Comparative Efficacy of Photodynamic Therapy versus Conventional Therapies for Actinic Keratosis: A Systematic Review and Meta-Analysis.

Summary

Across 13 RCTs (n=1,841), 5-fluorouracil outperformed PDT at 12 months (74.7% vs 37.7%; RR 0.50, 95% CI 0.40–0.64). PDT was comparable to cryotherapy overall but superior for Grade III lesions, and it surpassed imiquimod in organ transplant recipients. 5-FU pretreatment improved PDT efficacy, and PDT yielded better cosmetic outcomes and satisfaction than cryotherapy or imiquimod.

Key Findings

• 13 RCTs (n=1,841) comparing PDT with cryotherapy, 5-FU, and imiquimod
• 5-FU superior to PDT at 12 months (74.7% vs 37.7%; RR 0.50, 95% CI 0.40–0.64, P<0.001)
• PDT similar to cryotherapy overall (63.5% vs 52.4%, P=0.154) but superior for Grade III lesions (56.9% vs 13.4%, P=0.021)
• In immunocompetent patients, imiquimod > PDT (53.9% vs 37.7%, P=0.006); in transplant recipients, PDT > imiquimod (78% vs 61%, P<0.001)
• 5-FU pretreatment enhanced PDT efficacy (87% vs 74%, P<0.0001)
• PDT had better cosmetic outcomes than cryotherapy (hypopigmentation 0–3% vs 31%) and higher patient satisfaction than imiquimod (90% vs 61%)

Clinical Implications

Prefer 5-FU for highest long-term clearance; consider PDT for Grade III lesions, transplant recipients, and when cosmetic outcomes/tolerability are priorities; use 5-FU pretreatment to enhance PDT.

Limitations

• Potential heterogeneity in PDT protocols, photosensitizers, and illumination parameters
• Variable follow-up durations and outcome definitions across trials; risk-of-bias details not provided in abstract

Future Directions

Head-to-head RCTs with standardized PDT protocols and long-term recurrence/cosmesis/QoL endpoints; cost-effectiveness analyses and optimization of combination regimens.