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A Pilot, Prospective, Open-Label Study on the Effects of a Topical Photorepair
and Photoprotection Film-Forming Medical Device in Patients with Actinic
Keratoses Evaluated by Means of Skin Analysis Camera Antera 3D
Mario Puviani1 and Massimo Milani2*
1Simple structure of Dermatology and Surgical Dermatology, Hospital of Sassuolo (MO), Italy
2Medical Department ISDIN, Italy
*Corresponding author: Massimo Milani, Medical Department Isdin, Via le Abruzzi 3, Milan Italy, E-mail: massimo.milani@isdin.com
Received date: Jan 21, 2014, Accepted date: Feb 03, 2015, Published date: Feb 9, 2015
Copyright: © 2015 Mario Puviani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Actinic keratosis (AK) is a very common precancerous skin lesion caused by chronic exposure to
sunlight. UVA and UVB rays’ exposure is considered as the main pathogenic mechanism of keratinocytes alterations
and malignant transformations. UVB and UVA cause direct alterations of DNA molecules, such as the formation of
cyclobutane-pyrimidine dimers (CPD) and cellular structures damage, in particular membranes, trough free radicals
formation. Eryfotona AK-NMSC (Ery) is a film-forming medical device (MD) class II indicated for the prevention and
treatment of cancerization field in subjects with AK or non-melanoma skin cancers (NMSC). Ery is characterized by
a photorepair action, thanks to its content in photolyase, an enzyme able repairing DNA CPD, and by high broad-
spectrum photoprotection (SPF 100+) (Repairsome). Controlled clinical studies have shown that this MD, both in the
short and the long term, is able to induce in AK patients sub-clinical and clinical improvements at the cancerization
field level.
Study aim: In this pilot, prospective study, we evaluated the effects of 3-month application of this product in 11
subjects with AK through an objective assessment by skin camera ANTERA 3D instrument. The primary endpoints
of the study were to evaluate: a) the evolution of the skin haemoglobin content (parameter related to the level of
“vascularization” and "inflammation" of the skin lesions) at the level of a target AK lesion, identified and defined at
baseline visit and b) the evolution of AK lesion area.
Results: Ery treatment induced a statistically significant and clinically relevant reduction of AK target lesion area
(a -75% reduction in comparison with baseline, range: -100%- 50%) and a significant haemoglobin content reduction
as soon as after 1 month (-16%, p=0.01) and after 3 months of treatment (-34%, p=0.01) demonstrating an effect of
"normalization" of this parameter at the AK target lesion level. The product was well tolerated.
Conclusion: Data from this pilot study suggest that the use of a photorepair and photoprotection film-forming MD
in subjects with AK is able to change in the short-medium term, an objectively-assessed parameter such as AK
lesion area and the haemoglobin content via spectral analysis suggesting that this strategy could improve the skin
area affected by the AK process.
Keywords: Actinic keratosis; Photolyase; Photoprotection; Antera
3D
Introduction
Actinic keratosis (AK) is a precancerous lesion of the skin very
frequently caused by chronic exposure to sunlight (UVB and UVA)
[1]. AK is now considered a carcinoma in situ representing the initial
phase of non-melanoma skin cancers (NMSC) such as squamous cell
carcinoma and basal cell carcinoma [2].
The photo exposed areas (scalp, face, back of hands and forearms)
are the classic sites of occurrence of such injuries [3]. Chronic
exposure to UVA and UVB rays is considered as the main pathogenic
mechanisms of keratinocytes alterations and transformations. UVB
and UVA cause direct alterations of DNA molecules, such as the
formation of cyclobutane-pyrimidine dimers (CPD) and alterations of
cellular structures, in particular membranes mediated, by the
formation of free radicals [4]. At the level of primary DNA damage
caused by UVB is the formation of pyrimidine dimers (CPD) that
altering the spatial structure of the DNA double helix are the main
source of actinic mutagenic mechanisms [5].
Photolyase is an enzyme found in various organisms (plants,
bacteria, animals are not placental) can fix quickly and efficiently the
specific CPD which were formed after UV exposure [6]. The topical
application of photolyase on human skin after exposure to UVB is able
to quickly reduce by 55% the formation of CPD [7]. These data
support the rational clinical use of topical product containing
photolyase in order to reduce the damage to the DNA by exposure to
UV [8,9].
Eryfotona AK-NMSC is a medical devices indicated for the
treatment and prevention of field cancerization in patients with AK
[10]. Controlled clinical studies have shown that treatment in both the
short and the long term with such a product is accompanied by
Journal of Clinical &
Experimental Dermatology
Research Puviani et al., J Clin Exp Dermatol Res 2015, 6:2
http://dx.doi.org/10.4172/2155-9554.1000263
Research Article Open Access
J Clin Exp Dermatol Res
ISSN:2155-9554 JCEDR an open access journal Volume 6 • Issue 2 • 1000263
improvements in the field of cancerization at both sub-clinic and
clinical level [11,12].
The objective assessment of the texture of the skin and the
concentration and uniformity of skin chromophores can provide
important information on the response to medical treatment and are
therefore of great importance for dermatological research.
Antera 3D (Miravex, Ireland) is an optical skin scanning device and
it consists of a camera connected to a laptop computer via an USB
cable and is complemented by proprietary software that runs on
desktop computers or laptops with Windows operating system [13].
This device is able to evaluate the changes over the time of melanin,
haemoglobin and skin profiles [14]. In more details Anther 3D is
based on the acquisition of multiple images obtained with different
lighting: diodes at different wavelengths illuminate the skin with the
incident light at different illumination direction and the acquired data
are used for spatial analysis and multi-spectrum for the reconstruction
of the texture of the skin and the analysis of its chromophores. In
particular the analysis via dermal ANTERA 3 D allows performing an
analysis of the parameters profilometric skin is that of the colorimetric
parameters of the skin and skin lesions [15]. This device employs a
specific algorithm (Spot-On™) that automatically registers two or more
images to one another, by correcting displacements due to different
positions of the patient when capturing an image. This algorithm
allows comparing “before-and-after” images in an objective manner.
At the moment there are no data available concerning the effects of
Ery treatment at actinic keratosis skin lesions levels evaluated with
ANTERA 3D.
Patients and Methods
Patients with multiple AK after a baseline evaluation were treated
with a topical medical device with very high (109 and SPF 39 UVA)
photoprotection action and photorepair action through an enzyme
(photolyase), which can repair UV-induced DNA damage, carried in
liposomes (Repairsome®) (Eryfotona AK-NMSC, fluid Isdin, Spain).
The treatment consisted in the application of the product at the level
of the zones with the lesions (usually the face and scalp) twice daily
(morning and afternoon). The patient was instructed to use 2 Finger
Tip Unit (approximately equal to one gram of product) for each
application (treatment of the face and scalp). The study was approved
by the institutional review board of the investigator’center and
complied with the provision of the Declaration of Helsinki, Good
Clinical Practice guidelines and local law and regulations. All
participants provided written informed consent to participate in the
trial. ANTERA 3D images of a target lesion were performed as the
primary outcome of the study evaluating and comparing the content
of haemoglobin, expressed in Arbitrary Unit, considering this as a
“vascularization” and “inflammation” parameter. To measure
haemoglobin, we marked a representative (target lesion) area at
baseline. Subsequently, the identical area was automatically marked in
the follow-up image, and the concentration and distribution of
haemoglobin were calculated by the software. Target lesion was
identified at baseline visit as a well-defined AK lesion located in area of
the face easy to access for picture documentation. Target lesion area
evolution was evaluated calculating the size of the lesion at baseline
and after treatment. Evolution of the size area was compared and
calculated as % change in comparison with baseline. Treatment lasted
3 months. The clinical and instrumental evaluations were performed
at baseline, after 1 and 3 months. Two-tailed Wilcoxon test was
applied to compare baseline levels with values at month 1 and at the
end of study period. A p value <0.05 was considered statistically
significant. According to the characteristic of the study (pilot trial) no
formal sample size calculation was performed.
Results
We recruited a total of 11 subjects with actinic lesions, single or
multiple, localized to the face and/or head, aged between 50 and 75
years, 8 men and 3 women, mean age 68 years with a Fiztpatrick skin
type II. The average number of clinically visible lesions per patient was
7. Target lesion area during application was reduced by 60% and 75%
after 1 and 3 months of Ery application (Figure 1).
Figure 1: Evolution of AK target lesion area evaluated as % change
in comparison with baseline. 1 month vs. Baseline: p<0.05; 3
months vs. Baseline: p<0.01; Wilcoxon Test. X-axis shows time
points evaluation. Y-axis reports target lesion area in % (100% area
of the lesions at baseline)
The results relating to the variation of the content of haemoglobin
of a target lesion are reported in the graph of Figure 1. Application of
Ery is accompanied by a statistically significant and clinically relevant
reduction of the content of haemoglobin at level of the target lesion
both at 1 month (-16%, p=0.001) and after 3 months of treatment
(-34%, p=0.0125) (Figure 2).
Figure 2: Evolution of hemoglobin content at level of AK target
lesion level. 1 month vs. Baseline: p<0.01; 3 months vs. Baseline:
p<0.01; Wilcoxon Test. X-axis shows time-point evaluation. Y-axis
reports quantity of haemoglobin at the target lesion in Arbitrary
Units
The product was well tolerated. There were no reported serious
adverse events. Figure 3a and 3b shows two cases with assessment
Citation: Puviani M, Milani M (2015) A Pilot, Prospective, Open-Label Study on the Effects of a Topical Photorepair and Photoprotection Film-
Forming Medical Device in Patients with Actinic Keratoses Evaluated by Means of Skin Analysis Camera Antera 3D. J Clin Exp
Dermatol Res 6: 263. doi:10.4172/2155-9554.1000263
Page 2 of 4
J Clin Exp Dermatol Res
ISSN:2155-9554 JCEDR an open access journal Volume 6 • Issue 2 • 1000263
before and after with ANTERA 3 D at baseline after 1 month and after
3 months of topical application of the product.
Figure 3: a) Antera 3D assessed target lesions evolution b) Target
lesions are marked by the circle
Discussion
Actinic keratosis (AK) is a skin disease very common especially in
the elderly population. AK is a condition that increases the risk of
developing cancer lesions true as squamous cell cancer and basal cell
cancer. For this reason it is important to treat this type of skin lesions.
The main pathogenic mechanism of AK is the chronic exposure to UV
rays [16]. The actinic damage accumulated due to an alteration in the
DNA of keratinocytes either directly (UVB) and indirectly (UVA).
The DNA damage induced by UVB radiation sees the formation of
cyclobutane-pyrimidine dimers as the main mechanism of genetic
damage [17]. The accumulation of these alterations contributes to the
appearance of altered keratinocytes that can give rise to cell clones that
proliferate in an uncontrolled manner with the formation of lesions of
actinic keratosis that may later develop into cancer completely changes
such as squamous cell carcinoma and basal cell carcinoma. The
photoprotection is an important tool for prevention in patients at risk
for actinic damage [18]. Since not much time available topical
products that can associate with the photoprotection "passive" an
action of photorepair "active" able to help the correction of the actinic
damage that gradually accumulates at the level of cheratinociti.
Photolyase in particular is an enzyme able to correct in an effective
and specific CPD which are formed at the level of the epidermis as a
result of UV exposure [19]. Photolyase is not present in mammals
[20]. However, the application of the topically photolyase both in
experimental animals and in humans has shown that this enzyme is
able to repair up to 50% of the CPD which are formed after exposure
to UVB [21]. Eryfotona AK-NMSC is a medical device indicated for
prevention and treatment of field cancerization in patients with actinic
keratosis and non-melanoma skin cancers [22]. This product exerts a
photorepair action, through the presence of Anacistis nidulans
photolyase formulated in liposomes, and a photo protection action
due to the content of very high and broad spectrum (SPF 109 and
UVA protection 39) sun-filters. Several controlled trials, and not, have
shown that the use of Eryfotona is accompanied by improvements in
the field of cancerization evaluated by histology, confocal microscopy,
and genetic expression of proteins involved in the regulation of
keratinocytes. This product is in the medium and long term has been
shown to improve the field of cancerization and to reduce the
formation of new lesions in actinic subjects undergoing PDT. To date
there were available data on the effects of this topical treatment
assessed using objective analysis and spectrophotometric 3D. Some
limitations should be taken in account in evaluating the results of the
present study. First this was an open non controlled pilot trial.
However the primary outcome (change in haemoglobin content at
target lesion level) was assessed by operator-independent imaging
analysis, therefore the observed changes reflect a real modification of
this parameter. A second aspect to be considered is the lack of a
controlled treatment. The use of a simple photoprotection product
could have induced similar modification we observed. However
previous controlled trials comparing the use of Ery in AK patients with
simple photoprotection have been demonstrated that photorepair and
photoprotection improves at sub-clinical and clinical level AK lesions
better than sunscreens. After 3 months of Ery application, the change
in haemoglobin concentration we documented was quite relevant
(>30%). This result could be interpreted as a reduction in the
vascularization level that is increased in AK lesions as documented by
histological and microscopy confocal evaluations [23,24]. In fact
especially in hypertrophic and clinical visible AK lesions there is an
increased vascular density and vasodilation. These data suggest that
photorepair and photoprotection combined could have a relevant
effect at skin level in AK lesion.
Conclusion
The data from our pilot study show that the use of a product with
photorepair and photoprotection actions in subjects with AK is able to
change in the short-medium-term average levels of a parameter
objectively evaluated by spectral analysis, such as the content of
hemoglobin (considered as a marker of “vascularization” and
"inflammation") suggesting that the use of this product tends to
improve the skin area affected by actinic process. The use was also
associated with a relevant clinical improvement with a reduction in the
mean number of visible lesions.
References
1. Schwartz RA (1997) The actinic keratosis. A perspective and update.
Dermatol Surg 23: 1009-1019.
2. Ulrich M, Maltusch A, Röwert-Huber J, González S, Sterry W, et al.
(2007) Actinic keratoses: non-invasive diagnosis for field cancerisation.
Br J Dermatol 156 Suppl 3: 13-17.
3. Eder J, Prillinger K, Korn A, Geroldinger A, Trautinger F (2014)
Prevalence of actinic keratosis among dermatology outpatients in
Austria. Br J Dermatol 171: 1415-1421.
4. Brash DE, Ziegler A, Jonason AS, Simon JA, Kunala S, et al. (1996)
Sunlight and sunburn in human skin cancer: p53, apoptosis, and tumor
promotion. J Investig Dermatol Symp Proc 1: 136-142.
5. Rastogi RP, Richa, Kumar A, Tyagi MB, Sinha RP (2010) Molecular
mechanisms of ultraviolet radiation-induced DNA damage and repair. J
Nucleic Acids 2010: 592980.
6. Vink AA, Roza L (2001) Biological consequences of cyclobutane
pyrimidine dimers. J Photochem Photobiol B 65: 101-104.
Citation: Puviani M, Milani M (2015) A Pilot, Prospective, Open-Label Study on the Effects of a Topical Photorepair and Photoprotection Film-
Forming Medical Device in Patients with Actinic Keratoses Evaluated by Means of Skin Analysis Camera Antera 3D. J Clin Exp
Dermatol Res 6: 263. doi:10.4172/2155-9554.1000263
Page 3 of 4
J Clin Exp Dermatol Res
ISSN:2155-9554 JCEDR an open access journal Volume 6 • Issue 2 • 1000263
7. Thoma F (1999) Light and dark in chromatin repair: repair of UV-
induced DNA lesions by photolyase and nucleotide excision repair.
EMBO J 18: 6585-6598.
8. Jans J, Schul W, Sert YG, Rijksen Y, Rebel H, et al. (2005) Powerful skin
cancer protection by a CPD-photolyase transgene. Curr Biol 15: 105-115.
9. Camp WL, Turnham JW, Athar M, Elmets CA (2011) New agents for
prevention of ultraviolet-induced nonmelanoma skin cancer. Semin
Cutan Med Surg 30: 6-13.
10. Puviani M, Barcella A, Milani M (2013) Efficacy of a photolyase-based
device in the treatment of cancerization field in patients with actinic
keratosis and non-melanoma skin cancer. G Ital Dermatol Venereol 148:
693-698.
11. Puig S (2012) Evaluation of the effects of Eryfotona® AK-NMSC a
product containing photolyase and UV filters, to improve the subclinical
cancerization field in AK patients. JAAD
12. Vidal S (2012) Photolyase sunscreen decreases expression of p53 and
Ki67 in comparison to standard 50 SPF. JAAD
13. Coma M, Valls R, Mas JM, Pujol A, Herranz MA, et al. (2014) Methods
for diagnosing perceived age on the basis of an ensemble of phenotypic
features. Clin Cosmet Investig Dermatol 7: 133-137.
14. Miravex (2013) Antera 3D®, analysis of your skin [homepage on the
Internet] Dublin, Ireland.
15. Kohl E, Meierhöfer J, Koller M, Zeman F, Klein A, et al. (2014) Fractional
carbon dioxide laser resurfacing of rhytides and photoageing: a
prospective study using profilometric analysis. Br J Dermatol 170:
858-865.
16. Criscione VD, Weinstock MA, Naylor MF, Luque C, Eide MJ, et al.
(2009) Actinic keratoses: Natural history and risk of malignant
transformation in the Veterans Affairs Topical Tretinoin
Chemoprevention Trial. Cancer 115: 2523-2530.
17. Griffiths HR, Mistry P, Herbert KE, Lunec J (1998) Molecular and
cellular effects of ultraviolet light-induced genotoxicity. Crit Rev Clin Lab
Sci 35: 189-237.
18. Thompson SC, Jolley D, Marks R (1993) Reduction of solar keratoses by
regular sunscreen use. N Engl J Med 329: 1147-1151.
19. Joan Anton Puig-Butille, Josep Malvehy, Miriam Potrony, Carles Trullas,
Francisco Garcia-Garcıa, et al. (2013) Role of CPI-17 in restoring skin
homoeostasis in cutaneous field of cancerization: effects of topical
application of a film-forming medical device containing photolyase and
UV filters. Experimental Dermatology 22: 482–501.
20. Gerkema MP, Davies WI, Foster RG, Menaker M, Hut RA (2013) The
nocturnal bottleneck and the evolution of activity patterns in mammals.
Proc Biol Sci 280: 20130508.
21. Jans J, Schul W, Sert YG, Rijksen Y, Rebel H, et al. (2005) Powerful skin
cancer protection by a CPD-photolyase transgene. Curr Biol 15: 105-115.
22. Piaserico S, Milani M (2012) Efficacia clínica della fotoliasi tópica dopo
terapia fotodinámica in soggetti con cheratosi attinica: studio prospettico
randomizzato intrapaziente. Giornale Italiano Dermatologia
Venereologia 147: 109.
23. Strieth S, Hartschuh W, Pilz L, Fusenig NE (2000) Angiogenic switch
occurs late in squamous cell carcinomas of human skin. Br J Cancer 82:
591-600.
24. Ulrich M, Krueger-Corcoran D, Roewert-Huber J, Sterry W, Stockfleth E,
et al. (2010) Reflectance confocal microscopy for noninvasive monitoring
of therapy and detection of subclinical actinic keratoses. 220: 15-24.
Citation: Puviani M, Milani M (2015) A Pilot, Prospective, Open-Label Study on the Effects of a Topical Photorepair and Photoprotection Film-
Forming Medical Device in Patients with Actinic Keratoses Evaluated by Means of Skin Analysis Camera Antera 3D. J Clin Exp
Dermatol Res 6: 263. doi:10.4172/2155-9554.1000263
Page 4 of 4
J Clin Exp Dermatol Res
ISSN:2155-9554 JCEDR an open access journal Volume 6 • Issue 2 • 1000263
