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Laser assisted photodynamic therapy for non melanoma skin cancer

Doctors | Skin Cancer | Skin Medicine | Cosmetic

Laser-Assisted Photodynamic Therapy (LA-PDT) for skin cancer

An advanced, doctor-led treatment for non-melanoma skin cancers (NMSC) that combines the precision of medical lasers with targeted cellular destruction for surgery-level clearance and superior cosmetic results.

[Book a 20 minute appointment with Dr Chris]

For more information on what non melanoma skin cancer is, click here

Key Takeaways

  • Synergistic Technology: LA-PDT uses a two-step approach: laser ablation to destroy the bulk of the cancer, followed by a light-sensitive drug to “mop up” any remaining stray cells.
  • Exceptional Success Rates: Clinical research shows surgery-like clearance rates of up to 93.8-97.1% depending on clinical subtype
  • Minimal Downtime: Most patients heal within 5–7 days, a significant improvement over traditional chemotherapy creams or surgery which can cause weeks of visible irritation.
  • Superior Aesthetics: This method is specifically designed to be gentle on healthy skin, offering excellent cosmetic outcomes and a lower risk of scarring compared to standard surgery.

How Laser-activated Photodynamic Therapy (LA-PDT) works

Laser-activated Photodynamic Therapy (PDT) is an advanced skin treatment combining laser ablation (destruction) of cancers and using a light-sensitive drug (photosensitizer “metvix”, also known as Methyl aminolevulinate (MAL)) to mop up any stray cells the laser has missed.

After the laser has destroyed the bulk of the cancer, the light sensitive photosensitiser is then activated by red LED light to destroy any remaining abnormal cells. This is a very effective treatment for precancers (actinic keratosis) and superficial skin cancers (Squamous cell carcinoma in situ (SCCis), Superficial Basal Cell Carcinoma (sBCC) and nodular Basal cell carcinoma (nBCC). 

It has better cosmetic results and less downtime than traditional methods. 

It combines laser precision with PDT’s cellular targeting. 

Figure 1. Nodular BCC

Step 1)

Complete destruction of any visible lesions with extremely precise laser ablation.

Figure 2. Erbium laser ablation of nodular BCC Note that two dark purple nests of BCC still exist in the dermis.

Step 2: Fractional Laser Pre-Treatment to Enhance Absorption

Figure 2. Fractional laser ablation to the target area creating “laser wells” that will allow deeper penetration of the photosensitiser than would otherwise be possible.

A fractional ablative laser is then used to create microscopic channels into the skin. These “wells” help a medicated cream (in the next step) penetrate more effectively into the deeper skin and adnexal structures and also destroy some abnormal cells directly (4).

Step 3: Addition of a photosensitising drug to the surface of the skin – Methyl Aminolevulinate (MAL, metvix)

Figure 4. A photosensitizing drug, called MAL or Metvix, is applied as a cream to the skin, absorbed by abnormal cells for 3 hours.

Metvix is a “pro-drug.” After it has been applied to the skin, they enter skin cells and are converted through the body’s normal haem (red-blood-pigment) pathway into a natural light-sensitive molecule called protoporphyrin IX (PpIX).

Cancer cells have a more active and “imbalanced” haem pathway than healthy skin. This makes them

  • take up more drug MAL
  • make more of the upstream haem-pathway enzymes (ie convert more of the drug into PpIX)
  • have less of the final enzyme (ferrochelatase) that converts PpIX into safe molecules that the light won’t activate.

As a result, PpIX builds up to much higher levels in actinic keratoses and non-melanoma skin cancers than in the surrounding normal skin. 

Step 4.

The excess ALA is removed from the skin 

Figure 5. The photosensitising cream is wiped away after 3 hour incubation. The only remaining Metvix is inside predominantly cancerous or precancerous cells.

We then shine the red treatment light onto the skin. We call this “red light activation”. This wavelength of light is designed to specifically interact with the PpIX. It will generate reactive oxygen species (ROS) that preferentially damage and destroy cancerous and precancerous cells, while normal skin (with much lower PpIX levels) is relatively spared.

 

Figure 6. Cell Destruction: This red light activation creates reactive molecules that selectively destroy the targeted damaged or cancerous cells. The cells that absorbed the photosensitising cream are destroyed. Surrounding healthy tissue is relatively spared.

Treatment Comparison: At-a-Glance

Feature

LA-PDT (Laser-Assisted)

Surgery

Efudix (5-fluorouracil)

Aldara (imiquimod)

Indicated For

sBCC, SCCis, nBCC* (10-15)

sBCC, SCCis, nBCC*

SCCis (3)

sBCC (2)

Effectiveness

~94% – 100% ((10-14))

~97% 

70% (8)

~80% (non-facial); 42–76% (facial) (9)

Delivery

In-clinic, doctor-led

In-clinic

At-home, self-applied (3)

At-home, self-applied (2)

Typical Course

1–2 sessions

1 session

Twice daily for 6 weeks 

5 days a week for 6 weeks

Mechanism

Laser ablation + light-activated cell death 

Surgical excision

Topical chemotherapy (3)

Immune system stimulant (2)

Visible Reaction

Red, weeping area

Scarring 

Red, weeping area 

Red, weeping area

Systemic (whole body) side effects

None

None

5-10% can develop flu like illness, abdominal cramps, persistent vomiting, bloody diarrhoea, alopecia, rare bone marrow suppression. Very rarely life threatening (18,19).

5-10% can develop Flu like illness, headaches, dizziness, insomnia, diarrhoea(16,17,19).

Discontinuation before treatment complete due to severe side effects

None

None

5% (19)

3% (19)

Downtime

Short (days)

Weeks – 3 months (dependent on area and size)

Prolonged (weeks- two months)

Prolonged (weeks-two months

Cosmetic Outcome

Excellent (10-14)

Good (dependent on area and size)

Good (risk of pigment changes)

Good (risk of pigment changes)

*nBCC indication for LA-PDT may be considered off-label depending on clinical selection (36).

The Clinical Evidence – Detailed Efficacy of LA-PDT by Cancer Type

The “micro-channeling” and precise ablation combined with PDT used in this pathway allow for significantly higher success rates than traditional methods: (10-14)

  • Superficial BCC (sBCC): Near-perfect outcomes, with studies showing up to 100% clearance and long-term recurrence-free rates of 97.1%. 
  • SCC in situ (Bowen’s Disease): Highly effective, with 93.8% clearance
  • Nodular BCC (nBCC): Exceptionally high success for a non-surgical method, reaching a 98.97% cure rate when laser ablation is combined with PDT. 

Excellent Cosmetic Results After Healing

LA-PDT is gentle on surrounding healthy skin. Visible scarring or permanent pigmentation change is minimal. Many patients are highly satisfied with the appearance of their skin after healing (13).

Figure 7. Aesthetic outcome of laser combined PDT(10).

Figure 8. Comparing aesthetic outcome of laser combined PDT with standard surgery (10).

Book Your Assessment

Suitability for LA-PDT is determined by ax expert assessment of your lesion’s type, depth, and location.

[Book a 20 minute appointment with Dr Chris]

References

  1. Australian Prescriber. Non-surgical treatments for skin cancer. (2011). https://australianprescriber.tg.org.au/articles/non-surgical-treatments-for-skin-cancer.html
  2. DermNet NZ. Imiquimod. https://dermnetnz.org/topics/imiquimod
  3. DermNet NZ. 5-fluorouracil cream. https://dermnetnz.org/topics/5-fluorouracil-cream
  4. DermNet NZ. Basal cell carcinoma (treatment overview). https://dermnetnz.org/topics/basal-cell-carcinoma
  5. Griffin LL, et al. Photodynamic Therapy and Non-Melanoma Skin Cancer. (2016). https://pmc.ncbi.nlm.nih.gov/articles/PMC5082388/
  6. Choi SH, et al. Ablative fractional laser-assisted photodynamic therapy (protocol context). (2015). https://pubmed.ncbi.nlm.nih.gov/25400009/
  7. Steeb T, et al. Laser-assisted photodynamic therapy (mechanistic and comparative context). (2019). https://www.jaad.org/article/S0190-9622%2818%2932630-6/abstract
  8. Jansen, M. H. et al. (2018). Five-Year Results of a Randomized Controlled Trial Comparing Effectiveness of Photodynamic Therapy, Topical Imiquimod, and Topical 5-Fluorouracil in Patients with Superficial Basal Cell Carcinoma. https://pubmed.ncbi.nlm.nih.gov/29653835/
  9. Love, W. E. et al. (2010). Imiquimod 5% Cream: A Review of Its Safety and Efficacy in the Management of Superficial Basal Cell Carcinoma. https://pubmed.ncbi.nlm.nih.gov/21430752/
  10. Shokrollahi, K. et al. (2014). Laser-assisted photodynamic therapy for non-melanoma skin cancer. https://pubmed.ncbi.nlm.nih.gov/23407256/
  11. Genouw, et al. (2018). Laser-assisted photodynamic therapy for superficial basal cell carcinoma. https://pubmed.ncbi.nlm.nih.gov/29633367/
  12. Ko, D. Y. et al. (2014). Comparison of LA-PDT vs standard PDT for SCC in situ. https://pubmed.ncbi.nlm.nih.gov/24102369/
  13. Smucler, R. & Vlk, M. (2008). Combination of laser ablation and PDT for Nodular BCC. https://pubmed.ncbi.nlm.nih.gov/18306163/
  14. Lippert et al. (2013). Two-stage laser approach for nodular BCC. https://pubmed.ncbi.nlm.nih.gov/23725586/
  15. DermNet NZ. Photodynamic Therapy. https://dermnetnz.org/topics/photodynamic-therapy
  16. Konstantinidou S, Beliaeva V, Schisler RW, et al. Life-threatening reaction with topical 5-fluorouracil. Drug Safety – Case Reports. 2018;5(1):4. https://pubmed.ncbi.nlm.nih.gov/29330682/
  17. Cohen PR. Topical application of 5-fluorouracil 5 percent cream associated with severe neutropenia: discussion of a case and review of systemic reactions after topical treatment with 5-fluorouracil. Dermatol Online J. 2018;24(4) https://pubmed.ncbi.nlm.nih.gov/29906006/
  18. Avery RK, Avery AJ, Avery MJ. Topical imiquimod induces severe weakness and myalgias after three applications: a case report. Journal of Medical Case Reports. 2014;8(1):323. https://pubmed.ncbi.nlm.nih.gov/31360290/
  19. Love WE, Bernhard JD, Bordeaux JS. Topical imiquimod or fluorouracil therapy for basal and squamous cell carcinoma: a systematic review. Arch Dermatol. 2009;145(12):1431-1438. https://pubmed.ncbi.nlm.nih.gov/20026854/