by Laurie Wertich Medical Review by Dr. C.H. Weaver M.D. 11/2019
At 45 Rose Heller was the picture of health. The Fort Smith, Arkansas, resident cycled 200 miles per week, worked as a personal trainer, and taught Pilates classes. But there was one part of her body that bothered Rose: her skin. Years of physical activity outdoors without the protection of sunscreen had left her with dry, white growths on her nose, forearms, chest, and legs.
After visiting a dermatologist, she learned that the lesions were called actinic keratosis, and they could become cancerous if left untreated. Initially, the doctor sprayed liquid nitrogen on the growths to freeze them off (known as cryotherapy), but new lesions continued appearing over the next two years. The dermatologist suggested photodynamic therapy (PDT)—a treatment that uses medications and light to kill precancerous cells. The method could target a larger number of growths simultaneously.
After Rose underwent several rounds of PDT on the affected areas, the actinic keratosis started disappearing. She also stopped seeing new ones appear every year. “I was relieved to be getting rid of the cancer risk, and my skin became smoother and more even toned,” says Rose, now 53. “For all the sun exposure I’ve had, my skin looks really good. It better reflects my healthy lifestyle.”
Over the past several years, the options for reversing the effects of age and sun exposure have expanded significantly, says Anne Taylor, MD, a plastic surgeon in Columbus, Ohio. “I’ve been in practice for 20 years, and the field of anti-aging skin treatment is exploding because the baby boomers want to look and feel good.”
Although there are benefits to having a multitude of options, Dr. Taylor advises patients to take time to learn about a procedure or product before making a decision. “The treatment has to be customized to the patient,” says Dr. Taylor, vice president for health policy at the American Society of Plastic Surgeons. “Things like the goals of the patient and the time available for recuperation should be taken into consideration.”
She also encourages patients to find a physician who specializes in the desired treatment because plastic surgeons and dermatologists offer different options. “Do your homework and find a physician who is skilled in the procedure you are considering.”
Using Light to Treat Cancer
The PDT procedure that Rose underwent has become more widely used over the past five years, says Rose’s dermatologist, Sandy Johnson, MD. Dr. Johnson recommended PDT for Rose because the liquid nitrogen could treat visible lesions only one at a time.
“Traditionally, we freeze the actinic keratosis, but after a period of time some patients come back with even more,” Dr. Johnson says. “PDT is like treating the entire garden. It gets rid of the things we can see as well as the ones we can’t see.”
Dr. Johnson starts the procedure by applying medicine—a drug called a photosensitizer or photosensitizing agent—to the affected area of the skin. After 30 minutes, patients sit under blue light for 16 minutes, though times may vary depending on the drug used. The medicine contains a chemical that accumulates in precancerous cells and releases free radicals, which kills those cells.
While the main benefit of the treatment is reducing the risk of developing skin cancer, PDT also has cosmetic benefits, says Anne Marie McNeill, MD, PhD, a dermatologist at Newport Beach Dermatology and Plastic Surgery in California. “It can also reduce brown spots from the sun and help smooth fine lines and build collagen, which makes the skin smoother. But some people may need to undergo several treatments to get the full cosmetic and health benefits.”
Rose underwent the procedure several times on each of her affected areas. She also acknowledges that her skin burned significantly while she was under the blue light, and it was sensitive for more than a week after the procedure. She also had to avoid all sunlight for 48 hours after receiving PDT because the chemical on the skin increases the risk of sun burns and discoloration.
Actinic keratosis, which usually appears as a rough, dry, or scaly growth, affects more than 58 million Americans. Studies have shown that up to 10 percent may advance to squamous cell carcinoma, and about 2 to 10 percent of these carcinomas—if left untreated—spread to internal organs and are life-threatening, according to the Skin Cancer Foundation. New studies suggest that PDT is more effective than traditional liquid nitrogen cryotherapy. According to a study published in JAMA Dermatology that analyzed data from 641 participants, PDT had a 14 percent better chance of complete lesion clearance three months after treatment than cryotherapy. (1)
Laser resurfacing is another procedure that has been available for decades, but in the past the recovery was painful and lasted two weeks or longer, says Dr. McNeill, who is also a spokesperson for the Skin Cancer Foundation. Over the past several years, a newer type of treatment known as fractionated CO2 laser resurfacing has grown in popularity. Rather than applying a solid laser beam to the skin, the beam is in columns, which makes the recovery time shorter and less painful.
Unlike PDT, the primary purpose of laser resurfacing is typically cosmetic improvement, not cancer prevention, says Tina West, MD, a dermatologist in Chevy Chase, Maryland. The laser creates tiny holes in the skin, which triggers the body to repair the holes and make collagen. This process tightens the skin, smooths wrinkles, and decreases brown spots, says Dr. West. The recovery time is longer than with PDT because the treatment is more aggressive, and patients usually take a week off from work to allow the skin to heal. Also unlike PDT, this procedure is not usually covered by insurance. There is a risk of infection, and people with darker skin have a greater chance of experiencing hyperpigmentation, or dark spots, Dr. West says.
Another option uses a fractional thulium laser that targets the brown spots, and this method has been shown to treat actinic keratosis, says Hillary Johnson-Jahangir, MD, PhD, clinical assistant professor of dermatology at the University of Iowa. She finds that patients often prefer the CO2 laser over the thulium laser treatment because it more effectively tightens the skin and reduces the appearance of wrinkles.
Although cancer prevention may not be the primary goal of laser treatments, a 2015 study published in Current Problems in Dermatology2 found that existing evidence suggests that fractional laser treatments can be effective in removing widespread actinic keratosis. Large comparative studies about the cancer prevention benefits, however, are still scarce, according to the study.
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Chemical peels are another form of anti-aging skin treatment. They are milder than PDT or laser resurfacing, but the results may be less dramatic, says Dr. McNeill. During the treatment, a chemical is applied to the skin and then washed off.
“I would not use this for pre-cancers,” says Dr. McNeill. “The chemical peels off the top layer of skin, which can smooth fine lines, decrease brown spots, and brighten skin, but it’s not as effective as lasers for skin rejuvenation.”
Although the cosmetic and health benefits are not as significant as with other procedures, the pain is also less dramatic, she says.
The Least Invasive Strategy: Skin Products
Although procedures can have cosmetic and health benefits, skin creams are also a powerful tool against the effects of aging, says Dr. West.
“Skin that is glowing and even toned is not only attractive but also healthier,” she says. “Sun damage that results in fine lines, blotchy pigmentation, and broken capillaries can become precancerous and eventually cancerous.”
She says it is never too late to start using products like vitamin A or Retin-A® (tretinoin), which induce the expression of collagen fibers, a component of the skin responsible for plumpness and elasticity. By applying this to sun-exposed areas, people will notice improvements with wrinkling, mottling, brightness, and roughness.
Dr. Johnson-Jahangir, however, is cautious about recommending retinoids: “Studies have [shown] conflicting results about the uses of topical retinoids for actinic keratosis and skin cancer prevention. They can improve the skin tone and reduce the appearance of fine lines, but they can also make the skin more sensitive to subsequent sun damage in the absence of good sun protection.”
A new group of products that are attracting attention contain enzymes that repair damaged DNA, which could potentially prevent the development of skin cancer, says Victor Neel, MD, PhD, director of dermatologic surgery at Massachusetts General Hospital in Boston.
“There have been studies on patients who are prone to cancer, and these topical agents are shown to decrease the number of skin cancers in those patients,” says Dr. Neel.
By repairing the damaged DNA, these products also have the potential to reduce the effects of aging, such as discoloration, wrinkles, and sagging.
Don’t Forget Sunscreen
While the latest products and procedures may seem to turn back the clock on skin age, dermatologists are adamant that one of the best defenses against cancer and age is sunscreen.
“People still don’t understand the harm they are doing to themselves on a daily basis by not applying sunscreen,” says Jennifer Lucas, MD, a dermatologic surgeon at the Cleveland Clinic in Ohio. “It’s exciting to be finding different treatments, but I have many patients who say they wish they knew back then what they know now about protection against the sun.”
According to the Skin Cancer Foundation, regular daily use of sunscreen that has a sun protection factor (SPF) 15 or higher reduces the risk of developing melanoma by 50 percent and squamous cell carcinoma by about 40 percent. Dr. McNeill encourages people to use broad-spectrum sunscreen, which protects from both UVA and UVB radiation. Chemical sunscreen absorbs UV radiation before it affects the skin, whereas physical sunscreen uses minerals like titanium dioxide and zinc oxide to reflect or scatter UV radiation before it reaches skin. Most sunscreens of both types are typically effective for two hours in the sun, which means it’s important to reapply—and windows don’t protect from UVA radiation.
Although Rose regrets that she didn’t apply sunscreen when she was younger, she is grateful that it’s never too late to start protecting her skin—especially now that it looks healthier.
“I like the way my skin looks now, but I’m really aware of the sun and give it the respect I should have,” she says. “I’m still very active and love being outside, and now I’m doing these things in a way that will keep my skin safe.”
- Patel G, Armstrong AW, Eisen DB. Efficacy of photodynamic therapy vs other interventions in randomized clinical trials for the treatment of actinic keratoses: A systematic review and meta-analysis. JAMA Dermatology. 2014;150(12):1281-88. doi: 10.1001/jamadermatol.2014.1253.
- de Vries K, Prens EP. Laser treatment and its implications for photodamaged skin and actinic keratosis. Current Problems in Dermatology. 2015;46:129-35. doi: 10.1159/000367958.