Intensified fractional CO2 laser-assisted photodynamic therapy vs. laser alone for organ transplant recipients with multiple actinic keratoses and wart-like lesions: a randomized half-side comparative trial on dorsal hands

BackgroundPhotodynamic therapy (PDT) is a well-documented treatment for actinic keratosis (AK), but achieves inferior efficacy in organ transplant recipients (OTRs), particularly in acral regions. Ablative fractional laser (AFXL) intensifies the PDT response and may improve the efficacy of AK clearance when used as monotherapy. ObjectivesTo compare the efficacy of a single treatment with AFXL-assisted PDT vs. AFXL alone for difficult-to-treat AKs and wart-like lesions (WLLs) in OTRs. MethodsTen OTRs were included with a total of 680 AKs (severity grade I-III) and 409 WLLs on the dorsal hands. Both hands were initially treated with targeted fractional ablation of thick keratotic lesions followed by AFXL field treatment. Treatment regions were then randomized to (i) PDT (AFXL-PDT) or (ii) no further treatment (AFXL). The primary end point was complete response (CR) at 4months after treatment; secondary end points were improvement of AK severity grade, overall patient assessment of efficacy and tolerability of treatments. ResultsCR of AKs was significantly higher for AFXL-PDT (73%) compared with AFXL alone (31%) (P=0<bold>002</bold>). AFXL-PDT improved 82% of AKs to lower lesion grades compared with 52% after AFXL alone (P=0<bold>008</bold>). For WLLs, the rate of CR was 37% for AFXL-PDT compared with 14% for AFXL (P=0<bold>02</bold>). Overall assessment showed a preference for AFXL-PDT compared with AFXL (AFXL-PDT, n=8; AFXL, n=0; equal, n=2). Mild pigment changes were observed in four patients (AFXL-PDT, n=3; AFXL, n=1). No scarring was observed. ConclusionsAFXL-PDT is more effective than AFXL in the treatment of acral AKs and WLLs in OTRs.