A retrospective review of pain control by a two-step irradiance schedule during topical ALA-photodynamic therapy of non-melanoma skin cancer


  • Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.


Background and Objective

Photodynamic therapy (PDT) with topical δ-aminolevulinic acid (ALA) of non-melanoma skin cancers is often associated with treatment-limiting pain. A previous study on basal cell carcinomas (BCCs) at Roswell Park Cancer Institute evaluated a two-step irradiance scheme as a means of minimizing pain, preserving outcomes, and limiting treatment time. We used an initial low irradiance until 90% of the protoporphyrin IX was photobleached, followed by a high irradiance interval until the prescribed fluence was delivered. Success of this pilot investigation motivated integration of the protocol into routine practice. Here, we present a retrospective review of recent clinical experience in a broad patient population.

Study Design/Materials and Methods

This was a retrospective review of an existing dermatology database. Fourteen caucasion patients—nine men and five women, ages 18–80, with a total of 51 superficial and 73 nodular BCCs, and three Bowen's disease lesions—were included. ALA was applied to each lesion for approximately 4 hours. Lesions received an initial irradiance of 30–50 mW/cm2 for 20 J/cm2, followed by 150 mW/cm2 for a total fluence of 200–300 J/cm2. Pain was assessed using a visual analog scale (VAS). Clinical outcome was determined at 6–12 months.


Median VAS scores were 1.0 for both irradiances. Five of 127 lesions required pain control with 1% xylocaine. Pain was strongly influenced by lesion location but not by lesion type, number, or size. Complete responses were achieved in 84.1% of BCCs, which compares favorably with reported results for single ALA-PDT treatments. Two of three Bowen's disease lesions showed a complete response. Complete responses for nodular BCCs were 37%, which are also within the range of reported outcomes.


A two-step irradiance protocol in ALA-PDT effectively minimizes pain, maintains excellent clinical outcomes in superficial lesions, and adds minimal treatment time. Lasers Surg. Med. 45: 89–94, 2013. © 2013 Wiley Periodicals, Inc.