Non-Surgical Treatments For Extramammary Paget’s Disease

 

Are there any ways to treat EMPD without surgery?

Surgery is not always possible, or desired, for extramammary Paget’s disease (EMPD) treatment and when its not some patients use other treatments. Non-surgical EMPD treatments include: topical treatments (such as Imiquimod, also known as Aldara), CO2 laser, photodynamic therapy, cavitational ultrasonic surgical aspiration and radiotherapy. 

Imiquimod (Aldara)

Imiquimod is a topical cream that acts as an immune response modifier and is generally used to treat genital warts, basal cell carcinoma and actinic keratosis. The product was approved by the FDA in 1997 under the brand Aldara (produced by 3M) but later became available worldwide under many brands. Immune response modifiers attempt to activate the immune system to fight abnormal cell growth.

Imiquimod has been used by some doctors – in an off-label manner – in the treatment of extramammary Paget’s disease (EMPD). The length of use of Imiquimod in EMPD treatment often varies from weeks to many months.

Imiquimod is sold under several trade names including Aldara.

Some EMPD patients that have used Imiquimod mention that it causes redness, swelling, itching, burning, sores, blisters, tenderness and can be painful. Others mention a change in skin color that may or may not go away as well as flu-like symptoms, headache, and tiredness.

The success of Imiquimod treatment varies significantly by patient. Women often use Imiquimod more than men in their treatment of EMPD. Most EMPD research studies on Imiquimod have used only women in their studies.

Some physicians are apprehensive to prescribe Imiquimod for EMPD treatment due to its off-label use and lack of thorough research studies with EMPD patients, including men. Other doctors are concerned about the possibility of masking any future EMPD symptoms or causing EMPD to separate into multiple fragments, making future surgical margin unreliable.

Some doctors have prescribed Imiquimod (also known as Aldara) in combination with Efudix and Tretinoin for their patients treatment.

Imiquimod is also used when surgery is not an option either due to the location of the EMPD or the ability of the patient to tolerate what can often be complex surgery. 

CO2 Laser

The carbon dioxide laser (CO2) was developed in the 1960’s and is still used in specialized medical applications today. The CO2 laser works especially well with skin deficiencies and has been used with extramammary Paget’s disease (EMPD) patients.

Ablation by CO2 laser can reduce the number of EMPD cells, however, many EMPD patients have found it to be insufficient in achieving complete remission. Scarring is also possible. Some EMPD patients have used a combination of CO2 laser and photodynamic therapy (PDT).

Depending upon the size of the EMPD area involved, some CO2 laser patients require an operating room with the procedure done under sedation.

Photodynamic Therapy (PDT)

Photodynamic therapy (PDT) is a medical treatment that utilizes a photosensitizing molecule and a light source to activate the applied drug. Aminolevulinic Acid (marketed as Levulan Kerastick) is commonly used when treating extramammary Paget’s disease (EMPD).  

PDT essentially has three steps. First, a light-sensitizing liquid or cream (photosensitizer) is applied. Second, there is an incubation period of up to 18 hours. Finally, the target tissue is then exposed to a specific wavelength of blue light that activates the photosensitizing medication that causes the treated skin cells to slough away.

Serious side effects of Levulan Kerastick are unlikely but tingling, stinging, prickling, itching, swelling, or burning of the area treated are common during the light treatment. The side effects generally improve at the end of the light treatment. Following treatment, patients often experience temporary redness, swelling, and scaling of lesions and surrounding skin.

Cavitational ultrasonic surgical aspiration (CUSA) 

A few EMPD patients also report success Cavitational Ultrasonic Surgical Aspiration (CUSA) procedures when a small area of extramammary Paget’s disease (EMPD) needs to be removed. 

Using low frequency ultrasound energy, a CUSA device dissects and fragments tissue. The unit is similar in size to an handheld ultrasound device while it also inlcudes an aspirator to remove tissue particles. It has advantages of limited blood loss, improved visibility and less collateral tissue impacts than traditional surgery. 

Radiotherapy

While surgery is generally considered the primary treatment for EMPD, radiotherapy (also known as radiation therapy) may be beneficial to some that are medically unfit for surgery or when surgery is not considered due to the location the EMPD. Radiation works by disrupting the DNA inside the cells.

Radiotherapy has been known to impact the ability for skin to heal thus making potential future surgeries more difficult or impossible.  

Summary

All of the varied non-surgical treatments described here have varied levels of success as well as potential side-effects. Finding detailed research studies on non-surgical treatments for extramammary Paget’s disease (EMPD) is difficult as EMPD is rare making the number of patients available for such studies limited. Working closely with doctors that have experience treating EMPD can help EMPD patients find the best treatment for their situation.