PHOTODYNAMIC THERAPY WITH ALA FOR PRE-MALIGNANT LESIONS

ALA stands for aminolevulinic acid, and PDT stands for photodynamic therapy. This procedure has been used since the late 1990's and it is a way to kill premalignant cells called actinic keratoses. Rather than freezing or burning them which can definitely leave a scar or a white spot, and rather than applying creams which can be extremely inflammatory every day for up to four weeks, we simply apply the ALA to the treatment area in the office. This chemical is otherwise harmless and not painful. It finds and binds to the premalignant cells. It photosensitizes them so they are more likely to selectively die when treated with the proper source of light. After waiting one hour for penetration, we will then have you sit or lie in front of a bank of LED’s (light emitting diodes). The light itself doesn’t hurt, doesn’t burn, but is bright. You will be wearing eyeshields. After 20 minutes, the lights will automatically turn off and your treatment is finished.

When the treatment is finished and the inflammation starts, we will recommend treatment for that. There may be pain, itch, and discomfort. As the cells are killed and die, they will become inflamed - sometimes intensely inflamed. This will occur on a background of generalized pinkness or redness as well. You may be pink to red for several days followed by peeling, and over the next several weeks these premalignant actinic keratoses (AKs) will diminish or disappear. In some cases there may be a response without any redness at all, and if so, we may have you repeat the procedure with a longer incubation time and/or longer exposure to the LED light.

Rarely, there is a chance of extreme redness due to a photo toxic response that could not have been predicted. There may be immediate pain or discomfort. If so, we will shut the lights off and give you ice packs. If so, there may be blistering, oozing, and so forth, but we have topical medicines that can help minimize this effect.

The whole idea is that we are selectively killing premalignant cells but will get some background redness no matter what. The convenience is that you only have to come into the office and do this one time and get it over with rather than apply an inflammatory cream twice a day for two to three weeks. Currently we are using the Omnilux L.E.D. source. Other lights that can be used are the intense pulsed lights (FotoFacial or IPL) and the pulsed dye laser - we have access to all of these.

There are several new sources being used for this purpose. It is important to realize that the proper wavelength of light must be used for optimal activation of the ALA product and most of the basic legitimate published research was performed by Phototherapeutics in the United Kingdom. They have produced the Omnilux L.E.D. light device, which is the most extensively studied product for this purpose. This device offers a full array of full power LED lights, and offers three different wavelengths depending upon your needs. Only this company produces this device and Dr. Coverman was the first doctor in Austin to purchase and use the Omnilux for the photo reduction of actinic keratoses. Other competitors only offer one wavelength (Gentlewaves) or try to use two at a time (Clearlight) which may not be as effective.

There is no 100% cure for actinic keratoses - up to 90% cure rates have been demonstrated with this method. If done prophylactically every year whether you need it or not - it is theoretically possible to prevent any such skin cancers developing since you can’t develop one if you can’t begin to grow one. An additional extremely beneficial side effect is the dramatic improvement of photoaging. By killing or removing cells that were becoming premalignant your skin will definitely look fresher, younger, smoother and less blotchy. Such cells, even if they have not yet developed into cancers do make you look old. Removing these cells will give a remarkable refreshment to the skin.

The main contraindications to using this type of photosensitizing therapy is the potential for an exaggerated response to the light. You must not be taking any medicines that could be photosensitizing. The more common ones are certain diuretics, antibiotics that are any form of tetracycline, and antifungals. Likewise, if you have any photosensitive disease such as porphyria or lupus you should not do this treatment. Because the treatment is inflammatory it can flare herpes, and if you have a history of oral herpes anywhere on your face or in the treated area we will give you a series of anti-herpes pills to take the day before, the day of, and the day after.

DR. COVERMAN HAS PERFORMED THIS PROCEDURE ON HIMSELF. PART OF THE INSTRUCTIONS YOU READ BELOW WILL BE SPECIFICALLY FROM DR. COVERMAN’S OWN EXPERIENCE.

INSTRUCTIONS FOR PHOTODYNAMIC THERAPY

Plan your visit late in the afternoon. Then just before coming to our office, wash your face or scalp with a salicylic acid acne wash (DCL Active Cleanser). Bring your EltaMD UV Physical SPF 41.

Arrive at our office one and a half hours prior to your treatment time. When you arrive we will cleanse your skin to degrease it and remove any fatty residues.

We will apply the ALA - the ALA itself doesn’t hurt.

You will have to wait in the office for one hour for adequate penetration - please wear comfortable clothing and bring something to read. Bring your iPod! The actual treatment lasts 20 minutes, and after awhile it simply gets boring. Make sure you bring the small plug-in earpieces, larger earphones such as Bose and so forth will be too bulky and get in the way.

For the treatment you will lie down in front of a bank of lights. You won’t feel anything during the 20 minutes while you are sitting there. (Rarely patients do get unexplained pain. If it hurts, tell us, and we will stop the treatment.) The lights are extremely bright, even with the protective eyewear that we will give you. When you lie down we will put the bank of lights extremely close to your face. Your eyes will be covered but even then some patients may find this claustrophobic. If you normally have a problem with this, tell us before and we will give you a Xanax of Valium here at the office to make this more comfortable for you. If you require a Xanax or Valium you must schedule and arrange for a driver to take you home. The procedure will take exactly 20 minutes and the lights will automatically shut themselves off. This is where the iPod helps.

At the conclusion of the procedure, apply EltaMD UV Physical SPF 41 sunscreen, go directly home and avoid any sun exposure that day and particularly the next. Your face will be extremely photosensitive for the next 48 hours, and you will actually feel burning and stinging directly on your skin with even five seconds of direct sunlight exposure. Even sitting in your automobile behind the glass is not a great idea. You might want to take the next day off and stay 100% indoors!

The lights are extremely bright - shockingly so. We will give you appropriate eye protection, but the brightness of the light may surprise you. Do not be scared - this can’t hurt you and actually after you lie there for awhile it will seem less bright even though it isn’t. In fact, at some point you may even find it soothing, and some patients fall asleep.

Although there is some heat generated, it is not painful at all. We will have a very strong fan blowing across your face, so heat should not be a factor.

Your face will start to turn red, and sometimes intensely red. Don’t let that scare you - that is exactly the reaction we want and expect. You will be red when you leave, but the maximum redness will be visible by the next morning. At that point you will be extremely photosensitive - surprisingly so! Dr. Coverman noticed that even when he walked out to get the newspaper at 8:00 a.m. the next morning, his face immediately began to sting and he wasn’t even in direct sunlight. By 9:00, just walking from his car to the office, the low rays of the sun literally stung his face immediately. Even driving over to the office under the window glass of the car was a bit uncomfortable. We highly recommend that if you must be in the sun, you apply a “chemical-free” sunblock - even these might sting a little bit going on, but are free of other chemicals known to sting. Without any sunblock, as Dr. Coverman found out just walking up to the back door at 9:00 a.m., immediate exposure to the sun, within seconds caused a surprising amount of sharp pain.

Obviously if you go to work, you will have this sun exposure so wear the sunblock in the morning, but feel free to use the Silvadene when you get home, and the Synalar at bedtime. (See below).

Ideally, don’t get any sun exposure at all! This way you can start your Silvadene in the morning, your Biafine at night time and get immediate relief.

POST-TREATMENT PAIN

For normal post-operative pain following most of the procedures that we perform in our office, we do not recommend nor prescribe any of the stronger pain medicines including hydrocodone (Lortab; Darvocet N100; Mepergan Fortis; Ultram). We feel that a combination described below of over-the-counter medicines will be enough. This is what we recommend:

Take one Aleve or Advil pills every 4-6 hours with food. Wash it down well with liquid. Breakfast, lunch, dinner and bedtime snack.
Do not take Aleve or Advil if you are allergic to aspirin, these pills, or have any type of aspirin sensitivity or the syndrome of nasal polyps, allergies, atopic eczema, and aspirin-allergy. Likewise, do not take this if you have any bleeding problems, or have ever had any ulcer disease or similar stomach disease.
We also recommend that you take two Extra Strength (500 mg) Tylenol tablets every 4-6 hours as well.
Please remember that the side effects of Tylenol have nothing to do with the side effects of Aleve or Advil, thus these may be taken together.

If you have any liver disease or potential liver problems, do not take the Tylenol. Do not take Tylenol if you are allergic to it or acetaminophen. DO NOT DRINK ALCOHOL WITH THIS REGIMEN! Otherwise, follow the schedule below:

8:00 a.m. - Breakfast
One Aleve or Advil with breakfast and plenty of water.
Two 500 mg Tylenol for adults.
Noon to 2:00 p.m. - Lunch
One Aleve or Advil with dinner and plenty of water.
Two more 500 mg Tylenol.
6:00 p.m. - Dinner
One Aleve or Advil with dinner and plenty of water.
Two more Tylenol.
10:00 p.m. to midnight - Bedtime
One Aleve or Advil at bedtime and plenty of water.
Two more Tylenol.
Benadryl (diphenhydramine) 25-50 mg for sleep.

The Benadryl is a great idea. It is the main component of most over-the-counter sleeping pills. (Tylenol PM), and is not addicting. Never drink alcohol before or with this, and plan on going right to sleep and sleeping 8 hours. DO NOT take with any other sleeping pill, anti-depressant, MAO inhibitor, or anti-anxiety drug (Xanax, Valium, etc.). Do not drive or operate dangerous equipment.

Thus, in any given day you should never take more than the total of four Advil or Aleve or eight Tylenol total (two every four to six hours).

Normally you should be able to safely do this for one to three days - but never more. If the pain ever worsens or this fails to control it - call our office during normal office hours or the medical exchange (458-1121) after hours.

This combination of Aleve or Advil plus Tylenol is safe, covers you around the clock, and allows you to take two different pain medicines whose side effects don’t cross react with each other assuming you are not allergic to either.

You may find the descriptions of this redness disturbing or scary - just remember that you will have the exact same thing for 2-3 weeks if you use the 5 FU creams (Efudex/Carac) or Aldara. There is no way around it - it is going to be red, itchy, burning, and uncomfortable no matter what you do. At least with this method you do it the one day and it is over with. Dr. Coverman has used all the topical creams including Solaraze, Carac, and Efudex. For the simple matter of quickness and convenience - he prefers the ALA/PDT.

As soon as you get home, if you feel discomfort we recommend the following regimen:

Silvadene Cream - apply this every morning and you will find this extremely soothing and healing. It is normally used for burn victims so it will certainly be soothing for you.
Synalar Ointment (fluocinolone) - Use the Synalar Ointment at night. Although this is extremely greasy it will give you instant relief with all symptoms. Make sure you get the OINTMENT - not the cream! Creams have colors, fragrances, and preservatives - ointments don’t.
Refrigerate these. They will give you additional cool relief.
Men should shave as normal on the day of your treatment. You probably won’t want to shave for two to three days afterwards - so plan on this. If you must shave during the healing phase we do not recommend razor blades. They will cut you too close. Simply use an electric shaver, and even then just "buzz off" the top of your hair and do not attempt to get an actual close shave. All that rubbing will simply irritate your skin further and you won’t want to do that.
Use common sense! Do not use any astringent soaps, or any skin care products at all, no matter who tells you what they are for. Please use only those topicals we have discussed and/or prescribed.
After seven days you may resume normal activities, but be sure to keep sunscreen on your face at all times. Dr. Coverman did this procedure on a Monday but was able to play golf on a Friday wearing a double layer of sunscreen and a broad-brimmed hat. We recommend EltaMD UV Physical SPF 41. This is a chemical-free sunblock that won’t burn or sting. It is waterproof with excellent adhesiveness.

When applying sunblock, wash and dry your face thoroughly to get the oil off the skin so the sunblock will penetrate into your skin and not sit on top of your oil. Apply it evenly and THICK. Most studies have shown that people don’t apply enough of the product. After the first application, wait five minutes, and then apply a second coat all over again! Do this one hour before any intended sun exposed activity. It does no good to apply sunblock at the very last minute while on the golf or tennis courts or at the pool. You are already exposed, you are already sweating, and any sunblock will drip right off. Always apply a double layer of sunblock thickly at your home one hour before any intended sun exposure.

Wear broad brimmed hats - the broader the brim, the better. Baseball caps are simply not good enough.
Do not plan this treatment around any trips to the beach, or any obvious sun exposed vacations.
Plan this treatment around your school, travel, work, and social calendar. You are going to be fairly bright red for a minimum of one to two weeks after the treatment, so plan on that. After that, the redness will fade and it will look more like a sunburn reaction. You may have intense peeling or flaking.
If you ever had herpes or think you may have in the areas to be treated, tell us! We will prescribe for you an anti-viral medication to take daily beginning the day before, the day of, and the day after. Make sure you already have this prescription filled! Even so, herpes could theoretically breakthrough which could cause pigment and scarring.
Make an appointment NOW for two weeks after your treatment, and then one month after your treatment. We will need to see you to make sure things are going well, and to keep you comfortable. There will be a normal office charge for each of these return visits.
You should not have any laser or any light based therapy if you have any photosensitive diseases such as lupus erythematosus, porphyria, or albinism. You must stop any photosensitive medicines at least two days before your treatment unless your prescribing doctor told you not to. Always check! These include anti-arthritis drugs such as gold or methotrexate: any antibiotic from the tetracycline group including Tetracycline, Minocycline, Doxycycline, Vibramycin, Doryx, Solodyn, and Dynacin; acne medicines including Accutane, Cipro, or any of the "quinolone medications"; oral antifungals including Griseofulvin; anti-arrhythmia drugs including Chlorpromazine; NSAIDs including Naprosyn, Advil; St. John’s Wort; diuretics.

We don’t mean to scare you with all of this but we did want to give you some alternatives and some recommendations. On the other hand, if you are uncomfortable - don’t hesitate to use any of the above regimens if they are not otherwise contraindicated.

If you have any questions or concerns - either call your family physician or call us at 345-9411 or through the medical exchange at 458-1121 after hours.

You will find that the application of the creams described above will give a lot of pain relief just because they do rapidly decrease inflammation. That alone will help you.

Do not drink any alcohol while healing! Alcohol won’t interfere with the treatment process itself nor the healing, but alcohol can affect the liver and so can Tylenol. Any form of alcohol is never to be used as a method of pain relief!

FINAL REMINDERS - Things to purchase before your visit:

Silvadene Cream for the morning (prescription)
Synalar Ointment at night (prescription)
Aleve or Advil (over-the-counter) and Tylenol 500 mg caps
Broad brimmed hat - Bring to office
EltaMD UV Physical SPF 41 (Sold at Dr. Coverman’s office) - Bring to office
Golf umbrella to go home with - Bring to office
DCL Active Cleanser (sold at Dr. Coverman’s office)
If possible, plan on avoiding ALL sun exposure the rest of your treatment day and the following day...even brief incidental exposure!