An Open-label Phase I Study to Evaluate the Pharmacokinetics of 5-aminolevulinic Acid and Protoporphyrin IX in Human Plasma Under Maximal Use Conditions After Topical Application of 3 Tubes of BF-200 ALA 10% Gel for Photodynamic Therapy (PDT) in Subjects Suffering From Actinic Keratosis
Phase: PHASE1
Conditions: Actinic Keratoses
Sponsor: Biofrontera Bioscience GmbH

TITEL PAGE CSP, V2.0 DATED 17-JAN-2020 
 
Study ALA-AK-CT015, 
NCT04319159 
 
An open-label Phase I study to evaluate the pharmacokinetics of 5-aminolevulinic acid and 
protoporphyrin IX in human plasma under maximal use conditions after topical application of 
3 tubes of BF-200 ALA 10% gel for photodynamic therapy (PDT) in subjects suffering from 
actinic keratosis 
 
 

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TITLE PAGE 
CLINICAL STUDY PROTOCOL 
An open-label Phase I study to evaluate the pharmacokinetics of 5-aminolevulinic acid 
and protoporphyrin IX in human plasma under maximal use conditions after topical 
application of 3 tubes of BF-200 ALA 10% gel for photodynamic therapy (PDT) in 
subjects suffering from actinic keratosis 
 
Version 2.0 
ALA-AK-CT015 
 
Test Product: 
BF-200 ALA (Ameluz®) [in combination with BF-
RhodoLED®] 
Indication: 
Mild to severe actinic keratosis 
Study Design: 
non-randomized, open-label 
Study Identifier: 
ALA-AK-CT015, IND 115412, NCT: tbd 
Study Phase: 
Phase I study (in diseased subjects) 
Investigator: 
Janet C. DuBois, MD 
DermResearch, Inc. 
8140 N. Mopac, Bldg. 3, Suite 120 
Austin, TX 78759 (USA) 
Sponsor: 
Biofrontera Bioscience GmbH 
Hemmelrather Weg 201 
51377 Leverkusen, Germany 
Sponsor’s Signatory: 
 
Biofrontera Bioscience GmbH 
Hemmelrather Weg 201 
51377 Leverkusen, Germany 
e-mail: 
 
Tel.: 
 Fax: 
 
Date of issue 
17-Jan-2020 
 
 
The study is designed in accordance with the International Council for  
Harmonisation guideline for Good Clinical Practice (ICH-GCP E6). 

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DECLARATIONS OF SPONSOR AND INVESTIGATORS 
DECLARATION OF SPONSOR 
This clinical study protocol was subject to critical review and has been approved by the 
sponsor. The information it contains is consistent with: 
• the current risk-benefit evaluation of the investigational product and 
• the moral, ethical, and scientific principles governing clinical research as set out in 
the current version of the Declaration of Helsinki, the principles of ICH GCP E6, 
and the provisions of the applicable local law(s) and regulation(s). 
 
The investigator will be supplied with details of any significant or new findings, e.g. 
SUSARs, related to treatment with the investigational product. 
 
Sponsor 
Date: __________  
Signature: ______________________________________  
 
 
Name (block letters): ______________________________  
 
 

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DECLARATION OF INVESTIGATOR 
I will work in accordance with the moral, ethical, and scientific principles governing clinical 
research as set out in the current version of the Declaration of Helsinki, and the International 
Council for Harmonisation guideline for Good Clinical Practice [ICH E6].  
I will work according to the applicable local law(s) and regulation(s). 
I confirm that I have read the protocol. I understand it, and I agree that it contains all the 
information required to conduct the study. I agree to conduct the study as set out in this 
protocol. I do not deviate from it without prior discussion with the sponsor except where 
necessary to eliminate an immediate hazard(s) to trial subjects, or when the change(s) 
involves only logistical or administrative aspects of the trial (e.g. change of telephone 
number(s)). If I become aware of any protocol deviation, I will communicate details to a 
representative of the sponsor. 
 
Date: __________  
Signature: ______________________________________  
 
 
Name (block letters): ______________________________  
 
 

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DECLARATION OF BIOSTATISTICIAN 
The undersigned hereby declares his consent to the statistical part of the clinical trial protocol 
which is in compliance to current ICH guidelines. 
 
Date: 
 
Signature: ______________________________________  
 
 
Name (block letters): ______________________________  
 
Date:  
 
Signature:________________________________________ 
 
 
 
Name (block letters):_______________________________ 
 
 

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1 TABLE OF CONTENTS 
 
Title page ............................................................................................................................... 1 
Declarations of sponsor and investigators .......................................................................... 2 
Declaration of sponsor ......................................................................................................... 2 
Declaration of investigator ................................................................................................... 3 
Declaration of biostatistician ............................................................................................... 4 
1 
Table of contents ............................................................................................................ 5 
2 
Protocol outline .............................................................................................................. 9 
3 
Abbreviations and definitions .................................................................................... 18 
4 
Introduction and study rationale ............................................................................... 21 
4.1 
Introduction ................................................................................................................ 21 
4.2 
Study rationale ........................................................................................................... 23 
4.3 
Risk/benefit analysis .................................................................................................. 24 
5 
Study objectives ........................................................................................................... 26 
5.1 
Primary objectives ...................................................................................................... 26 
5.2 
Secondary objectives .................................................................................................. 26 
5.3 
Tertiary objectives ...................................................................................................... 26 
6 
Study design, duration and dates ............................................................................... 28 
6.1 
Study design ............................................................................................................... 28 
6.2 
Study duration, dates and end-of-study definition ..................................................... 29 
6.3 
Definitions .................................................................................................................. 29 
7 
Selection of subjects .................................................................................................... 30 
7.1 
Number of subjects .................................................................................................... 30 
7.2 
Recruitment arrangements ......................................................................................... 30 
7.3 
Inclusion criteria......................................................................................................... 30 
7.4 
Exclusion criteria ....................................................................................................... 31 
7.5 
Screening failures ....................................................................................................... 33 
7.6 
Subjects of reproductive potential .............................................................................. 33 
8 
Study treatment ........................................................................................................... 35 
8.1 
Details of investigational products ............................................................................. 35 
8.1.1 Investigational Medicinal Product ........................................................................ 35 
8.1.2 Investigational Medical Device............................................................................. 35 
8.2 
Storage........................................................................................................................ 36 

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8.3 
Application of BF-200 ALA ...................................................................................... 37 
8.4 
Illumination with BF-RhodoLED® ............................................................................ 38 
8.5 
Dosage schedule ......................................................................................................... 39 
8.6 
Treatment assignment ................................................................................................ 39 
8.7 
Blinding, packaging, and labeling .............................................................................. 39 
8.7.1 Investigational medicinal product ......................................................................... 39 
8.7.2 Investigational medical device .............................................................................. 39 
8.8 
Supplies and accountability ....................................................................................... 40 
8.9 
Compliance ................................................................................................................ 40 
9 
Prior and concomitant illnesses and treatments ....................................................... 42 
9.1 
Prior and concomitant illnesses .................................................................................. 42 
9.2 
Prior and concomitant treatments............................................................................... 42 
10 Study procedures and schedule .................................................................................. 45 
10.1 Description of study days ........................................................................................... 45 
10.1.1 Screening visit (≤ 14 days prior to PDT) ............................................................ 45 
10.1.2 Visit 2/Baseline (PDT) ........................................................................................ 45 
10.1.3 Phone call (7 (± 3) days post PDT) ..................................................................... 47 
10.1.4 Visit 3 (Tolerability & safety assessment 28 (± 7) days after PDT) ................... 47 
10.2 Assessments ............................................................................................................... 48 
10.2.1 Evaluation of demographic data .......................................................................... 48 
10.2.2 Clinical criteria for diagnosis of AK ................................................................... 48 
10.2.3 Assessment of target lesions ............................................................................... 48 
10.2.4 Assessment of AK history ................................................................................... 49 
10.2.5 Assessment of skin type ...................................................................................... 49 
10.2.6 Pharmacokinetics ................................................................................................ 49 
10.2.7 Safety ................................................................................................................... 50 
10.3 General and dietary restrictions ................................................................................. 54 
11 Adverse events ............................................................................................................. 55 
11.1 Definitions .................................................................................................................. 55 
11.1.1 Adverse events .................................................................................................... 55 
11.1.2 Serious adverse events ........................................................................................ 56 
11.1.3 Alert terms and other reasons for expedited reporting to Pharmacovigilance .... 57 
11.1.4 Investigational medicinal product complaints ..................................................... 57 
11.1.5 Investigational medical device complaints ......................................................... 57 
11.2 Period of AE collection .............................................................................................. 57 
11.3 Documentation and reporting of adverse events by investigator ............................... 57 
11.3.1 Immediate reporting ............................................................................................ 59 
11.3.1.1 Reporting of SAEs to sponsor ..................................................................... 59 
11.3.1.2 Reporting of USADEs to the sponsor and to IRB ....................................... 60 
11.3.1.3 Reporting of expeditable adverse events to IRB ......................................... 60 

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11.3.2 Unblinding ........................................................................................................... 61 
11.4 Documentation and reporting of adverse events by sponsor ..................................... 61 
11.4.1 Determination of expectedness, Reference Safety Information .......................... 61 
11.4.2 Reporting of expeditable adverse events to competent authorities and 
investigators ...................................................................................................................... 61 
11.4.3 Periodic reporting of adverse events by sponsor ................................................. 61 
11.4.3.1 Development safety update report (DSUR) ................................................. 61 
11.5 Continuous risk assessment........................................................................................ 61 
12 Withdrawals ................................................................................................................. 62 
12.1 Withdrawal of subjects ............................................................................................... 62 
12.2 Replacement of subjects ............................................................................................. 62 
12.3 Withdrawal of samples ............................................................................................... 62 
13 Emergency procedures ............................................................................................... 63 
13.1 Emergency sponsor contact ....................................................................................... 63 
13.2 Emergency identification of investigational medicinal products ............................... 63 
13.3 Emergency treatment ................................................................................................. 63 
14 Statistical procedures .................................................................................................. 64 
14.1 Analysis variables ...................................................................................................... 64 
14.2 Analysis sets ............................................................................................................... 66 
14.3 Statistical methods ..................................................................................................... 66 
14.4 Handling of missing data ........................................................................................... 68 
14.5 Interim analysis .......................................................................................................... 68 
14.6 Sample size justification ............................................................................................ 68 
15 Ethical and legal aspects ............................................................................................. 70 
15.1 Good clinical practice ................................................................................................ 70 
15.2 Delegation of investigator duties ............................................................................... 70 
15.3 Subject information and informed consent ................................................................ 70 
15.4 Confidentiality ........................................................................................................... 70 
15.5 Protocol deviations ..................................................................................................... 71 
15.6 Protocol amendments ................................................................................................. 71 
15.7 Approval of the clinical study protocol and amendments .......................................... 71 
15.8 Ongoing information for ethics committee/institutional review board ...................... 72 
15.9 Closure of the study ................................................................................................... 72 
15.10 Record retention ......................................................................................................... 72 
15.11 Liability and insurance ............................................................................................... 72 
15.12 Financial disclosure .................................................................................................... 73 

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16 Quality control, quality assurance, and inspections ................................................. 74 
16.1 Study monitoring and source data verification .......................................................... 74 
16.2 Site audits ................................................................................................................... 74 
16.3 Site Inspections .......................................................................................................... 74 
17 Documentation and use of study findings ................................................................. 75 
17.1 Documentation of study findings ............................................................................... 75 
17.2 Use of study findings ................................................................................................. 75 
18 References .................................................................................................................... 77 
19 Appendices ................................................................................................................... 81 
 
 
 

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2 PROTOCOL OUTLINE 
Title 
An open-label Phase I study to evaluate the pharmacokinetics of 5-aminolevulinic 
acid and protoporphyrin IX in human plasma under maximal use conditions after 
topical application of 3 tubes of BF-200 ALA 10% gel for photodynamic therapy 
(PDT) in subjects suffering from actinic keratosis  
Study no: ALA-AK-CT015 
IND no: IND 115412 
NTC: 
Clinical Phase: I (in diseased subjects) 
 
 
Study design: non-randomized, open-label 
Study purpose and objectives 
To assess the pharmacokinetics (PK) of the parent drug 5-aminolevulinic acid (ALA) and 
its active metabolite protoporphyrin IX (PpIX) during photodynamic therapy applying 3 
tubes of BF-200 ALA 10 % gel (Ameluz®) in combination with the BF-RhodoLED® lamp 
in the systemic circulation of diseased individuals presenting with actinic keratosis (AK) on 
the face/scalp or in the periphery (neck/trunk/extremities) along with subjects’ 
safety/tolerability during and after treatment. Disease severity and drug dose are supposed 
to represent conditions of maximal use in line with the Guidance for Industry on Topically 
Applied Active Ingredients (May 2019; docket no. 2019-09692) provided by the Food and 
Drug Administration (FDA). 
Primary objectives  
• Assessment of baseline-adjusted plasma concentration-time curves for ALA after a 
single PDT treatment applying 3 tubes of BF-200 ALA in conjunction with the BF-
RhodoLED® under maximal use conditions in subjects with mild to severe actinic 
keratosis. 
• Assessment of baseline-adjusted plasma concentration-time curves for PpIX after a 
single PDT treatment applying 3 tubes of BF-200 ALA in conjunction with the BF-
RhodoLED® under maximal use conditions in subjects with mild to severe actinic 
keratosis. 
Secondary objectives 
• Evaluation of baseline-adjusted pharmacokinetic parameters of ALA. 
• Evaluation of baseline-adjusted pharmacokinetic parameters of PpIX. 
• Assessment of safety and tolerability of PDT with BF-200 ALA under maximal use 
conditions 
Tertiary objectives 
• Evaluation of unadjusted plasma concentration-time curve for ALA and evaluation 
of unadjusted pharmacokinetic parameters of ALA. 
• Evaluation of unadjusted plasma concentration-time curve for PpIX and evaluation 
of unadjusted pharmacokinetic parameters of PpIX. 
 
 

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Investigators / study sites 
One Phase I unit in the United States of America (US) will participate in this study where 
all study visits and procedures will be conducted. Subjects will be screened and upon 
eligibility subjected to PDT and PK blood sampling. Study site will consider the two 
strata (face/scalp versus periphery (neck/trunk/extremities)) for enrolment. 
Investigational medicinal product (IMP) and medical device 
IMP: BF-200 ALA 
• Description: BF-200 ALA is a gel formulation of 10 % 5-aminolevulinic acid 
hydrochloride, corresponding to 7.8 % 5-aminolevulinic acid (ALA). It is FDA-
approved and marketed in the US as Ameluz® for the lesion-directed and field-
directed treatment of AK of mild to moderate severity on the face and scalp, in 
combination with BF-RhodoLED® lamp. The IMP will be packed in tubes, 
containing 2 g each (medication is identical to the marketed formulation). 
• Route of administration: topical, field-directed treatment in a film of 1 mm 
thickness over treatment field(s) of approximately 60 cm2 in total. 
• Dose: Three tubes, each containing 2 g gel. Each tube contains 156 mg ALA, 
resulting in a total exposure of 468 mg ALA (free base). 
 
Investigational medical device (IMD): BF-RhodoLED® 
The study treatment requires illumination of treatment fields with the BF-RhodoLED® 
lamp (red light with emission at ~635 nm). The applied light dose of ~37 J/cm² will be 
achieved with a 10 min illumination. Please refer to the BF-RhodoLED® user manual for 
detailed lamp operating and safety instructions.  
Subjects and lesions  
Eligible subjects will be of all genders, between 18 and 85 years of age and suffering 
from at least 12 clinically confirmed AK lesions of mild to severe severity (according to 
Olsen et al., 1991) with a diameter of ≥ 4 mm each, either in the face/scalp (including 
forehead, excluding eyes, nostrils, ears, and mouth) or on neck/trunk/extremities. AK 
lesions must be located in one or several treatment fields with a combined area of 
approximately 60 cm2. Treatment fields may be discontinuous, but up to 2 illumination 
areas with the BF-RhodoLED® lamp (6 cm x16 cm each) should be sufficient to 
illuminate the treatment fields.  
Number of subjects 
32 subjects (16 subjects in each stratum) 
Study Duration and Dates 
Screening of subjects, including diagnosis and safety analyses, will be conducted at Visit 1. 
The study will include two further visits (Visit 2 where the photodynamic therapy (PDT) is 
performed with PK blood sampling and Visit 3 for final safety assessment). The time 
interval between Visit 1 (screening) and Visit 2 (treatment) will be no longer than 14 days 
but can be extended for up to additional 14 days in case a dosing day criterion is met. 
At Visit 2, three tubes of BF-200 ALA will be applied to each eligible subject. After three 
hours of incubation, subjects will receive PDT illumination with the BF-RhodoLED® lamp. 
In terms of the PDT procedure (preparation of treatment field(s), drug application, 
incubation, illumination), the treatment will be done according to the labels of BF-200 ALA 
and BF-RhodoLED® with the exceptions that 3 tubes are applied per subject and the 

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periphery is treated in addition to the approved treatment of head and scalp. Blood samples 
will be taken from subjects starting 0.5 h prior to BF-200 ALA application and then for up 
to 10 h afterwards. Subjects will be called by telephone for safety assessment 7 (± 3) days 
post Visit 2. The final Visit 3, 28 (± 7) days after Visit 2, will entail safety assessment. 
Recruitment period           approx. 6 months 
FSFV                                approx. Feb 2020 
LSFV                                approx. Aug 2020 
LSLV/end of study           approx. Oct 2020 
Sample size 
The suggested sample size for the study is 32 subjects, stratified into two groups of 16 
subjects each. One of the groups will receive PDT applying 3 tubes of BF-200 ALA on the 
face/scalp, the other group will receive PDT applying 3 tubes of BF-200 ALA on the 
neck/trunk/extremities. A previous PK Phase I study under maximal use conditions in AK 
subjects with 1 tube of BF-200 ALA (ALA-AK-CT006) had revealed homogeneous 
baseline-adjusted levels of ALA and PpIX in 12 subjects, with a coefficient of variation of 
53-73% in the key pharmacokinetic parameters after drug application. As statistical 
evaluation of PK and safety is intended to be performed as descriptive statistics only, no 
calculation of predictive power is required.  
Inclusion and exclusion criteria 
Inclusion criteria 
1. Subjects with at least 12 distinctive and clinically confirmed mild to severe AK 
lesions (according to Olsen et al., 1991) with a diameter of ≥ 4 mm each, on 
either the face/scalp (including forehead, excluding eyes, nostrils, ears, and 
mouth) or the neck/trunk/extremities, within treatment field(s) of about 60 cm² 
in total. Treatment field(s) may be discontinuous but must be within 2 
illumination areas of the BF-RhodoLED® lamp (6 cm x 16 cm each). 
2. All genders 18 - 85 years of age (inclusive). 
3. Willingness and ability of the subject to provide informed consent and to sign 
the Health Insurance Portability and Accountability Act (HIPAA) form. A 
study-specific informed consent form and HIPAA form must be obtained in 
writing for all subjects prior to starting any study procedures.  
4. Willingness and ability to comply with study procedures, particularly 
willingness to receive one PDT with up to two illumination devices 
simultaneously. 
5. Subjects with good general health and subjects with clinically stable medical 
conditions will be permitted to be included in the study. 
6. Subjects receiving any drugs affecting coagulation (e.g. anticoagulants, anti-
platelet drugs) should be on a stable dose. 
7. Acceptance to abstain from extensive sunbathing and the use of a solarium 
during the clinical study. 
8. Women of child-bearing potential must have a negative serum pregnancy test 
and must use an adequate and highly effective or two effective methods of 
contraception throughout the study. 
 

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Exclusion criteria: 
To reduce risks for the subjects and to ensure that the subjects are in a comparable status, 
subjects will be excluded if they meet at least one of the following exclusion criteria: 
1. Any known history of hypersensitivity to ALA, porphyrins or excipients of 
BF-200 ALA. 
2. History of soy or peanut allergy. 
3. Subjects with sunburn within illumination areas (reassessment of subjects is 
allowed once if the sunburn is expected to resolve within the screening period. 
Reassessment can be done on the day of the actual treatment).  
4. Clinically significant medical conditions making implementation of the 
protocol or interpretation of the study results difficult or impairing subjects’ 
safety such as: 
a. Presence of porphyria or known photodermatoses  
b. Known diagnosis of human immunodeficiency virus (HIV) based on clinical 
history 
c. Metastatic tumor or tumor with high probability of metastasis  
d. Infiltrating skin neoplasia (suspected or known). 
e. Unstable cardiovascular disease (New York Heart Association [NYHA] 
class III, IV) 
f. Unstable hematologic (including Myelodysplastic syndrome), hepatic, renal, 
neurologic, or endocrine condition  
g. Unstable collagen-vascular condition 
h. Unstable gastrointestinal condition 
i. Immunosuppressive condition 
j. Presence of clinically significant inherited or acquired coagulation defect 
5. Clinical diagnosis of atopic dermatitis, Bowen’s disease, BCC, eczema, 
psoriasis, rosacea, squamous cell carcinoma (SCC), other malignant or benign 
tumors in the treatment field(s), or other possible confounding skin conditions 
(e.g. wounds, irritations, bleeding or skin infections) within or in close 
proximity (< 5 cm distance) to treatment field(s). (Reassessment of subjects is 
allowed once if wounds, irritations, bleeding or skin infections are expected to 
resolve within the screening period. Reassessment can be done on the day of 
actual treatment.) 
6. Presence of strong pigmentation or tattoos or any other abnormality that may 
impact lesion assessment or light penetration in the treatment field(s). 
7. More than moderate smoker (e.g. > 10 cigarettes/day or equivalent). 
8. Suspicion of drug or alcohol abuse. For the purpose of this study, alcohol 
abuse is defined as more than moderate alcohol consumption (> 1 drink/day for 
women and > 2 drinks/day for men). 
9. Physical treatment of malignant or benign tumors of the skin within the 
treatment field(s) and at a distance of < 5 cm to the treatment field(s) during 
the last 4 weeks prior to screening.  

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10. Any therapy such as cryotherapy, laser therapy, electrodessication, surgical 
removal of lesions, curettage, or treatment with chemical peels such as 
trichloroacetic acid within the treatment field(s), or within a radius less than 
5 cm away from the treatment field(s) 4 weeks prior to screening. 
11. Any topical medical treatment of the skin within the designated time period 
below:  
a. Topical treatment with ALA or methyl-aminolevulinate (MAL) or an 
investigational drug in- and outside the treatment field(s) within 8 weeks 
prior to screening. 
b. Topical treatment with immunomodulatory/immunosuppressive anti-
inflammatory, or cytotoxic agents inside the treatment field(s) or within a 
radius less than 5 cm away from the treatment field(s) within 8 weeks prior 
to screening. 
c. Start of topical administration of medication with hypericin or other drugs 
with phototoxic or photoallergic potential in- and outside the treatment 
field(s) within 8 weeks prior to screening. Subjects may, however, be 
eligible if such medication was applied for more than 8 weeks prior to 
screening visit without evidence of an actual phototoxic/photoallergic 
reaction.  
12. Any use of the below specified systemic treatments within the designated 
periods:  
a. Use of cytotoxic drugs within 24 weeks, immunomodulators or 
immunosuppressive therapies or use of ALA or ALA-esters (e.g. MAL) 
within 12 weeks, investigational drugs or drugs known to have major organ 
toxicity within 8 weeks, interferon or corticosteroids (oral or injectable) 
within 6 weeks prior to screening. 
b. Start of intake of medication with hypericin or systemically-acting drugs 
with phototoxic or photoallergic potential within 8 weeks prior to screening. 
Subjects may, however, be eligible if such medication was taken in or 
applied for more than 8 weeks prior to screening visit without evidence of an 
actual phototoxic/photoallergic reaction.  
13. Laboratory values outside the reference range that are clinically significant in 
the opinion of the investigator (e.g., suggesting an unknown disease and 
requiring further clinical evaluation according to investigator), especially 
aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma 
glutamyl transpeptidase (gamma-GT).  
14. Impaired renal function (Glomerular filtration rate below 50 mL/min/1.73m² 
estimated by Modification of Diet in Renal Disease equation (MDRD)). 
15. Positive test for HIV antibodies, Hepatitis B-virus surface antigen (HBsAg) or 
positive Anti-hepatitis C-virus antibody (Anti-HCV) test. 
16. Significant blood donation or blood loss (≥ 500 mL) within three months prior 
to Visit 2. 
17. Breast-feeding women. 

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18. Subject unlikely to comply with the protocol, e.g. inability to return for visits, 
unlikely to complete the study, or inappropriate in the opinion of the 
investigator. 
19. Prior participation in the study (participation is defined as having been 
screened). 
20. A member of study staff or sponsor staff directly involved in the conduct of the 
protocol or a close relative thereof. 
21. Simultaneous participation in a further clinical study. 
Reassessment of subjects is allowed once if sunburn, wounds, irritations, bleeding or skin 
infections detected at Visit 1 are expected to resolve within the screening period. 
Reassessment can be done on the day of the actual treatment. 
Dosing day exclusion criteria: 
1. Febrile or infectious illness within 7 days prior to Visit 2. 
2. Subjects with sunburn, wounds, irritations, bleeding or other confounding skin 
conditions within illumination areas at Visit 2.  
3. Use of topical NSAIDs inside and outside the treatment field(s) or systemic 
intake of NSAIDs within 7 days prior to Visit 2. 
In case a subject meets one of the dosing day exclusion criteria, Visit 2 can be rescheduled 
once within 14 days. Meeting any of the dosing day exclusion criteria on the rescheduled 
visit will lead to discontinuation from the trial.  
Procedures 
• Screening 
• 
Assessment of eligibility along inclusion/exclusion criteria including 
vital signs, and physical examination 
• 
Blood sampling for safety laboratory and PK-baseline parameters 
• PDT  
• 
Field-directed application of BF-200 ALA on face/scalp or 
trunk/neck/extremities (3 x 2 g BF-200 ALA) subsequent to degreasing 
and lesion preparation on a total skin area of about 60 cm², which may be 
discontinuous, as long as it can be covered by two illumination areas of 
BF-RhodoLED® lamp (6 cm x 16 cm).  
• 
Occlusive, light-blocking dressing of treatment fields during incubation 
with BF-200 ALA. 
• 
PDT-illumination is performed 3 h after topical application according to 
label. If two illumination areas are needed, two BF-RhodoLED® lamps 
are used simultaneously. Thus, for the entire 60 cm² treatment only one 
illumination step is performed. 
• 
For further treatment details refer to the Prescribing Information of 
Ameluz® and/or the user manual of BF-RhodoLED®. 
 
• Blood sampling (approx. 10 mL/sample) for ALA and PpIX 
• 
At screening (Visit 1), together with the blood for the safety laboratory 
evaluation 

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• 
On the treatment day (Visit 2) at the following timepoints (in relation to 
BF-200 ALA application): -0.5; 0*; 0.5; 1; 1.5; 2; 2.5; 3**; 3.5; 4; 5; 6; 8; 
10 hours;  
*: Prior to topical application 
**: Prior to illumination  
• Safety assessments 
• 
Immediately following PDT, treatment-emergent adverse events 
(TEAEs) including application site skin reactions, discomfort, and pain 
(using an 11-point Numeric Rating Scale (NRS-11)) will be assessed  
• 
Subjects will be called by telephone on day 7 (±3) post PDT to assess the 
safety profile of the treatment 
• 
At Visit 3, 28 (±7) days post PDT, assessment of TEAEs including 
application site skin reactions and discomfort, vital signs, physical 
examination, and blood sampling for safety laboratory 
Criteria of evaluation 
 
Pharmacokinetics  
Primary endpoints  
• Baseline-adjusted plasma concentrations of ALA for obtaining baseline-adjusted 
plasma concentration-time curves 
• Baseline-adjusted plasma concentrations of PpIX for obtaining baseline-adjusted 
plasma concentration-time curves  
 
Secondary endpoints  
• Baseline-adjusted AUC0-t, baseline-adjusted AUC0-∞, baseline-adjusted Cmax, Tmax, 
T1/2, and λZ for ALA (if data permit)  
• Baseline-adjusted AUC0-t, baseline-adjusted AUC0-∞, baseline-adjusted Cmax, Tmax, 
T1/2, and λZ for PpIX (if data permit)  
 
Safety  
• Local and overall tolerability, pain assessment (NRS-11), safety laboratory, physical 
examination, and vital signs 
 
Tertiary endpoints 
• Unadjusted plasma concentration-time curve for ALA and pharmacokinetic 
parameters of ALA: unadjusted AUC0-t, unadjusted AUC0-∞, unadjusted Cmax, Tmax, 
T1/2, and λZ if data permit 
Unadjusted plasma concentration-time curve for PpIX and pharmacokinetic 
parameters of PpIX: unadjusted AUC0-t, unadjusted AUC0-∞, unadjusted Cmax, Tmax, 
T1/2, and λZ if data permit 
 
Statistical methods 
 
• Pharmacokinetics 
Individual plasma concentrations and baseline-adjusted plasma concentrations of 
ALA and PpIX will be listed and summarized. Graphical displays will be provided 
as appropriate. If data permit, calculation of pharmacokinetic parameters will be 
performed on baseline-adjusted (and unadjusted) plasma concentration data of ALA 

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and PpIX. The results will be listed and summarized as appropriate. Data will be 
analyzed overall and according to strata. 
 
• Safety 
Safety results will be listed and summarized using descriptive statistics. Data will be 
analyzed overall and according to strata. 
Bioanalytics 
 
• Bioanalyses of ALA and PpIX in plasma will be performed using internally 
standardized liquid chromatography tandem mass spectrometry methods. 
End of study 
Last subject last visit  
 
 
 

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Table 1: Study schedule 
AE: Adverse Event; AK: Actinic Keratosis; ALA: 5-aminolevulinic acid; BP: Blood Pressure; HR: Heart Rate; eCRF: electronic case report form; HIV: Human 
Immunodeficiency Virus; EoS: End of study; NRS; 11-point Numeric Rating Scale; PDT; Photodynamic Therapy; PpIX: Protoporphyrin IX; SAE: Serious 
Adverse Event; WOCBP: Women of Childbearing Potential 
a Visit 2 can be rescheduled within 2 weeks after the scheduled date if at least one of the dosing day exclusion criteria is met. 
b  Re-check of eligibility and check of dosing day exclusion criteria. 
c Skin type will be evaluated according to Fitzpatrick criteria (Fitzpatrick 1988). 
d Lesions will be evaluated according to Olsen criteria (Olsen et al., 1991). 
e In case the subjects come to the screening visit in a fasted state, blood and urine sampling will be performed. In case the subject is not fasted, blood and  
urine sampling will be postponed 1-2 days. 
f  Blood sampling time points (at Visit 1: one baseline sample and at Visit 2: 14 samples in total (timepoints in relation to BF-200 ALA application: -0.5; 0; 0.5; 
1; 1.5; 2; 2.5; 3; 3.5; 4; 5; 6; 8; 10 h)). 
 
 
 
 
 
All subjects  
 
Visit 1 
Visit 2a 
Phone call  
Visit 3 
 
Screening 
PDT/baseline 
 
EoS 
 
≤ 14 days    
prior to 
PDT 
 
Day 0 
7 days 
( 3 days) 
post PDT 
28 days 
(± 7 days) 
post PDT 
Clinic visit 
X 
X 
 
X 
Informed consent/HIPAA 
X 
 
 
 
Assign subject number 
X 
 
 
 
Demographics 
X 
 
 
 
Inclusion/ exclusion criteria  
X 
Xa,b 
 
 
Skin type assessment c 
X 
 
 
 
AK history 
X 
 
 
 
Concomitant diseases/relevant medical history 
X 
 
 
 
Selection of treatment fields and assessment of target 
lesions (size, number, location, and clinical 
assessment according to Olsend) 
X 
 
 
 
Generation of template of AK treatment field(s) on 
grid foil; sketching of treatment field(s) and 
suggested illumination area(s) into cartoon 
X 
 
 
 
Instruction of subjects of concomitant medication 
permitted/forbidden within 7 days before and after 
PDT  
X 
X 
 
 
General physical examination 
X 
 
 
X 
Vital signs (HR, BP) 
X 
X 
 
X 
Clinical laboratory tests (routine hematology, blood 
chemistry, serum pregnancy test (in WOCBP), and 
urinalysis) 
Xe 
 
 
X 
Hepatitis and HIV serology, examination of 
coagulation parameters and eGFR 
X 
 
 
 
Urine pregnancy test in WOCBP  
 
X 
 
 
Blood sampling for ALA and PpIX analysisf 
X 
X  
 
 
Application of BF-200 ALA and PDT with BF-
RhodoLED® (including preparation of treatment 
field(s)) 
 
X 
 
 
Assessment of application site pain during PDT via 
11-point pain questionnaire (NRS-11)  
 
X 
 
 
(S)AEs  
X 
X 
X 
X 
Concomitant medications/ treatments 
X 
X 
X 
X 
eCRF entry 
X 
X 
X 
X 

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3 ABBREVIATIONS AND DEFINITIONS 
β-hCG  
 
Human chorionic gonadotropine 
5-FU  
 
5-Fluorouracil 
ADE  
 
Adverse device event 
AE 
 
 
Adverse event 
AK 
 
 
Actinic keratosis 
ALA  
 
5-aminolevulinic acid 
ALT  
 
Alanine aminotransferase 
ASS 
 
 
Acetylsalicylic acid 
AST 
 
 
Aspartate aminotransferase 
ATC  
 
Anatomical Therapeutic Chemical Classification System 
AUC  
 
Area under the curve 
BCC  
 
Basal cell carcinoma 
BF 
 
 
Biofrontera 
BF-200 ALA  
Nanoemulsion gel formulation containing 7.8 % ALA 
(development name for Ameluz®) 
BP 
 
 
Blood pressure 
CI 
 
 
Confidence interval 
cm 
 
 
centimeter 
CRO  
 
Contract Research Organization 
CSP 
 
 
Clinical study protocol 
CV 
 
 
Coefficient of variation 
DSUR  
 
Development safety update report 
EC 
 
 
Ethics committee 
eCRF  
 
Electronic case report form 
EDTA  
 
Ethylendiaminetetraacetic acid 
EMA  
 
European Medicines Agency 
EoS 
 
 
End-of-Study 
EU 
 
 
European Union 
FDA  
 
Food and Drug Administration 
g 
 
 
Gram(s) 

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GCP  
 
Good clinical practice 
GmbH  
 
Gesellschaft mit beschränkter Haftung, Ltd, limited liability company 
GMP  
 
Good manufacturing practice 
HBsAg 
 
Hepatitis B-virus surface antigen 
HCV  
 
Hepatitis C-virus 
HIPAA 
 
Health Insurance Portability and Accountability Act 
HIV 
 
 
Human immunodeficiency virus 
HR 
 
 
Heart rate 
IB 
 
 
Investigator’s brochure 
ICF 
 
 
Informed consent form 
ICH 
International Council for Harmonisation of Technical Requirements for 
Registration of Pharmaceuticals for Human Use 
Illumination area 
Area which is effectively illuminated by one BF-RhodoLED® lamp 
(6 cm x 16 cm) in one illumination session. 
IMD 
Investigational medical device 
IMP 
Investigational medicinal product 
IND 
Investigational New Drug 
IRB 
Institutional review board 
ISF 
 
 
Investigator Site File 
LED  
 
Light emitting diode 
MAL  
 
Methyl aminolevulinic acid 
MCH  
 
Mean corpuscular hemoglobin 
MCHC 
 
Mean corpuscular hemoglobin concentration 
MCV  
 
Mean corpuscular volume 
MDRD 
 
Modification of Diet in Renal Disease 
MedDRA 
 
Medical Dictionary for Regulatory Activities 
NMSC  
 
Non-melanoma skin cancer 
NRS-11 
 
Numeric Rating Scale (11-point pain rating scale) 
NSAID 
 
Non-steroidal anti-inflammatory drugs 
NYHA 
 
New York Heart Association 
PDT 
 
 
Photodynamic therapy 

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PI 
 
 
Prescribing Information 
PK 
 
 
Pharmacokinetic(s) 
PpIX  
 
Protoporphyrin IX 
ROS  
 
Reactive oxygen species 
RSI 
 
 
Reference safety information 
SAE 
 
 
Serious adverse event 
SAF 
 
 
Safety set 
SAP 
 
 
Statistical analysis plan 
SAR  
 
Serious adverse reaction 
SCC 
 
 
Squamous cell carcinoma 
SD 
 
 
Standard deviation 
SOP 
 
 
Standard Operating Procedure 
SUSAR 
 
Suspected unexpected serious adverse reaction 
TEAEs 
 
Treatment-emergent adverse events 
Treatment area 
Body area in which the treatment field is located 
Treatment field 
Area within the illumination area to which medicinal product was 
applied 
USADE 
 
Unanticipated serious adverse device effect 
UV 
 
 
Ultraviolet 
WOCBP 
 
Women of childbearing potential 
 
 

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4 INTRODUCTION AND STUDY RATIONALE 
4.1 Introduction 
(Solar) actinic keratosis (AK), also known as squamous cell carcinoma (SCC) in situ, 
represents the most common neoplasia affecting fair-skinned subjects and develops in 
chronically sun-exposed skin areas. It is assumed that AK is the result of the accumulation of 
damage in keratinocytes caused by irradiation with ultraviolet (UV) light. Lesions of different 
sizes are found in affected subjects, characterized by rough, scaly and erythematous patches. 
Epidermal changes can include hyperkeratosis, parakeratosis, dyskeratosis, acanthosis, or 
keratinocyte atypia. In one prospective study by Czarnecki et al. (1), 72 % of 208 subjects 
with invasive SCC had AK contiguous to the SCC. It was concluded that the SCC arose in 
these AK lesions. Today, it is generally accepted that AK represents an early stage of a 
malignant condition (carcinoma in situ) that can progress into SCC. Between 0.025 % and 
16 % of the AK lesions develop into SCC (2). Therefore, it is highly recommended to treat 
lesions of AK before they evolve to skin cancer. However, the line of progression from mild 
AK lesions to lesions of moderate or severe phenotype and further progression into SCC was 
counteracted by the finding that the clinical classification of lesions using the Olsen grade 
does not accurately match the histopathological classification according to Röwert-Huber (3). 
This reinforces the need to treat even AK lesions of mild clinical phenotype and cancerous 
fields as they could histopathologically present forms of early in situ SCC type II or in situ 
SCC type III already (3). In addition, epidemiological data have indicated that AK lesions, as 
an indicator for chronic sun damage, are a reliable marker for people who are most 
predisposed to the development of an invasive SCC (4). 
Based on these observations, early and field-directed treatment is advised by recent guidelines 
and expert recommendations to address all AK severity grades, including subclinical 
manifestations (5–10). Photodynamic therapy (PDT) is one of several treatment options 
available for the field-directed treatment of cutaneous neoplasms and non-neoplastic lesions. 
It requires three components: a photosensitizer, light with sufficient energy at suitable 
wavelengths, and oxygen.  
Kennedy et al. (11) discovered that the topical application of 5-aminolevulinic acid (ALA), an 
endogenous metabolite found in essentially all eukaryotic cells, as a prodrug is convenient for 
PDT of subjects with a variety of neoplastic and non-neoplastic cutaneous diseases. This 
precursor in the porphyrins’ synthetic pathway is converted by the target cells to 
protoporphyrin IX (PpIX), an effective natural photosensitizer. Anomalous cells in dermal 
lesions seem to be metabolically different from normal cells resulting in a higher 
accumulation of PpIX. Eventually, these target cells will be selectively destroyed by events 
triggered by PDT (12–16). 
PpIX can be activated by the absorption of energy at different wavelengths, ranging from blue 
to red light. PpIX shows a maximal excitation at around 410 nm (Soret band) with four 
smaller peaks in the visible range around 510, 530, 580, and 630 nm. Illumination with red 
light (e.g. by light emitting diode (LED) devices around 630 nm) may be advantageous for the 
treatment of deeper lesions because it penetrates tissue better when compared with light at 
shorter wavelengths. The use of LED devices results (as shown in several Phase III studies) in 
high clearance rates but is accompanied by a high frequency of adverse events (AE), in 

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particular transient application site reactions such as erythema, edema, irritation, pruritus, and 
pain. 
In ALA PDT, luminous energy is transferred by the photosensitizer PpIX to oxygen, leading 
to the formation of reactive oxygen species (ROS), eventually causing cell death. The light-
induced damage depends on the applied doses and incubation periods. Preneoplastic and 
neoplastic cells are eliminated, and the epidermis is regenerated after healing of the induced 
local inflammation. Since the penetration of ALA is mostly prevented by the basal membrane 
separating the epidermis from the dermis, no scar formation is observed. 
Due to ALA PDT’s mode of action, AEs are mainly local application site reactions such as 
erythema, pain, edema, and irritation which are transient and self-limiting, normally within 1-
2 weeks. 
Topically applied ALA is well tolerated in humans. Over the past 25 years, the use of ALA 
PDT was extended from the treatment of dermal lesions to the identification and eradication 
of neoplastic or preneoplastic cells in additional tissues/organs such as vagina, bladder, 
gastrointestinal tract, respiratory tract, and brain. For non-dermal indications, systemic 
applications of ALA are commonly used. 
Biofrontera Bioscience GmbH has developed a nanoemulsion-based gel formulation of ALA 
(development code: BF-200 ALA; brand name: Ameluz®). BF-200 ALA gel contains 10 % 
ALA hydrochloride, equivalent to 7.8 % ALA in a nanoemulsion formulation and was shown 
to improve skin penetration and uptake of ALA in the target area due to the lipophilic 
component of the nanoemulsion (17,18). Thus, as a result of the better penetration capacities, 
the amount of ALA in the marketed formulation could be reduced to 7.8 %, half of 
comparable formulations on the market. Furthermore, this formulation significantly enhances 
the shelf-life as well as in-use stability of the active ingredient. This is considered a relevant 
advantage, given the instability of ALA in aqueous formulations. 
In the US, Ameluz® in combination with the red-light BF-RhodoLED® lamp has been 
approved for the lesion-directed and field-directed PDT of actinic keratoses of mild to 
moderate severity on the face and scalp by the Food and Drug Administration (FDA) on May 
10th, 2016 (NDA 208081). 
In the European Union (EU), the European Medicines Agency (EMA) granted a centralized 
Marketing Authorization for Ameluz® for the treatment of mild to moderate AK on the face 
and scalp in December 2011 (EU/1/11/740/001). In November 2012, the BF-RhodoLED® 
medical device was CE-marked and subsequently launched in the European market. In 
September 2016 the approval was extended to the indication of field cancerization, and in 
January 2017 to the treatment of superficial and nodular basal cell carcinoma (BCC). In 
March 2018, the EMA granted extension of the posology to the treatment of mild to moderate 
AK on the face and scalp and field cancerization with daylight PDT.  
Ameluz® furthermore received marketing approval in Switzerland for the treatment of mild to 
moderate AK on the face and scalp with conventional PDT in November 2015 (Swissmedic 
number: 65693) and for the treatment with daylight PDT in September 2018. Subsequently, 
Swissmedic approved Ameluz® for the treatment of field cancerization and BCC in May 2018 
(Swissmedic number: 65693). In Israel, Ameluz® was granted marketing registration approval 
for the treatment of mild to moderate AK on the face and scalp in May 2016. Subsequently, 

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Biofrontera’s illumination device BF-RhodoLED® was registered in Israel in May 2017 as 
well. 
In a dose-finding clinical study (ALA-AK-CT001) in vivo pharmacokinetics of BF-200 ALA 
were investigated. ALA and PpIX serum levels and ALA urine levels were measured before, 
3 and 24 hours after administration of BF-200 ALA for PDT. None of the post dose levels 
were increased in comparison to the naturally occurring pre-dose levels, suggesting the 
absence of relevant systemic absorption after topical administration. 
Further pharmacokinetic data with BF-200 ALA were collected in one previous 
pharmacokinetics (PK) Phase I study (ALA-AK-CT006). This maximal use study, in which 
one tube of BF-200 ALA was applied to subjects suffering from at least 10 mild to moderate 
AKs in a 20 cm² skin area on the face or forehead, no systemic elevation of PpIX levels was 
observed. A slight and transient elevation of systemic ALA levels was well below the daily 
rate of ALA synthesis. Taking into consideration the available data from the scientific 
literature, the elevation in the concentration of ALA is not expected to yield any noticeable 
clinical effect and thus regarded as uncritical for the subjects (19–22). Systemic absorption of 
ALA after application of a dose of 7.8 mg ALA/cm² to treatment fields >20 cm² has not been 
investigated so far. 
A recent European study (ALA-AK-CT010) compared the efficacy of BF-200 ALA with 
placebo for the field-directed treatment of AK located on extremities and trunk/neck 
(periphery) with PDT when using the BF RhodoLED® lamp. This study demonstrated 
significant efficacy on extremities, trunk and neck that compare favorably with other 
treatment options. Thus, it can be assumed that Ameluz® in conjunction with BF-RhodoLED® 
may provide a new, safe and effective treatment option for mild to moderate AK on the 
extremities, trunk and neck as well. 
The Marketing Authorization Holder (Biofrontera Bioscience GmbH) intends to perform a 
Phase I study to obtain pharmacokinetic profiles of ALA and its metabolite PpIX in a single 
PDT applying 3 tubes of BF-200 ALA (458 mg ALA in total) in conjunction with the BF-
RhodoLED® lamp in diseased subjects presenting with AK on the face and scalp as well as 
the periphery under maximal use conditions. 
4.2 Study rationale 
Given that extension of fields with chronic actinic sun damage can exceed the usually treated 
area size of 20-25 cm² (23), particularly when also taking AK in the periphery into 
consideration, safe and efficient options for the treatment of these expanded AK areas are 
needed. 
FDA-approved treatment options for field-directed AK treatment comprise formulations 
containing ingenol mebutate or diclofenac/hyaluronic acid (3 %/2.5 %), most of which require 
repeated applications for up to several months or lead to side effects related to cytotoxic 
and/or inflammatory reactions induced by the treatment that may last for the entire treatment 
period or even longer. 
Compared with other methods like surgery, abrasion, cryotherapy, and alternative topical 
treatments, use of PDT is advantageous especially due to the high selectivity of the treatment, 
but also based on the short treatment period that can be entirely controlled by the physician, 

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and the excellent cosmetic results (24). In addition, a European network meta-analysis of the 
relative clinical efficacy of 10 different treatment modalities for mild to moderate AK on the 
face and scalp, including PDT products as well as formulations containing cryotherapy, 5-
fluorouracil, imiquimod, ingenol mebutate or diclofenac/ hyaluronic acid, has shown that 
ALA PDT using BF-200 ALA was the most efficacious treatment option (25). 
Today, besides Ameluz®, one further PDT product containing ALA is available in the US 
market. Levulan® Kerastick® contains ALA at a concentration of 20 % and is provided as a 2-
component system. Consequently, ALA has to be dissolved immediately before use. By label, 
use of Levulan® Kerastick® is restricted to lesion-directed treatment of minimally to 
moderately thick AKs located on the face and scalp as well as on upper extremities. Thus, 
Ameluz® is the only PDT product available in the US market which has been approved for the 
field-directed treatment of AKs.  
So far, availability of clinical data for the treatment of large AK areas is limited. However, 
several studies for treatment of AK areas >20 cm² using ALA PDT have indicated good 
efficacy and tolerability (26–29). Therefore, PDT may represent an adequate option for the 
treatment of extended cancerous fields preventing long treatment duration with sequential 
treatment sessions.  
For these reasons, this exploratory study aims at obtaining pharmacokinetic profiles of ALA 
and its metabolite PpIX after a single PDT treatment with BF-200 ALA in subjects with 
actinic keratosis in an expanded treatment field of 60 cm² located on the face/scalp or in the 
periphery, applying approx. 458 mg ALA in total (7.8 mg ALA/cm²). In addition, subjects’ 
safety/tolerability during and after treatment will be assessed.  
4.3 Risk/benefit analysis 
This open-label Phase I study will include diseased subjects presenting with at least 12 AK 
lesions with diameter of ≥ 4 mm within the 60 cm2 treatment field. All participants will 
receive active BF-200 ALA treatment - already marketed for the treatment of AK in the US, 
EU, Switzerland and Israel under the brand name Ameluz® - in combination with 
conventional red-light PDT illumination. 
Clinical efficacy and safety of BF-200 ALA in combination with conventional red-light PDT 
illumination for the treatment of mild to moderate AK on the face and scalp were previously 
examined in one dose-finding study, and three confirmatory studies encompassing a total of 
885 randomized subjects comprising 462 subjects (2674 lesions) exposed to BF-200 ALA 
(7.8% ALA) (30–32). Additionally, one confirmatory intra-individual study (ALA-AK-
CT010) with 50 subjects was performed for the assessment of clinical efficacy and safety of 
BF-200 ALA for the treatment of AKs located on extremities or trunk/neck. In these pivotal 
clinical trials, complete clearance of subjects 12 weeks after the first PDT with BF-200 ALA 
was shown to be up to 61.8 % and total lesion clearance was up to 84.2 % (30–32). Thus, we 
expect that a comparable percentage of participating subjects will benefit from the single PDT 
treatment which will be administered in the current study. 
In previous clinical trials with BF-200 ALA, local application site reactions were observed in 
84-100 % of the subjects. These reactions are expected, given the therapeutic principle of 
PDT, which is based on phototoxic effects. The most common signs and symptoms were 
application site erythema, pain/burning, irritation, and edema. Most adverse reactions 

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occurred during illumination or shortly afterwards. Symptoms were usually of mild or 
moderate intensity (investigator’s assessment on a 4-point scale) and lasted for 1 to 4 days in 
most cases; however, in some cases, they persisted for 1 to 2 weeks or even longer. It is 
known that the intensity of AEs depends on the type of illumination used for PDT and 
correlates with the higher clearance rate achieved by the use of narrow spectrum lamps, e.g. 
BF-RhodoLED®. In rare cases, adverse reactions may require interruption or discontinuation 
of the illumination.  
Common adverse effects of PDT with BF-200 ALA include headache and reactions at the 
application site, such as abnormal sensation, increased sensitivity to pain, discomfort, erosion, 
and discharge. More detailed information on known adverse reactions is provided in the 
prescribing information (PI) for Ameluz® (19). This drug is contraindicated in subjects with 
known hypersensitivity to ALA, to porphyrins or to any excipients of Ameluz®, and in 
subjects with porphyria or photodermatoses. 
It is assumed that local adverse reactions in more extended treatment fields will be similar to 
those known from treatment of AK lesions as well as cancerous fields described previously. 
Nonetheless, an appropriate form of pain management has to be considered as PDT pain may 
be related to the size of the treatment field(s) (33). For this reason, pain management will be 
performed according to established guidelines (34,35) but restrictions for co-medication 
described in this protocol must be taken into consideration.  
In this study, inclusion and exclusion criteria have been chosen to minimize possible risks due 
to the administration of BF-200 ALA, and to ensure a uniform study population. BF-200 ALA 
and the PDT lamp BF-RhodoLED® will be handled by appropriately trained study personnel. 
For maximal comparability to previous studies, up to two BF-RhodoLED® lamps will be used 
simultaneously, such that the light dose of 37 J/cm2 will be applied to the entire 60 cm2 
treatment field in 10 min. 
 
 

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5 STUDY OBJECTIVES 
5.1 Primary objectives 
The primary objectives of the study are:  
• Assessment of baseline-adjusted plasma concentration-time curves for ALA after a 
single PDT treatment applying 3 tubes of BF-200 ALA in conjunction with the BF-
RhodoLED® under maximal use conditions in subjects with mild to severe actinic 
keratosis. 
• Assessment of baseline-adjusted plasma concentration-time curves for PpIX after a 
single PDT treatment applying 3 tubes of BF-200 ALA in conjunction with the BF-
RhodoLED® under maximal use conditions in subjects with mild to severe actinic 
keratosis. 
Data will be analyzed overall and according to strata (treatment area: face/scalp or periphery 
(neck/trunk/extremities)). 
5.2 Secondary objectives 
The secondary objective of this study is to calculate pharmacokinetic parameters based on 
baseline-adjusted plasma concentration data of ALA and PpIX (if data permits) and to 
evaluate the safety and tolerability of PDT with BF-200 ALA under maximal use conditions. 
Pharmacokinetics: 
The secondary objectives of the study regarding pharmacokinetics include: 
• Evaluation of baseline-adjusted pharmacokinetic parameters of ALA. 
• Evaluation of baseline-adjusted pharmacokinetic parameters of PpIX. 
Safety: 
The secondary objectives of the study regarding safety include: 
• Assessment of safety and tolerability of PDT with BF-200 ALA under maximal use 
conditions 
All secondary parameters will be analyzed descriptively and in an exploratory way overall 
and according to strata. 
5.3 Tertiary objectives 
To compensate for situations in which baseline-adjustment mathematically impairs 
calculation of PK parameters, the tertiary objective of this study is to calculate unadjusted PK 
parameters of ALA and PpIX as well.  
The tertiary objectives include: 
• Evaluation of unadjusted plasma concentration-time curve for ALA and evaluation of 
unadjusted pharmacokinetic parameters of ALA. 
• Evaluation of unadjusted plasma concentration-time curve for PpIX and evaluation of 
unadjusted pharmacokinetic parameters of PpIX. 

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All tertiary parameters will be analyzed descriptively and in an exploratory way overall and 
according to strata. 
 
 

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6 STUDY DESIGN, DURATION AND DATES 
6.1 Study design 
This protocol describes a non-randomized, open-label Phase I study that will be conducted in 
the US. All study visits and procedures will be conducted at one Phase I unit. 
The clinical study will consist of: 
• a screening visit (within 14 days before treatment), at which eligibility of subjects for 
study participation will be assessed (Visit 1) and 1 baseline PK blood sample will be 
taken 
• a baseline/treatment visit, at which eligible subjects will receive PDT with application 
of 3 tubes of BF-200 ALA, and 14 PK blood samples will be collected, starting 0.5 h 
prior to BF-200 ALA application and then for up to 10 h afterwards (Visit 2) 
• a phone call for safety assessment at 7 (± 3) days post PDT  
• a further clinic visit, 28 (± 7) days after treatment, at which safety and tolerability 
assessments will be performed (Visit 3) 
Figure 1 illustrates treatment details on study visits. An overview of scheduled assessments is 
provided in Table 1. 
 
 
 
* Visit 2 can be rescheduled within 2 weeks after the scheduled date if at least one of the dosing day exclusion 
criteria is met. 
Figure 1: Summary of study visits 
 
The PDT procedure (preparation of treatment field(s), drug application, incubation, 
illumination) will be performed according to the labels of BF-200 ALA and BF-RhodoLED® 
with the exceptions that 3 tubes of BF-200 ALA (totaling in 458 mg ALA) are applied per 
subject and the treatment will be performed on scalp/face or in the periphery (neck/trunk/ 
extremities). 
Visit 3 
Day 28 (±7)
final safety assessment/
end of study (EoS)
Visit 2 / baseline 
Day 0*
PDT + PK blood 
sampling
Visit 1
      days prior to PDT
Screening
Phone call 
Day 7 (±3)
safety assessment

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6.2 Study duration, dates and end-of-study definition 
For each subject the duration of trial participation is expected to be approximately 42-63 days 
(including the screening period) and the overall study duration is estimated to be about 9 
months. Subject recruitment is estimated to start approx. in February 2020 (first subject first 
visit) and to end approx. in August 2020 (6 months recruitment). The duration of the overall 
study or the subject recruitment period may vary. The end of study will be defined as last 
subject last visit. 
6.3 Definitions 
Definition of treatment area: 
For this study, the treatment area is a body region to be treated with PDT. The following 
treatment areas will be investigated: 
• Face/scalp: the whole face (except the upper and lower eyelids, the lip area (not past 
the vermilion border) and the nostrils) and the bald scalp 
• Periphery: any part of the extremities and/or trunk/neck excluding the genitalia 
(minimal distance of about 1 cm) 
Definition of illumination area: 
The illumination area is the area effectively illuminated by one BF-RhodoLED® lamp 
(6 cm x 16 cm) in one illumination session. In this study, up to two illumination areas can be 
illuminated simultaneously using two BF-RhodoLED® lamps. 
Definition of treatment field(s) 
The treatment field is defined as the field to which medicinal product is applied.  
In this study, at least 12 distinctive AK lesions (each with a diameter of ≥ 4 mm) within one 
or several treatment field(s) located either within the treatment area face/scalp or within the 
treatment area periphery will be treated with PDT. 
The treatment field(s) may be discontinuous and several patches within the same treatment 
area can be combined to form a total area of approximately 60 cm2. In case of discontinuous 
treatment field(s), all patches must be located within up to two illumination areas of the BF-
RhodoLED® lamp (6 cm x 16 cm each). Lesions included in the study should be entirely 
located within the treatment field(s), leaving a minimal distance of ≥ 0.5 cm of the lesion 
margin to the treatment field border.  
The location of all treatment field(s) and suggested illumination area(s) should be clearly 
marked in the graphic templates (cartoon and grid foil) for re-identification during the course 
of the study. The investigator will also describe treatment field(s), illumination area(s) and 
lesions in source data and the electronic case report form (eCRF).  
 
 

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7 SELECTION OF SUBJECTS 
7.1 Number of subjects 
The suggested sample size for the study is 32 subjects, stratified into 2 groups of 16 subjects 
each. Based on the results of a previous PK study, a group size of 12 subjects is considered to 
be sufficient for proper pharmacokinetic evaluation which is also in agreement with FDA 
guidance (36). In order to compensate for potential drop-outs of subjects as well as potentially 
higher variability of data due to combined investigation of two treatment areas, the stratum 
size was adapted from 12 to 16 subjects. For this reason, the sample size of 32 subjects is 
considered to be adequate for pharmacokinetic evaluation in this PK study. 
7.2 Recruitment arrangements 
Subjects will be screened at the Phase I unit and, if eligible, subjected to PDT and PK blood 
sampling. The study site will be responsible for obtaining equal stratum size and has to stop 
recruitment once 16 subjects for one stratum have been treated.  
7.3 Inclusion criteria 
Eligible subjects must meet the following criteria: 
1. Subjects with at least 12 distinctive and clinically confirmed mild to severe AK lesions 
(according to Olsen et al. 1991 (37)) with a diameter of ≥ 4 mm each, on either the 
face/scalp (including forehead, excluding eyes, nostrils, ears, and mouth) or the 
neck/trunk/extremities, within treatment field(s) of about 60 cm² in total. Treatment 
field(s) may be discontinuous but must be within 2 illumination areas of the BF-
RhodoLED® lamp (6 cm x 16 cm each). 
2. All genders 18-85 years of age (inclusive). 
3. Willingness and ability of the subject to provide informed consent and to sign the 
Health Insurance Portability and Accountability Act (HIPAA) form. A study-specific 
informed consent form and HIPAA form must be obtained in writing for all subjects 
prior to starting any study procedures.  
4. Willingness and ability to comply with study procedures, particularly willingness to 
receive one PDT with up to two illumination devices simultaneously. 
5. Subjects with good general health and subjects with clinically stable medical 
conditions will be permitted to be included in the study.  
6. Subjects receiving any drugs affecting coagulation (e.g. anticoagulants, anti-platelet 
drugs) should be on a stable dose.  
7. Acceptance to abstain from extensive sunbathing and the use of solarium during the 
clinical study. 
8. Women of child-bearing potential must have a negative serum pregnancy test and 
must use an adequate and highly effective or two effective methods of contraception 
throughout the study. 
 

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7.4 Exclusion criteria 
To reduce risks for the subjects and to ensure that the subjects are in a comparable status, 
subjects will be excluded if they meet at least one of the following exclusion criteria: 
1. Any known history of hypersensitivity to ALA, porphyrins or excipients of BF-
200 ALA. 
2. History of soy or peanut allergy. 
3. Subjects with sunburn within illumination areas (reassessment of subjects is allowed 
once if the sunburn is expected to resolve within the screening period. Reassessment 
can be done on the day of the actual treatment.).  
4. Clinically significant medical conditions making implementation of the protocol or 
interpretation of the study results difficult or impairing subjects’ safety such as: 
a. Presence of porphyria or known photodermatoses  
b. Known diagnosis of human immunodeficiency virus (HIV) based on clinical 
history 
c. Metastatic tumor or tumor with high probability of metastasis  
d. Infiltrating skin neoplasia (suspected or known) 
e. Unstable cardiovascular disease (New York Heart Association [NYHA] class 
III, IV) 
f. Unstable hematologic (including Myelodysplastic syndrome), hepatic, renal, 
neurologic, or endocrine condition  
g. Unstable collagen-vascular condition 
h. Unstable gastrointestinal condition 
i. Immunosuppressive condition 
j. Presence of clinically significant inherited or acquired coagulation defect 
5. Clinical diagnosis of atopic dermatitis, Bowen’s disease, BCC, eczema, psoriasis, 
rosacea, SCC, other malignant or benign tumors in the treatment field(s), or other 
possible confounding skin conditions (e.g. wounds, irritations, bleeding or skin 
infections) within or in close proximity (< 5 cm distance) to treatment field(s). 
(Reassessment of subjects is allowed once if wounds, irritations, bleeding or skin 
infections are expected to resolve within the screening period. Reassessment can be 
done on the day of the actual treatment.) 
6. Presence of strong pigmentation, tattoos or any other abnormality that may impact 
lesion assessment or light penetration in the treatment field(s). 
7. More than moderate smoker (e.g. > 10 cigarettes/day or equivalent). 
8. Suspicion of drug or alcohol abuse. For the purpose of this study, alcohol abuse is 
defined as more than moderate alcohol consumption (> 1 drink/day for women and > 2 
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9. Physical treatment of malignant or benign tumors of the skin within the treatment 
field(s) and at a distance of < 5 cm to the treatment field(s) during the last 4 weeks 
prior to screening. 
10. Any therapy such as cryotherapy, laser therapy, electrodessication, surgical removal of 
lesions, curettage, or treatment with chemical peels such as trichloroacetic acid within 
the treatment field(s), or within a radius less than 5 cm away from the treatment 
field(s) 4 weeks prior to screening. 
11. Any topical medical treatment of the skin within the designated time period below:  
a. Topical treatment with ALA or methyl-aminolevulinate (MAL) or an 
investigational drug in- and outside the treatment field(s) within 8 weeks prior 
to screening. 
b. Topical treatment with immunomodulatory/immunosuppressive anti-
inflammatory, or cytotoxic agents inside the treatment field(s) or within a 
radius less than 5 cm away from the treatment field(s) within 8 weeks prior to 
screening. 
c. Start of topical administration of medication with hypericin or other drugs with 
phototoxic or photoallergic potential in- and outside the treatment field(s) 
within 8 weeks prior to screening. Subjects may, however, be eligible if such 
medication was applied for more than 8 weeks prior to screening visit without 
evidence of an actual phototoxic/photoallergic reaction.  
12. Any use of the below specified systemic treatments within the designated periods:  
a. Use of cytotoxic drugs within 24 weeks, immunomodulators or 
immunosuppressive therapies or use of ALA or ALA-esters (e.g. MAL) within 
12 weeks, investigational drugs or drugs known to have major organ toxicity 
within 8 weeks, interferon or corticosteroids (oral or injectable) within 6 weeks 
prior to screening. 
b. Start of intake of medication with hypericin or systemically-acting drugs with 
phototoxic or photoallergic potential within 8 weeks prior to screening. 
Subjects may, however, be eligible if such medication was taken in or applied 
for more than 8 weeks prior to screening visit without evidence of an actual 
phototoxic/photoallergic reaction.  
13. Laboratory values outside the reference range that are clinically significant in the 
opinion of the investigator (e.g., suggesting an unknown disease and requiring further 
clinical evaluation according to investigator), especially aspartate aminotransferase 
(AST), alanine aminotransferase (ALT), gamma glutamyl transpeptidase (gamma-
GT).  
14. Impaired renal function (Glomerular filtration rate below 50 mL/min/1.73m² estimated 
by Modification of Diet in Renal Disease equation (MDRD)). 
15. Positive test for HIV antibodies, Hepatitis B-virus surface antigen (HBsAg) or positive 
Anti-hepatitis C-virus antibody (Anti-HCV) test. 

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16. Significant blood donation or blood loss (≥ 500 mL) within three months prior to Visit 
2. 
17. Breast-feeding women. 
18. Subject unlikely to comply with the protocol, e.g. inability to return for visits, unlikely 
to complete the study, or inappropriate in the opinion of the investigator. 
19. Prior participation in the study (participation is defined as having been screened). 
20. A member of study site staff or sponsor staff directly involved in the conduct of the 
protocol or a close relative thereof. 
21. Simultaneous participation in a further clinical study. 
Reassessment of subjects is allowed once if sunburn, wounds, irritations, bleeding or skin 
infections detected at Visit 1 are expected to resolve within the screening period. 
Reassessment can be done on the day of the actual treatment. 
 
Dosing day exclusion criteria: 
1. Febrile or infectious illness within 7 days prior to Visit 2. 
2. Subjects with sunburn, wounds, irritations, bleeding or other confounding skin 
conditions within illumination areas at Visit 2. 
3. Use of topical NSAIDs inside and outside the treatment field(s) or systemic intake of 
NSAIDs within 7 days prior to Visit 2. 
In case a subject meets one of the dosing day exclusion criteria, Visit 2 can be rescheduled 
once within 14 days. Meeting any of the dosing day exclusion criteria on the rescheduled visit 
will lead to discontinuation of the trial.  
7.5 Screening failures 
All subjects whose eligibility cannot be confirmed at Visit 2 will be considered as screening 
failures if eligibility cannot be achieved and Visit 2 rescheduled within 2 weeks.  
Subjects assessed as screening failures will not be treated at Visit 2.  
7.6 Subjects of reproductive potential 
Female subjects of childbearing potential (i.e. ovulating, pre-menopausal, or post-menopausal 
for less than one year, not surgically sterile) must use a medically accepted contraceptive 
regimen during the clinical study as outlined below.  
• Use of one highly effective method proven to have an acceptably low failure rate 
(Pearl Index below 1, failure rate less than 1 % per year) such as: 
o surgical sterilization (e.g., bilateral tubal ligation, hysterectomy),  
o hormonal contraception (implantable, patch, oral, injectable) 
o sexual intercourse with a vasectomized partner 
o true abstinence 

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• Combined use of two effective methods such as: 
o latex condoms with spermicidal gel 
o Diaphragms with spermicidal gel 
o Cervical caps with spermicidal gel 
o Vaginal sponge with spermicidal gel 
 
Periodic abstinence (e.g. calendar, ovulation, symptothermal, post ovulation methods) and 
withdrawal are not acceptable methods of contraception. 
If a subject becomes pregnant during the study, she must inform the investigator immediately. 
The further treatment of AK lesions should be addressed on a case-by-case basis with the 
treating physician and the investigator. 
If pregnancy occurs, the investigator must contact the sponsor immediately for further 
instructions and must be followed up until the outcome of the pregnancy is known. Both, the 
detection and the outcome of the pregnancy must be reported to the sponsor on special forms. 

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8 STUDY TREATMENT 
8.1 Details of investigational products 
8.1.1 Investigational Medicinal Product 
The investigational medicinal product (IMP) will be BF-200 ALA, a gel formulation of 7.8 % 
ALA. 
The composition is as follows: 
Table 2: Composition and manufacturer of study medication 
Drug 
BF-200 ALA 
Brand name:  
Chemical name:  
Ameluz®  
5-amino-4-oxopentanoat hydrochloride  
International non-
proprietary name:  
ALA hydrochloride  
Formulation:  
BF-200 ALA containing 7.8 % ALA in a lecithin-based 
nanoemulsion gel with preservatives (sodium benzoate) and 
xanthan gum in purified water  
Manufacturer:  
Biofrontera Pharma GmbH Hemmelrather Weg 201, 51377 
Leverkusen, Germany  
ALA: 5-aminolevulinic acid 
No excipients of human or animal origin are contained in the IMP or are used during the 
manufacturing process. Furthermore, no novel excipients are contained in the IMP used in this 
study. 
The BF-200 nanoemulsion gel is an oil-in-water dispersion of very small and homogenous 
vesicles, composed of a lipid core surrounded by a lecithin/co-surfactant monolayer. BF-200 
nanoemulsion has a mean vesicle size of less than 30 nm with a very narrow size distribution. 
BF-200 ALA contains ingredients that are well established and approved worldwide in 
medicinal and cosmetic products. The formulation of BF-200 ALA, as applied in this study, is 
identical to the currently marketed formulation as well as the formulation that was used in the 
confirmatory clinical trials summarized in Section 1.2. 
The IMP will be delivered in aluminum tubes containing 2 g gel (containing 156 mg ALA). 
Three tubes will be provided per subject for PDT treatment totaling in 458 mg ALA. The 
quantity provided is sufficient to cover the 60 cm2 skin area of the treatment field(s) with a 
1 mm thick layer. 
8.1.2 Investigational Medical Device 
The Class III device BF-RhodoLED® (in this document also referred to as investigational 
medical device, IMD) was granted US marketing approval as a combination product with 
Ameluz® for the lesion- or field-directed treatment of mild to moderate AK on the face and 
scalp in May 2016 (NDA 208081). 

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BF-RhodoLED® is manufactured in compliance with ISO 13485 standards by: 
Biofrontera Pharma GmbH 
Hemmelrather Weg 201 
51377 Leverkusen 
Germany 
BF-RhodoLED® utilizes 128 LEDs and lenses (arranged in a rectangle) to emit a uniform, 
bundled, visible red light with a typical peak wavelength at approximately 635 nm and a half 
bandwidth of 20 nm. The total area illuminated by the lamp is 8 cm x 18 cm with an effective 
illumination area of 6 cm x 16 cm. The optimum treatment distance is 5-8 cm. The calibration 
of the lamp ensures that the skin area illuminated receives a total light dose of 37 J/cm2 when 
maintaining a total illumination time of 10 min at a distance of 5-8 cm. Therefore, it must be 
confirmed and documented that the specified illumination time and distance between the lamp 
and the treatment field(s) have been met. Otherwise, reasons for not meeting the requirements 
must be provided. The lamp is programmed to automatically provide a total illumination time 
of 10 min. In case of necessary interruptions, e.g. due to unbearable pain or repositioning of 
the subject, the lamp will continue until the required illumination time is achieved. 
For the purpose of this study, the study site will be equipped with at least two BF-
RhodoLED® lamps. All site personnel handling the lamp will be instructed properly on the 
handling and usage of the lamp, according to the user manual. 
The recommended conditions for illumination with the LED lamp are shown in Table 3. 
 
Table 3: Key parameters of LED lamp used 
 
Recommendation 
Wave length (ʎem) 
approx. 635 nm 
Light dose (energy) 
approx. 37 J/cm² 
Intensity 
Max. 77 mW/cm2 
Illumination time 
10 min 
Distance skin-lamp 
5-8 cm 
 
Detailed handling and operating instructions as well as a list of warnings and precautions 
when handling BF-RhodoLED® are provided in the user manual. 
8.2 Storage 
At the study site, study medication has to be stored at 2 °C to 8 °C (36 °F-46 °F) (rounded) in 
a temperature-controlled cabinet, located in an area inaccessible by unauthorized persons. 
Used study medication can be stored at room temperature. Temperature records (minimal-
actual-maximal or continuously records) should be taken on a daily basis except for weekends 
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(35.5 °F-46.4 °F) or problems to store BF-200 ALA appropriately after delivery at study site) 
have to be immediately announced to the monitor and the sponsor, and study medication 
cannot be used unless sponsor’s release for this specific event was given. 
Transport of study medication to the study site will be temperature-controlled. The control of 
correct transport and measures to be taken in case of deviations are in the responsibility of 
Biofrontera Pharma GmbH. Each delivered study medication cannot be used unless released 
by sponsor. 
The BF-RhodoLED® study lamps must be stored inaccessible to unauthorized persons.  
8.3 Application of BF-200 ALA 
Treatment field(s) will be localized and documented as described in Section 6.3. A treatment 
field does not necessarily have to be continuous, but (discontinuous) treatment field(s) should 
cover a total area of approximately 60 cm2 and must allow illumination in a single step (see 
Section 7.3 and 8.4). 
AK lesions located outside the specified treatment field(s) will not be considered for treatment 
in this study. For treatment of these AK lesions, subjects will be referred to a licensed 
dermatologist after the end of the clinical trial for follow up care. 
Treatment field(s) should be prepared for drug application by degreasing (using ethanol or 
isopropanol), removal of all scabs and crusts, and if appropriate roughening of the surface, 
(e.g. by mild debridement for the removal of crusts) within 1 h before application of the study 
medication. Care should be taken to avoid bleedings. Therefore, special care has to be taken 
when screened subjects report non-significant acquired or inherited coagulation defects and/or 
receive treatment with e.g.100 mg acetylsalicylic acid (e.g. ASS) per day or warfarin. 
After this preparation, 3 tubes of BF-200 ALA will be administered to the entire 60 cm² 
treatment field(s), covering the skin with a film of approximately 1 mm thickness. The 
application will be performed using glove-protected fingertips or a spatula. Care should be 
taken to avoid that the study medication is applied to the upper and lower eyelids, the lip area 
(not past the vermilion border), in the nostrils or near genitalia (keep a distance of about 1cm). 
In case of accidental contact of BF-200 ALA with the eyes or mucous membranes, rinsing 
with water for at least 5 min will be performed. 
The gel will be allowed to dry for approximately 10 min, before an occlusive, light-blocking 
dressing (e.g. TegadermTM dressing plus aluminum foil) will be placed over the treatment 
field(s). The subject should stay in an environment with comfortable temperature during 
incubation time. It is particularly important to ascertain that extremities will not be cold 
during the 3 h incubation. After the incubation time of 3 h ± 10 min, the occlusive, light-
blocking dressing will be removed and the remaining gel should be wiped off. 
The following information concerning this procedure will be documented in the subjects’ 
eCRF: 
• preparation of treatment field(s) including lesions within one hour prior to dosing 
• occurrence of bleedings in the application area 
• unique IMP number (on subject package and allocated tubes) 

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• time of IMP application and removal  
• application of occlusive, light-blocking dressing  
8.4 Illumination with BF-RhodoLED® 
After removal of remaining gel, the entire treatment field(s) will be illuminated using BF-
RhodoLED®, until a total light dose of approximately 37 J/cm2 is achieved. During 
illumination, the lamp(s) will be positioned at a distance of 5-8 cm from the skin surface as 
indicated in the user manual.  
In case of discontinuous treatment field(s) that may not be covered by the 96 cm² 
(6 cm x 16 cm) illumination field of a singular device, two BF-RhodoLED® lamps are used 
simultaneously, such that for the entire 60 cm² surface only one illumination step is 
performed. 
The calibration of the lamp ensures that the skin area illuminated receives a total light dose of 
37 J/cm2 (an illumination time of 10 min) at a distance of 5-8 cm. Therefore, it must be 
confirmed and documented that the specified illumination time and distance between the lamp 
and the treatment field(s) have been met. Otherwise, reasons for not meeting the requirements 
must be provided. The lamp is programmed to automatically provide a total illumination time 
of 10 min. In case of necessary interruptions, e.g. due to unbearable pain, the lamp will 
continue until the required illumination time is achieved. 
For the purpose of this study, the study site will be equipped with at least two BF-
RhodoLED® lamps. All site personnel handling the lamp will be instructed properly on the 
handling and usage of the lamp, according to the user manual. 
During illumination, subjects and medical personnel must wear suitable protective eye 
goggles, even if PDT is performed in areas where little light reaches the subject’s eyes.  
Detailed handling and operating instructions as well as a list of warnings and precautions 
when handling BF-RhodoLED® can be derived from the user manual. 
Discomfort and pain during PDT are caused by the intended phototoxic reaction. Although 
the emitted light is in the visible red spectrum and has no emission in the (heat-transmitting) 
infra-red spectrum, subjects may have the feeling of being burned. The latter is caused by a 
generally harmless, but in some subjects very unpleasant, biochemical reaction during PDT 
which may be enhanced by a strong psychological component. 
As pain experienced during PDT will be evaluated by all subjects after the treatment, the PDT 
should be started without measures to relieve pain. In cases where the pain is regarded as 
unbearable by the subject, pain relieving measures as outlined in Section 9.2 may be applied.  
The subject should be informed about restrictions defined in Table 4 and in Section 9.2. 
A surgical dressing of the treated area is normally not required and should be avoided 
whenever possible.  
Although a nearly complete loss of PpIX by photobleaching is assumed to occur during PDT, 
subjects should avoid exposure to intensive sun light for about 48 h since new PpIX may 
accumulate from remaining ALA. Additional light exposure may enhance the typical side 
effects of PDT. Subjects should not expose themselves to intensive ultraviolet (UV)-radiation 

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(solarium, sun bathing, etc.) during the course of the study (see also Section 7.4) to avoid UV-
induced post inflammatory hyperpigmentation of the healing tissue. 
8.5 Dosage schedule 
A single PDT session will be applied according to the study design described in Section 6.1, 
Section 8.3 and Figure 1. 
8.6 Treatment assignment 
This is a non-randomized, open-label study, i.e., all eligible subjects will receive active 
treatment.  
8.7 Blinding, packaging, and labeling 
This is an open-label study. i.e., blinding is not applicable. 
8.7.1 Investigational medicinal product 
The sponsor will ascertain that all study medication is manufactured and packaged in 
accordance with regulatory requirements and the principles of Good Manufacturing Practice 
(GMP). 
Responsible for manufacturing and release of BF-200 ALA: 
Biofrontera Pharma GmbH 
Hemmelrather Weg 201 
D-51377 Leverkusen 
Germany 
The appropriate number of tubes and card board boxes will be labeled in English according to 
the pre-defined distribution of treatment numbers. The labels will include all information 
required by 21 CFR 312.6 (including the statement: “Caution: New Drug—Limited by 
Federal (or United States) law to investigational use”). 
For each subject, a card box is provided containing three tubes with BF-200 ALA. Each box 
is labeled with a tear-off label and can be identified and assigned to a specific subject by a 
unique identification number. 
In addition, each tube will be labeled accordingly. This label information must be documented 
in the appropriate space in the subject’s source data when the IMP is dispensed prior to PDT. 
Additional statements may be printed on the label as required by local regulations. 
The sponsor will maintain a complete record of batch numbers and expiry dates of the IMP 
and the labels of the IMP in the Trial Master File (TMF). 
8.7.2 Investigational medical device  
BF-RhodoLED® will be distributed and assembled/maintained at the sites by technicians or 
other properly trained delegates of: 
 
 

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Biofrontera Inc. 
120 Presidential Way, Suite 330 
Woburn, MA 01801  
USA 
The appropriate number of lamps will be labeled in English as investigational device in 
accordance with 21 CFR 801.1 and 21 CFR 812.5. Labels will include: 
• the name and place of business of the manufacturer, packer, and distributor 
• the statement: “CAUTION Investigational device. Limited by Federal (or United 
States) law to investigational use”). 
• and/or references to all relevant contraindications, hazards, adverse effects, interfering 
substances, warnings and precautions. 
For the purpose of this study, the Phase I unit will be provided with at least two BF-
RhodoLED® lamps. It is exclusively intended to be used in conjunction with study medication 
within the scope of clinical trials conducted by Biofrontera. As the lamp will be assembled on 
site by a technician or delegate of Biofrontera, there will be no immediate packaging 
available. All labeling will be applied directly to the lamp. 
8.8 Supplies and accountability 
After the study protocol was approved or accepted by the Institutional Review Board(s) 
(IRB(s)) and by FDA, the sponsor will initiate the study site which includes installation of at 
least two BF-RhodoLED® lamps, and thereafter supply the study site with study medication, 
together with all relevant documentation. The sponsor is responsible for delivery of the 
investigational products to the study site. 
The investigator will inventory and acknowledge receipt of all shipments of the IMP and 
IMD. The investigator is responsible for maintaining documentation showing the amount of 
investigational products provided to the study site and the used IMP for each study subject. 
Discrepancies in accountability of the investigational products must be explained and 
documented. The monitor is responsible to verify the investigator’s documentation on receipt, 
use, and return of the investigational products. The monitor will check drug and medical 
device accountability at the Phase I unit on an ongoing basis during the study. At the end of 
the study, all remaining study medication or empty tubes must be returned to the drug supplier 
acting on behalf of Biofrontera Pharma GmbH for disposal. The monitor will prepare a final 
report of accountability of the investigational products for filing in the investigator site file 
(ISF). 
After the last subject completed the treatment and no further trials are planned, all lamps will 
be disassembled by a technician and returned to Biofrontera Inc. Receipt and return of BF-
RhodoLED® will be acknowledged and documented accordingly. 
8.9 Compliance 
The application of study medication will be administered/supervised by the investigator or 
subinvestigator. Any delegation of this responsibility should follow the guidelines stated in 
Section 15.2. 

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The study medication will never be handed out to the subjects but applied by study personnel, 
rendering individual compliance assessments unnecessary. 
BF-RhodoLED® lamps will be exclusively operated by previously trained study personnel. 

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9 PRIOR AND CONCOMITANT ILLNESSES AND TREATMENTS 
9.1 Prior and concomitant illnesses 
Additional diseases present at the time of signing the informed consent are regarded as 
concomitant diseases and must be documented in the eCRF. Relevant past diseases must also 
be documented in source data and in the medical history section of the eCRF. 
Illnesses first occurring or detected during the study, and worsening of a concomitant disease 
during the study, are to be regarded as AEs and must be documented in source data and in the 
AE section of the eCRF (see Section 11). 
9.2 Prior and concomitant treatments 
Any medication taken by a subject at study entry or treatments the subject is undergoing 
throughout the study that are not related to any study-specific procedures (PDT with IMP), are 
considered concomitant treatments. The use of required concomitant treatments, which are 
known not to interfere with the IMP or to mask their effect, is unrestricted and may be 
continued during the study.  
Inflammation triggered by the photodynamic reaction is an important part of the therapeutic 
principle and is intended. Therefore, intake of systemic anti-inflammatory drugs must be 
stopped prior to PDT, especially systemic corticosteroids and antiphlogistics (NSAIDs) (see 
Section 7.4 and below). 
Nevertheless, the following treatments are permitted in the designated trial periods to alleviate 
pain and discomfort: 
• During PDT 
o In cases where the pain is regarded as unbearable by the subject, the PDT may 
be interrupted and/or cooling with an air stream or nebulized water may be 
offered. 
o Severe cases of pain might require to briefly interrupt illumination, e.g. to 
inject a local, fast-acting anesthetic, such as xylocaine or to cool briefly with 
cooling packages. 
• Treatment of pain and discomfort after PDT 
o Cooling the illuminated area(s) with wet or refrigerated compresses 
o Analgesic treatment with acetaminophen (e.g. Tylenol®) 
Cooling compresses and acetaminophen (e.g. Tylenol®) should be offered by the study staff to 
all subjects after PDT for the purpose of pain management. 
Further treatments are also allowed for the management of pain and discomfort but should be 
used as a second line treatment option: 
o Topical corticosteroids 
o Topical diclofenac up to 2.5 % outside the treatment field(s) 
All concomitant treatments underwent/taken during the study must be documented in source 
data and on the appropriate pages of the eCRF along with the indication, single dose, route of 
administration, frequency of administration as well as start and stop date of administration. 

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The subject should confer with the investigator prior to the use of new medication during the 
course of the study. 
The following concomitant treatments/procedures are not permitted: 
• Any therapy such as cryotherapy, laser therapy, electrodessication, surgical removal of 
lesions, curettage, or treatment with chemical peels such as trichloroacetic acid within 
the treatment field(s), or within a radius less than 5 cm away from the treatment 
field(s) 4 weeks prior to screening and throughout the study. Non-target lesions may 
be treated with these methods if the distance to the treatment field is more than 5 cm. 
• A list of forbidden, concomitant medication is provided in Table 4. 
If the investigator, at any time in the study, suspects a lesion within or outside the treatment 
field(s) to have progressed into a manifest malignancy, they should refer the subject for 
standard medical treatment, irrespective of whether or not this results in exclusion of the 
subject from the study.  
Table 4: List of forbidden concomitant medication with designated time periods. 
Medication 
Topical administrationa 
Systemic administration 
 
start of 
restriction  
forbidden until 
start of 
restriction  
forbidden 
until 
ALA or ALA-esters 
(except IMP at Visit 2) 
8 weeks  
prior to Visit 1 
end of study 
12 weeks  
prior to Visit 1 
end of study 
Cytotoxic drugs 
8 weeks  
prior to Visit 1 
(within treatment 
field(s))b 
end of study 
(within treatment 
field(s))b 
24 weeks prior 
to Visit 1 
end of study 
Immunomodulators/ 
immunosuppressive 
therapies 
8 weeks  
prior to Visit 1 
(within treatment 
field(s))b 
end of study 
(within treatment 
field(s))b 
12 weeks prior 
to Visit 1 
end of study 
7 days 
prior to PDT 
(within and outside 
treatment field(s)) 
end of study 
(within and outside 
treatment field(s)) 
Interferon --- 
--- 
6 weeks prior to 
Visit 1 
end of study 
Corticosteroids (allowed) 
(allowed) 
6 weeks prior to 
Visit 1d 
end of studyd 
 
NSAIDs 
7 days 
prior to PDTc 
7 days post 
PDTc 
7 days 
prior to PDT 
 
7 days 
post PDT 
Acetylsalicylic acid  
> 100 mg/day  
--- 
--- 
7 days 
prior to PDT 
 
7 days 
post PDT 
Ibuprofen > 200 mg/day 
--- 
--- 
7 days 
prior to PDT 
7 days 
post PDT  

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Medication 
Topical administrationa 
Systemic administration 
 
start of 
restriction  
forbidden until 
start of 
restriction  
forbidden 
until 
Diclofenac (> 2.5 %) 
8 weeks  
prior to Visit 1 
(within treatment 
field(s))b 
end of study 
(within treatment 
field(s))b 
7 days 
prior to PDT 
 
7 days 
post PDT 
Hypericin or drugs 
with phototoxic/ 
photoallergic 
potentiale 
8 weeks  
prior to Visit 1 
end of study 
8 weeks prior to 
Visit 1 
end of study 
Investigational drugs 
8 weeks prior to 
Visit 1 
end of study 
8 weeks prior to 
Visit 1 
end of study 
Drugs known to have 
major organ toxicity 
--- 
--- 
8 weeks prior to 
Visit 1 
end of study 
Medication that 
influence coagulation 
(e.g. anticoagulants, 
anti-platelet drugs) 
--- 
--- 
Visit 1  
(may be used 
throughout the 
study if taken in a 
dose stable prior to 
study) 
end of study 
(may be used 
throughout the 
study if taken in a 
dose stable prior to 
study) 
EMLA® cream 
Visit 2 
(within treatment 
field(s))b 
7 days post PDT 
(within treatment 
field(s))b 
--- 
--- 
a Within and outside the treatment field(s). 
b Restriction is limited to the use within treatment field(s) and surrounding skin areas within a radius less than   
5 cm away from the treatment field(s). 
c Topical use of diclofenac up to 2.5 % may be used outside treatment field(s) throughout the study. 
d For oral or injectable corticosteroids. 
e Start of therapy with any photosensitizer or systemically-acting drugs with phototoxic or photoallergic 
potential, such as psoralenes, tetracyclines, nalidixic acid, furosemide, amiodarone, phenothiacines, chinolones, 
fibrates, or phytotherapy with St. John’s wort, arnica, or valerian or topically applied phototoxic substances like 
tar, pitch, psoralenes or some dyes like thiazide, methylene blue, toluidine blue, eosin, rose bengal, or acridine 
within 8 weeks prior to screening. Subjects may, however, be eligible if such medication was taken in 8 weeks 
prior to screening without evidence of an actual phototoxic/photoallergic reaction. These medications must not 
be newly prescribed within 8 weeks prior to screening. If such a prescription becomes unavoidable for medical 
reasons in between Visit 2 and Visit 3, the study participation of the affected subject should be continued 
regularly. 
 
 

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10 STUDY PROCEDURES AND SCHEDULE 
10.1 Description of study days 
Table 1 summarizes the study schedule. 
10.1.1 Screening visit (≤ 14 days prior to PDT) 
Potential subjects will be evaluated to determine if they fulfill the inclusion and exclusion 
criteria (see Sections 7.3 and 7.4). The following evaluations and procedures will be 
performed at Visit 1 (screening) and recorded in the eCRF: 
NOTE: In case the subjects come to the screening visit in a fasted state, blood and urine 
sampling will be performed. In case the subject is not fasted, blood and urine sampling will be 
postponed 1-2 days.  
• Obtain informed consent prior to any study-related procedures. 
• Assign subject number 
• Document concomitant diseases and relevant medical history  
• Document AK history  
• Obtain demographic data 
• Check inclusion and exclusion criteria 
• Assess skin type according to Fitzpatrick, 1988 (38) 
• Select treatment field(s) and assess target lesions (size, number, location and clinical 
assessment according to Olsen et al., 1991 (37)) 
• Generate template of AK treatment field(s) on provided grid foil and sketch treatment 
field(s) and suggested illumination area(s) into cartoon (to be kept in the subject file) 
• General physical examination 
• Measure vital signs (HR, BP) 
• Fasting clinical laboratory tests (including routine hematology, blood chemistry, 
serum pregnancy tests, coagulation parameters, eGFR and urinalysis) 
• Hepatitis and HIV serology.  
• Blood sampling for ALA and PpIX baseline levels 
• Documentation of (S)AEs. 
• Instruct subject about forbidden concomitant treatments (see Section 9.2). 
10.1.2 Visit 2/Baseline (PDT) 
The following procedures will be performed at Visit 2 and recorded in the eCRF: 
• Reevaluation of inclusion and exclusion criteria for confirmation of subject’s 
eligibility 
• Evaluation of dosing day exclusion criteria 

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• Explanation of allowed/forbidden medication 7 days after PDT to subjects (see 
Section 9.2 and Table 4) 
• Measurement of vital signs (HR and BP) prior to PDT 
• Pregnancy test (urine) for females of reproductive potential prior to PDT 
• Blood sampling for ALA and PpIX analysis: In total, 14 blood samples will be 
collected at the time points defined below (Figure 2) 
• Preparation of treatment field(s) and application of BF-200 ALA and occlusive, light-
blocking dressing according to treatment description in Section 8.3 
• Date and time of study drug application and removal will be recorded in source data 
and in the eCRF 
• Illumination of treatment field(s) with the BF-RhodoLED® lamp until a total light dose 
of 37 J/cm² is achieved (according to treatment description in Section 8.4). In case of 
discontinuous treatment field(s), two BF-RhodoLED® lamps are used simultaneously, 
such that for the entire 60 cm² surface only one illumination step is performed 
• Duration of illumination and distance between the BF-RhodoLED® lamp and the 
treatment field(s) will be documented in source data and in the eCRF. Otherwise, 
reasons for not meeting the requirements must be given. The duration, reason, and 
frequency of any interruptions must be recorded in the subject’s source data and the 
eCRF. Pain relieving measures should be documented accordingly, if applicable 
• Documentation of concomitant medications/treatments (e.g. for pain management) 
that might be required during or after PDT (see Section 9.2 and Table 4) 
• Assessment of application site pain during PDT via NRS-11 (should be performed in 
between the blood sampling time points 3.5 h and 4 h after application of BF-200 
ALA) 
• (S)AEs including application site skin reactions, application site discomfort, pain 
during and post PDT, and new lesions in the treatment field(s) (assessment of pain 
after PDT should be performed as described in Section 10.2.7 before discharge of the 
subject) 
• Reinform subjects about restrictions to intensive UV-radiation for 48 h (please see 
also Section 8.4 for detailed information) 

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*Blood sampling time points are specified in hours relating to the time point of BF-200 ALA application. 
Timepoint 0 is defined as the start of the application of BF-200 ALA. 
Figure 2: Time points for PK blood sampling at Visit 2.  
 
10.1.3 Phone call (7 (± 3) days post PDT) 
The aim of this safety telephone call is to achieve an overall impression on the tolerability of 
the photodynamic treatment with BF-200 ALA and to evaluate the subject‘s health condition 
since the PDT session. Using non-leading questions like “How did you feel since your 
photodynamic treatment session,” the investigator or delegated persons will evaluate any 
discomfort the subject may be experiencing. Any reported AE or concomitant treatment will 
be recorded in the source data and the eCRF.  
The following information will be collected during the phone call and recorded in the eCRF: 
• Documentation of (S)AEs and concomitant medication, application site skin reactions, 
and application site discomfort 
10.1.4 Visit 3 (Tolerability & safety assessment 28 (± 7) days after PDT) 
The following procedures will be performed at Visit 3 and recorded in the eCRF: 
• General physical examination 
• Measurement of vital signs (HR, BP) 
• Fasting clinical laboratory tests (including routine hematology, blood chemistry, and 
urinalysis) (In case the subject is not fasted, blood and urine sampling will be 
postponed 1-2 days.) 
• Serum pregnancy tests for female subjects of reproductive potential 
• Documentation of concomitant medications/treatments (please see also listing of 
allowed and restricted medications in Section 9.2) 
• Documentation of (S)AEs, including application site skin reactions and application 
site discomfort, and new lesions in the treatment field(s) 
3 h ± 10 min
blood sampling
timepoints (in h*) 
 10
0
1
2
1.5
- 0.5
0.5
3
2.5
3.5
4
5
6
8
treatment 
procedures
accepted devations 
(in min)
± 10
± 10
± 5
± 2
- 5
Pain assessment 
(NRS-11)
1. assessment of 
pain after PDT
application of 
BF-200 ALA
incubation
removal of 
dressing & gel
illumination
drying of gel & 
light blocking 
dressing

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10.2 Assessments 
10.2.1 Evaluation of demographic data 
The following informations will be obtained as demographic data from all participants at 
screening visit: 
• Gender 
• Age 
• Race 
• Ethnicity 
• Height 
• Weight 
• BMI 
 
10.2.2 Clinical criteria for diagnosis of AK 
Lesions will be considered AK if they present clinically as rough, crusted, flesh-colored to 
reddish-brown papules, or with an adherent scale in a field of sun-damaged skin (39–41). 
AK lesion severity will be evaluated according to the Olsen Severity Grading (37) as follows: 
• No AK/grade 0 i.e. no AK lesion present, neither visible nor palpable 
• Mild/grade 1 AK lesions should present flat, pink maculae without signs of 
hyperkeratosis and erythema. The lesions should be slightly palpable, with AK better 
felt than seen. 
• Moderate/grade 2 AK lesions should present as pink to reddish papules and 
erythematous plaques with hyperkeratotic surface. These AK lesions should be 
moderately thick and can be easily seen and felt. 
• Severe/grade 3 AK lesions should present as very thick plaques with hyperkeratotic 
surface. These AK lesions should be very thick and/or obvious. 
10.2.3 Assessment of target lesions 
In this clinical trial, AK lesions of mild to severe intensity (according to Olsen et al., 1991 
(37)), of which at least 12 lesions are of a diameter of ≥ 4 mm at screening, will be treated 
with (field-directed) PDT. AK lesions should be distinguishable; however, no distance 
restrictions between lesions will be applied.  
All lesions within the treatment field(s) have to be counted. For circular or almost circular 
lesions with a diameter of ≥ 4 mm its location, (e.g. upper arm, forehead), severity and size 
(diameters) must be documented. For non-circular lesions, the largest diameter and the 
corresponding perpendicular diameter will be measured and the mean diameter will be 
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Furthermore, for smaller actinic lesions (< 4 mm) in the treatment field(s) only the total 
number has to be documented. 
10.2.4 Assessment of AK history 
Subject’s AK history will be assessed at the screening visit. The following information will be 
documented in the eCRF: 
• Is this the first diagnosis of AK? 
• Date of first AK diagnosis, if applicable 
• Were AK lesions diagnosed in the past located in the same region or in the proximity 
of the region which will be treated at Visit 2? 
10.2.5 Assessment of skin type 
Subjects’ skin type will be assessed at the screening visit using the six-level Fitzpatrick Skin 
Type Rating Scale (38). Further details are provided in Appendix A. 
10.2.6 Pharmacokinetics 
Sample collection and sample handling 
For assessment of ALA and PpIX baseline plasma concentrations, the first of three pre-dose 
blood samples will be taken at Visit 1. All remaining blood samples for pharmacokinetic 
analyses will be collected at Visit 2 at the time points depicted in Figure 2 and in Table 5. 
Timing of blood samples for pharmacokinetic analysis has priority over any other scheduled 
activities. Time windows for accepted deviations for pharmacokinetic sampling are also given 
in Table 5. Deviations outside these windows will be considered as protocol deviations. 
Approximately 10 mL of blood per sample will be taken using lithium heparin tubes. The 
combined blood loss for pharmacokinetics sample analyses will be approximately 150 mL per 
subject.  
Details on sample collection, handling and processing will be provided in a separate 
document. 
 
 

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Table 5: Accepted deviations for pharmacokinetic sampling 
Nominal time of blood sampling  
Accepted deviations 
Predose (Visit 1) 
Not applicable 
Predose (-0.5 h) 
± 10 min   
Predose (0 h) 
Must be within 5 min before dosing 
0.5 h 
± 2 min 
1 h, 1.5 h, 2 h, 2.5 h, 3 h, 3.5 h, 4 h 
± 5 min 
5 h, 6 h, 8 h, 10 h 
± 10 min 
 
Bioanalytical measurements 
The concentrations of ALA and PpIX in plasma will be measured by an analytical laboratory 
using validated internally standardized liquid chromatography-tandem mass spectrometry 
methods. Incurred sample re-analysis will be performed. The methods will be validated 
according to FDA and EMA guidelines, before pharmacokinetic analysis of study samples. 
For PK analysis, the arithmetic mean of the ALA and PpIX plasma concentrations estimated 
based on the three predose samples (Visit 1, -0.5 h and 0 h predose at Visit 2) will be used as 
ALA respectively PpIX baseline concentration.  
Safety pharmacology measurements will be performed at the time points given in the study 
schedule (Table 1).  
The following laboratory is responsible for bioanalytical measurements (sample transfer will 
be via 
): 
 
 
 
 
 
10.2.7 Safety 
Safety pharmacology measurements will be performed at the time points given in the study 
schedule (Table 1). 
 
Physical examination 
The physical examination will involve head and neck, skin, lymph nodes, thorax including 
heart and lungs, abdomen, and musculoskeletal, peripheral vascular and nervous system 
status. 
 

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Vital signs 
Blood pressure (systolic and diastolic) and pulse rate will be measured after 5 min rest in 
supine position. 
 
Safety laboratory 
Blood and urine sampling for clinical safety analysis, except for the urine dip-stick pregnancy 
test, will be performed when the subject is in a fasted state. Fasting is defined as abstinence 
from food and beverage consumption (other than water) for at least 8 hours. 
The following central laboratory is responsible for safety laboratory assessments: 
 
 
 
 
Blood 
An approximately 3 mL EDTA (ethylenediaminetetraacetic acid) blood sample, a 2.7 mL 
sodium citrate blood sample, a 5 mL serum sample and a 7.5 mL serum sample will be 
collected at Visit 1 and approximately 3 mL EDTA blood and a 7.5 mL serum sample at Visit 
3. Serology examinations and pregnancy test will be performed to ensure the safety of the 
subjects before treatment. The total blood loss for safety laboratory examinations will be 
approximately 28.7 mL. 
 
• Serology parameters1 
HIV-1/2 antibodies, HBsAg, and Anti-HCV. 
• Coagulation parameters1 
International normalized ratio, prothrombin time, and activated partial prothrombin 
time. 
• Clinical chemistry parameters 
Blood urea nitrogen, creatinine, cholesterol, alkaline phosphatase, total bilirubin, 
ALT, AST, gamma-GT, low-density lipoprotein, high-density lipoprotein, 
triglycerides, albumin, phosphorus, total protein, uric acid, sodium, potassium, 
calcium, chloride, glucose, lactate dehydrogenase, bicarbonate and creatine 
phosphokinase. 
• Hematology parameters 
Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean 
corpuscular hemoglobin concentration (MCHC), hemoglobin, hematocrit, red 
blood cell count, white blood cell count with differential count (neutrophils, 
lymphocytes, monocytes, eosinophils, basophils), and platelet count. 
1 Only at Visit 1 

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Urine 
An approximately 30 mL urine sample will be collected at Visit 1 and at Visit 3. The 
following parameters will be measured: 
 
• Urinalysis parameters 
Leukocytes, nitrite, pH, protein, glucose, ketone, urobilinogen, bilirubin, blood 
(hemoglobin and erythrocytes). Microscopic examination of the sediment will be 
performed if considered necessary. 
 
Pregnancy test in females of childbearing potential  
A serum pregnancy test (β-human chorionic gonadotropin (β-hCG) test) will be performed at 
screening (Visit 1) and Visit 3. At PDT-visit (Visit 2), a urine dip-stick pregnancy test will be 
performed. 
 
Adverse events 
During the study, all (S)AEs have to be recorded as outlined in Section 11. If possible, each 
subject should be assessed by the same investigator/staff personnel throughout the study.  
 
Assessment of pain at the application site during PDT 
At Visit 2, subjects will assess the pain experienced during PDT using an 11-point Numeric 
Rating Scale (NRS-11) ranging from 0 (no pain at all) to 10 (worst possible pain). This score 
should reflect the subject’s respective maximum pain during PDT (see Appendix B). 
Importantly, pain during PDT has to be documented in pain eCRF (as result of NRS-11) and 
also as AE (see 11.1.1). 
For documentation on the AE eCRF page, the NRS-11 result indicated by the subject should 
be transformed as follows: pain 1-3 = mild, 4-7 = moderate, 8-10 = severe. 
 
Application site reactions 
The term application site reaction encompasses all reactions occuring in the treatment field(s) 
after starting PDT treatment and can be subclassified into the more specific categories 
application site discomfort and application site skin reactions.  
  
Application site discomfort 
At Visit 2, application site discomfort during and after PDT, and at the phone call and Visit 3 
application site discomfort after PDT will be assessed asking non-leading questions like 
“Have you noticed anything in the treatment surrounding areas since we last saw you?” Any 
signs or symptoms reported by the subject that correspond to the application site discomfort 
categories as outlined below should be assessed as described in section 11.1.1.  

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Application site discomfort categories are: 
• Burning 
• Pain 
• Itching 
• Stinging 
• Warmth 
• Others  
 
Application site skin reactions 
Application site skin reactions in the treatment field(s) will be evaluated separately by the 
investigator (or equally qualified physicians) in source and on the AE eCRF page at the 
clinical visit after PDT (Visit 3). The AE intensity grading should be used (see section 
11.1.1). In addition to the investigator assessments of application site skin reactions during 
and after PDT at Visit 2 and after PDT at Visit 3 subjects will be asked for application site 
skin reactions during the phone call.  
The application site skin reaction categories listed below will be checked by visual inspection 
of the respective subject’s treatment field(s) by a designated member of the study team during 
Visit 2 and Visit 3 (and documented in source data and on AE eCRF page). Intensity 
assessment will follow the AE intensity grading (see section 11.1.1).  
 
• Erythema 
• Edema 
• Induration 
• Vesicles 
• Erosion 
• Ulceration 
• Scaling/flaking 
• Scabbing/crusting 
• Discharge/exudate 
• Others 
 
At the phone call, application site skin reactions will be assessed by asking for AEs using 
non-leading questions as described above. Application site skin reactions will be recorded as 
reported by the subject and as assessed by the investigator (as AE) in source data and in the 
eCRF.  

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10.3 General and dietary restrictions 
The consumption of alcoholic beverages should be moderate. In this study, moderate alcohol 
consumption is defined in accordance to the “Dietary Guidelines for Americans 2015-2020” 
(42) as drinking up to 1 drink per day for women and up to two drinks per day for men. One 
alcoholic drink-equivalent is defined as containing 14 grams (0.6 fl oz) of pure alcohol. 
Subjects should not smoke more than 10 cigarettes/day or equivalent. The use of certain 
concomitant medications is restricted. For further information see Sections 7 and 9. 
 
 

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11 ADVERSE EVENTS 
11.1 Definitions 
11.1.1 Adverse events 
Adverse event means any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related. This includes any unfavorable and 
unintended sign, symptom, syndrome, or illness that develops or worsens during the clinical 
study whether or not related to the investigational products and the study procedures. 
For the purpose of the study, clinically significant abnormal results of diagnostic procedures 
including abnormal laboratory findings (e.g. requiring unscheduled diagnostic procedures or 
treatment measures or resulting in withdrawal from the study) discovered at screening will be 
related to medical history or are considered to be AEs if they are detected post screening. Any 
AEs first occurred or worsened in severity post treatment are considered as treatment-
emergent adverse event (TEAE).  
 
Maximum severity should be assigned to one of the following categories: 
• Mild: For example, an AE which is easily tolerated by the subject, causing minimal 
discomfort and not interfering with everyday activities.  
• Moderate: For example, an AE which is sufficiently discomforting to interfere with 
normal everyday activities. 
• Severe: For example, an AE which is incapacitating and prevents normal everyday 
activities. 
Worsening of a sign or symptom of the condition under treatment will be recorded as AE and 
if this worsening matches any criterion for an “SAE”, it must be recorded as such (see Section 
11.1.2). 
Examples of AEs include one of the following or a combination of two or more of these 
factors: 
• A new sign, symptom, illness, or syndrome. 
• Worsening of a concomitant or pre-existing illness. 
• An effect of the IMP or concomitant medication. 
• An effect of the IMD, if applicable 
• An effect of an invasive procedure required by the protocol. 
• An accident or injury. 
AEs can be categorized as “non-serious” and “serious” (see Section 11.1.2). 
Surgical procedures themselves are not AEs; they are therapeutic measures for conditions that 
require surgery. The condition for which the surgery is required is an AE, if it occurs or is 
detected during the study period. Planned surgical measures and the condition(s) leading to 
these measures are not AEs, if the condition(s) was (were) known before the study period (see 

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Section 9.1) and do not worsen during the study. In the latter case, the condition should be 
reported as medical history. 
11.1.2 Serious adverse events 
An AE is considered “serious” if, in the view of either the investigator or sponsor, it results in 
any of the following outcomes: 
• Results in death. 
• Is life-threatening. 
“Life-threatening” means that the subject was at immediate risk of death at the time of 
the SAE; it does not refer to an SAE that hypothetically might have caused death if it 
were more severe. 
• Requires inpatient hospitalization or prolongation of existing hospitalization. 
This means that hospital inpatient admission or prolongation of hospital stay were 
required for the treatment of the AE, or that they occurred as a consequence of the 
event. 
• Results in persistent or significant disability or incapacity. 
“Persistent or significant disability or incapacity” means a permanent or significant 
and substantial disruption of a person’s ability to carry out normal life functions”. 
• Is a congenital anomaly or birth defect. 
• Is an important medical event. 
Medical and scientific judgment should be exercised in deciding whether expedited 
reporting is appropriate in situations where none of the outcomes listed above 
occurred. 
Important medical events that may not be immediately life-threatening or result in 
death or hospitalization but may jeopardize the subject or may require interventions to 
prevent one of the other outcomes listed in the definition above should also usually be 
considered serious. Examples of such events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasia, or convulsions 
that do not result in inpatient hospitalization, or the development of drug dependency 
or drug abuse. 
A diagnosis of a second cancer during a treatment should be considered as medically 
important. 
 
The term “severe” is often used to describe the intensity (severity) of a specific event (as in 
mild, moderate, or severe myocardial infarction); the event itself, however, may be of 
relatively minor medical significance (such as severe headache). This is not the same as 
“serious”, which is based on the outcome or action criteria usually associated with events that 

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pose a threat to life or functioning. Seriousness (not severity) serves as a guide for defining 
regulatory reporting obligations. 
11.1.3 Alert terms and other reasons for expedited reporting to 
Pharmacovigilance 
No particular AEs are subject to reporting as alert terms in this study. 
For details on known adverse reactions see Ameluz® PI (19) and corresponding IB. 
Although not regarded as an SAE, any pregnancy in a subject occurring during treatment with 
the investigational products must be reported to the sponsor immediately. Information related 
to the pregnancy must be given on a “Pregnancy report form” that will be provided by the 
sponsor. This information must be provided regardless of the decision to withdraw the subject 
from the study or discontinue the treatment. 
11.1.4 Investigational medicinal product complaints 
Complaints associated with the IMP quality must be reported to the sponsor. 
11.1.5 Investigational medical device complaints 
All AEs reported in previous studies were not directly related to BF-RhodoLED® but rather to 
the medication or PDT. Therefore, we do not expect any AEs affecting subjects or third 
persons (e.g. study personnel) that relate directly to BF-RhodoLED® also referred to as 
Medical Device Effects (ADEs), provided that it is properly used as described in the user 
manual. 
Nevertheless, if occurring ADEs as well as technical complaints associated with the medical 
device BF-RhodoLED® must be reported to the sponsor and IRB (in cases of (U)SADEs) 
ADEs reported by the treated subject must be reported via the eCRF and on the AE log. 
11.2 Period of AE collection 
Collection of AEs starts with signing the informed consent documents until the end of the 
study. AEs will be discriminated as AEs and TEAEs.  
• AEs developing between signing the ICF until Visit 2 with a suspected causal 
relationship to any study procedures will be considered and documented as an AE.  
• Collection of TEAEs extends from Visit 2 (baseline) until end of the study at Visit 3.  
• If the investigators detect an SAE in a subject after end of study, and considers the 
event possibly related to prior study treatment or procedures, they should report this 
event to the pharmacovigilance department of the sponsor (see section 11.3.1). 
11.3 Documentation and reporting of adverse events by investigator 
All AEs as well as any SAE that occur throughout the study must be documented in 
accordance with the instructions for the completion of AE reports in clinical studies. If 
possible, AEs should be assigned to be either unrelated (corresponding to unrelated or 
unlikely related) or related (corresponding to probably, possibly or definitely related) to the 

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IMP or the IMD, or both, as this will be important for evaluation of the safety of BF-200 ALA 
or the PDT lamp. 
The following approach will be taken for documentation: 
• All AEs (whether serious or non-serious) must be documented throughout the study. 
• If the AE is serious (see Section 11.1.2), the investigator must complete, in addition to 
the “Adverse Event” page in the eCRF, a “SAE report” form at the time the SAE is 
detected. This form must be marked as “initial” and be sent immediately (within 24 h) 
to the sponsor’s Pharmacovigilance department by email or fax (according to 
Biofrontera’s Standard Operating Procedure (SOP)). SAEs must be identified as such 
in eCRF by stating the applicable SAE criteria that were met. 
• When a “significant overdose” of IMP occurs without an AE or in other situations 
where the sponsor requires an expedited report without an AE (see Section 11.1.3), the 
investigator should only complete a “Serious Adverse Event/Expedited Report from a 
Clinical Trial for Combination products” form. It should be clearly stated that no 
adverse event was observed. Instructions on where to send this form will be provided. 
In this case, there is no need to complete the “Adverse Event” page in the eCRF. 
• The following details regarding AEs are required:  
- confirmed medical diagnosis or symptoms (if applicable)  
- location (inside/outside treatment field(s))  
- time frame (by providing start/stop date and time) 
-  intensity (see Section 11.1.1)  
- outcome  
- seriousness criteria (if applicable), and  
- if the AE is related to IMP only, IMD only, or cannot be ambiguously assigned 
to one of both.  
• The causality/relatedness of AEs has to be assessed: 
- UNRELATED: AEs that are judged to be clearly and incontrovertibly due to a 
cause other than the IMP/IMD and study procedure (concurrent illness etc.). 
- UNLIKELY RELATED: the temporal sequence is atypical, and the AE does 
not follow a known pattern of response to IMP/IMD another causative factor is 
present but causal role of the study drug cannot be excluded. 
- POSSIBLY RELATED: either an event that is temporally associated with the 
use of the IMP/IMD or a known pharmacological effect/associated reaction, 
which is also recognized with another concomitant therapy/illness or other 
external cause. 
- PROBABLY RELATED: appropriate temporal association, known 
pharmacological effect, recognized to be an associated IMP/IMD reaction and 
for which no other possible cause is evident. 

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- DEFINITELY RELATED: the reaction has occurred with this IMP/IMD 
previously (i.e. positive re-challenge) and there is an appropriate temporal 
relationship between therapy and reaction; and the reaction follows a known or 
expected response pattern to the suspected drug. 
The investigator should use medical judgment to determine whether he/she assumes a 
reasonable causal relationship, including into his/her evaluation all relevant factors and 
factual evidence such as 
- temporal course and latency 
- results from re-challenge 
- pattern of the reaction 
- known pharmacological properties of the product 
- and alternative explanations (e.g. other drugs, medical history, concomitant 
diseases). 
Every attempt should be made to describe the AE in terms of a diagnosis. If a clear diagnosis 
has been made, individual signs and symptoms will not be recorded as separate AEs unless 
they represent atypical or extreme manifestations of the diagnosis, in which case they should 
be documented as separate events. In the case of SAEs or SARs, respectively, component 
signs and symptoms may be recorded in addition to a diagnosis if they further clarify the 
clinical picture. If a clear diagnosis cannot be established, each sign and symptom must be 
recorded individually. 
All subjects who have AEs, whether considered associated with the use of the IMP and/or the 
IMD or not, should be monitored to determine the outcome. The clinical course of the AE will 
be followed up according to accepted standards of medical practice, even after the end of the 
study, until a satisfactory explanation is found, or the investigator considers it medically 
justifiable to terminate the follow-up. Should the AE result in death, a full pathologist’s report 
should be supplied, if possible. 
11.3.1 Immediate reporting  
11.3.1.1 Reporting of SAEs to sponsor  
SAEs observed throughout the study must be documented on an “SAE report” form in 
accordance with instructions for completing the “SAE report” form. This form and the 
instructions will be provided in the investigator file and must be completed and supplied 
immediately (within 24 h) to the sponsor (21CFR§ 312.32, 21CFR§ 312.64). 
Any SAE that occurs throughout the study, whether or not related to the IMP or the medical 
device, must be reported by the investigator within 24 h by fax, or by e-mail, to the following 
contact data: 
Email: 
 
Fax: 
  
The initial report must be as complete as possible, including details of the current illness and 
(serious) AE, and an assessment of the causal relationship between the event and the IMP or 
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Information not available at the time of the initial report (e.g. an end date for the AE or 
laboratory values received after the report) must be documented on an “SAE report” form, 
with the box “Follow-up”/”Final report”. 
The instructions for completing the “SAE report” form give more detailed guidance on the 
reporting of SAEs, and AEs initially reported as non-serious that become serious. In the latter 
situation, when a non-serious event becomes serious, details must be forwarded immediately 
(within 24 h) to the sponsor on an “SAE report” form. 
Pregnancies occurring during a subject's participation in the study, although not typically 
considered SAEs, must be notified to the sponsor within the same timelines as an SAE (within 
24 h after becoming aware of the pregnancy) on a pregnancy notification form. Further 
treatment will be addressed on a case-by-case basis with the treating physician and the 
investigator. 
Any pregnancy should be followed up until completion. If relevant, the development of the 
newborn will be monitored for an appropriate time post-delivery. 
The drug safety department of the sponsor or designee has to be notified by fax or e-mail. 
The sponsor will ensure that all legal reporting requirements to the competent authorities and 
the IRB(s) are met. 
Note: 
For regulatory reporting purposes, events which are assessed by the sponsor as “unrelated” or 
“unlikely related” to the study medication will be considered as having no reasonable causal 
relation and will not be reported on an expedited basis. 
Events assessed by the sponsor as “possibly, probably or definitely related” will be considered 
as having a plausible causal relation to the study medication and will be reported if they are 
also considered unexpected and serious. 
11.3.1.2 Reporting of USADEs to the sponsor and to IRB 
Events which can be clearly assigned to the IMD and which are assessed by the investigator 
as “possibly, probably or definitely related” to the IMD and which are both serious and 
unanticipated will be considered as unanticipated serious adverse device effect (USADE). A 
report of any USADE occurring during an investigation shall be submitted to the reviewing 
IRB and the sponsor within 10 working days after the investigator first learns of the effect (21 
CFR §812.150). 
In case a serious and unexpected event cannot be clearly assigned to the IMD, it should be 
treated as an SAE (see Section 11.1.2). 
Note: Reporting of USADEs to the sponsor is equal to SAE reporting described in Section 
11.3.1.1. 
11.3.1.3 Reporting of expeditable adverse events to IRB 
The investigator will promptly forward IND safety reports received from sponsor (see section 
11.4.2) and report all unanticipated problems involving risk to human subjects or others, and 
changes in the research activity to the IRB. 

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11.3.2 Unblinding  
This is an open-label study, i.e., unblinding is not applicable. 
11.4 Documentation and reporting of adverse events by sponsor 
11.4.1 Determination of expectedness, Reference Safety Information 
Expectedness of serious AEs will be determined by the sponsor according to the designated 
Reference Safety Information (RSI). Any updates or substantial amendments will be 
considered accordingly. The RSI for the investigational products will be included in the IB 
‘ALA-AK-CT015-IB’ in section 7.2.  
Unexpected: An AE or suspected adverse reaction is considered unexpected if it is not listed 
in the RSI or is not listed with the specificity or severity that has been observed. Unexpected, 
as used in this definition, also refers to AEs or suspected adverse reactions that are mentioned 
in the RSI as occurring with a class of drugs or as anticipated from the pharmacological 
properties of the drug, but are not specifically mentioned as occurring with the particular drug 
under investigation. 
11.4.2 Reporting of expeditable adverse events to competent authorities and 
investigators 
The sponsor will report all serious and unexpected AEs, which are judged by the sponsor as 
having a reasonable suspected causal relationship (suspected unexpected serious adverse 
reaction - SUSAR) as IND safety reports to the FDA and all participating investigators 
according to applicable law.  
The sponsor will also report USADEs to the FDA, all reviewing IRBs and to all investigators. 
11.4.3 Periodic reporting of adverse events by sponsor 
A summary of all Investigational New Drug (IND) safety reports will be included in the 
progress report submitted annually to the competent authorities within 60 days of the 
international anniversary date of the product (14 June, in agreement with authorities). The 
same report will also be submitted to the IRB(s) to ensure a continuing review of the project. 
11.4.3.1 Development safety update report (DSUR) 
The sponsor will prepare and submit annual safety reports to competent authorities and 
concerned ethics committees. 
11.5 Continuous risk assessment 
The sponsor’s safety department will apply appropriate monitoring measures to continuously 
survey the benefit risk ratio of the IMP, the IMD and study procedures. 

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12 WITHDRAWALS 
12.1 Withdrawal of subjects 
Subjects must be withdrawn from study (i.e. from any further study procedure) for the 
following reasons: 
• At their own request (withdrawal of informed consent). 
• If, in the investigator’s opinion, continuation in the study would be detrimental to the 
subject’s well-being. 
In all cases, the reason for and date of withdrawal must be documented. Subjects can 
withdraw consent at any time of the study without being obliged to specify a reason for their 
withdrawal. In case of an AE causing the withdrawal of consent, the AE has to be 
documented as cause of withdrawal.  
As far as possible, all examinations scheduled for the final study day should be performed on 
all subjects who receive the IMP but who do not complete the study according to protocol. 
For subjects that may not be treated due to screening failures or who decide to terminate the 
study prior to treatment, at least the following parameters must be documented in the eCRF: 
date of informed consent, demographics and date and reason for withdrawal. 
12.2 Replacement of subjects 
Subjects who discontinue will not be replaced.  
12.3 Withdrawal of samples 
In the data review meeting criteria for withdrawal of PK samples will be defined on case-by-
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13 EMERGENCY PROCEDURES 
13.1 Emergency sponsor contact 
In emergency situations, the investigator should contact the sponsor by telephone at the 
number given below, if that is regarded as necessary: 
 
13.2 Emergency identification of investigational medicinal products 
In this open-label study, all eligible subjects will receive one active treatment. For this reason, 
special emergency identification procedures are not applicable for this trial.  
13.3 Emergency treatment 
There is no substance-specific treatment for adverse reactions. For treatment of PDT 
associated pain and discomfort please see Section 9.2. 
During and after a subject’s participation in the trial, the investigator or institution should 
ensure that adequate medical care is provided to a subject for any AEs, including clinically 
significant laboratory values, related to the trial. The investigator or institution should inform 
a subject when medical care is needed for intercurrent illness(es) of which the investigator 
becomes aware. 
 
 

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14 STATISTICAL PROCEDURES 
Subjects who withdraw from study participation before administration of PDT (including 
treatment field preparation) are considered screening failures. The demographic data, date of 
informed consent as well as date and reason for withdrawal from screening failures are 
entered into the clinical database and will not be passed through the data cleaning process. 
Their data are listed separately from data of treated subjects. A detailed overview of statistical 
procedures is provided in the SAP. The SAP will encompass demographics, PK and safety 
analysis. 
14.1 Analysis variables 
The primary endpoints for pharmacokinetics are the  
• Baseline-adjusted plasma concentrations of ALA for obtaining baseline-adjusted 
plasma concentration-time curves 
• Baseline-adjusted plasma concentrations of PpIX for obtaining baseline-adjusted 
plasma concentration-time curves  
Secondary endpoints are the  
• Baseline-adjusted AUC0-t, baseline-adjusted AUC0-∞, baseline-adjusted Cmax, Tmax, 
T1/2, and λZ for ALA (if data permit)  
• Baseline-adjusted AUC0-t, baseline-adjusted AUC0-∞, baseline-adjusted Cmax, Tmax, 
T1/2, and λZ for PpIX (if data permit)  
• Assessment of safety and tolerability of PDT with BF-200 ALA under maximal use 
conditions, including: 
o Frequency and severity of treatment-emergent adverse events (TEAEs), 
including serious adverse events (SAEs). TEAEs are defined as all AEs with 
onset or worsening after treatment with the investigational medicinal product 
and device. 
o Overall tolerability. 
o Application site skin reactions in the treatment field(s) during and post PDT. 
o Application site discomfort during and after illumination reported by the 
subjects. 
o Application site pain during PDT on an 11-point Numeric Rating Scale (NRS-
11). 
o Vital signs data. 
o Safety laboratory data if clinically significant deviations occur. 
o Data from the physical examinations if clinically significant findings occur. 
Tertiary endpoints are the 
• Unadjusted plasma concentration-time curve for ALA and pharmacokinetic 
parameters of ALA: unadjusted AUC0-t, unadjusted AUC0-∞, unadjusted Cmax, Tmax, 
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• Unadjusted plasma concentration-time curve for PpIX and pharmacokinetic 
parameters of PpIX: unadjusted AUC0-t, unadjusted AUC0-∞, unadjusted Cmax, Tmax, 
T1/2, and λZ if data permit 
All pharmacokinetic characteristics (AUC0-t,AUC0-∞, T1/2 and λz) will be derived from 
baseline-adjusted as well as unadjusted plasma concentrations of ALA and PpIX as described 
above.  
The pharmacokinetic parameters for ALA and PpIX will be derived from plasma using 
noncompartmental methods and are listed in Table 6. Values < LLOQ and negative values 
after baseline adjustment are set to zero and disregarded when displaying data on a 
logarithmic scale. 
Table 6: List of pharmacokinetic parameters 
Parameter 
Description 
Cmax  
Observed maximum baseline-adjusted or unadjusted plasma concentration 
AUC0-t 
Area under the baseline-adjusted as well as unadjusted plasma 
concentration-time curve from time zero to the last sampling time point at 
which the concentration was at or above lower limit of quantification 
(LLOQ); t(last) is defined as the last value > 0 after baseline adjustment. 
AUC0-t will be calculated according to the linear trapezoidal formula 
AUC0-∞ 
Area under the baseline-adjusted as well as unadjusted plasma 
concentration-time data extrapolated to infinity 
(AUC0-∞ = AUC0-t + Ct/λz) 
%AUCt- 
Proportion of extrapolated part (%AUCt-∞) 
(1- [AUC0-t/AUC0-∞])•100 
tmax 
time to reach Cmax 
t1/2,λz 
apparent terminal half-life, calculated by ln2/z  
λz 
Terminal rate constant  
λz denotes the terminal rate constant estimated by linear regression analysis 
from a range of concentrations in the terminal phase estimated for each 
treatment and subject by log-linear regression from the linear portion of the 
logarithmic transformed concentration-time plot. The algorithm will start 
with the last 3 points with quantifiable concentrations and increases the 
number of involved points by 1 until the time point after Cmax restricted on 
time points after removing of the BF-200 ALA gel.  
For each regression an adjusted R2 will be computed:  
Adjusted R2 = 
2
)1
(
)
1(
1
2
−
−

−
−
n
n
R
, 
 
where n denotes the number of data points (n  3). 
 
The regression with the largest adjusted R2 > 0.8 will be selected for the 
estimation of λz using WinNonlin option “BestFit”.  
 

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14.2 Analysis sets 
Any decision for exclusion of individual subjects from an analysis population will be made 
before database lock in a data review meeting; Documentation concerning which subjects are 
to be excluded from an analysis population will be prepared and reported, i.e., as data review 
minutes. 
Enrolled set 
All subjects enrolled in this study i.e. that provided informed consent to participate in the 
study. 
Treated set  
All subjects that received IMP treatment (including subjects whose PDT treatment was 
terminated for any reason without illumination). This set is the analysis set for the summary 
of subject discontinuation. 
Safety set 
The safety set (SAF) will include all subjects who undergo at least one of the following 
treatment procedures: preparation of the treatment field(s), application of BF-200 ALA, or 
illumination. The SAF is the analysis set for all safety analyses. 
Pharmacokinetic sets 
The pharmacokinetic sets are defined for each of the two analytes separately. The 
pharmacokinetic set per analyte includes all subjects who have at least one evaluable pre-dose 
and post dose pharmacokinetic sample (i.e., samples taken after the application of BF-
200 ALA) for the respective analyte. A post dose sample is regarded evaluable if the plasma 
concentration is at or above LLOQ.  
As plasma concentration data of ALA and PpIX are considered separately, e.g., a subject can 
be in the pharmacokinetic set for evaluation of PpIX but not for evaluation of ALA.  
Subjects who develop bleeding during preparation of the treatment area are not to be excluded 
from the pharmacokinetic set. 
14.3 Statistical methods 
The planned analyses are of exploratory nature without any formal statistical hypotheses. All 
measured variables and derived parameters of subjects who are treated will be listed and, if 
appropriate, tabulated in summaries. For categorical variables, frequency counts and 
percentages will be used to summarize the results.  
Descriptive statistics of continuous variables will be provided including number of 
observations, arithmetic mean, standard deviation (SD), coefficient of variation (CV) (if 
appropriate), median as well as minimum and maximum.  
Descriptive statistics of pharmacokinetic parameters and plasma concentrations for ALA and 
PpIX additionally included the geometric mean, geometric SD, and geometric CV. If a zero 
occurs in a sample, the corresponding geometric mean and geometric SD will be computed, 
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The PK data will be presented for all subjects in the respective PK sets. Selected data may be 
presented excluding outliers as well. Safety data will refer to the SAF set. 
Disposition of subjects and exposure 
Descriptive analysis of subjects in each analysis set such as the enrolled set, the treated set, 
the SAF, the pharmacokinetic set for ALA and PpIX, respectively, will be presented.  
Premature discontinuation from the study and completion of the study will be summarized. 
Reasons for discontinuation will be tabulated.   
PDT details (e.g. incubation time of the IMP, duration of illumination, interruptions/pauses, 
interferences) and sampling time points for PK blood samples will be presented overall and 
by strata. 
Demographics and background characteristics 
All variables concerning demographic and background characteristics will be summarized to 
describe the study population.   
Concomitant medications will be coded according to Anatomical Therapeutic Chemical 
Classification System (ATC) and number and frequency of subjects with previous or 
concomitant medication will be summarized. 
Safety analyses 
All safety endpoints will be analyzed descriptively and in an exploratory way. These safety 
analyses will be performed for the safety set. Safety analyses will be conducted overall and 
according to strata. 
AEs will be coded according to the latest Medical Dictionary for Regulatory Activities 
(MedDRA) version available at the day of database closure. The analysis will focus on the 
TEAEs. TEAEs will be summarized and tabulated according to primary system organ class 
and preferred term. TEAEs leading to death and TEAEs resulting in discontinuation of study 
will be tabulated using frequency tables if a reasonable number of AEs of this type are 
observed.   
A listing of subjects with AEs will be provided for all AEs reported and all subjects enrolled. 
The frequency of application site skin reactions and of application site discomfort will be 
presented overall and per strata. The mean and the maximal pain score (NRS-11) and the 
respective confidence intervals (CIs) will be presented overall and per strata.  
All laboratory values will be classified as normal or abnormal according to the laboratory’s 
normal ranges and indicated as clinically significant or non-clinically siginificant by the 
investigator. Out of range laboratory values that are considered clinically significant will be 
documented in the medical history (Visit 1) or as AEs (Visit 3) and listed as such.  
The analyses of variables for vital signs will focus on the evaluation of the change from 
baseline to the scheduled time point after baseline. Descriptive analysis (number of subjects, 
mean, median and SD, minimum, maximum) of the time course and of changes from baseline 
to post baseline time point will be presented. 

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General physical examinations will include the following body systems: head and neck, skin, 
lymph nodes, thorax including heart and lung, abdomen, and musculoskeletal, peripheral 
vascular and nervous system. All clinically significant abnormal physical findings will be 
listed. Details of further analyses will be specified in the statistical analysis plan (SAP).  
Pharmocokinetics 
Descriptive statistics of unadjusted and baseline-adjusted plasma concentrations for ALA and 
PpIX by nominal blood sampling time will be provided. 
The following graphics will be provided for ALA and PpIX: 
• Geometric mean concentrations (unadjusted and baseline-adjusted) will be given on 
linear and logarithmic concentration scale. 
• Individual concentrations (unadjusted and baseline-adjusted) will be provided overall 
for each subject on linear and logarithmic concentration scale (by-patient plot). 
• Individual concentrations (unadjusted and baseline-adjusted) will be provided according 
to strata for each subject on linear and logarithmic concentration scale (by-patient plot).  
For unadjusted concentrations, the mean overall baseline concentration will be presented as a 
dotted line in the overall graphic, and the respective average baseline of all subjects will be 
presented in  the corresponding by-patient plots. 
Descriptive statistics of calculated PK parameter for ALA and PpIX will be provided overall 
and according to strata.  
14.4 Handling of missing data 
Missing data of safety or pharmacokinetics variables will not be replaced. Details on the 
handling of missing data will be specified in the SAP.  
14.5 Interim analysis 
No formal interim analysis will be performed.  
14.6 Sample size justification 
Thirty-two (32) subjects will be included in this study, stratified into two groups of 16 
subjects each. One of the groups will receive PDT applying 3 tubes of BF-200 ALA in the 
face/scalp, the other group will receive PDT applying 3 tubes of BF-200 ALA on the 
neck/trunk/extremities.  
A previous PK Phase I study under maximal use conditions in AK subjects with 1 tube of BF-
200 ALA (ALA-AK-CT006) had revealed homogeneous baseline-adjusted levels of ALA and 
PpIX in 12 subjects, with a CV of 53-73% in the key pharmacokinetic parameters after drug 
application. As statistical evaluation of PK and safety is intended to be performed as 
descriptive statistics only, no calculation of predictive power is required.  
Based on the results of a previous PK study (ALA-AK-CT006), a group size of 12 subjects is 
considered to be sufficient for proper pharmacokinetic evaluation and in agreement with the 
findings from the pilot study. In order to compensate for potential drop-outs of subjects as 
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areas, stratum size was adapted from 12 to 16 subjects. A drop-out rate of 25% (4 of 16 
patients) was assumed taking into account the complex nature of the study procedures 
comprising PDT treatment with three tubes and up to two illuminations, and frequent blood 
sampling on one single day. For this reason, the sample size of 32 subjects is considered to be 
adequate for pharmacokinetic evaluation in this PK study. 
 
 

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15 ETHICAL AND LEGAL ASPECTS 
15.1 Good clinical practice 
This study is to be conducted according to globally accepted standards of GCP (as defined in 
the ICH E6 (R2) Guideline for GCP), in agreement with the Declaration of Helsinki in its 
current version and in keeping with local regulations. 
15.2 Delegation of investigator duties 
The investigator should ensure that all persons contributing to the trial are adequately 
qualified, informed about the protocol, any amendments to the protocol, the study treatments, 
and their trial-related duties and functions. 
The investigator should immediately report any changes in study personnel to the sponsor. 
Any regulatory requirement regarding a change in site personnel has to be met. Besides that, 
the investigator should maintain a list of subinvestigators and other appropriately qualified 
persons to whom they have delegated significant trial-related duties. 
If required by local regulations, the investigator should designate a deputy investigator with 
appropriate qualifications being able to fully replace the investigator in cases of absence. 
15.3 Subject information and informed consent 
Every trial participant will receive a complete and comprehensive explanation of the 
significance, nature, extent, and possible risks of the trial. To this end, a detailed, written 
subject information sheet will be made available. In addition, an investigator/subinvestigator 
will carry out an oral information session during which the subjects will be given ample time 
and opportunity to clarify remaining questions. 
Afterwards, the subject or their legal representative and the investigator/subinvestigator will 
sign the informed consent form (ICF). To grant direct access to the subject's original medical 
records for verification of clinical trial procedures and/or data, without violating the 
confidentiality of the subject, the subject/legal representative will also sign an agreement. 
Depending on the local legal requirements this agreement can be part of the ICF or a separate 
form, such as the HIPAA form. The original signed ICF and, if applicable, HIPAA forms will 
be archived in the ISF. The subject will receive a copy of these documents. The investigator 
will acknowledge instruction of every subject in accordance with the clinical study protocol 
(CSP) and the existence of a signed consent and HIPAA form. 
Before valid consent has been obtained the subject will not undergo any study related 
procedures. The investigator should inform the subject’s primary physician about the 
subject’s participation in the trial if the subject agrees to this. 
During the course of the trial, ICF may need to be updated and thus, requires re-consenting of 
subjects. The investigator /subinvestigator will inform every active trial participant in a timely 
manner and obtain updated ICF in line with above mentioned obligations.  
15.4 Confidentiality 
To ensure confidentiality the subject’s data will be collected for the clinical data base and 
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name. The subject number will also be used for SAE reporting purposes. On supporting 
documents of an SAE report, such as hospital reports or laboratory reports, the subject’s name 
and if required by regulations the physician’s name has to be obliterated. 
The investigator will maintain a personal subject identification list (subject numbers with the 
corresponding subject names) to enable records to be identified.  
Subject identity and personal data will be safeguarded according to national requirements on 
data protection. 
The sponsor adheres to data protection regulations.  
15.5 Protocol deviations 
Protocol deviation have to be documented and explained by the investigator and/or the 
sponsor. Major protocol deviations have to be escalated to the sponsor. If there is a legal 
requirement, the investigator needs to report major protocol deviations to the responsible 
ethics committee (EC)/IRB. 
The sponsor is obliged to report serious breaches (severe violations of GCP regulations as 
well as all events that affect to a significant degree, the safety or physical or mental health of 
the subjects of the trial or the scientific value of the trial) to the IRB(s) and the applicable 
authorities. 
15.6 Protocol amendments 
The investigators cannot alter the protocol without the sponsor’s approval. If the sponsor 
amends the protocol all principal investigators need to agree to adhere to the amended 
protocol.  
In case of protocol changes that might affect the subjects’ safety and well-being or the validity 
and integrity of the study data, the amendment is deemed substantial. Minor changes to the 
protocol, such as administrative changes, correction of typos and inconsistencies etc. stipulate 
a non-substantial amendment. 
15.7 Approval of the clinical study protocol and amendments 
Prior to the start of the study, the CSP, subject information leaflet and ICF, and any other 
appropriate documents will be submitted to the IRB(s) in charge. If applicable, the documents 
will also be submitted to the authorities, in accordance with local legal requirements.  
All ethical and legal requirements must be met before the sites can start enrolling subjects. 
A protocol amendment has to be submitted to the IEC/IRB and, if required, to the regulatory 
authority(ies). In case of a non-substantial amendment these bodies only will be notified but 
they need to approve any substantial amendment to the protocol before it can be implemented. 
Amendments must be evaluated to determine whether the subject information leaflet and 
informed consent form should also be revised. 
The investigator must keep a record of all communication with the IRB(s) and, if applicable, 
between a Coordinating Investigator and the IRB(s). This also applies to any communication 
between the investigator (or Coordinating Investigator, if applicable) and the authorities. 

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15.8 Ongoing information for ethics committee/institutional review board 
Periodic reports (e.g. annually) will be generated and submitted regarding to the requirements 
of the respective IRB or any applicable law(s) for IRB continuing review. 
15.9 Closure of the study 
Upon study completion or premature termination, each investigational site will be closed.  
Completion or premature termination of the study will be reported to the regulatory agency 
and to the IRB if required by local regulation or by the IRB(s). 
Furthermore, the sponsor has the right to close a study site at any time. As far as possible, 
premature closure should occur after mutual consultation. 
Study materials must be returned, disposed of, or retained as directed by the sponsor. 
15.10 Record retention 
At the close-out visit the monitor will inform the sites about the required archiving period. 
The investigator must obtain approval in writing from the sponsor prior to destruction of any 
records and must document any change of ownership. 
Within the United Stated of America the investigator has a legal obligation to retain records 
required to be maintained under 21 CFR §312.62 for a period of 2 years, following the date a 
marketing application is approved for the drug and the indication for which it is being 
approved. In case no application is to be filed or if the application is not approved for such 
indication, records will be kept for two years after the investigation is discontinued and FDA 
is notified. 
This regulation applies to: 
• Adequate and accurate case histories that record all observations and other data 
pertinent to the investigation on each individual administered IMP and PDT such as: 
 
- Case report forms and supporting data. 
- Signed and dated consent forms. 
- Medical records including e.g. progress notes of the physician and nurse. 
- The case history of each subject shall document that informed consent was 
obtained prior to participation in the study. 
• Records documenting disposition of the IMP and IMD (including dates, quantity, use 
and return to the sponsor) if the investigation is terminated, suspended, discontinued 
or completed. 
15.11 Liability and insurance 
Liability and insurance provisions for subjects will be arranged according to legal 
requirements. If required by legal requirements, the subjects will receive a copy of the general 
conditions of insurance. Liability and insurance provisions for investigators participating in 
this study will be defined in a separate agreement, if applicable. 

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15.12 Financial disclosure 
Prior to the start of the study, the investigator will disclose to the sponsor any proprietary or 
financial interests he or she might hold in the IMP, the IMD or the sponsor company as 
outlined in the financial disclosure forms (e.g. Form FDA 3454 or FDA 3455). By signing the 
financial disclosure form the investigator is also obliged to inform the sponsor about any 
changes up to one year after study completion/termination. 
Where required by regulation, the sponsor will also submit the financial arrangements for the 
study to the regulatory authorities and if applicable to the IRB(s). Similar information will be 
provided by each subinvestigator to whom the investigator delegates significant study-related 
responsibilities. 
 
 

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16 QUALITY CONTROL, QUALITY ASSURANCE, AND 
INSPECTIONS  
Quality control mechanisms are implemented on a functional level and quality assurance 
audits will be done according to GCP (ICH Topic E6 (R2) GCP guideline) and the applicable 
regulatory requirements. Direct access to the on-site study documentation and medical records 
must be ensured. 
16.1 Study monitoring and source data verification 
Monitoring is the act of overseeing the progress of a clinical trial, and of ensuring that it is 
conducted, recorded, and reported in accordance with the protocol, SOPs, GCP, and the 
applicable regulatory requirement(s). The frequency of monitoring and co-monitoring visits, 
and the degree of source data verification are defined in the monitoring plan. Monitoring will 
be done by onsite visits. In addition to the monitoring visits, frequent communications (letter, 
telephone, and fax) by the clinical monitor will ensure that the investigation is conducted 
according to protocol design and regulatory requirements. 
The results of monitoring visits will be documented in monitoring reports. Issues arising will 
be escalated and dealt with in a timely manner. The escalation process is defined in the 
respective SOPs of the contract research organization (CRO) or sponsor. 
Study closeout will be performed by the clinical monitor upon closure of the study. 
16.2 Site audits 
Audits can be conducted at any time during or after the trial to assure the validity and integrity 
of the study data, the protection of the right, safety and well-being of the subjects and the 
adherence to the protocol, to ICH-GCP, ISO 14155 (if applicable) and to the applicable legal 
requirements. On-site audits will be conducted by an independent auditor from the respective 
quality assurance unit of the CRO or the sponsor or by a contracted auditor. Direct access to 
these documents must be guaranteed by the investigator, who must provide support at all 
times for these activities.  
16.3 Site Inspections 
Domestic and foreign regulatory authority(ies) may conduct an official review of documents, 
facilities, records, and any other resources that are deemed by the authority(ies) to be related 
to the clinical trial and that may be located at the site of the trial. For this, the 
investigator/institution has to give access to all source documents, eCRFs, and other study 
documentation for an inspection. The investigator should inform the sponsor as soon as 
possible about any announced inspection. Site personnel should fully comply with inspection 
procedures. 
 
 

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17 DOCUMENTATION AND USE OF STUDY FINDINGS 
17.1 Documentation of study findings 
This study will be performed using an eCRF. The investigator and study site staff will receive 
system documentation, training, and support for the use of the eCRF. 
All protocol-required information collected during the study must be entered by the 
investigator, or a designated representative, in the eCRF as soon as possible, preferably on the 
same day that a study subject is seen for an examination, treatment, or any other study 
procedure. Any outstanding entries must be completed immediately after the final 
examination. An explanation should be given for all missing data. All data entry, modification 
or deletion will be recorded automatically in an electronic audit trail, indicating the individual 
subject, original value, the new value, the reason for change, who made the change, and when 
the change was made. All data changes will be clearly indicated with a means to locate prior 
values. The system will be secured to prevent unauthorized access to the data or the system. 
This will include the requirement for a user identification and password to enter or change 
data. The investigator will maintain a list of individuals who are authorized to enter or correct 
data and their system identification. 
All electronic data entered by the site (including an electronic audit trail) as well as computer 
hardware and software (for accessing the data) will be maintained or made available at the site 
in compliance with applicable record retention regulations. The computerized system is able 
to generate accurate and complete copies of records in both human-readable and electronic 
form for inspection, review, and copying by regulatory authorities, the IRB(s), and auditors 
authorized by the sponsor. Site documentation will identify the software and hardware 
systems used to create, modify, maintain, archive, retrieve, or transmit data. 
A source data location list will be prepared and updated during the study. It will specify which 
types of source data are available and where they are stored (e. g. electronic or paper subject 
files etc.), and which data may be entered directly into the eCRF. This list will be filed in both 
the TMF and the investigator study file and updated as necessary. The sites can establish 
appropriate work sheets or record the source data directly in subjects’ notes. Source data 
entries have to be signed and dated by the respective investigator or delegated person in 
compliance with the delegation log in which responsibilities and duties of the study 
performance are laid down. In addition, all changes and additional entries have to be made 
visible and signed and dated by the respective study team member. 
The investigator, or designated subinvestigator, following review of the data in the eCRF, will 
confirm the validity of each subject’s data by electronic signature. The sponsor will retain the 
original eCRF data and audit trail. A copy of all eCRFs completed by the site will be provided 
to the concerned investigator. 
17.2 Use of study findings 
All information concerning the product as well as any matter concerning the operation of the 
sponsor, such as clinical indications for the drug or medical device, the drug formula, methods 
of manufacture and other scientific data relating to it, that have been provided by the sponsor 
and are unpublished, are confidential and must remain the sole property of the sponsor. The 

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investigator will agree to use the information only for the purposes of carrying out this study 
and for no other purpose unless prior written permission from the sponsor is obtained. 
The sponsor has full ownership of the eCRFs completed as part of the study. 
By signing the CSP, the investigator agrees that the results of the study may be used for the 
purposes of national and international registration, publication, and information for medical 
and pharmaceutical professionals. The authorities will be notified of the investigator’s name, 
address, qualifications, and extent of involvement. 
The sponsor will ensure that a final report on the study is prepared. 
As required by local regulation or by the IRB(s), a summary of the clinical study will be 
submitted by the sponsor to the regulatory authorities and by the sponsor or investigator to the 
IRB(s). 
The Coordinating Investigator of a multi-center trial or the Investigator in a single-center trial 
will be required to sign a statement in the clinical study report in which he or she confirms 
that, to the best of his or her knowledge, it accurately describes the conduct and results of the 
study. 
All materials, documents, and information supplied by the sponsor to the investigator, and all 
materials, documents, and information prepared or developed in the course of the study to be 
performed under this protocol, shall be the sole and exclusive property of the sponsor. 
Scientific publication of the study results may be planned mutually between the sponsor and 
the Investigator. Details of the publication policy will be specified in the investigator 
contracts. 
 
 

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18 REFERENCES 
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24. Braathen LR, Szeimies R-M, Basset-Seguin N, Bissonnette R, Foley P, Pariser D, et al. 
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25. Vegter S, Tolley K. A Network Meta-Analysis of the Relative Efficacy of Treatments for 
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26. Schmieder GJ, Huang EY, Jarratt M. A multicenter, randomized, vehicle-controlled 
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27. Touma D, Yaar M, Whitehead S, Konnikov N, Gilchrest BA. A trial of short incubation, 
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28. Willey A, Anderson RR, Sakamoto FH. Temperature-modulated photodynamic therapy 
for the treatment of actinic keratosis on the extremities: a pilot study. Dermatologic 
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29. Taub AF, Garretson CB. A randomized, blinded, bilateral intraindividual, vehicle-
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30. Dirschka T, Radny P, Dominicus R, Mensing H, Bruning H, Jenne L, et al. 
Photodynamic therapy with BF-200 ALA for the treatment of actinic keratosis: results of 
a multicentre, randomized, observer-blind phase III study in comparison with a registered 
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31. Szeimies RM, Radny P, Sebastian M, Borrosch F, Dirschka T, Krahn-Senftleben G, et al. 
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a prospective, randomized, double-blind, placebo-controlled phase III study. The British 
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32. Reinhold U, Dirschka T, Ostendorf R, Aschoff R, Berking C, Philipp-Dormston WG, et 
al. A randomized, double-blind, phase III, multicentre study to evaluate the safety and 
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RhodoLED((R)) lamp. The British journal of dermatology 1 Jan. 2016;175(4):696–705. 
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33. Warren CB, Karai LJ, Vidimos A, Maytin EV. Pain associated with aminolevulinic acid-
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PubMed PMID: 19925929. 
34. Christensen E, Warloe T, Kroon S, Funk J, Helsing P, Soler AM, et al. Guidelines for 
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doi: 10.1111/j.1468-3083.2009.03430.x. PubMed PMID: 19807828. 
35. Philipp-Dormston W. Professionelles Schmerzmanagement bei der 
PhotodynamischenTherapie. Ästhetische Dermatologie 1 Jan. 2012(3):52 German. 
36. Guidance for Industry: Bioavailability and Bioequivalence Studies for Orally 
Administered Drug Products - General Considerations. 1st ed.; 2003 [cited 2019 Aug 
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37. Olsen EA, Abernethy ML, Kulp-Shorten C, Callen JP, Glazer SD, Huntley A, et al. A 
double-blind, vehicle-controlled study evaluating masoprocol cream in the treatment of 
actinic keratoses on the head and neck. J Am Acad Dermatol 1 Jan. 1991;24(5 Pt 1):738–
43. doi: 10.1016/0190-9622(91)70113-g. PubMed PMID: 1869646. 
38. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch 
Dermatol 1 Jan. 1988;124(6):869–71. doi: 10.1001/archderm.124.6.869. PubMed 
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39. Frost CA, Green AC. Epidemiology of solar keratoses. Br J Dermatol 1 Jan. 
1994;131(4):455–64. doi: 10.1111/j.1365-2133.1994.tb08544.x. PubMed 
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40. Schwartz RA. The actinic keratosis. A perspective and update. Dermatol Surg 1 Jan. 
1997;23(11):1009-19; quiz 1020-1. PubMed PMID: 9391557. 
41. Yantsos VA, Conrad N, Zabawski E, Cockerell CJ. Incipient intraepidermal cutaneous 
squamous cell carcinoma: a proposal for reclassifying and grading solar (actinic) 
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42. U.S. Department of Health and Human Services Food and Drug Administration. 2015-
2020 Dietary Guidelines for Americans 1 Dec. 2015;8th edition. 
 
 
 

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19 APPENDICES 
 
Appendix A: Fitzpatrick’s Skin Type Test according to Fitzpatrick (1988) 
Appendix B: NRS-11 for pain during PDT 
 
 

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APPENDIX A 
Fitzpatrick´s Skin Type Test 
Fitzpatrick´s Skin Type according to Fitzpatrick, 1988 (38) 
 
One of the important parameters for the success of your treatment is the correct typing of your 
skin.  
Skin type is often categorized according to the Fitzpatrick skin type scale, which ranges from 
very fair (skin type I) to very dark (skin type VI). The 2 main factors that influence skin type 
and the treatment program devised by your doctor are: 
• Genetic disposition -Skin types I to III should add one level when you have blood 
relatives with darker skin type IV or higher. 
• Reaction to sun exposure and tanning habits.  
Skin type is determined genetically and is one of the many aspects of your overall appearance, 
which also includes color of eyes, hair, etc. The way your skin reacts to sun exposure is 
another important factor in correctly assessing your skin type. Recent tanning (sun bathing, 
artificial tanning or tanning creams) have a major impact on the evaluation of your skin color.  
So, please help us determine your skin type to assist us in your treatment. 
 
Genetic disposition 
Score 
0 
1 
2 
3 
4 
What is the color of 
your eyes? 
Light blue, 
Gray, Green 
Blue, Gray 
or Green 
Blue 
Dark Brown 
Brownish 
Black 
What is the natural 
color of your hair? 
Sandy Red 
Blond 
Chestnut/ 
Dark Blond 
Dark Brown 
Black 
What is the color of 
your skin (non 
exposed areas)? 
Reddish 
Very Pale 
Pale with 
Beige tint 
Light Brown 
Dark Brown 
Do you have freckles 
on unexposed areas? 
Many 
Several 
Few 
Incidental 
none 
Total score for genetic disposition: _____ 
 
 
 

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Fitzpatrick’s Skin Type Test 
(cont.) 
 
 
Reaction to sun exposure 
 
Score 
0 
1 
2 
3 
4 
What happens when 
you stay in the sun 
too long? 
Painful 
redness, 
blistering, 
peeling 
Blistering 
followed by 
peeling 
Burns 
sometimes 
followed by 
peeling 
Rare burns 
Never had 
burns 
To what degree do 
you turn brown? 
Hardly or 
not at all 
Light color 
tan 
Reasonable 
tan 
Tan very 
easy 
Turn dark 
brown quickly 
Do you turn brown 
within several hours 
after sun exposure? 
Never 
Seldom 
Sometimes 
Often 
Always 
How does your face 
react to the sun? 
Very 
sensitive 
Sensitive 
Normal 
Very 
resistant 
Never had a 
problem 
 
Total score for reaction to sun exposure: _____ 
 
 
Fitzpatrick skin type will be assessed according to skin type score as follows: 
 
Skin Type Score 
Fitzpatrick Skin Type 
0 – 7 
I 
8 – 16 
II 
17 – 24 
III 
25 – 30 
IV 
>30 
V – VI 
 
 
 

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APPENDIX B 
Numeric rating pain scale for pain during photodynamic therapy 
 
Pain sensation during photodynamic therapy (PDT) will be assessed using the 11-point 
numeric rating pain scale, shown below: 
 
Please rate your pain intensity by circling the number that best describes your maximum pain 
during PDT. 
 
 
 
 
To be transferred into the 4-point scale if applicable 0= none, 1-3 = mild, 4-7 = moderate,  
8-10 = severe. 
 
0
1
2
3
4
5
6
7
8
9
10
No
Pain
Pain as
bad as
you can
imagine
0
1
2
3
4
5
6
7
8
9
10
No
Pain
Pain as
bad as
you can
imagine