Combined carbon dioxide laser with photodynamic therapy for nodular and superficial basal cell carcinoma

Basal cell carcinomas (BCCs) are often seen by general practitioners, plastic surgeons, and dermatologists in the outpatient setting. Photodynamic therapy (PDT) and CO2 laser when used as monotherapy have been successfully used to treat small BCC, with greatest success in the superficial histological subtype but have limitations compared to surgical excision due to a limited depth of penetration of PDT (2 mm absorption) limiting efficacy. We describe our experience of dual-modality treatment improving efficacy, cosmetic outcomes, and minimizing recurrence.

One hundred ten patients with a total of 177 lesions mainly on the head and neck were treated with combined therapy using an UltraPulse CO2 laser and PDT using methyl aminolevulinate (METVIX) at the same sitting, with repeat PDT 1 week later. We evaluated recurrences, cosmetic outcomes, patient satisfaction, and costs.

The mean age of patients was 67 years. The mean follow-up period was 32.2 months, with a range of 7.7 to 68.5 months. Eighty six lesions were followed up for more than 3 years. A total of 177 lesions were diagnosed and treated. Only biopsy-proven BCCs were included in this study. Histologically, 34 (19.2%) were superficial subtype, 50 (28.2%) nodular, 9 (5.08%) infiltrative, 7 (3.95%) morpheic, 3 (1.69%) mixed, and in 74 (41.8%) diagnosis was simply BCC. All lesions responded to treatment as assessed by clinical evaluation with regular follow-up. The total recurrence-free rate was 97.1%. In 88.1% lesions, a single cycle of treatment was required; 9.03% had 2 cycles and 0.56% underwent 3 cycles. In 3 of the patients, no data were available. Recurrences were noted in 5 (2.82%) cases. All recurrences were treated successfully, all but one using repeat laser-PDT. One patient underwent surgical excision. No significant complications were encountered, although mild hypopigmentation was occasionally seen and some discomfort is experienced with PDT.

Combined CO2 laser and PDT have equivalent cure rates to surgery for BCCs--notably of the nodular subtype--these modalities acting synergistically. This strategy provides cure often with scarless outcomes as illustrated. Laser with PDT is most appropriate for patients who value excellent cosmetic outcomes and where avoidance of an invasive procedure is an important factor. In addition, this modality comes into its own for specific groups of patients, such as those on Warfarin or those with diffuse or multiple lesions.