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Conventional and combination topical photodynamic therapy for basal cell carcinoma: systematic review and meta-analysis

N J Collier, A K Haylett, T H Wong, C A Morton, S H Ibbotson, K E McKenna, R Mallipeddi, H Moseley, D Seukeran, K A Ward, M F Mohd Mustapa, L S Exton, A C Green, L E Rhodes
British Journal of Dermatology 2018 June 11

BACKGROUND: Topical photodynamic therapy (PDT) is an established treatment option for low-risk basal cell carcinoma (BCC).

OBJECTIVES: Compare efficacy, cosmesis and tolerability of PDT for BCC with alternative treatments.

METHODS: MEDLINE/PubMed/EMBASE/CENTRAL databases were searched from inception until 1 September 2017. Included studies were randomised controlled trials (RCTs) of PDT for nodular (n) and superficial (s) BCC reporting at least one of the outcomes: clearance at 3 months, and sustained at 1 or 5 years; recurrence at ≥1 year; cosmesis; adverse events; tolerability.

RESULTS: From 2,331 search results, 15 RCTs (2,327 patients; 3,509 BCCs) were included. PDT efficacy (5-year sustained clearance) was high although inferior to excisional surgery (nBCC pooled RR 0.76; 95% CI 0.63-0.91), and without re-treatment of partially-responding lesions, was modestly inferior to imiquimod (sBCC: RR 0.81; 95% CI 0.70-0.95) and similar to fluorouracil (sBCC: RR 0.88; 95% CI 0.75-1.04). Five-year sustained clearance was inferior with conventional versus fractionated PDT (sBCC: RR 0.76; 95% CI 0.68-0.84). PDT cosmesis was superior to surgery (sBCC: RR 1.68; 95% CI 1.32-2.14; nBCC: RR 1.82; 95% CI 1.19-2.80) and cryosurgery (BCC: RR 3.73; 95% CI 1.96-7.07), and without re-treatment of partially-responding lesions was similar to imiquimod (sBCC: RR 1.01; 95%CI 0.85-1.19) and fluorouracil (sBCC: RR 1.04; 95% CI 0.88-1.24). Peak pain was higher but of shorter duration with PDT than topical treatments. Serious adverse reactions were rarer with PDT than imiquimod (sBCC: RR 0.05; 95% CI 0.00-0.84) and fluorouracil (sBCC: RR 0.11; 95% CI 0.01-2.04). Combination PDT regimens demonstrated reduced recurrence and improved cosmesis; however, results from these small studies were often non-significant.

CONCLUSIONS: PDT is an effective treatment for low-risk BCC, with excellent cosmesis and safety. Imiquimod has higher efficacy than single-cycle PDT though more adverse effects. Highest efficacy is with excisional surgery. Fractionated and combination PDT options warrant further study. This article is protected by copyright. All rights reserved.


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