5-Aminolevulinic Acid May Be Useful for Intense Pulsed-Light Treatment of Facial Photoaging CME

5-Aminolevulinic Acid May Be Useful for Intense Pulsed-Light Treatment of Facial Photo aging CME

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: October 20, 2005; Valid for credit through October 20, 2006

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Oct. 20, 2005 — A randomized trial reported in the October issue of the Archives of Dermatology supports the use of 5-aminolevulinic acid (5-ALA) for intense pulsed-light (IPL) treatment of photo aging.

"The adjunctive use of 5-ALA with intense pulsed-light (IPL) treatments has been suggested to increase the benefit of IPL for photo aging; however, to our knowledge, no controlled trials have been performed," write Jeffrey S. Dover, MD, FRCPC, from the Yale University School of Medicine in New Haven, Connecticut, and colleagues. "The desirable results and safety of IPL treatments have made it a favorite modality for no ablative therapy. At least five manufacturers actively market IPL devices in the United States, and further research on refining this modality is proceeding briskly."

In this prospective study, 20 subjects received a series of three split-face treatments three weeks apart, in which half of the face was pre-treated with 5-ALA followed by IPL treatment while the other half was treated with IPL alone. Subjects then received two additional full-face treatments with IPL alone, delivered three weeks apart. A blinded investigator evaluated global photo damage, fine lines, mottled pigmentation, tactile roughness, and sallow ness (on a scale of 0 - 4) before each treatment and four weeks after the final treatment. At the conclusion of the study, patients also completed an assessment comparing their results with pre-treatment photographs.

All 20 volunteers completed the study. Compared with IPL treatment alone, pre-treatment with 5-ALA was associated with more improvement in the global score for photo aging (16 [80%] vs 9 [45%] subjects; P = .008) and mottled pigmentation (19 [95%] vs 12 [60%] subjects; P = .008). Compared with the side treated with IPL alone, the side pre-treated with 5-ALA had better results for fine lines (12 [60%] vs 5 [25%] subjects; P = .008) and mottled pigmentation (17 [85%] vs 4 [20%] subjects; P <.001).

Tactile roughness and sallow ness noticeably improved from baseline, but pre-treatment with 5-ALA did not seem to enhance the results of the IPL treatment. The 5-ALA–pre-treated side had better final investigator cosmetic evaluations (P = .0002) and subject satisfaction scores (P = .005). Both treatments were well-tolerated, with little difference in the incidence or profile of adverse effects.

"The adjunctive use of 5-ALA in the treatment of facial photo aging with IPL provides significantly greater improvement in global photo damage, mottled pigmentation, and fine lines than treatment with IPL alone, without a significant increase in adverse effects," the authors write. "This combination treatment enhances the results of photo rejuvenation and improves patient satisfaction."

The authors note that in clinical practice, photo toxicity would be expected at least to some extent in patients undergoing 5-ALA pre-treatment with IPL. They also point out that each application of 5-ALA adds approximately $100 to the cost of each treatment.

DUSA Pharmaceuticals, Inc., the maker of 5-ALA, has disclosed that they supported this study.

Arch Dermatol. 2005;141:1247-1252

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

Compare the efficacy of IPL with topical 5-ALA pre-treatment vs IPL alone for the treatment of photo aging.
Compare adverse effects of 5-ALA pre-treatment vs IPL alone for the treatment of photo aging.

Clinical Context

According to the current authors, individual treatments with IPL devices (500 - 1200 nm) have been used for the treatment of telangiectasia, erythema, reduction of lentigines, and dyspigmentation of photoaging for more than 10 years. The benefits of this nonablative treatment vs laser treatments include faster patient recovery time and minimal posttreatment erythema, desquamation, and crusting. However the nonablative methods are less efficacious than laser resurfacing. The adjunctive use of topical 5-ALA has been suggested to enhance the therapeutic effect of IPL, but studies have been small to date, according to the current authors.

This is a prospective, randomized, controlled, split-face study to examine the effect of three split-face treatments using 5-ALA pre-treatment on one half of the face compared with no pre-treatment.

Study Highlights

20 volunteers were recruited from a single group practice and randomized as to which side of the face would receive pre-treatment with 5-ALA.
The indication for treatment was photo aging with skin types I through IV.
All patients were white, mean age was 55 years, and the degree of photo aging was modest by the Global Score for photo aging (mean score, 2 or more on a scale from 0 - 4).
The IPL source was a single broadband, filtered source with a wavelength from 515 to 1,200 nm. The fluence ranged from 23 to 28 J per cm².
The first pulse was set at 2.4 milliseconds and the second pulse was set at 4.0 with a 15-millisecond delay between pulses.
All treated areas were covered with a cooling gel.
The 5-ALA solution (Levulan Kerastick; DUSA Pharmaceuticals, Inc., Wilmington, Massachusetts) was applied and left on for 30 to 60 minutes before 3 of the IPL treatments.
Patients washed their faces, applied sunscreen, and were educated about sun avoidance after each treatment session.
Each patient received a total of 5 full-faced treatments spaced 3 weeks apart. Before 3 of the IPL treatments, 5-ALA was applied to the randomized half of the face. The last 2 treatments consisted of IPL only.
Photo damage was assessed by Global Score (score of 0 to 4, with 0 indicating smooth skin to touch and 4 representing the presence of significant roughness, dyspigmentation, and fine lines) and by individual components of fine lines, mottled pigmentation, tactile roughness, and sallow ness.
Patient satisfaction was assessed as excellent, good, or poor at visit 9. A blinded assessor rated the improvement from baseline as excellent, good, fair, or poor.
Tolerability was assessed at each visit by an unblinded assessor using a 5-point scale for erythema, scaling, dryness, edema, and oozing.
Pre-treatment with 5-ALA resulted in greater improvement in photo damage variables, including the global score, mottled pigmentation, and fine lines vs IPL alone.
For the global score, a score of 0 or 1 was more likely to be achieved by pre-treatment with 5-ALA vs no pre-treatment.
After the fourth treatment, the 5-ALA pre-treated side of the face had greater improvement in mottled pigmentation and fewer fine lines vs the non-pre-treated side.
Similar intensities of erythema, scaling, crusting, edema, and oozing were observed by the 2 groups after the fourth visit.
95% of the 5-ALA pre-treated sides were rated as good to excellent by blinded assessors vs 60% of the IPL-only sides.
95% of the 5-ALA pre-treated sides were rated as good to excellent by patients vs 70% for the IPL-only sides.

Pearls for Practice

The use of 5-ALA as pre-treatment for IPL vs IPL alone is associated with improved outcomes of photo aging.
Adverse effects and tolerability were similar between 5-ALA pre-treatment and IPL alone.

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Target Audience

This article is intended for primary care physicians, dermatologists, and other specialists caring for patients with photo aging.

Goal

The goal of this activity is to provide the latest medical news to physicians and other healthcare professionals in order to enhance patient care.

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