Photodynamic Therapy in Actinic Keratosis: Evolving Approaches and Combination Strategies

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor.

In this episode of Topical Conversations, Shannon Trotter, DO, sits down with Fabrizio Galimberti, MD, to discuss photodynamic therapy (PDT) and its role in managing actinic keratoses (AKs). PDT is experiencing renewed interest, both for prevention and treatment, as dermatologists recognize its value across a broader patient spectrum.

Early intervention and the chronic nature of AK

Dr Trotter notes that while she once reserved PDT for older adults, she now increasingly uses it in younger patients who are presenting with actinic damage earlier. Dr Galimberti explains the value of intervening before AKs progress to squamous cell carcinoma, emphasizing the importance of viewing AK as a chronic, recurrent condition. Both agree that dermatologists must set clear expectations with patients about recurrence risk and the importance of ongoing management.

Rethinking field therapy

Dr Galimberti reflects on how his perspective has evolved regarding when to initiate field therapy. Previously, he believed it was only necessary when patients had extensive lesions across large areas; he explains that newer data, however, demonstrate that even a handful of lesions in a single field can increase SCC risk. As a result, he now considers patients with more limited but concentrated lesions as candidates for field treatment, reframing therapy as a proactive rather than reactive strategy.

PDT in practice

The conversation then turns to PDT itself. Both dermatologists highlight PDT’s effectiveness in clearing visible and subclinical lesions, and its role as a versatile component of combination treatment. Dr Trotter notes that dermatologists should think beyond clearance alone and consider strategies to reduce recurrence.

Combination approaches with PDT

Dr Galimberti emphasizes that treatment is rarely “this or that” but often “this and this,” integrating PDT with other modalities to optimize outcomes.  

Dr Trotter shares some of her approaches, in which she pre-treats with topical retinoids or adapalene, uses vitamin D or 5-FU, and works to balance efficacy with the need to temper inflammation. She has also experimented with debridement, salicylic acid, or even acne patches for resistant lesions.

Dr Galimberti often combines tirbanibulin with retinols for layered efficacy and prefers multiple PDT sessions as part of a long-term plan. While he has used vitamin D in the past to accentuate response, he now tends to start with conventional PDT and escalate only if needed.

Practical strategies and patient profiles

Both stress the importance of tailoring therapy to patient preferences and lifestyles. For example, patients unable to take downtime may do better with tirbanibulin, while those able to accommodate post-treatment recovery may benefit more from PDT.  

Customizing PDT for better outcomes

Drs Trotter and Galimberti conclude that PDT, particularly when combined with other therapies, offers dermatologists the flexibility to individualize care. By embracing combination strategies, clinicians can address clearance, recurrence, and patient-specific needs more effectively, reinforcing PDT’s place as a mainstay in modern AK management.

Key takeaways

• AK is chronic and recurrent; patient education should emphasize recurrence risk and the need for long-term management
• Field therapy decisions are evolving; even a limited number of lesions in one field may warrant proactive treatment
• Combination strategies enhance PDT outcomes; options include pretreatment with retinoids, vitamin D, 5-FU, tirbanibulin, or procedural adjuncts
• Tailor treatment to patient profiles; consider lifestyle, tolerance for downtime, and treatment goals when choosing between PDT, topical agents, or integrated regimens
• Flexibility is key; PDT, especially when paired with other modalities, allows dermatologists to balance clearance, recurrence reduction, and patient satisfaction