration of the light and ability to target cells within at most 1/3 of an inch ( approximately 1cm) of the light source. Therefore tumors or atypical growths must be fairly close to the skin or treatment surface for PDT to work.

What is Photodynamic Therapy used for?
PDT is currently used in multiple medical fields including oncology (cancer), dermatology (skin), and cosmetic surgery.

In oncology, it is FDA approved for non-small cell lung cancer, esophageal cancer, and pre-cancerous changes of Barrett’s esophagus. Its use is also being further investigated through clinical trials in general oncology for conditions including cancers of the cervix (mouth of uterus), prostate gland, brain, and peritoneal cavity (the abdominal space that contains the stomach, liver, and internal organs).

In dermatology, PDT using Levulan Kerastick® (20% delta-aminolevulinic acid HCl) became FDA approved in 2001 for the treatment of pre-skin cancers called actinic keratosis (AK). The initial approval was specifically for normal (non-hyperkeratotic) actinic keratosis of the face and scalp with a specified 14 to 18 hour drug incubation time, and 1,000 seconds (16 minutes and 40 seconds) of activation by a proprietary blue light source.

Since 2001, PDT has also received many other non-FDA approved ( also called “off-label” ) uses including acne, rosacea, skin cancer, sun damage, cosmetic skin improvement, oily skin, enlarged sebaceous glands, wrinkles, rejuvenation (anti-aging), warts, hidradenitis suppurativa, psoriasis, and many other skin conditions.

What photosensitizer drugs are available?
At least 3 currently FDA approved photosensitizers are available including Photofrin (porfimer sodium), Levulan ( 5-aminolevulinic acid or ALA ), Metvix (methyl aminolevulinate (MAOP)) . More drugs are undergoing trials and may become available in the near future. Photofrin is used intravenously ( IV)for internal cancers while Levulan and Metvix are applied topically for skin therapy.

What light sources are available?
PDT can essentially use many types of light sources. These include laser, intense pulsed light, light-emitting diodes (LEDs) , blue light, red light, many other visible lights, including natural sunlight. Photosensitizer drugs may become activated by one or several types of applied light depending on the ideal wavelength for the particular drug used and target tissue.

How is the light applied?
The light source needs to be directly applied to the target tissue for a specific amount of time. For surface skin treatments, the light is easily directly applied to the area of the skin where the photosensitizer drug has been applied ( such as face, scalp, arms, etc.).
For internal cancers, delivering the light to the desired area is more challenging. The light may be delivered through small fiber optic cables into the body cavity or area being treated. Sometimes endoscopes ( a thin lighted elongated tube which is inserted into a body space) are used to deliver the light into the lungs, stomach, or bladder.

How does PDT work?
PDT works by direct injury to the target cells and tissues. While all of the exact mechanisms are not fully known yet, the basic pathway seems to involve an activated oxygen molecule that has the ability to injure or destroy nearby or specific cells.
Aminolevulinic acid is then incorporated into the body’s natural heme ( blood) biosynthesis pathway and activated to form protoporphyrin IX, a potent photosensitier. Protoporphyrin IX then becomes excited to an activated singlet state. This active singlet state is then directly toxic to cells.
Other potential pathways include directly killing abnormal or cancerous cells, damaging the blood vessels and blood supply to the tissue, causing inflammation and irritation, and possibly also activating the person’s own immune system to attack the abnormal or cancerous cells.

Does PDT make me permanently more sensitive to light?
No, PDT causes a temporary sensitivity to light, including natural sunlight and some indoor lights. The light sensitivity resolves with time depending on both the photosensitizer drug and dosage used.

How long do I have to stay out of the sun and light?
Light avoidance is generally required after PDT. The duration depends on the drug and dosage used. Intravenously given Porfimer may make the body including the skin and eyes sensitive to light for about 6 weeks after treatment. Proper protection including long sleeves and sunglasses may be required.
Topically applied aminolevulinic acid (Levulan) or methyl aminolevulinate (Metvix) may cause skin sensitivity only on the treatment areas for approximately 24-72 hours. These do not usually cause sensitivity on other body parts other than where the drug was directly applied.  Your physician will need to discuss with you the required sun and light avoidance period required after your particular treatment.

How is PDT used to treat the skin?

PDT using Levulan ( 5-aminolevulinic acid or ALA ) and a proprietary Blue light is currently FDA approved for the treatment of skin pre-cancers called actinic keratosis ( rough scaly spots generally on sun exposed skin in more fair skin individuals).
PDT is also known as “ALA/PDT treatment” or “Super Blue Light”. It has been referred to as a “super photo facial” when the photosensitizer is used with a machine called intense pulsed light or IPL. These treatments may help remove sun damaged pre-cancerous zones and spots. Sun damage, fine lines, and blotchy pigmentation may also be improved because of the positive effect of PDT. IN some patients, PDT also has been shown to help decrease the appearance of pores and reduce oil glands, effectively treating some subtypes of patients with stubborn acne, rosacea, and help improve the appearance of some small superficial acne scars.
Although PDT’s use in skin was first investigated in 1990’s for actinic keratosis, it was not as popular or widely used because of the required long incubation times (usually 18-24 hours) and limited indications. Since approximately 2001, PDT has become more widespread in use primarily because of advances including shorter incubation times (30-60 minutes) and more applications including acne and cosmetic skin rejuvenation.

What is a photosensitizer drug?
Photo sensitizers are chemical compounds that become activated only when exposed to light.

What is Aminolevulinic acid or Levulan?
5-aminolevulinic acid also called Levulan or ALA for short is a naturally occurring protein in the body. It is found in small quantities as part of the normal heme ( blood) synthesis pathway. In larger quantities, it is a substance known to increase sensitivity to certain wavelengths of light.

How does PDT work?
By preferentially attacking the active or abnormal cells, PDT combines a very high success rate with good preservation of normal skin without significant risks for scarring. Once the areas have healed following PDT, the areas are re- examined to see if additional treatments or possible biopsies are needed.

PDT is special because it is a targeted treatment to preferentially target more rapidly dividing cells and atypical skin growths. With regular or traditional cryosurgery ( freezing with liquid nitrogen) or burning, only the visible pre skin cancers are treated thereby leaving ones that aren’t as apparent ( sub clinical or hidden) lesions undetected. Photodynamic Therapy allows for field or blanket treatment of an entire area of sun damage thereby reducing the chance that undetected pre skin cancer cells will be left untreated.

Photodynamic Therapy is usually scheduled in the doctor’s office because of the required photosensitizing prescription / physician applied medication and the special light activation equipments. Currently PDT procedures are generally performed with the patient waiting in the office during the 30 minute to several hours incubation time before the application of the light source.

What is a typical skin PDT session like?
You may be given a written procedure consent form to read and sign before your first treatment. The medical staff may take some before photography prior to applying the photosensitizer medication.
In the treatment room, you may be sitting or comfortably lying back on a table. This part is generally painless and comfortable. Often a thorough cleansing of the face is done using alcohol and or acetone to degrease the skin. The less oil on the skin, the more readily the skin will absorb the applied topical medication. In some patients microdermabrasion may additionally be performed prior to the application of the medication to further prepare the skin to optimally absorb the photosensitizer.
The photosensitizer liquid or cream is applied topically to the whole area being treated (such as the entire face, scalp, back of the hands, back part of the forearms, legs, feet, scalp, chest, or back).
The medication is allowed to air dry for a few minutes and then you will wait anywhere from 30-60 minutes for the incubation time. Some areas such as chest, back and particularly forearms and legs require longer incubation times of 2-18 hours for better results. No two people or skin on different areas of the body are exactly alike. PDT requires physician adjustments for specific individualized incubation times and treatment durations.
After the proper incubation time, you are brought back into the light source room where the medication is activated with a specific wavelength light source. There may be sensations of warmth, tingling, heat, or burning in some patients. Frequently, you will have a fan to help cool off during the treatment.
The treatment area is then washed off and sunscreen applied before leaving the office. Instructions and an appointment for follow up may then be given on how to care for the improved skin.

How much improvement can I expect?
No two individuals are the same and results may vary. As with any medical procedure, some conditions can improve dramatically in some patients and not respond in others.

Overall, patients with severe sun damaged skin manifested by actinic keratosis, texture, and tone changes including mottled pigmentation, dull or sallow skin, and skin laxity may see good to excellent improvement with PDT. There have been reports of possible improvement of large pores, non- pitted acne scars, and active acne.

Depending on the area being treated and the recommended incubation time, different numbers of treatment sessions spaced 4-6 weeks apart may be required to achieve the desired improvement and reduction in lesions. It is not always possible to predict ahead of time how many treatments your specific condition may take or how you will respond to PDT.

Photodynamic Therapy requires your patience and your willingness to follow the post procedure instructions, including staying out of the sun for 24-28 hours depending on the area treated and your physician’s requirements.

How many treatments will it take to see the best results?
To achieve maximum improvement of pre-cancerous (actinic keratosis) sun damage, skin tone and texture, on average a series of 2-3 treatments 2-6 weeks apart may be quite effective. Some patients with milder actinic keratosis are happy with one treatment. More treatments can be done at periodic intervals in the future to maintain the rejuvenated appearance of the skin.

Where can I have Photodynamic Therapy?
Photodynamic Therapy for skin therapy is usually comfortably performed in an outpatient setting like a doctor’s office and without any sedation or anesthesia.
You may check the www.AAD.org for board certified dermatologist members of the American Board of Dermatology in your area or www.ASPDT.org for members of the American Society of Photodynamic Therapy. Additionally, oncologists and other physicians may be trained in this area.
While these photosensitizer medications may currently only be available to medical personnel, it may be foreseeable or possible in the distant future where patients could be given a prescription for the topical or oral photosensitizer and a light source for physician directed home use.

How long does a skin PDT procedure take?
You are generally in the medical office for several hours( average 1 1/2 hours) on the day of your Photodynamic Therapy. Facial PDT may take 10 minutes to apply the medication, 30-60 minutes to allow proper skin incubation, and 15-20 minutes for light application. Other areas may require longer incubation times and you may leave the office and come back when it is time to have the light.

Many patients prefer to schedule their treatment later in the afternoon so they may go directly home after the treatment. It is not usually advised to have any sun exposure such as from running errands or driving around after the treatment.

What kind of physician can perform Photodynamic Therapy?
Most skin PDT is performed only by specially trained dermatologists and their medical staff. Other physicians including oncologists, family physicians, internal medicine doctors, plastic surgeons, or Ear, Nose and Throat ( ENT) surgeons and their medical staff who are trained and may also perform Photodynamic Therapy.
While it is generally advisable to undergo this or any medical treatment in an established board-certified physician’s office, there are medical spa type environments that may also offer these skin services with or without physician supervision.

Where can I find a doctor board certified in Photodynamic Therapy?
There is no current Board Certification, residency, or fellowship training for Photodynamic Therapy. There is a new national organization called the American Society for Photodynamic Therapy (ASPDT). You may check the website for members of this group at http://www.aspdt.org. There are many other photomedicine interest groups and societies dedicated to this evolving field.

Some dermatologists and oncologists have received special residency or post graduate training for photodynamic therapy. Many other physicians may be trained by companies that manufacturer the photosensitizing material and /or the light source.

Is skin PDT only for pre-cancerous growths?
No, Photodynamic Therapy is a widely used method of treating many conditions including pre-cancers (actinic keratosis), some types of superficial skin cancers, acne, rosacea, warts, sebaceous hyperplasia ( enlarged oil glands), fine wrinkles, psoriasis, and other cosmetic indications. It is currently not used to remove malignant melanoma or deeply invasive cancers. It is not used to remove moles or birthmarks.
Less frequently, Photodynamic Therapy may also be used “off-label” for other less common conditions including hidradenitis suppurativa, porokeratosis, disseminated actinic porokeratosis (DSAP), and other investigational conditions.

What are the advantages with Photodynamic Therapy for treating skin pre-cancers?
The greatest advantage of PDT is the ability to selectively treat an entire area of skin damage and pre-cancers (blanket or field treatment). PDT generally decreases the likelihood of lighter or darker skin spots ( post-inflammatory hyper or hypo pigmentation) caused by routine freezing with liquid nitrogen. Additionally, PDT frequently may facilitate smoother skin and an overall improved appearance, tone, color, and enhanced skin texture.

In several studies, PDT has been preferred by many patients for ease of use and recovery as compared to alternative treatments including freezing and chemotherapy creams like fluorouracil (Efudex). The PDT side effects may be milder with less down time than with fluorouracil.

For patients with many skin lesions, PDT may be generally more effective than repeated spot treatment with topical liquid nitrogen. Some patients are unable to tolerate the prolonged treatment required with fluorouracil (Efudex) or imiquimod (Aldara) because of the irritation, redness, and possible downtime with these topical creams.
PDT has become a very well tolerated, essentially painless, non-invasive (no needles or surgery required) procedure to help reduce sun damage and enhance the overall cosmetic outcome (particularly in sensitive areas of the face and chest).

How many treatments of Photodynamic Therapy will I need?

No two people’s skin is exactly the same and therefore individual results and number of required treatments vary. On average, most patients may benefit from 1 to 3 PDT treatments for an area and annual touch up treatments. While the face tends to respond faster and to fewer treatments, areas like the forearms and legs are much harder ( resistant and tough skin) to treat and may require many more treatments.

There is no way to reliably predict ahead of time exactly how many treatments your condition will require. Photodynamic Therapy physicians always strive to treat your condition in as few treatments as possible without causing a severe burn.

Can I go out in the sun right after PDT?
No. There are very specific strict sun restrictions for the treated area after Photodynamic Therapy.
You may not go out in the sun even with sunscreen for usually 24-48 hours after PDT especially after facial treatment. Arms, legs, chest or back PDT may be much easier since you can wear high SPF protective clothing and sunscreen to protect the areas during the post-procedure period..
It is important to follow your own physician’s instructions for wound care and sun protection.

Can I remove my moles or birthmarks using Photodynamic Therapy?
No, at present Photodynamic Therapy is usually not for mole removal. Moles are usually removed by standard or traditional surgery.

Am I a good candidate for Photodynamic Therapy?
The best candidates for PDT may be those with lighter or fair skin with sun damage.

You may not be a good candidate for Photodynamic Therapy if you have darker skin that tends to turn brown or discolor with certain light or laser treatments. You may also not be a good candidate for PDT if you are very sensitive to light, burn extremely easily, would be unable to stay out of sunlight for the required 24-48 hours, or on taking medications which may make you very sensitive to sunlight or light based therapies.

Your decision on the best treatment choice may depend on different factors such as the location and type of skin lesions, your past treatments, your overall health, and level of comfort. Your physician can help you sort through the different treatments and assist in your shared decision making process. However, the right decision for you is always yours and your doctor’s to make.
Generally, there is not much of a problem with other health issues and PDT is safely performed in many thousands of people annually worldwide.

Your Photodynamic Therapy physician needs to know of any other medical conditions that may affect your procedure or overall wound healing. You would want to make sure to tell your physician beforehand if you have any extreme sensitivity to light based treatments, take medications which make you very sensitive to light, have had a problem or bad effect from prior PDT, have lupus, or suffer from a condition called porphyria.

Your Photodynamic Therapy physician needs to know if you have had a history of “Staph” or other skin infections in the recent past. You will want to advise your physician if you have a history of frequent cold sores ( Herpes virus infections on your face). In that case, you ay be prescribed an antiviral tablet (cold sore prevention pill) to take before and after your procedure. You may be asked to wash with a special antibiotic soap or wash like Hibiclens ( Chlorhexidine) the night or morning before your procedure to help reduce the number of bacteria on your skin.

Patients may need to also advise their physician of any drug allergies such as to topical anesthetics or other photosensitizers. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, Hepatitis, HIV/ AIDS, or pregnancy.

What areas are treatable by Photodynamic Therapy?
Essentially any area of the body may be treated by PDT.

Photodynamic Therapy is used primarily for the treatment of head and face pre cancers and acne. It is particularly useful for areas with a large number of pre-skin cancers in difficult areas such as the face.

It is also used on hands, feet, forearms, chest, back, legs and anywhere where there are AK’s. However, some of those areas may not be as responsive and may require longer incubation and or light treatment times for effectiveness.

What growths is PDT not good for?
Photodynamic Therapy is not as effective for thick skin pre-cancers called hypertrophic actinic keratosis (HAK). This may be due to the inability of the photosensitizer drug to penetrate the thick skin. These growths may need to be frozen or surgically removed or thinned using a curette prior to PDT.

PDT may also not be very useful for more advanced skin cancers like morpheaform or sclerosing basal cell carcinoma, moderately to poorly differentiated squamous cell carcinomas, recurrent tumors (tumors that were previously removed and have re-grown at the same site, or lesions in previously radiated ( x-ray or radiation treatments)sites, and malignant melanoma.

What are possible complications of Photodynamic Therapy?
As with any surgery or procedure, Photodynamic Therapy is associated with some possible minor risks and complications. While it is overall a very safe and effective minor in office treatment, there are some possible uncommon complications. Since an exaggerated light sensitive reaction is expected by definition of PDT, most patients understand and expect some type of a sunburn or red reaction after skin PDT. Not everyone gets a sunburn reaction and in fact some patients may have no visible reaction or redness.

Possible risks and complications of Photodynamic Therapy include (but are not limited to) burning, skin discoloration, skin redness, broken blood vessels called telangeictasia, pain, infection, cold sore ( Herpes) activation, blisters, scabs, unsightly scar, keloid ( raised, thick scar), cosmetic disfigurement, skin discoloration, eye injury or swelling, allergic reactions, reaction to topical anesthesia, pre-cancer or cancer recurrence, need for further treatment including biopsy, radiation or plastic surgery, and rarely death. Acne may need additional treatments and may not respond at all or sustain a long lasting response to the treatment.

Eye injuries and prolonged sun sensitivity may be possible with inadvertent exposure to the photosensitizer drug.

Minor, serious, or life threatening reactions can occur with the use of anesthetics or with medications given before, after or during a procedure. Overall, most patients tolerate the minor procedure very well without any complications.

Shared decision making is very important in your treatment and you are involved in how you prefer to treat your condition. Your Photodynamic Therapy physician may make some recommendations on how to proceed with further treatments..

The main goal with Photodynamic Therapy is to reduce the number of pre- skin caners and thereby potentially decrease the chance of future skin cancers.

Is there scarring from Photodynamic Therapy?
No, PDT usually does not leave scars in typical cases. Overall when you undergo PDT, there will be some type of a red skin reaction and irritation for 3-10 days after the treatment. Some people are more sensitive to PDT and the light treatment than others. Similarly, some people heal better or faster than others. Some residual redness may be more noticeable depending on the location and skin type. Some people may have temporary skin discoloration that may last weeks to months. Patients with darker skin types may have more skin discoloration after treatment.

What are alternatives for Photodynamic Therapy?
It is important to understand that as with any medical treatment, there are alternative treatments and options to PDT. You may want to discuss alternative treatment options with your doctor at your consultation appointment.

There are many options for treatment of actinic keratosis ( AK’s) including but not limited to freezing ( cryotherapy or cryosurgery), burning, chemical peels, lasers, chemotherapy creams like fluorouracil or Efudex, immune modulator creams like Aldara ( Imiquimod), local radiation , plastic surgery, curettage and desiccation (scrape and burn), surgical removal, no treatment, and other choices depending on the skin condition.

In acne, there are many alternatives to PDT including oral Accutane ( isotretinoin), oral antibiotics, topical washes, acne facials, and many acne creams.

What about insurance coverage and costs?
Photodynamic Therapy is currently considered a medical service for the treatment of some conditions particularly for skin pre-cancers called AK’s. However, it may be considered cosmetic, off’ label, or not medically indicated for many other conditions for which it is regularly used.

Currently, some insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling any treatment and confirm your eligibility and benefits.

Photodynamic Therapy, like any procedure, will result in additional procedure charges above the routine office visit fees. These fees may range from two to several hundred dollars depending on the area, number of treatments, and the type of insurance you purchase. The more number of treatments and greater the amount of photosensitizer medication required, the higher the cost.

Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally typically covers 80% of Photodynamic Therapy for pre cancers. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare.

Standard commercial or non-Medicare insurances currently generally may cover a large percentage of PDT for pre-cancers unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or your insurance coordinator for an approximate estimate of your charges before scheduling the procedure.

What about other treatments options?

You may decide to have alternative treatments instead of PDT. Alternatively, you may also choose a hybrid option where you have Photodynamic Therapy and additional other treatments. In some cases, the most effective treatment for certain conditions may utilize a combination treatment using two or more modalities to help team up and treat the condition.

How do I prepare for my procedure?
Your personal physician and their medical personnel will likely let you know the pre-operative instructions specific for your condition.

For many typical PDT in a physician’s office, most patients are advised come in with a clean, washed area without any lotions or makeup. You may generally eat your regular diet on the day of their procedure and take all of your regular daily medications.
Your skin should be fully clean and free of all make-up, moisturizers, and sunscreens. Bring a wide brimmed hat (6 inches), sunglasses, and scarf when appropriate to the appointment.
Patients are advised to wear comfortable casual clothes and bring a wide brim hat for facial or scalp treatments. You should bring gloves or a long sleeve shirt if having hands or forearms treated.

In nearly all cases, patients are usually able to drive after most procedures and do not necessarily need a driver unless they feel uncomfortable or have taken any sedative medications.

Since you will be in the office for generally at least one hour (and sometime more), you may want to bring some personal snacks, drinks, and reading or knitting material. Personal music headsets or Ipods may also provide relaxation and help pass time during your PDT application, incubation time, and treatment.

Most patients continue all doctor prescribed medications including aspirin and any blood thinners unless specifically advised otherwise only by the PDT physician.

Can I smoke and drink alcohol before PDT?
While there is no absolute contraindication, smoking may be discouraged for at least a few days before and 1-2 weeks after your procedure. As with any procedure, smoking can slow down wound healing and cause an increased risk of wound infections.

Heavy alcohol use is not advised at least a few days before PDT. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding.

Your physician will want to know of any factors that may affect your surgery or wound healing.

How is recovery?
Recovery is usually fairly easy and uneventful for 90% or more of patients. Many patients have mild dryness and a faint to mild sunburn of the treated area. A small percent of patients may have moderate or marked discomfort and a harder recovery because of more skin dryness, redness, or burning.

Some of these patients have had inadvertent sun exposure even as short as a minute or two during their immediate post treatment time casing a more severe reaction. A handful of patients have reported some minor sun exposing activities like briefly stepping out to fill their yard bird feeder or walk out for a moment to grab the mail from the mailbox.

You will want to plan to stay indoors and avoid any sunlight for 24-48 hours as directed by your physician. Overall, you may be able to resume all normal indoor activities the first day.

Most patients may resume going outdoor with proper sun protection including sunscreen and hat or cover up clothing 24-48 hours after this treatment. Again, it is always advised to check your personal physician’s guide for this care.

Can I return to work or school?
Most patients are able to return to work or school the 24-48 hours after Photodynamic Therapy. Avoiding direct sunlight for the first 1-2 days in crucial to avoiding getting an exuberant (red) response. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure. Your skin may appear very red causing you to need to explain that you either had a PDT treatment or perhaps just say you went skiing all day and forgot to wear sunscreen.

Is there pain after PDT?
Usually not much. No two individuals and their skin is exactly the same and therefore individual reactions and tolerance to discomfort levels vary. Most patient report mild skin irritation including minimal to mild dryness and tight feeling of their skin after PDT. This discomfort is usually improved with frequent application of bland topical emollients or plain Vaseline.

A small number of patients may actually complain that they felt nothing and didn’t have any pain or peeling.

Less commonly, a small percentage of patients for various reasons may have significant pain, a very exaggerated sunburn response, moderate overall discomfort, and pain from the tightness and warmth of the skin.

If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take Tylenol (Acetaminophen) or another pain reliever over the counter. Rarely, prescription pain medications may be required for severe pain.

Your physician will let you know what pain medications are recommended for your specific condition.

How do I take care of my treatment area after Photodynamic Therapy?
It is generally required to check with your doctor for their specific wound care instructions before your procedure. Often, you will be asked to go home and stay indoors for the rest of the day, “couch potato day”. Your physician will usually give you more detailed instructions depending on the area and size of the procedure.
Many physicians suggest you shower and wash the area immediately and as often as you would like. Wound care may require gently washing the area with soap and water or hydrogen peroxide 2-3 times a day and applying an over the counter antibiotic ointment or a non-irritating moisturizer like Purpose, Cetaphil or Aquaphor to the area. Avoidance of harsh or abrasive cleansers are advised. Picking or scrubbing the skin could cause in severe irritation or scarring.
Mild to moderate redness and or swelling is not uncommon the 1st day or two after PDT and can be lessened by use of an ice bag, ice cubes or chips in a small Ziplock baggie, or frozen peas in their bag. Applying cool packs or ice use every 5-15 minutes every hour for the first 8-24 hours after your procedure may be very soothing. Swelling may be more common for procedures around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after treatment of the head and face area.

Your physician should be notified of any infections, cold sore outbreaks, extreme swelling, or other unexpected reactions. Rarely, a visit to the physician’s office may be necessary for severe swelling or infection. Oral antibiotics, cortisone creams or pills, or other medications may be required for adverse reactions.

Your physician will need to know if pain is increasing after 1-2 days after your procedure or if you are having fever or other concerning symptoms. In such cases, you may need to be seen at the physician’s office.

What about makeup?
Most patients are advised to try to avoid applying makeup or powder directly on a fresh or open wound unless the surface is fully healed. Makeup or other cover-up is generally tolerated starting on the 1st or later dates after PDT.
A non-irritating sunscreen such as zinc or titanium may be applied immediately after the procedure before leaving the physician’s office. Sunscreens are ideally also applied twice a day after PDT.
It is important to follow your own physician’s instructions for wound care.

What is the chance that my pre-cancers will recur?
While PDT is a very effective treatment, there is a reasonable chance that you may l continue to need periodic treatments for pre cancers depending on your individual sin and severity of prior sun damage. Often there are layers of underlying sun damage from prior years that rise to the surface over time.

Photodynamic Therapy clearance rates have been reported as high as 60-90% with even one treatment. Additional treatments are advisable for patients with multiple lesions or hard to clear areas.

It is important to understand that very few treatments or surgeries have a 100% cure rate. A skin pre-cancer or cancer may recur or a new cancer may arise in the same or adjacent area even after Photodynamic Therapy or other treatments. Some skin pre- cancers are more aggressive than others and need additional treatment and closer follow up.
Skin sun damaged skin frequently needs additional follow up and possible further treatment, at least annual rechecks and possible touch up PDT treatments are advised. Several studies have shown that Photodynamic Therapy tends to have a cure rate comparable to the gold standard treatment with Efudex ( fluorouracil).
It is important to note that PDT may not be necessarily curative in advanced skin cancer (rare cases) and may need one or more procedures such as biopsy, surgery, radiation or other procedures to fully treat the lesion.

 

Good follow up appointments with your dermatologist or physician are very important, especially in the first few years after Photodynamic Therapy. Many patients are seen every 4-6 months after their diagnosis of a skin pre-cancers.
Self skin examinations monthly are good practice for patients with a history of skin cancer. Any changing or new growth should be promptly checked by your physician. More regular follow up appointments may be needed for those with more aggressive tumors or tumors in high risk areas.
Your physician will recommend the proper follow up for your specific condition.

How are skin cancers treated?
There are many good and effective ways to treat skin cancers. Depending on the type and location, options may include Mohs surgery, local radiation (X-ray) treatments, curettage and desiccation “C&D” ( scrape and burn), cryosurgery ( specialized deep freezing), photodynamic therapy, regular surgical excision, plastic surgery treatment, interferon injections, laser removal and surgery, and several prescription creams including Aldara ( imiquimod) and Efudex ( fluorouracil).


Psoriasis
• What is Psoriasis?
• What causes it?
• What does it look like?
• How many people have it?
• Can it affect my joints?
• Can it affect my nails only?
• Is it curable?
• Is it contagious?
• Can I pass to my children?
• What kind of doctor treats psoriasis?
• How can I find a specialist?
• How is it treated?
• What creams or lotions are available?
• What pills are available?
• What injections are available?
• What about light therapy?
• Where can I get more information?
• Is there a psoriasis support group?
• What is my long term prognosis?
• What does the future hold?
• Psoriasis at a glance.

What is Psoriasis?
• Psoriasis is a non-contagious common condition of the skin which usually causes rapid skin cell replication and red, dry patches of thickened skin in classic areas like the elbows and knees. The dry flakes and skin scales are thought to result from the build up of the rapid production of skin cells.

• It is considered a chronic (long term) skin condition causing inflammation and increased turn over or production of skin cells.

• It has a variable course with periodic ups and downs. Sometimes psoriasis may clear for years and stay in remission. Some people have worsening of their symptoms in the colder winter months. Many people report improvement in warmer months, climates, or increased sunlight exposure.

• Psoriasis is seen worldwide, in all races, and both sexes.

• Some people have very mild cases with just small dry patches on their elbows and knees and some people may have very severe disease where their entire body is fully covered with psoriasis.

• Some people with psoriasis may not know they have the disease because it is so mild. Although psoriasis can be seen in any age from babies to seniors, usually patients are first diagnosed in their early adult years.

• Patients with more severe psoriasis may have social embarrassment, job stress, emotional distress, and other personal issues because of the appearance of their skin.

What causes it?
• The exact cause remains unknown.
• There may a combination of factors including genetic predisposition and environmental factors.
• The immune system is thought to play a major role in most types of psoriasis.
• Despite research over the past 30 years looking at many triggers, the “master switch” is still a mystery.

What does psoriasis look like?
• Psoriasis typically looks like red or pink areas of thickened, raised, dry skin in classic areas like the elbows, knees, and scalp. Essentially any body area may be involved. It tends to be more common in areas of trauma, repeat rubbing, use, or abrasions.

• Psoriasis has many different appearances. It may be small flattened bumps, large thick plaques of raised skin, red patches, and pink mildly dry skin to big flakes of dry skin that flake off.

• There are several different types of psoriasis including Psoriasis Vulgaris ( common type), Guttate Psoriasis (small, drop like spots), Inverse Psoriasis (in the folds like of the underarms, navel, and buttocks), and Pustular Psoriasis ( yellow, liquid filled small blisters).

• Sometimes pulling of one of these small dry white flakes of skin causes a tiny blood spot on the skin. This may be a special diagnostic sign in psoriasis called Auspitz sign.

• Genital lesions especially on the head of the penis are common. Psoriasis in moist areas like the navel or area between the buttocks (intergluteal folds) may look like flat red patches. These atypical appearances may be confused with other skin conditions like fungal infections, yeast infections, skin irritation, or bacterial “staph” infections.

• On the nails it can look like very small pits ( pinpoint depressions or white spots on the nail) or as larger yellowish , brown separations of the nail bed called “oil spots”. Nail psoriasis may be confused with and incorrectly diagnosed as a fungal nail infection.

• On the scalp it may look like severe dandruff with dry flakes and red areas of skin. It may hard to tell the difference between scalp psoriasis and seborrhea ( dandruff). Often, the treatment is very similar for both conditions.

Can it affect my joints?
• Yes, psoriasis affects the joints in about 10-35% of patients.

• In fact, sometimes joint pains maybe the only sign of the disorder with completely clear skin. Patients may have aches of any joints (arthritis), although the joints of the hands, knees, and ankles tend to be most commonly affected.

• The average age for onset of psoriatic arthritis is 30-40 years old.

• In most cases, the skin symptoms occur before the onset of the arthritis.

• The diagnosis of psoriatic arthritis is typically made by a physician examination, medical history, and relevant family history. Sometimes, lab test and x-rays may be used to exclude other diagnosis like rheumatoid arthritis and osteoarthritis.

Can it affect only my nails?
• Yes, psoriasis may involve solely the nails in a limited number of patients. Usually, the nail symptoms accompany the skin and arthritis symptoms. Nails may have small pinpoint pits or large yellowish separations of the nail plate called “oil spots”. Nail psoriasis is typically very difficult to treat. Treatment option are somewhat limited and include potent topical steroids applied at the nail base cuticle, injection of steroids at the nail base cuticle, and oral or systemic medications.

How many people have it?
• You are not alone. Psoriasis is a fairly common skin condition and estimated to affect approximately 1-3% of the U.S. population.
• It currently affects roughly 7.5 to 8.5 million people in the U.S.
• It is seen worldwide in about 125 million people.
• African Americans have about half the rate of psoriasis as Caucasians.

Is it curable?
• No, psoriasis is not currently curable.
• Ongoing research is actively making progress on finding better treatments and a possible cure in the future.

Is Psoriasis contagious?
• No, studies have not shown it to be contagious from person to person.
• You didn’t catch it from anyone and you can’t give it to anyone else by skin to skin contact.
• You can directly touch someone with psoriasis every day and not ever catch the skin condition.

Can I pass it on to my children?
• Yes, it is possible. Although psoriasis is not contagious from person to person, there is a known genetic tendency and it may be genetically passed on from parents to their children.
• It does tend to run in some families and a family history is helpful in the diagnosis.

What kind of doctor treats psoriasis?
• Many kinds of physicians may treat psoriasis including dermatologists, family physicians, internal medicine physicians, rheumatologists, and other medical doctors.
• Some patients have also seen other allied health professionals such as acupuncturists, holistic practitioners, chiropractors, and nutritionists.
• Typically, dermatologists specialize in the diagnosis and treatment of psoriasis and rheumatologists specialize in the treatment of joint disorders and psoriatic arthritis.

How can I find a specialist?
• The American Academy of Dermatology and The National Psoriasis Foundation are excellent references to help find physicians who specialize in this disease.
• Not all dermatologists and rheumatologists treat psoriasis.
• The National Psoriasis Foundation has one of the most up to date databases of current Psoriasis specialists.( http://www.psoriasis.org/treatment/directory / )
• There are many physician experts in this field and several at educational institutions. Dr. Gerald Weinstein at the University of California, Irvine, Dr. John Koo at the University of California, San Francisco, Dr. Mark Lebwohl
Mount Sinai School of Medicine, and Dr Craig Leonardi, of the St Louis University Medical School are four of the many well known experts who have published extensively in the field.

How is it treated?
• There are many effective treatment choices for improving psoriasis. The best treatment is individually determined by your physician depending on the type of disease, the severity, and the total body area involved.

• For mild disease that involves only small areas of the body (like less than 10% of the total skin surface), topical (skin applied) creams, lotions, and sprays may be very effective and safe to use. Occasionally, a small local injection of steroids directly into a tough or resistant isolated psoriasis plaque may be helpful.

• For moderate to severe disease that involves much larger areas of the body (like 20% or more of the total skin surface) topical products may not be effective or practical to apply. These cases may require systemic or total body treatments such as pills, light treatments, or injections. Stronger medications usually have greater associated possible risks.

• For psoriatic arthritis, generally systemic oral or injectable medications may be required. Topical therapies are not effective.

• It is important to keep in mind that as with any medical condition, all medications carry possible side effects. No medication is 100% effective for everyone, and no medication is 100% safe. The decision to use any medication generally requires thorough consideration and discussion with your physician.

• The risks and potential benefit of medications have to be considered for each type of psoriasis and the individual patient. Some patients are not bothered at all by their skin symptoms and may not want any treatment. Other patients are bothered by even small patches of psoriasis and want to keep their skin clear. Everyone is different and therefore treatment choices vary depending on the patient’s goals and expressed wishes.

• A particularly effective approach to psoriasis has been commonly called “rotational” therapy. This is a common practice among some dermatologists who recommend changing cycles of psoriasis treatments every 6-24 months in order to minimize the possible side effects from any one type of therapy or medication.

For example, if a patient has been using oral methotrexate for 2 years, then it may be reasonable to take them off of methotrexate and try light therapy or a biologic injectable medication for a while. By rotating to a medication that doesn’t affect the liver, the potential of liver damage may be reduced.

In another example, a patient who has been using strong topical steroids over large areas of their body for prolonged periods may benefit from stopping the steroids for a while and rotating onto a different therapy like calcipotriene (Dovonex), light therapy, or an injectable biologic.

What creams or lotions are available?

• Topical ( skin applied) medications include topical corticosteroids, vitamin D analogue creams (Dovonex), topical retinoids (Tazorac), moisturizers, topical immunomodulators ( tacrolimus and pimecrolimus) coal tar, anthralin, and others.

-Topical corticosteroids (steroids) are very useful and often first line treatment for limited or small areas of psoriasis. These come in many preparations including sprays, liquid, creams, gels, ointments, and mousses. Steroids come in many different strengths; stronger ones are used for elbows, knees, and tougher skin areas while milder ones are used for areas like the face, underarms, and groin. These are usually applied once or twice a day to affected skin areas.

Strong steroid preparations should be limited in use. Overuse or prolonged use may cause problems including potential permanent skin thinning and damage called atrophy.

-A vitamin D analogue cream called calcipotriene (Dovonex) has also been useful in psoriasis. The advantage of calcipotriene is that it is not known to overly thin the skin like topical steroids. It is important to note that this drug is not regular vitamin D and is not the same as taking regular vitamin D or rubbing it on the skin.

Calcipotriene may be used in combination with topical steroids for better results. There is a newer 2 in 1 combination preparation of calcipotriene and a topical steroid called Taclonex. Results with calcipotriene alone may be slower and less than results achieved with typical topical steroids. Not all patients may respond to calcipotriene as well as to topical steroids.

A special precaution with calcipotriene is that it should not be used in more than 20% of the skin in one person. Overuse may cause absorption of the drug and an abnormal rise in body calcium levels.

-Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription or over the counter. These help moisten and lessen the appearance of thickened psoriasis scales. Some available preparations include Salex (salicylic acid) , AmLactin ( lactic acid), or Lac Hydrin ( lactic acid) lotions. These may be used 1-3 times a day on the body and do not generally have a risk of problematic skin thinning (atrophy). Overuse or use on broken, inflamed skin may cause stinging, burning, and more irritation. These stronger preparations should not be used over delicate skin like eyelids, face, or genitals. Other bland moisturizers including Vaseline and Crisco Vegetable Shortening may also be helpful in at least reducing the dry appearance of psoriasis.

-Immunomodulators ( tacrolimus and pimecrolimus) have also been used with some success in limited types of psoriasis. These have the advantage of not causing skin thinning. They may have other potential side effects including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.

-Bath salts or bathing in high salt concentration waters like the Dead Sea in the Middle East may help some psoriasis patients. Epsom salt soaks ( available over the counter) may also be helpful for a number of patients. Overall, these are quite safe and have very few possible side effects.

-Coal tar is available in multiple preparations including shampoos, bath solutions, and creams. Coal tar may help reduce the appearance and decrease the flakes in psoriasis. The odor, staining, and overall messiness with coal tar may make it harder to use and less desirable than other therapies. A major advantage with tar is lack of skin thinning.

-Anthralin is available for topical use as a cream, ointment, or paste. The stinging, possible irritation, and skin discoloration may make this more problematic to use. Anthralin may be applied for 10-30 minutes to psoriatic skin.

What pills are available?
• Oral medications include acitretin, cyclosporine, methotrexate, mycophenalate mofetil, and others. Oral prednisone (corticosteroids) are generally not used in psoriasis and may cause a disease flare if administered to many patients.

• Acitretin (Soriatane) is an oral drug used for certain types of psoriasis. It is not effective in all types of the disease. It may be used in males, and females who are not pregnant and not planning to become pregnant for at least three years. The major side effects include dryness of skin and eyes, and temporarily elevated levels of triglycerides and cholesterol (fatty substance) in the blood. Blood tests are generally required before starting this therapy and periodically to monitor triglyceride levels. Patients should not become pregnant while on this drug and usually for at least 3 years after stopping this medication.

• Cyclosporine is a potent immunosuppressive drug used for other medical uses including organ transplant patients. It may be used for severe, hard to treat cases of widespread psoriasis. Improvement and results may be very rapid in onset. It may be hard to get someone off of cyclosporine without flaring their psoriasis. Because of the potential cumulative toxicity, cyclosporine should not be used for more than 1-2 years for most psoriasis patients. Major possible side effects include kidney and blood pressure problems.

• Methotrexate is a common drug used in rheumatology for rheumatoid arthritis and oncology (cancer treatments). In Psoriasis, it has been used for many years to effectively treat the disease. It is usually given in small weekly doses (5mg to 15mg). Blood tests are required before and during therapy. The drug may cause liver damage in some patients, particularly if there is pre-existing liver disease or if given for prolonged periods of time. Close physician monitoring and monthly to quarterly visits and labs are generally required.

What injections are available?

• The newest category of injectable psoriasis drugs are called biologics. All biologics modulate (adjust) and sometime suppress (quiet) the immune system. These currently available drugs include Amevive, Humira, Remicade, Enbrel, Raptiva, and ustekinumab. Newer drugs are in development and may be on the market in the near future. Some biologics are self injections for home use while others are intravenous or intramuscular injections in the physicians office.

Usually biologics may have some screening requirements such as a tuberculosis screening test (“TB” skin test or PPD test) and other labs prior to starting therapy.

Currently, all of the biologics except Raptiva are dosed as one size fits all. Raptiva has weight adjusted dosing so patient with higher body weights get larger doses. Future testing may support dosage adjustments for other biologics based on weight or other factors.

As with any drug, side effects are possible with all biologic drugs. Common potential side effects include mild local injection site reactions (redness and tenderness). There is concern of serious infections and potential malignancy with nearly all biologic drugs.

Precautions include patients with known or suspected Hepatitis B or C infection, active tuberculosis, and possibly HIV/AIDS. As a general consideration, these drugs may not be an ideal choice for patients with a history of cancer and patients actively undergoing cancer therapy.

In particular, there may be an increased association of lymphoma in patients taking biologics. It is not at all certain if this association is directly caused by these drugs. It is known that certain diseases like rheumatoid arthritis or psoriasis may be associated with an inherent increase in the overall risk of some infections and malignancies.

Biologics are fairly expensive medications ranging in price from several to tens of thousands of dollars per year per person. Their use may be limited by availability, cost, and insurance approval. Not all insurance drug plans may fully cover these drugs for all conditions. You will need to check with your insurance and maybe submit prior authorization requests to your carrier for coverage approval. Some of the biologics manufacturers have patient assistance programs to help with financial issues.

The choice of the right injectable medication for your condition depends on many medical factors. Additionally, convenience of receiving the medication and life style may be factors in choosing the right biologic for you.

• Currently, the four main classes of biologic drugs for psoriasis are:
1. TNF-alpha blockers ( Tumor Necrosis Factor)
2. drugs that block T-cell activation and the movement of T-cells
3. drugs that decrease the number of activated T-cells
4. drugs that interfere with interleukin mechanisms

• TNF blockers include Enbrel (etanercept), Remicade (infliximab) and Humira (adalimumab). TNF-alpha blocking drugs may have an advantage of treating psoriatic arthritis and psoriasis skin disease. Their disadvantage is that some patients may notice a decrease effectiveness of TNF-alpha blocking drugs over months to years.

TNF blockers are generally not used in patients with demyelinating (neurological) diseases like multiple sclerosis, congestive heart failure, or patients with severe overall low blood counts called pancytopenia.

The major side effect of these class of drugs is suppression of the immune system. Because of the increased risk of infections while on these drugs, patients should promptly report fevers or signs of infection to their physicians. Minor side effects have included auto-immune conditions like lupus or flares in lupus. Additionally, it may be best to avoid any live vaccines while patients are on TNF blockers.

-Enbrel (etanercept) is a self injectable medication for home use. It is injected via a small needle just under the skin called subcutaneous injection. It is usually dosed once or twice week by patients at home after training with their physician or the nursing staff. Sometimes a higher loading dose is used for the first 12 weeks and then it is “stepped down” to ½ the dose after the first 12 weeks. Enbrel has the advantage of at least 16 years of clinical use and long term experience.

-Remicade (infliximab) is an intravenous (IV) medication strictly for physician office or special infusion medical center use. It is currently not for home use or self injection. It is injected slowly over time via a small needle into a vein. It may usually be dosed once a week. There have been reports of antibodies to this drug in patients taking it for some time. These antibodies may cause a greater drug dose requirement for achieving disease improvement or failure to improve. The IV route may be more time consuming requiring physician monitoring during the infusions. Remicade has the advantage of fast disease response and good potency.

-Humira (adalimumab)- is a self injectable medication for home use. It is injected via a small needle just under the skin as a subcutaneous dose. It is usually dosed once every other week, totaling 26 injections in one year. Dosing is individualized and should be discussed with your physician. Sometimes a higher loading dose is used for the first dose (80mg) and then it is continued at 40mg every other week . It may give results as soon as 1-2 weeks of therapy. Humira has the advantage of at least 11 years of clinical use and long term experience.

• Raptiva (efalizumab) blocks both T-cell activation and the movement of T-cells into the skin. This is the only biologic drug so far that is dosed specifically based on your weight. Labs are required before starting injections and weekly for the 12 weeks of therapy. Injections are placed just under the skin (sub-cutaneous) and may be given in the physician office or at home.

Currently, Raptiva seems to work well over several years without losing its effectiveness, therefore having the advantage of “staying power”. Raptiva may cause flares of arthritis in some patients.

As with all biologics, Raptiva has been associated with possible infections and malignancy (cancer). The relative risk of these two side effects is fairly low. Raptiva may also cause a decrease or drop in the platelet ( blood clotting cell) count. Platelet counts are usually checked before starting and periodically (often quarterly) while patients continue Raptiva.

Live vaccines are not advised while patients are taking Raptiva. It is usually best to have any required vaccines weeks before starting therapy.

• Amevive (alefacept) decreases the number of available activated T-cells. It is given intramuscularly (injected in the muscle) usually in the physician’s office and given once a week for twelve weeks. Many patients may see improvement in their symptoms that lasts approximately 12 months (more or less). Amevive may not be uniformly effective for all patients and some patients improve more than others. 14 weeks is about the average time to maximum improvement for many patients.

Amevive should generally not be used in patients with HIV infections as the drug causes a decrease in the CD4 cells ( part of the immune system that HIV also attacks).

Also because of the immune system suppression, Amevive may not be a good drug in patients with active cancer or infection.

• Ustekinumab is the newest biologic injectable medication used to modulate the immune system. It is an interleukin-12/23 monoclonal antibody, a type of drug known as a fully human monoclonal antibody. Ustekinumab targets chemical messengers in the immune system involved in skin inflammation and skin cell production. This drug is planned to be dosed subcutaneously (just under the skin) once a quarter ( every 3 months). It has been very promising with very good clearance rates in the clinical trials thus far. A major advantage may be the convenience of a quarterly medication. The concerns for infection and malignancy may be similar to the other biologics.

What about light therapy?
• Light therapy is also called phototherapy. There are several types of traditional medical light therapies called PUVA, UVB, and narrow band UVB. These artificial light sources have been used for decades and generally available in a physician’s office. There are a few companies who may sell light boxes or light bulbs for prescribed home light therapy.

• Old fashioned sunlight is also used to treat psoriasis. Daily, short, controlled exposures to natural sunlight may help or clear psoriasis in some patients. Non psoriasis skin, and sensitive areas such as the face and hands may need to be protected during sun exposure.

• There are also multiple newer light sources like lasers and photodynamic therapy (use of a light activating medication and a special light source) that have been used to treat psoriasis.

• PUVA is a special treatment using a photosensitizing drug and controlled, timed artificial light exposure. The photosensitizing drug in PUVA is called psoralen. These treatments are usually administered in a physician’s office 2-3 times per week. Several weeks of PUVA is usually required before seeing significant results. The light exposure time is slowly and gradually increased during each subsequent treatment.

Psoralens may be given orally as a pill, or topically as a bath or lotion. After a short incubation period, the skin is exposed to a special wavelength of ultraviolet light called UVA. Patients are generally sun sensitive and must avoid sun exposure for a period of time after PUVA.

Common side effects with PUVA include burning, tanning of the skin, potential skin damage, increased brown spots called lentigines, and possible increased risk of skin cancer including melanoma. The relative increase in skin cancer risk with PUVA treatment is controversial. PUVA treatments need to be closely monitored by a physician and discontinued when a maximum number of treatments have been reached.

• UVB phototherapy is an artificial light treatment using a special wavelength of light. It is frequently given daily or 2-3 times per week. UVB is also a component of natural sunlight. UVB dosage is based on time and exposure is gradually increased by 15-60 seconds per treatment or per week. Potential side effects with UVB include skin burning, skin damage, and possible increased risk of skin cancer including melanoma. The relative increase in skin cancer risk with UVB treatment needs further study.

• Sometimes UVB is combined with other treatments such as tar application. Goeckerman is the name of a special psoriasis therapy using this combination. Some centers like (the University of California, San Francisco) have used this therapy in a “day care” type of setting where patients are in the Psoriasis treatment clinic all day for several weeks and go home each night.

Where can I get more up to date information?
Your dermatologist, www.AAD.org, and http://www.psoriasis.org/home/ may be excellent sources of more information.

There are many ongoing clinical trials for psoriasis all over the United States and in the world. Many of these clinical trials are ongoing at academic or university medical centers and are frequently open to patients without cost.

Clinical trials frequently have specific requirements for types and severity of psoriasis that may be enrolled into a specific trial. Patients need to contact these centers and inquire regarding the specific study requirements. Some studies have restrictions on what recent medications have been used for psoriasis, current medication, and overall health.

Some of the many medical centers in the U.S. offering clinical trials for psoriasis include the University of California, San Francisco Department of Dermatology, the University of California, Irvine Department of Dermatology, and the St Louis University Medical School.

Is there a national psoriasis support group?
Yes, the National Psoriasis Foundation (NPF) is a highly reputable and long standing organization dedicated to helping patients with psoriasis and furthering research in this field. They hold national and local chapter meetings. The NPF website shares up to date reliable medical information and statistics on the condition. http://www.psoriasis.org/home/

What is my long term prognosis?
Overall, the prognosis for most patients with psoriasis is fairly good with no related other health issues. While it is not curable, it is controllable.

There have been a few studies showing a possible association of psoriasis and other medical conditions including obesity and heart disease.

What does the future hold?
• Psoriasis research is heavily funded and holds great promise for the future.
• Just the last 5-10 years have brought great strides in treatment of the disease with self- injectabale medications called biologics.
• New biologics are in the pipeline including quarterly subcutaneous injections that modulate the immune system at different levels.

Psoriasis at a glance:
• Chronic inflammatory skin disease
• Unknown cause
• Genetic predisposition
• Not contagious
• Periodic ups and down
• Periodic remissions (clear skin)
• Controllable with medication
• Currently not curable
• Promising therapies with injectable biologic drugs
• Immunotherapies are becoming prime
• Future research promising.

 



 

Current Research and Clinical Trials in Acne
www.ClinicalTrials.gov for a list of current acne research opportunities.


Rank Status Study
1 Completed Safety and Efficacy of MBI 226 1.25% and 2.5% Topical Acne Solutions in the Treatment of Acne

Conditions: Acne Vulgaris;   Acne;   Propionibacterium Acnes
Intervention: Drug: MBI 226 Acne Solutions
2 Completed Safety and Efficacy of MBI 226 2.5% and 5.0% Topical Acne Solutions in the Treatment of Acne

Conditions: Acne Vulgaris;   Acne;   Propionibacterium Acnes
Intervention: Drug: MBI 226 Acne Solutions
3 Active, not recruiting Comparative Antimicrobial Efficacy of Two Topical Acne Therapies for the Treatment of Facial Acne

Condition: Acne
Interventions: Drug: Antibiotic and benzoyl peroxide gel;   Drug: Antibiotic and topical retinoid gel
4 Completed A Study of Acne Treatment in Children Ages 9 to 11

Condition: Acne Vulgaris
Interventions: Drug: Retin-A Micro 0.04% facial acne treatment;   Drug: Vehicle control
5 Completed Comparison Study of Topical Acne Regimens

Condition: Acne
Intervention: Drug: Acne Free, Proactiv
6 Terminated Pilot Study of a Dietary Intervention to Prevent Acne Recurrence

Condition: Acne
Intervention: Behavioral: Minimization of milk and dairy products in the diet
7 Active, not recruiting Plant-based Dietary Intervention for Treatment of Acne

Condition: Acne
Interventions: Behavioral: Low-fat, vegan diet;   Behavioral: Control
8 Terminated Photodynamic Therapy in the Treatment of Acne

Condition: Acne Vulgaris
Intervention: Device: LumaCare LC-122M non-coherent light source with LUM-I, fiber optic probe, 610 nm-660 nm output range
9 Recruiting Safety and Efficacy of Skin Cleanser Contained Roselle Extract in Acne

Condition: Acne
Interventions: Other: skin cleanser contained Hibiscus sabdariffa extract;   Other: marketed skin cleanser
10 Recruiting Efficacy of Lappa Arctium (Homoeopathic Medicine) in Treatment of Acne Vulgaris

Condition: Acne Vulgaris
Intervention: Drug: Lappa Arctium
11 Active, not recruiting Adherence to Study Medication Compared to Generic Topical Clindamycin Plus Generic Topical Tretinoin in Subjects With Mild to Moderate Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: clindamycin phosphate 1.2% and tretinoin 0.025%;   Drug: clindamycin 1% gel plus tretinoin 0.025%
12 Completed A Study of Different Use Regimens Using Two Acne Treatments

Condition: Acne Vulgaris
Intervention: Drug: benzoyl peroxide wash and tretinoin gel
13 Completed Comparative Efficacy and Safety of Benzoyl Peroxide Used in Combination With Clindamycin vs. Benzoyl Peroxide Used in Combination With Clindamycin and Doxycycline in the Treatment of Moderate Acne

Condition: Acne
Interventions: Drug: Benzoyl peroxide with clindamycin;   Drug: Benzoyl peroxide with clindamycin and doxycycline
14 Active, not recruiting A Study to Compare the Tolerability and Efficacy of Tazorac Cream Used With Duac Gel or Acanya Gel for Treatment of Acne

Condition: Acne Vulgaris
Interventions: Drug: Tazorac Cream and Duac Topical Gel;   Drug: Tazorac Cream (tazarotene 0.1%) plus Acanya Gel (clindamycin phosphate 1.2%/benzoyl peroxide 2.5%).
15 Terminated
Has Results
Efficacy And Safety Of Azithromycin SR Compared With Minocycline In Acne

Condition: Acne Vulgaris
Interventions: Drug: Azithromycin microspheres;   Drug: minocycline-placebo capsules;   Drug: Azithromycin microspheres-placebo;   Drug: Minocycline capsules,
16 Active, not recruiting NdYag Laser for Acne Keloidalis Nuchae

Conditions: Acne Keloidalis Nuchae;   NdYag Laser;   AKN;   Acne Keloidalis;   AK;   Dermatitis Papillaris Capillitii;   Folliculitis Keloidalis Nuchae;   Sycosis Nuchae;   Acne Keloid;   Keloidal Folliculitis;   Lichen Keloidalis Nuchae;   Folliculitis Nuchae Scleroticans;   Sycosis Framboesiformis
Interventions: Device: NdYag Laser(hair removal laser) plus topical corticosteroid;   Drug: Topical corticosteroid alone
17 Recruiting A Study to Examine the Safety and Efficacy Of Drospirenone and Ethinyl Estradiol (YAZ) Compared With Placebo In The Treatment Of Moderate Truncal Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: drospirenone and ethinyl estradiol;   Drug: Placebo tablets
18 Completed Microdermabrasion for Acne

Condition: Acne Vulgaris
Intervention: Device: microdermabrasion
19 Enrolling by invitation Proof of Concept Study to Investigate the Recurrence of Acne Post Isotretinoin

Condition: Acne
Interventions: Drug: tretinoin microsphere 0.04% gel;   Drug: vehicle gel
20 Completed Infrared Non-Cutting Laser Therapy for Acne

Condition: Acne Vulgaris
Intervention: Device: CoolTouch II laser
21 Active, not recruiting Non-Cutting Laser Therapy in the Treatment of Acne

Condition: Acne Vulgaris
Intervention: Device: V-Beam laser, Candela Corp., 595 nm wavelength
22 Completed Study of Two Different 10.0% Benzoyl Peroxide Creams for Mild to Moderate Acne Vulgaris

Condition: Acne Vulgaris
Intervention: Drug: topical benzoyl peroxide 10.0% cream – Formulations #1 and #2
23 Active, not recruiting Trial of Clindamycin / Benzoyl Peroxide Gel in Subjects With Acne

Condition: Acne Vulgaris
Interventions: Drug: clindamycin / benzoyl peroxide gel;   Drug: clindamycin gel;   Drug: BPO gel;   Drug: vehicle gel
24 Completed Safety and Efficacy Study of Topical Methyaminlevulinate (MAL) in Subjects With Facial Acne

Condition: Acne
Intervention: Drug: MAL
25 Completed A Split-Face, Paired-Comparison, Pilot Study to Evaluate Safety and Efficacy of Two Topical Salicylic Acid 1.0% Creams for Mild to Moderate Acne Vulgaris

Condition: Acne Vulgaris
Intervention: Drug: topical salicylic acid 1.0% cream
26 Completed Comparison of Efficacy and Safety of Azelaic Acid 15% Gel With Its Vehicle in Subjects With Mild to Moderate Acne

Condition: Acne Vulgaris
Interventions: Drug: Azelaic Acid Gel 15% (Finacea, BAY39-6251);   Drug: Vehicle gel (SH H 655 PBA)
27 Completed Evaluation of the Effectiveness, Safety, and Tolerability of Duac Akne Gel and Epiduo Gel in the Treatment of Facial Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: Epiduo Gel;   Drug: Duac Gel
28 Completed A Study to Evaluate Tolerability of Two Topical Drug Products in the Treatment of Facial Acne

Condition: Acne Vulgaris
Interventions: Drug: clindamycin and benzoyl peroxide gel (Duac® Topical Gel);   Drug: benzoyl peroxide and adapalene gel (EPIDUO™ Gel)
29 Recruiting the Comparison Efficacy of Azithromycin With Doxycycline in the Treatment of Acne Vulgaris

Condition: Acne
Interventions: Drug: Doxycycline;   Drug: Azithromycin
30 Completed Comparison of Stacked-Pulses Vs. Double-Pass Treatments of Facial Acne With a 1450 Nm Laser

Conditions: Acne;   Acne Scars
Intervention: Device: 1450nm diode laser
31 Completed Phase IV Study to Gather More Information About the Safety of ACZONE Gel, 5% in Treating Subjects With Acne Who Have G6PD Deficiency

Condition: Acne Vulgaris
Interventions: Drug: ACZONE Gel, 5%;   Drug: Vehicle
32 Recruiting Safety and Efficacy of the Use of Botox on Acne

Condition: Acne Vulgaris
Interventions: Drug: Botulinum Neurotoxin Type A;   Drug: Bacteriostatic saline
33 Completed Study to Demonstrate the Efficacy and Safety of Adapalene/Benzoyl Peroxide Topical Gel in Subjects With Acne Vulgaris

Condition: Acne Vulgaris
Intervention: Drug: Adapalene/Benzoyl Peroxide
34 Recruiting A Study to Evaluate the Safety and Efficacy of Tazarotene Foam, 0.1%, in Subjects With Common Facial Acne

Condition: Acne Vulgaris
Interventions: Drug: Tazarotene Foam;   Drug: Vehicle Foam
35 Completed Fractional Resurfacing Device for Treatment of Acne Scarring

Condition: Acne Scarring
Intervention: Device: 10,600 nm fractional CO2 laser system
36 Active, not recruiting Efficacy & Safety of Clindamycin and Tretinoin in Acne

Condition: Acne
Intervention: Drug: Clindamycin Phosphate 1.2% and Tretinoin 0.025% Gel
37 Completed A Phase 2 Study of ASC-J9 Cream in Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: ASC-J9 cream;   Drug: placebo
38 Completed Study of Benzoyl Peroxide Cream for Mild to Moderate Acne Vulgaris

Condition: Acne Vulgaris
Intervention: Drug: Benzoyl Peroxide
39 Completed Measuring Adherence in Subjects With Acne Vulgaris in a Clinic Population Subtitle: Topical Benzoyl Peroxide for Acne

Condition: Acne Vulgaris
Intervention: Drug: Benzoyl Peroxide
40 Active, not recruiting Safety and Efficacy of 1550nm Fractional Laser Treatment for Acne Scars in Fitzpatrick Type IV-VI Skin

Condition: Acne Scarring
Intervention: Procedure: Fractionated Laser Resurfacing
41 Completed Safety and Efficacy Study of Clindamycin/Benzoyl Peroxide/Tazarotene Cream in Subjects With Acne

Condition: Acne Vulgaris
Interventions: Drug: Benzoyl peroxide/clindamycin gel + tazarotene cream;   Drug: Benzoyl peroxide/clindamycin gel + vehicle cream;   Drug: Benzoyl peroxide gel + tazarotene cream;   Drug: Clindamycin gel + tazarotene cream;   Drug: Vehicle gel+ tazarotene cream;   Drug: Vehicle gel + vehicle cream
42 Recruiting Apremilast in the Treatment of Moderate to Severe Acne

Condition: Acne
Intervention: Drug: apremilast
43 Completed
Has Results
Treatment of Acne Vulgaris With Doryx Tablets Compared to Doxycyline Hyclate

Condition: Acne Vulgaris
Interventions: Drug: Doxycycline hyclate (Doryx);   Drug: Doxycycline hyclate
44 Not yet recruiting Safety and Efficacy Study of Acnase Creme in the Treatment of Acne Vulgaris I and II

Condition: Acne Vulgaris
Interventions: Drug: Benzoyl Peroxide 5% and Sulphur 2%;   Drug: Vehicle of Acnase
45 Recruiting Study to Compare the Acne Relapse Rate of Oral Minocycline to Oral Minocycline in Combination With Topical Tretinoin, Followed by Topical Tretinoin Alone

Condition: Acne Vulgaris
Interventions: Drug: Minocycline;   Drug: Minocycline + Tretinoin 0.01%
46 Active, not recruiting Efficacy and Safety Study of Finacea to Treat Acne Vulgaris and Post-Inflammatory Hyperpigmentation

Conditions: Acne Vulgaris;   Post Inflammatory Hyperpigmentation
Intervention: Drug: Azelaic acid
47 Completed The Development and Evaluation of an “E-Visit” Program for the Management of Acne

Condition: Acne Vulgaris
Interventions: Other: Evisit;   Other: Office visit
48 Completed Pulsed Dye Laser Treatment of Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: Fixed combination of clindamycin 1% + benzoyl peroxide 5%;   Device: Pulsed dye laser
49 Withdrawn The Treatment of Acne Vulgaris With Radiofrequency Device

Condition: Acne Vulgaris
Intervention: Device: Radio Frequency
50 Completed Efficacy and Tolerance of a Derivative of Salicylic Acid and 5% Benzoyl Peroxide in Facial Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: Lipo Hydroxy Acid;   Drug: 5% benzoyl peroxide gel
51 Terminated Topical 5-ALA-PDT With Blu-U Therapy Versus Topical 5-ALA With Pulse Dye Laser In Treating Recalcitrant Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: 5-ALA with Blu-U Light;   Drug: 5-ALA with Candela V-beam Pulse Dye Laser
52 Completed A Comparative Study of the Tolerability of Two Combination Therapies for the Treatment of Acne

Condition: Acne Vulgaris
Interventions: Drug: BENZOYL PEROXIDE/ CLINDAMYCIN;   Drug: BENZOYL PEROXIDE/ ADAPALENE
53 Completed Evaluate Safety & Efficacy of an OC Preparation vs Placebo for 6 Treatment Cycles in Women With Moderate Acne

Condition: Acne Vulgaris
Interventions: Drug: YAZ (DRSP 3 mg/EE 0.02 mg, BAY86-5300);   Drug: Placebo
54 Completed Evaluate Safety & Efficacy of an Oral Contraceptive (OC) Preparation Versus Placebo for 6 Treatment Cycles in Women With Moderate Acne

Condition: Acne Vulgaris
Interventions: Drug: YAZ (DRSP 3 mg/EE 0.02 mg, BAY86-5300);   Drug: Placebo
55 Recruiting A Study to Evaluate the Efficacy of Silk – Like Bedding Fabric, as Used in a Standard Pillow Case, in the Treatment of Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Device: silk-like fabric standard pillowcase;   Device: pillowcase made of 100% cotton
56 Recruiting “A Randomized, Controlled, Evaluator-blinded Pilot Study to Evaluate the Effect of Automated Text Message Reminders on Patient Compliance With Topical Medications and Its Efficacy on Skin Disease Control in Adolescents and Adults With Mild to Moderate Acne”

Conditions: Acne;   Patient Compliance
Intervention: Other: Text message reminders
57 Completed Safety and Efficacy Study of Association Between Tretinoin and Clindamycin on the Treatment of Acne Mild and Moderate

Condition: Acne Vulgaris
Intervention: Drug: application of the topic gel
58 Recruiting Exploratory Study to Evaluate the Efficacy and Safety of CD07223 Gel in Subjects With Acne

Condition: Acne
Intervention: Drug: Epiduo vehicle gel
59 Completed
Has Results
A Study to Demonstrate the Efficacy and Safety of Adapalene/Benzoyl Peroxide Topical Gel in Subjects With Acne Vulgaris

Condition: Acne Vulgaris
Interventions: Drug: Adapalene/Benzoyl Peroxide;   Drug: Adapalene;   Drug: Benzoyl Peroxide;   Drug: Topical Gel Vehicle
60 Not yet recruiting Open and Comparative Study to Measure Tolerability and Efficacy of Taro Elixir

Conditions: Acne Vulgaris II or III Degree;   Boils
Interventions: Drug: oxytetracycline, taro elixir;   Drug: Taro Elixir

 

 

 



 

Information in this publication and site is not intended to serve as medical advice. Individuals may use the information as a guide to discuss their treatments with their own physicians. This site does not promote nor endorse the unauthorized practice of medicine by non-physicians or state licensed health care providers.

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of these articles have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert.

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