Photodynamic therapy using intense pulsed light for cutaneous sarcoidosis

Dear Editor, Sarcoidosis is a multi-organ systemic disease characterized by the formation of non-caseous epithelioid-cell granulomas in many, possibly even all, organs. Skin involvement occurs in approximately 25% of cases. Cutaneous sarcoid tends to involve the face and may be the only manifestation of this disease. Corticosteroid doses adequate for significant systemic sarcoidosis consistently clear the skin of cutaneous lesions. However, longterm use of systemic corticosteroids has numerous side-effects. Other systemic therapies, such as immunosuppressive drugs, dapsone, anticancer agents, allopurinol and minocycline, are often difficult to use in older and ⁄ or high-risk patients. On the other hand, topical treatment such as corticosteroids, tacrolimus, phototherapy, cryotherapy, radiation and the Q-switched ruby laser have fewer efficacies than systemic steroids. As demonstrated in four previous studies, photodynamic therapy (PDT) offers a potentially safe and convenient option for cutaneous sarcoidosis. It has antiproliferative and anti-inflammatory actions, making it effective for refractory sarcoidosis. Topically applied d-aminolevulinic acid (ALA) is theorized to be primarily taken up by epidermal keratinocytes. Upon irradiation with a light source, cytokines would then be released, thereby changing the cytokine environment and ultimately disrupting the granuloma formation process. Our patient was a 60-year old woman with multiple 1–2-cm small red–brown indurated facial plaques, which had first appeared 2 years earlier (Fig. 1a). Histological evaluation revealed typical sarcoid non-caseating epithelioid-cell granulomas with several multinucleated foreign body giant cells. She had no systemic symptoms and a negative reaction to the tuberculin skin test. X-ray and computed tomography examinations, electrocardiography, abdominal ultrasonography and ophthalmological examinations revealed no abnormalities. However, gallium-67 citrate scintigraphy revealed some accumulation in the hilum of the lungs. There were no abnormal findings on routine blood test and blood biochemistry tests including angiotensin-converting enzyme (ACE), except for a high immunoglobulin (Ig)G concentration of 2200 mg ⁄ dL (normal range 850–1800 mg ⁄ dL). Topical treatment with corticosteroids (hydrocortisone butyrate) and repeated cryotherapy using liquid nitrogen achieved no clinical improvement. Thus, a therapeutic trial with PDT with topical ALA using intense pulsed light (IPL-ALA-PDT) was started after obtaining her informed consent in writing. We managed this patient according to our previously reported protocol. Briefly, we applied 20% 5-ALA cream on the lesions and covered them with dressings. Three hours later, the lesions were irradiated using IPL (Quantum SR; Lumenis, Santa Clara, CA, USA) with standard parameters (cut-off wavelength, 640 nm; fluence, 22–24 J ⁄ cm; total fluence, >100 J ⁄ cm; double-pulse mode, 4.0 msec; interpulse delay, 20 msec; chiller tip for epidermal cooling set to maximum). Chilled gel was applied to the head of the device (which was cooled to )4 to )6 C) to avoid direct contact. After irradiation, the treated area was washed and protected from sunlight exposure. Additional treatments were administered at 2-week intervals, according to the standard regimen consisting of five sessions. The treated lesions were simultaneously evaluated 3 months after the