Conventional and combination topical photodynamic therapy for basal cell carcinoma: systematic review and meta-analysis

Background Topical photodynamic therapy (PDT) is an established treatment option for low-risk basal cell carcinoma (BCC). Objectives Methods To compare efficacy, cosmesis and tolerability of PDT for BCC with alternative treatments. MEDLINE, PubMed, Embase and CENTRAL databases were searched from inception until 1 September 2017. Included studies were randomized controlled trials (RCTs) of PDT for nodular (n) and superficial (s) BCC reporting at least one of the following outcomes: clearance at 3 months and sustained at 1 or 5 years; recurrence at >= 1 year; cosmesis; adverse events; tolerability. Results Conclusions From 2331 search results, 15 RCTs (2327 patients; 3509 BCCs) were included. PDT efficacy (5-year sustained clearance) was high but inferior to excisional surgery [nBCC pooled risk ratio (RR) 0 center dot 76; 95% confidence interval (CI) 0 center dot 63-0 center dot 91], and without re-treatment of partially responding lesions, was modestly inferior to imiquimod (sBCC: RR 0 center dot 81; 95% CI 0 center dot 70-0 center dot 95) and similar to fluorouracil (sBCC: RR 0 center dot 88; 95% CI 0 center dot 75-1 center dot 04). Five-year sustained clearance was inferior with conventional vs. fractionated PDT (sBCC: RR 0 center dot 76; 95% CI 0 center dot 68-0 center dot 84). PDT cosmesis was superior to surgery (sBCC: RR 1 center dot 68, 95% CI 1 center dot 32-2 center dot 14; nBCC: RR 1 center dot 82, 95% CI 1 center dot 19-2 center dot 80) and cryosurgery (BCC: RR 3 center dot 73, 95% CI 1 center dot 96-7 center dot 07), and without re-treatment of partially responding lesions was similar to imiquimod (sBCC: RR 1 center dot 01, 95% CI 0 center dot 85-1 center dot 19) and fluorouracil (sBCC: RR 1 center dot 04, 95% CI 0 center dot 88-1 center dot 24). Peak pain was higher but of shorter duration with PDT than topical treatments. Serious adverse reactions were rarer with PDT than imiquimod (sBCC: RR 0 center dot 05, 95% CI 0 center dot 00-0 center dot 84) and fluorouracil (sBCC: RR 0 center dot 11, 95% CI 0 center dot 01-2 center dot 04). Combination PDT regimens demonstrated reduced recurrence and improved cosmesis; however, results from these small studies were often nonsignificant. PDT is an effective treatment for low-risk BCC, with excellent cosmesis and safety. Imiquimod has higher efficacy than single-cycle PDT but more adverse effects. Highest efficacy is with excisional surgery. Fractionated and combination PDT options warrant further study.