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Skin and Medical Topics – The Skin Center

Posted in Skin Art on Oct 25, 2017

Mohs Surgery

What is Mohs micrographic Surgery (MMS)? Where can I have Mohs Surgery? How long does the surgery take? What kind of physician can perform Mohs Surgery? Where can I find a doctor board certified in Mohs? Is Mohs only for skin cancer? Can I remove my moles using Mohs? Am I a good candidate for Mohs Surgery? What if I have artificial joints or other health issues? What areas are treatable by Mohs Surgery? What are possible complications of Mohs? Is there scarring from surgery? What are alternatives for Mohs Surgery? What about plastic surgery? What about insurance coverage and costs? How do I prepare for my surgery? Can I smoke and drink alcohol before surgery? How is recovery? Can I return to work or school? Is there pain after surgery? What is the chance that my cancer will recur? Can I go out in the sun after surgery? How are skin cancers treated? Why is it called Mohs?

What is Mohs micrographic Surgery (MMS)?Mohs micrographic surgery is a minor surgical procedure and special method of removing skin cancers using local anesthesia (numbing). The majority of cases are performed right in the physicians office. Mohs is a very precise, highly detailed technique whereby small layers of skin are removed and immediately examined under the microscope to make sure the skin cancer is completely removed.

The procedure uses frozen sections of skin which are then stained with special dyes. The dyed frozen pieces of skin are further examined under the microscope and a tumor map is drawn by the Mohs surgeon. The freezing process allows an immediate examination of the entire tumor margin and tissue histology (microscopic examination of cells).

If more cancer cells or roots are seen under the microscope, then another skin layer is removed and again examined. Each time that a skin level is removed, it is called a level. If no more cancer roots are seen, then it is called clear (no more tumor) and no additional levels are needed.

By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with good preservation of normal skin. Once the cancer has been fully removed, the Mohs surgeon looks at the wound to determine the way to get the best wound repair and cosmetic result for you.

Mohs is special because the entire edge and under-surface of each skin cancer layer is carefully examined under the microscope for the presence of very small cancer cells. With regular or traditional surgery only about 1 to 3% of the tumor margins are actually examined thereby increasing the chances that a small tumor root would be missed and left behind. Mohs allows for examination of 100% of the tumor margins thereby reducing the chance that tumor cells will be left behind.

Mohs is usually scheduled only on certain days in the doctors office because of the required equipment, tissue stains (dye), Mohs technologists, and microscopes. Most of these procedures are generally performed with the patient waiting in the office for the tissue to be read or interpreted by the Mohs surgeon.

Where can I have Mohs Surgery?Mohs micrographic surgery is usually performed in an outpatient setting like a doctors office and under local anesthetic (lidocaine). Sometimes the procedure may be performed in an outpatient surgical center with the assistance of an anesthesiologist. Rarely, it is performed in an inpatient hospital setting.

How long does the surgery take?You are generally in the medical office for several hours( average 2-7 hours) on the day of your Mohs procedure. Depending on how large or difficult your skin cancer is, different numbers of levels may be required to achieve clearance. Mohs requires your patience and your doctors careful effort and skill. It is not always possible to predict ahead of time how many hours your specific procedure will take. Most patients leave their days schedule open to allow for adequate time to complete their Mohs.

What kind of physician can perform Mohs Surgery?Most Mohs surgeons are specially trained dermatologists. There are also some plastic surgery, or Ear , Nose and Throat ( ENT) surgeons who are trained and may also perform Mohs.

Where can I find a doctor board certified in Mohs?There is no current Board Certification for Mohs Surgery. There are two nationally recognized and respected national Mohs specialty groups called the American College of Mohs Surgery and the American Society for Mohs Surgery (ASMS).Both of these medical groups have specialty training and certification exams for their members. Members of The American College of Mohs Surgery usually have completed an additional 1 to 2 years of Mohs training. Members of the American Society for Mohs Surgery are also trained and required to actively participate in an annual quality control Mohs slide peer review.

Is Mohs only for skin cancer?Yes, Mohs is a widely used method of surgically removing the most common types of skin cancers including basal cell carcinoma and squamous cell carcinoma. It is currently not used to remove non-cancerous growths.Less frequently, Mohs may also be used for other malignant tumors. In special cases, Mohs may be used to surgically treat malignant melanoma, lentigo maligna, dermatofirosarcoma protuberans, merkel cell tumor, microcystic adnexal carcinoma, malignant trichoepithelioma, angiosarcoma, atypical fibroxanthoma and other cancerous tumors. However, most Mohs surgeons treat primarily basal and squamous cell cancers by this technique.

Can I remove my moles using Mohs?

No, Mohs is usually not for mole removal. It is primarily designed for removing skin cancers. Moles are usually removed by standard or traditional surgery.

Am I a good candidate for Mohs Surgery?You may not be a good candidate for Mohs if you are unable to tolerate local anesthesia, have extreme anxiety, have a surgical phobia, or are in very poor health.Your decision on the best treatment choice may depend on different factors such as the location and type of skin cancer, your past treatments, your overall health, and level of comfort. Your physician can help you sort through the different treatments and assist in your shared decision making process. However, the right decision for you is always yours and your doctors to make.

What if I have artificial joints or other health issues?Your Mohs surgeon needs to know of any other medical conditions that may affect your surgery or wound healing. You would want to make sure to tell your surgeon beforehand if you have any artificial parts (implants) like knees or hips , a pacemaker or defibrillator, or need to take antibiotics before dental procedures because of a heart condition or murmur.Your Mohs surgeon needs to know if you have had a history of Staph or other skin infections in the recent past. You may be asked to wash with a special antibiotic soap or wash like Hibiclens ( Chlorhexidine) the night or morning before surgery to help reduce the number of bacteria on your skin.

Patients need to also advise their surgeon of any drug allergies such as to anesthetics like lidocaine, xylocaine, epinephrine, or novacaine. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, Hepatitis, HIV/ AIDS, or pregnancy.

What areas are treatable by Mohs Surgery?Mohs is used primarily for the treatment of head and neck basal and squamous cell skin cancers. It is particularly useful for skin cancers in difficult areas such as nose, lips, ears, and genitals.

It is also used on hands and feet where there is not a lot of extra tissue for bigger surgical removals. Mohs is very effective for the treatment of recurrent tumors (tumors that were previously removed and have re-grown at the same site). However, depending on the specific patient and tumor type, any area of the body may be treated by Mohs surgery.

What are possible complications of Mohs?As with any surgery or procedure , Mohs is associated with some possible risks and complications. While it is overall a very safe and effective minor surgical treatment, there are some possible uncommon complications. Since a scar usually forms anytime you cut the skin, most patients understand and expect some type of a scar after skin cancer removal.

Possible risks and complications of Mohs include (but are not limited to) bleeding, bruising, wound infection, pain, unsightly scar, keloid ( raised, thick scar), cosmetic disfigurement, skin discoloration, nerve damage, allergic reactions, pain, reaction to local anesthesia, widened or sunken in( depressed) scar, wound opening ( dehiscence) and spitting or retained stitches, cancer recurrence, need for further surgery or treatment including radiation or plastic surgery, and rarely death.

Minor, serious, or life threatening reactions can occur with the use of anesthetics or with medications given before, after or during surgery. Nerves controlling muscle movement, sensation, or other functions may be damaged. This nerve damage may be permanent.Overall, most patients tolerate the minor surgery very well without any complications.

What is reconstruction?Reconstruction is repairing or fixing the wound.

Repairing or closing the wound may involve having your surgeon stitch the wound closed side by side. Sometime an area may heal better by letting the wound heal in by itself naturally without stitches. Additional reconstruction options include using a skin graft, moving a flap of skin, and plastic surgery closure.

Shared decision making is very important in this part and you are involved in how you prefer to repair the wound. Your Mohs surgeon may make some recommendations on how to close your wound.

The main goal with Mohs surgery is to remove the skin cancer first. Once the cancer is cleared out, then your Mohs surgeon will look at how to best fix the area. The goal of Mohs is to clear skin cancer, achieve the smallest scar, and preserve normal tissue.

Is there scarring from Mohs surgery?Yes, all human beings heal by permanent scar formation. In general, when you cut the skin, there will be some type of scar. Some people heal better than others. Some scars are more noticeable depending on the location and skin type.

There are many options for treatment of surgical scars including lasers, scar creams and gels, cortisone injections, and many other choices depending on the scar. You may want to discuss ways to help minimize scarring with your doctor at your stitch removal appointment.

What are alternatives for Mohs Surgery?It is important to understand that there are alternative treatments and options to Mohs. Additional treatment choices include (but are not limited to) local radiation, prescription topical creams, plastic surgery, curettage and desiccation (scrape and burn), regular surgery, chemotherapy creams or injections, cryosurgery ( deep freezing), photodynamic therapy ( uses a type of light and a light activated chemical called a photosensitizer).

What about insurance coverage and costs?Mohs surgery is generally considered a medical service and is not considered cosmetic. Currently, most insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling surgery and confirm your eligibility and benefits.

Mohs, like any surgical procedure, will result in additional procedure charges above the routine office visit fees. These surgical fees may range from one to two thousand dollars depending on the area, number of Mohs levels, and the type of closure or repair required. The more number of levels required, the higher the cost. Surgical centers and hospitals usually have a much greater costs associated with a facility fee in addition to the surgery fee.

Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally covers 80% of Mohs cancer surgery. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare.

Commercial or non-Medicare insurances currently generally cover a large percentage of your surgery unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or hospital for an approximate estimate of your charges before scheduling the procedure.

What about plastic surgery?You may decide to have regular surgery with a plastic surgeon instead of having Mohs.

Alternatively, you may also choose a hybrid option where your Mohs surgeon removes the tumor and clears it for you and then you have the plastic surgeon fix up the wound and stitch it up for you.

If you prefer to have your plastic surgeon repair the wound, you will want to let your plastic surgeon and dermatologist know ahead of time and plan that into your Mohs schedule.

Heavy alcohol use is not advised at least one week before surgery. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding. Your physician will want to know of any factors that may affect your surgery or wound healing.

How is recovery?Recovery is usually very easy and uneventful. Overall, resting as much as possible the first few days after surgery is generally helpful.

Stitches (sutures) are usually removed at the surgeons office anywhere from 4-14 days from the date of surgery. Your physician will let you know what date to return for stitch removal .

Can I return to work or school?Most patients are able to return to work or school the same day or next day after Mohs. Avoiding heavy lifting, straining, or strenuous exercise for 7-21 days may be required depending on the area of surgery. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure.

Is there pain after surgery?Most patient report no or minimal discomfort after surgery and require no pain medication.

If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take Tylenol (Acetaminophen) or another pain reliever over the counter. Aspirin or Aspirin containing pain relievers may cause increased bleeding. Rarely, prescription pain medications may be required for severe pain.

Your physician will let you know what pain medications are recommended for your specific condition.

How do I take care of my surgical area after Mohs?It is generally required to check with your surgeon for their specific wound care instructions just after surgery.Often, you will be asked to go home and take it east for the rest of the day couch potato day. A few patients like to return to work and resume their work day after surgery.

It may be advisable to avoid heavy lifting and exercise especially the first 24-48 hours after surgery. Your physician will usually give you more detailed instructions depending on the area and size of the surgery.

You will have usually have a bulky pressure dressing on the surgery area for 1 day. You may be asked to keep the area dry until 24 hours. Swimming pools, oceans, and jaccuzis are usually off limits while the stitches are in. These may increase your chance of infection. Many physicians allow you to shower the next day after surgery. Wound care may require cleaning the wound with soap or hydrogen peroxide 2-3 times a day and applying an over the counter antibiotic ointment to the area.

Mild swelling is not uncommon the 1st day or two after surgery and can be lessened by use of an ice bag, ice cubes or chips in a small Ziplock baggie, or frozen peas in their bag. Leaving the dressing in place, ice use every 5-15 minutes every hour for the first 8-24 hours after surgery. Swelling is more common around for surgeries around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after surgery of the head and face area.The surgical area may ooze a little blood or clear liquid especially in the first few hours after surgery; activity may aggravate this. Hot drinks or bending over at the waist can also initiate or worsen bleeding of face wounds. If bleeding occurs, firm pressure applied directly to for ten to fifteen minutes to the site may be helpful. Most bleeding will stop if you apply enough pressure. Your surgeon should be notified of non-stopping bleeding. Rarely, a visit to the hospital emergency room may be necessary for severe bleeding.Your surgeon will need to know if pain is increasing after 1-2 days after your surgery or you are having fever or other concerning symptoms. In such cases, you may need to be seen at the surgeons office. The surgical area may need to be promptly checked for bleeding or infection.

Limiting hot foods, hot drinks, and heavy chewing for 48 hours may help decrease the chances of postoperative bleeding for wounds around the mouth or cheek areas.

Your physician will let you know their recommended wound care.

What about makeup?Most patients are advised to try to avoid applying makeup or powder directly on a fresh wound unless the surface is fully healed. Skin colored tape strips called steristrips are available to minimize and help cover-up a visible wound.It is important to follow your own physicians instructions for wound care.

What is the chance that my cancer will recur?There is a very low chance that your skin cancer will recur after Mohs surgery. Mohs cure rates have been reported as high as 96-99%.It is important to understand that no cancer treatment or surgery has a 100% cure rate. A skin cancer may recur or a new cancer may arise in the same or adjacent area even after Mohs or other surgery. Some skin cancers are more aggressive than others and need additional treatment and closer follow up.Skin cancers frequently need additional follow up and possible further treatment. Although Mohs surgery tends to have the highest cure rate compared to other treatments, Mohs may not be necessarily curative in advanced skin cancer ( rare cases) and may need one or more procedures such as radiation or further surgery to fully treat the lesion.Good follow up appointments with your physician are very important, especially in the first few years after Mohs. Many patients are seen every 4-6 months after their diagnosis of a skin cancer. Self skin examinations monthly are good practice for patients with a history of skin cancer. Any changing or new growth should be promptly checked by your physician. More regular follow up appointments may be needed for those with more aggressive tumors or tumors in high risk areas.Your physician will recommend the proper follow up for your specific condition.

How many levels of Mohs will I need?On average, most patients may only need 1 or 2 levels before clearing the tumor roots. Depending on the skin cancer type and location, a patient may need anywhere from 1 to 10 or more levels of Mohs to clear a tumor.There is no way to predict ahead of time how many levels your cancer will require for cure. The number of Mohs levels needed to completely remove the skin cancer depends on how big your cancer is and where the roots are. Mohs surgeons alway strive to remove your cancer in as few levels as possible.There is also very little way to predict beforehand how large a skin cancer is because often there are invisible portions roots which can be seen only with the help of a microscope. Sometimes, more than one surgical procedure may be required to remove very large or invasive tumors, cancers in small areas or difficult areas, or to obtain the best medical and cosmetic result.

Can I go out in the sun after surgery?

There are no specific strict sun restrictions after Mohs surgery. You may go out in the sun with sunscreen and protective hats and clothing. Overall, the sun is not your friend and should be avoided in excess. Excess sun exposure has been linked to possible skin cancer.Use of sunscreen or other cover up on the scar is very helpful for at least 6 months after surgery to help minimize scarring. It is important to follow your own physicians instructions for wound care and sun protection.

How are skin cancers treated?There are many good and effective ways to treat skin cancers. Options include local radiation (X-ray) treatments, curettage and desiccation C&D ( scrape and burn), cryosurgery ( specialized deep freezing), photodynamic therapy using Levulan and laser and or blue light, regular surgical excision, plastic surgery treatment, interferon injections, laser removal and surgery, Mohs surgery, and several prescription creams including Aldara ( imiquimod) and Efudex ( flurouracil).

Why is it called Mohs?Mohs is named after its inventor Dr. Frederic Mohs who first described the technique in 1941.

Photodynamic Therapy

What is Photodynamic Therapy?Photodynamic Therapy (PDT) is a special medical treatment that uses a photosensitizing drug and a light source to activate the applied drug. The result is an activated oxygen molecule that can destroy specific cells, including pre-cancerous or certain types of cancer cells. The procedure is generally minor and performed in a physicians office or outpatient setting.

PDT essentially has three steps. First, a light sensitizing liquid, cream, or intravenous drug (photosensitizer) is applied or administered. Second, there is an incubation period of minutes to days. Finally, the target tissue is then exposed to a specific wavelength of light which then helps activate the photosensitizing medication.

Steps: 1. Application of photosensitizer drug 2. Incubation period 3. Light activation

Although first discovered around 1913, PDT in the modern sense is a fairly new, evolving science whereby varying incubation times of a light sensitizing drug are used in combination with varying types of available light sources depending on the target tissue. The basic premise of PDT is selective tissue destruction. Although the photosensitizer may be absorbed all over by many cells, atypical or cancerous cells preferentially take up more of the drug and also may retain the drug for longer duration than normal tissues.

At present, the primary limitation of available PDT techniques is the depth of penetration of the light and ability to target cells within at most 1/3 of an inch ( approximately 1cm) of the light source. Therefore tumors or atypical growths must be fairly close to the skin or treatment surface for PDT to work.

What is Photodynamic Therapy used for?PDT is currently used in multiple medical fields including oncology (cancer), dermatology (skin), and cosmetic surgery.

In oncology, it is FDA approved for non-small cell lung cancer, esophageal cancer, and pre-cancerous changes of Barretts esophagus. Its use is also being further investigated through clinical trials in general oncology for conditions including cancers of the cervix (mouth of uterus), prostate gland, brain, and peritoneal cavity (the abdominal space that contains the stomach, liver, and internal organs).

In dermatology, PDT using Levulan Kerastick (20% delta-aminolevulinic acid HCl) became FDA approved in 2001 for the treatment of pre-skin cancers called actinic keratosis (AK). The initial approval was specifically for normal (non-hyperkeratotic) actinic keratosis of the face and scalp with a specified 14 to 18 hour drug incubation time, and 1,000 seconds (16 minutes and 40 seconds) of activation by a proprietary blue light source.

Since 2001, PDT has also received many other non-FDA approved ( also called off-label ) uses including acne, rosacea, skin cancer, sun damage, cosmetic skin improvement, oily skin, enlarged sebaceous glands, wrinkles, rejuvenation (anti-aging), warts, hidradenitis suppurativa, psoriasis, and many other skin conditions.

What photosensitizer drugs are available?At least 3 currently FDA approved photosensitizers are available including Photofrin (porfimer sodium), Levulan ( 5-aminolevulinic acid or ALA ), Metvix (methyl aminolevulinate (MAOP)) . More drugs are undergoing trials and may become available in the near future. Photofrin is used intravenously ( IV)for internal cancers while Levulan and Metvix are applied topically for skin therapy.

What light sources are available?PDT can essentially use many types of light sources. These include laser, intense pulsed light, light-emitting diodes (LEDs) , blue light, red light, many other visible lights, including natural sunlight. Photosensitizer drugs may become activated by one or several types of applied light depending on the ideal wavelength for the particular drug used and target tissue.

How is the light applied?The light source needs to be directly applied to the target tissue for a specific amount of time. For surface skin treatments, the light is easily directly applied to the area of the skin where the photosensitizer drug has been applied ( such as face, scalp, arms, etc.).For internal cancers, delivering the light to the desired area is more challenging. The light may be delivered through small fiber optic cables into the body cavity or area being treated. Sometimes endoscopes ( a thin lighted elongated tube which is inserted into a body space) are used to deliver the light into the lungs, stomach, or bladder.

How does PDT work?PDT works by direct injury to the target cells and tissues. While all of the exact mechanisms are not fully known yet, the basic pathway seems to involve an activated oxygen molecule that has the ability to injure or destroy nearby or specific cells.Aminolevulinic acid is then incorporated into the bodys natural heme ( blood) biosynthesis pathway and activated to form protoporphyrin IX, a potent photosensitier. Protoporphyrin IX then becomes excited to an activated singlet state. This active singlet state is then directly toxic to cells.Other potential pathways include directly killing abnormal or cancerous cells, damaging the blood vessels and blood supply to the tissue, causing inflammation and irritation, and possibly also activating the persons own immune system to attack the abnormal or cancerous cells.

Does PDT make me permanently more sensitive to light?No, PDT causes a temporary sensitivity to light, including natural sunlight and some indoor lights. The light sensitivity resolves with time depending on both the photosensitizer drug and dosage used.

How long do I have to stay out of the sun and light?Light avoidance is generally required after PDT. The duration depends on the drug and dosage used. Intravenously given Porfimer may make the body including the skin and eyes sensitive to light for about 6 weeks after treatment. Proper protection including long sleeves and sunglasses may be required.Topically applied aminolevulinic acid (Levulan) or methyl aminolevulinate (Metvix) may cause skin sensitivity only on the treatment areas for approximately 24-72 hours. These do not usually cause sensitivity on other body parts other than where the drug was directly applied. Your physician will need to discuss with you the required sun and light avoidance period required after your particular treatment.

How is PDT used to treat the skin?

PDT using Levulan ( 5-aminolevulinic acid or ALA ) and a proprietary Blue light is currently FDA approved for the treatment of skin pre-cancers called actinic keratosis ( rough scaly spots generally on sun exposed skin in more fair skin individuals).PDT is also known as ALA/PDT treatment or Super Blue Light. It has been referred to as a super photo facial when the photosensitizer is used with a machine called intense pulsed light or IPL. These treatments may help remove sun damaged pre-cancerous zones and spots. Sun damage, fine lines, and blotchy pigmentation may also be improved because of the positive effect of PDT. IN some patients, PDT also has been shown to help decrease the appearance of pores and reduce oil glands, effectively treating some subtypes of patients with stubborn acne, rosacea, and help improve the appearance of some small superficial acne scars.Although PDTs use in skin was first investigated in 1990s for actinic keratosis, it was not as popular or widely used because of the required long incubation times (usually 18-24 hours) and limited indications. Since approximately 2001, PDT has become more widespread in use primarily because of advances including shorter incubation times (30-60 minutes) and more applications including acne and cosmetic skin rejuvenation.

What is a photosensitizer drug?Photo sensitizers are chemical compounds that become activated only when exposed to light.

What is Aminolevulinic acid or Levulan?5-aminolevulinic acid also called Levulan or ALA for short is a naturally occurring protein in the body. It is found in small quantities as part of the normal heme ( blood) synthesis pathway. In larger quantities, it is a substance known to increase sensitivity to certain wavelengths of light.

How does PDT work?By preferentially attacking the active or abnormal cells, PDT combines a very high success rate with good preservation of normal skin without significant risks for scarring. Once the areas have healed following PDT, the areas are re- examined to see if additional treatments or possible biopsies are needed.

PDT is special because it is a targeted treatment to preferentially target more rapidly dividing cells and atypical skin growths. With regular or traditional cryosurgery ( freezing with liquid nitrogen) or burning, only the visible pre skin cancers are treated thereby leaving ones that arent as apparent ( sub clinical or hidden) lesions undetected. Photodynamic Therapy allows for field or blanket treatment of an entire area of sun damage thereby reducing the chance that undetected pre skin cancer cells will be left untreated.

Photodynamic Therapy is usually scheduled in the doctors office because of the required photosensitizing prescription / physician applied medication and the special light activation equipments. Currently PDT procedures are generally performed with the patient waiting in the office during the 30 minute to several hours incubation time before the application of the light source.

What is a typical skin PDT session like?You may be given a written procedure consent form to read and sign before your first treatment. The medical staff may take some before photography prior to applying the photosensitizer medication.In the treatment room, you may be sitting or comfortably lying back on a table. This part is generally painless and comfortable. Often a thorough cleansing of the face is done using alcohol and or acetone to degrease the skin. The less oil on the skin, the more readily the skin will absorb the applied topical medication. In some patients microdermabrasion may additionally be performed prior to the application of the medication to further prepare the skin to optimally absorb the photosensitizer.The photosensitizer liquid or cream is applied topically to the whole area being treated (such as the entire face, scalp, back of the hands, back part of the forearms, legs, feet, scalp, chest, or back).The medication is allowed to air dry for a few minutes and then you will wait anywhere from 30-60 minutes for the incubation time. Some areas such as chest, back and particularly forearms and legs require longer incubation times of 2-18 hours for better results. No two people or skin on different areas of the body are exactly alike. PDT requires physician adjustments for specific individualized incubation times and treatment durations.After the proper incubation time, you are brought back into the light source room where the medication is activated with a specific wavelength light source. There may be sensations of warmth, tingling, heat, or burning in some patients. Frequently, you will have a fan to help cool off during the treatment.The treatment area is then washed off and sunscreen applied before leaving the office. Instructions and an appointment for follow up may then be given on how to care for the improved skin.

How much improvement can I expect?No two individuals are the same and results may vary. As with any medical procedure, some conditions can improve dramatically in some patients and not respond in others.

Overall, patients with severe sun damaged skin manifested by actinic keratosis, texture, and tone changes including mottled pigmentation, dull or sallow skin, and skin laxity may see good to excellent improvement with PDT. There have been reports of possible improvement of large pores, non- pitted acne scars, and active acne.

Depending on the area being treated and the recommended incubation time, different numbers of treatment sessions spaced 4-6 weeks apart may be required to achieve the desired improvement and reduction in lesions. It is not always possible to predict ahead of time how many treatments your specific condition may take or how you will respond to PDT.

Photodynamic Therapy requires your patience and your willingness to follow the post procedure instructions, including staying out of the sun for 24-28 hours depending on the area treated and your physicians requirements.

How many treatments will it take to see the best results?To achieve maximum improvement of pre-cancerous (actinic keratosis) sun damage, skin tone and texture, on average a series of 2-3 treatments 2-6 weeks apart may be quite effective. Some patients with milder actinic keratosis are happy with one treatment. More treatments can be done at periodic intervals in the future to maintain the rejuvenated appearance of the skin.

Where can I have Photodynamic Therapy?Photodynamic Therapy for skin therapy is usually comfortably performed in an outpatient setting like a doctors office and without any sedation or anesthesia.You may check the http://www.AAD.org for board certified dermatologist members of the American Board of Dermatology in your area or http://www.ASPDT.org for members of the American Society of Photodynamic Therapy. Additionally, oncologists and other physicians may be trained in this area.While these photosensitizer medications may currently only be available to medical personnel, it may be foreseeable or possible in the distant future where patients could be given a prescription for the topical or oral photosensitizer and a light source for physician directed home use.

How long does a skin PDT procedure take?You are generally in the medical office for several hours( average 1 1/2 hours) on the day of your Photodynamic Therapy. Facial PDT may take 10 minutes to apply the medication, 30-60 minutes to allow proper skin incubation, and 15-20 minutes for light application. Other areas may require longer incubation times and you may leave the office and come back when it is time to have the light.

Many patients prefer to schedule their treatment later in the afternoon so they may go directly home after the treatment. It is not usually advised to have any sun exposure such as from running errands or driving around after the treatment.

What kind of physician can perform Photodynamic Therapy?Most skin PDT is performed only by specially trained dermatologists and their medical staff. Other physicians including oncologists, family physicians, internal medicine doctors, plastic surgeons, or Ear, Nose and Throat ( ENT) surgeons and their medical staff who are trained and may also perform Photodynamic Therapy.While it is generally advisable to undergo this or any medical treatment in an established board-certified physicians office, there are medical spa type environments that may also offer these skin services with or without physician supervision.

Where can I find a doctor board certified in Photodynamic Therapy?There is no current Board Certification, residency, or fellowship training for Photodynamic Therapy. There is a new national organization called the American Society for Photodynamic Therapy (ASPDT). You may check the website for members of this group at http://www.aspdt.org. There are many other photomedicine interest groups and societies dedicated to this evolving field.

Some dermatologists and oncologists have received special residency or post graduate training for photodynamic therapy. Many other physicians may be trained by companies that manufacturer the photosensitizing material and /or the light source.

Is skin PDT only for pre-cancerous growths?No, Photodynamic Therapy is a widely used method of treating many conditions including pre-cancers (actinic keratosis), some types of superficial skin cancers, acne, rosacea, warts, sebaceous hyperplasia ( enlarged oil glands), fine wrinkles, psoriasis, and other cosmetic indications. It is currently not used to remove malignant melanoma or deeply invasive cancers. It is not used to remove moles or birthmarks.Less frequently, Photodynamic Therapy may also be used off-label for other less common conditions including hidradenitis suppurativa, porokeratosis, disseminated actinic porokeratosis (DSAP), and other investigational conditions.

What are the advantages with Photodynamic Therapy for treating skin pre-cancers?The greatest advantage of PDT is the ability to selectively treat an entire area of skin damage and pre-cancers (blanket or field treatment). PDT generally decreases the likelihood of lighter or darker skin spots ( post-inflammatory hyper or hypo pigmentation) caused by routine freezing with liquid nitrogen. Additionally, PDT frequently may facilitate smoother skin and an overall improved appearance, tone, color, and enhanced skin texture.

In several studies, PDT has been preferred by many patients for ease of use and recovery as compared to alternative treatments including freezing and chemotherapy creams like fluorouracil (Efudex). The PDT side effects may be milder with less down time than with fluorouracil.

For patients with many skin lesions, PDT may be generally more effective than repeated spot treatment with topical liquid nitrogen. Some patients are unable to tolerate the prolonged treatment required with fluorouracil (Efudex) or imiquimod (Aldara) because of the irritation, redness, and possible downtime with these topical creams.PDT has become a very well tolerated, essentially painless, non-invasive (no needles or surgery required) procedure to help reduce sun damage and enhance the overall cosmetic outcome (particularly in sensitive areas of the face and chest).

How many treatments of Photodynamic Therapy will I need?

No two peoples skin is exactly the same and therefore individual results and number of required treatments vary. On average, most patients may benefit from 1 to 3 PDT treatments for an area and annual touch up treatments. While the face tends to respond faster and to fewer treatments, areas like the forearms and legs are much harder ( resistant and tough skin) to treat and may require many more treatments.

There is no way to reliably predict ahead of time exactly how many treatments your condition will require. Photodynamic Therapy physicians always strive to treat your condition in as few treatments as possible without causing a severe burn.

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Skin and Medical Topics – The Skin Center

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