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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although a wide range of effective topical and oral treatments are available for the treatment of acne&#44; it is important to be aware of therapeutic alternatives&#44; such as photodynamic therapy &#40;PDT&#41; for use in refractory cases&#44; in patients with contraindications for a given treatment&#44; or in those patients who do not wish to use oral treatments&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 21-year-old woman consulted for nodular acne of several years&#8217; duration&#44; predominantly on the face&#44; with a poor response to antibiotics and topical keratolytic agents&#46; She had a history of autoimmune hepatitis of 7 years duration&#44; in treatment with oral corticosteroids and azathioprine&#44; with good disease control&#46; She was treated with oral clarithromycin for one month&#44; causing hepatic decompensation requiring hospital admission&#46; For this reason&#44; and given her underlying liver disease&#44; we ruled out oral isotretinoin treatment and considered daylight photodynamic therapy &#40;DL-PDT&#41; with 5-methyl aminolevulinate &#40;MAL&#41; and no other associated topical treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After application of a chemical photoprotector to the entire face&#44; MAL was applied directly to both cheeks&#46; After half an hour&#44; she was exposed to sunlight for 2<span class="elsevierStyleHsp" style=""></span>hours&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Five sessions of DL-PDT were performed&#44; with 4 weeks between each session&#46; From the third session onward&#44; a substantial decrease in inflammatory lesions was noted with absence of nodules&#46; Mild erythema and some scarring remained &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The treatment was well tolerated&#46; No adverse effects were observed and the patient was very satisfied with the process&#44; as it was a painless technique&#44; readily applied in the clinic&#44; and with excellent cosmetic results&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Three months after the first cycle of 5 sessions &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; an additional session of DL-PDT was administered along with topically applied adapalene gel in combination with benzoyl peroxide&#46; At the follow-up visit at 3 months&#44; the patient continued to use the topical treatment&#46; This was well tolerated and she had no significant lesions&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Acne is a chronic inflammatory disease of the skin that affects around 85&#37; of the general population and that can have a major impact on quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The pathophysiology of acne includes factors such as sebaceous hypersecretion&#44; follicular hyperkeratosis&#44; proliferation of <span class="elsevierStyleItalic">Cutibacterium acnes</span>&#44; and innate immune imbalances&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">PDT has been used in the treatment of acne&#44; because it is a noninvasive treatment&#44; has a high specificity for the target tissue&#44; is well tolerated&#44; has an antimicrobial effect&#44; can treat multiple lesions in a single session&#44; has no systemic toxicity&#44; and leads to good cosmetic outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although the mechanism of action is not completely known&#44; the use of PDT with 5-aminolevulinic acid &#40;ALA&#41; and its methylated derivative &#40;MAL&#41; has been reported as useful alternatives&#44; both to conventional PDT with a lamp &#40;C-PDT&#41; and with daylight &#40;DL-TFD&#41;&#46; Other light-based therapies that have been shown to be useful include intense pulsed light and pulsed dye laser&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It has been reported that after application to the skin&#44; ALA accumulates in the pilosebaceous unit&#46; After activation by light at a specific wavelength&#44; reactive oxygen species are produced&#44; leading to the photodynamic reaction&#46; In addition&#44; the technique supresses the proliferation and secretion of sebocytes and a local inflammatory reaction occurs through increased levels of proinflammatory cytokines such as IL-1&#44; IL-6&#44; TNF&#945;&#44; and CXCL8&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinically&#44; a local inflammatory response is observed characterized by erythema and pustules&#44; with a positive correlation between these findings and efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Currently&#44; few case series on acne treatment with PDT have been published&#46; Light sources used include red light&#44; blue light&#44; polychromatic visible light with halogen lamps&#44; pulsed dye laser light&#44; and visible light&#46; There are no recommendations as to the most appropriate sensitizer&#44; time between sessions&#44; total treatment duration&#44; or long-term follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although DL-PDT and C-PDT have similar efficacy&#44; the former has certain advantages over the latter&#46; The main one is that it is less painful&#46; In C-PDT&#44; the pain is more intense probably because of the sudden light absorption and the high levels of protoporphyrin that accumulate after hours of occlusion of the photosensitizer&#46; In contrast&#44; DL-PDT causes continuous production and progressive photoactivation of small amounts of protoporphyrin&#160;IX&#44; and so it is better tolerated&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> An additional advantage of DL-PDT during the pandemic is the reduced time spent in hospital&#44; with subsequent decreased risk of COVID contagion&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; as in other cases described in the literature&#44; PDT represents a useful tool in the management of patients with severe acne in whom systemic treatment is contraindicated due to the underlying disease&#44; achieving a reduction in inflammatory and noninflammatory lesions&#44; with good tolerance and treatment satisfaction&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">We have not received funding to produce this article&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The remaining authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letter
Severe Acne Treated With Daylight Photodynamic Therapy in a Young Woman With Autoimmune Hepatitis
Acné grave en una joven con hepatitis autoinmune: tratamiento con terapia fotodinámica luz de día
A. Giacaman
Corresponding author
anizagiacaman@gmail.com

Corresponding author.
, L.J. del Pozo, J. Garcías-Ladaria, A. Martín-Santiago
Departamento de Dermatología, Hospital Universitari Son Espases, Palma de Mallorca, Spain
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    "titulo" => " Severe Acne Treated With Daylight Photodynamic Therapy in a Young Woman With Autoimmune Hepatitis"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although a wide range of effective topical and oral treatments are available for the treatment of acne&#44; it is important to be aware of therapeutic alternatives&#44; such as photodynamic therapy &#40;PDT&#41; for use in refractory cases&#44; in patients with contraindications for a given treatment&#44; or in those patients who do not wish to use oral treatments&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 21-year-old woman consulted for nodular acne of several years&#8217; duration&#44; predominantly on the face&#44; with a poor response to antibiotics and topical keratolytic agents&#46; She had a history of autoimmune hepatitis of 7 years duration&#44; in treatment with oral corticosteroids and azathioprine&#44; with good disease control&#46; She was treated with oral clarithromycin for one month&#44; causing hepatic decompensation requiring hospital admission&#46; For this reason&#44; and given her underlying liver disease&#44; we ruled out oral isotretinoin treatment and considered daylight photodynamic therapy &#40;DL-PDT&#41; with 5-methyl aminolevulinate &#40;MAL&#41; and no other associated topical treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After application of a chemical photoprotector to the entire face&#44; MAL was applied directly to both cheeks&#46; After half an hour&#44; she was exposed to sunlight for 2<span class="elsevierStyleHsp" style=""></span>hours&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Five sessions of DL-PDT were performed&#44; with 4 weeks between each session&#46; From the third session onward&#44; a substantial decrease in inflammatory lesions was noted with absence of nodules&#46; Mild erythema and some scarring remained &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The treatment was well tolerated&#46; No adverse effects were observed and the patient was very satisfied with the process&#44; as it was a painless technique&#44; readily applied in the clinic&#44; and with excellent cosmetic results&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Three months after the first cycle of 5 sessions &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; an additional session of DL-PDT was administered along with topically applied adapalene gel in combination with benzoyl peroxide&#46; At the follow-up visit at 3 months&#44; the patient continued to use the topical treatment&#46; This was well tolerated and she had no significant lesions&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Acne is a chronic inflammatory disease of the skin that affects around 85&#37; of the general population and that can have a major impact on quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The pathophysiology of acne includes factors such as sebaceous hypersecretion&#44; follicular hyperkeratosis&#44; proliferation of <span class="elsevierStyleItalic">Cutibacterium acnes</span>&#44; and innate immune imbalances&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">PDT has been used in the treatment of acne&#44; because it is a noninvasive treatment&#44; has a high specificity for the target tissue&#44; is well tolerated&#44; has an antimicrobial effect&#44; can treat multiple lesions in a single session&#44; has no systemic toxicity&#44; and leads to good cosmetic outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although the mechanism of action is not completely known&#44; the use of PDT with 5-aminolevulinic acid &#40;ALA&#41; and its methylated derivative &#40;MAL&#41; has been reported as useful alternatives&#44; both to conventional PDT with a lamp &#40;C-PDT&#41; and with daylight &#40;DL-TFD&#41;&#46; Other light-based therapies that have been shown to be useful include intense pulsed light and pulsed dye laser&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It has been reported that after application to the skin&#44; ALA accumulates in the pilosebaceous unit&#46; After activation by light at a specific wavelength&#44; reactive oxygen species are produced&#44; leading to the photodynamic reaction&#46; In addition&#44; the technique supresses the proliferation and secretion of sebocytes and a local inflammatory reaction occurs through increased levels of proinflammatory cytokines such as IL-1&#44; IL-6&#44; TNF&#945;&#44; and CXCL8&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinically&#44; a local inflammatory response is observed characterized by erythema and pustules&#44; with a positive correlation between these findings and efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Currently&#44; few case series on acne treatment with PDT have been published&#46; Light sources used include red light&#44; blue light&#44; polychromatic visible light with halogen lamps&#44; pulsed dye laser light&#44; and visible light&#46; There are no recommendations as to the most appropriate sensitizer&#44; time between sessions&#44; total treatment duration&#44; or long-term follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although DL-PDT and C-PDT have similar efficacy&#44; the former has certain advantages over the latter&#46; The main one is that it is less painful&#46; In C-PDT&#44; the pain is more intense probably because of the sudden light absorption and the high levels of protoporphyrin that accumulate after hours of occlusion of the photosensitizer&#46; In contrast&#44; DL-PDT causes continuous production and progressive photoactivation of small amounts of protoporphyrin&#160;IX&#44; and so it is better tolerated&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> An additional advantage of DL-PDT during the pandemic is the reduced time spent in hospital&#44; with subsequent decreased risk of COVID contagion&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; as in other cases described in the literature&#44; PDT represents a useful tool in the management of patients with severe acne in whom systemic treatment is contraindicated due to the underlying disease&#44; achieving a reduction in inflammatory and noninflammatory lesions&#44; with good tolerance and treatment satisfaction&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">We have not received funding to produce this article&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The remaining authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Article information
ISSN: 00017310
Original language: English
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