1Department of Microbiology, S.V.K.T College Deolali Camp, Nashik, India.
2Department of Microbiology, Sanjivani Arts, Science and Commerce College, Kopargaon, India.
*Corresponding Author E-mail: ashwinikadbhane8888@gmail.com
ABSTRACT:
Skin is the first line of the defense mechanism of the immune system which resists many outer invasions. Antimicrobial photodynamic treatment (APDT) is a challenging approach to dealing with infectious skin diseases and other pathogenic organisms. APDT uses photodynamic therapy (PDT) to treat different skin diseases including cancerous and noncancerous cells. APDT shows activity against various infectious diseases caused by broad spectra of microorganisms like bacteria, fungi, and algae. APDT is a successive method to treat multi- drug resistant antibiotics against different bacteria like Staphylococcus aureus, Enterococcus spp., Klebsiella pneumoniae, etc. Decades ago, applications of PDT were initiated by the use of sun rays as a Photosensitizing agent. APDT works combined with photosensitizers (PS), light, and oxygen to inhibit or kill the growth of pathogens or target cells. Different Natural and chemical PS is used to treat cancer cells, noncancerous cells, skin diseases, and acne vulgaris. PDT kills cells by showing the different mechanisms in host tissues directing the inflammatory response. In contrast to traditional therapeutic medications, APDT confers maximum clearness against infectious cells since PS is used directly to invade codocytes. The article presents a brief review of the mechanism of APDT, APDT uses for skin infections along with PS and different natural and synthetic PS.
KEYWORDS: Skin, Antimicrobial photodynamic treatment (APDT), Photodynamic Therapy (PDT), photosensitizers (PS), Cancer cells, Inflammatory response, Codocytes.
INTRODUCTION:
The convalescence potentiality of light has proven a boon procedure to treat different diseases. Photodynamic therapy is one of the prominent approaches which uses advanced techniques, and minimal therapeutic tools that show felicitous cytotoxicity towards cancerous cells and skin infections1. This therapy relies on the Photodynamic property of inducing light by illumination of a photosensitizer (PS). The anomaly was first introduced in the year 1990 by Raab2.
Photosensitizers are innocuous compounds that absorb and get activated by certain wavelengths of illumination and convert them to usable energy3. Though photosensitizers are harmless but after activation of light these sensitizers become harmful to the codocytes4. PS can absorb light in the wavelength range of 600 to 900 nm and emits a photochemical response5. Photosensitizers have distinct applications in the sectors like photodynamic
therapy, dry-sensitive photovoltaic cell, energy production, and fabricated chemistry6. Generally, this therapy involves a combination of energy in the form of light along with medicines i.e. photosensitizer to kill lethal, abnormal cells and helps to diminish dysplasia7. With the evolution of antibiotics, antifungal resistant microbes, and in the epoch of growing superbugs “anti-microbial photodynamic analysis” has been intimated a promising way for deactivation and elimination of infectious bacteria and other morbific organisms8. Photodynamic therapy (PDT) is effective in treatment to cure blisters, scars, and Paget’s illness9. Paget’s illness is an atypical dermatological state that appears in a region where odoriferous glands (sweat glands) are generous. Unwanted malignant development of cells in body parts like the eyes, esophagus, mouth, lungs, and skin can be treated with the help of PDT treatment10. Antibacterial photodynamic treatment is used against a broad range of opportunistic pathogens including Gram-positive and Gram-negative organisms present on the skin11. The review focuses on photodynamic therapy against pathogenic microbes and treatment against different skin diseases.
The widest organ of the human body is the skin. Many fungi and bacterial species can cause skin disorders like psoriasis, moles, blisters, eczema, skin bullosa, pemphigus, Ichthyosis, etc. One of the common skin trouble is acne coarse which alters nearly all pubescent and may continue till adulthood. About 70 article reports signify that antibacterial photodynamic treatment (APDT) for skin acne is favorable therapy, especially for persons who don’t show the effect of ointments, or medications, and not that great to isotretinoin12. The antibacterial photodynamic treatment uses photosensitizer in the presence of oxygen which helps to kill the pathogenic microbes. In 1999, a breakthrough in the past of topical photodynamic treatment (PDT) was made in the dermatology field. U.S. FDA in the year 1999 approved 1st topical PDT agent 5 aminolevulinic acid (ALA), a pioneer of heme-biosynthesis generating protoporphyrin IX for the therapy of senile keratosis in medical dermatology12,13. Methyl aminolevulinate and 5 aminolevulinic acids are commonly used photosensitizers for skin infections13. Currently, chemical components showing photochemical characteristics of various classes were checked with distinct outcomes against both gram-positive (+) and gram-negative (-) bacteria14. Generally, APDT uses ultraviolet or visible light combined with photosensitizers (PS) to generate a photochemical and photoactive reaction resulting in cell destruction or death 14.
Over many centuries ago the light was first used as a medical treatment tool. People from different countries like India, Egypt, and China used light as a therapeutic agent in numerous infections such as rickets, vitiligo, psoriasis, and skin cancer14. Over 3000 periods ago, the Greeks introduced a review of sunrays as a curable therapy agent and termed ‘Heliotherapy’ where the human body is exposed to sunlight for repair and fitness of wellness15. Light is an essential source for living forms to maintain the proper functioning of cells yet excessive light can destroy explicit conditions. Cauvin, a physician in the year 1815 stated that ‘Sunlight act as a preventive agent for scurvy, rickets, rheumatism, dropsy, paralysis and swellings16. A photodynamic treatment is defined as a photochemical reaction involving a photosensitizer that absorbs light and production of oxygen radical species17. German researcher, Oscar Raab in 1900 was first to represent that, light radiations can damage the living cells and named this effect as a photodynamic effect18. Fascination in photosensitizers showing early cytotoxic action was observed in the early 1900. In 1903, German scholar Hermann Von
Tappeiner and his team developed that a bacterial stain acridine had toxic consequences when disclosed to a beam of light19. Further, Tappeiner and Jesionek in 1913, described the application of light as an active stain for therapy purposes and defined the therapy as ‘photodynamic therapy’20. The modern eon of photodynamic therapy (PDT) began in the year 1960 by scientists Schwartz and Lipon at Mayo health center21. They synthesized a component of hematoporphyrin from red blood cells and termed it a hematoporphyrin derivative (HPD)22. This HPD was seen to be getting accumulated particularly in the cancerous cells which act as a biological marker and produces free oxygen radicals by inducing light that Killed cancerous cells21,22. Like Photodynamic therapy, antibacterial photodynamic treatment (APDT) is an approach used to treat many diseases including skin infections which shows antimicrobial characteristics and can stop or kill bacterial survival20,21. The advances of ADPT serve great attention to cure skin infections in the modern age22.
Firstly, scientists Appaeiner and Jesionek in 1904, perform the first photodynamic therapy for skin lymphoma 19,20. Eosin dye was used as a photosensitizing agent along with an illumination source6. The Antimicrobial photodynamic treatment was initiated in 1960. The dye toluidine blue was used against different microbes like algae, yeast, and bacteria by researcher Macmillan23. He noticed that the dye killed 99% of microbes in 30 minutes by applying a continuous gas laser at a wavelength of 632 nanometers23,24. Photodynamic therapy history represents the moderate progression and clarification in PDT, originating from the ancient inspection of beam-induced demised tumor cells to present status and established effective therapeutic tools in different medical Sciences7,22,23.
Contrivance of APDT:
Examining the increased number of antibiotic and antiseptic-resistant pathogens for many diseases there is a vital need for developing ingenious microbicidal approaches for inhibiting the pathogens without threat of causing protection14,24,25. Here a preference choice is antimicrobial photodynamic treatment (APDT) and Photodynamic therapy (PDT)14,24,25. Both PDT and APDT are noninvasive and unique medical therapy that relies mainly on three components: an illumination source, photosensitizer, and oxygen molecule (Fig.1)26.
Figure 1: Elements of Photodynamic Therapy (PDT)
PDT targets abnormal tissues, malignant tumors, and specific innocuous benign states, while APDT is practiced especially to fight against bacterial infections caused by microorganisms like Staphylococcus aureus, Streptococcus, E.coli, Pseudomonas etc by lowering the number of microorganisms or killing it27.
Mechanism of APDT:
The initial stage in PDT is the dispensation of harmless dyes called photosensitizers (PS). The photosensitizers are radiant sensitive which gets gathered in the codocytes25,26.
Examples of photosensitizers include dyes, porphyrins, and phthalocyanines28. Photosensitizers can be delivered either topically, by injection method, or intravenously depending on the patient's condition28. Because of specific properties of photosensitizing agents like a rapid supply of blood or expression of particular receptors, they can centralize in the codocytes or defective cells of the host6,28. The light of a specific wavelength of approximately 700 to 800 nm is exposed to the target site. When light gets absorbed by photosensitizers it experiences a photochemical response29. After radiation and retention of light the photosensitizers get active from the ground (low) level to the excited (high) level
i.e. transferred to maximum energy of atomic orbital30. The electrons (e-) lose their energy while returning to a low energy level by releasing either heat or fluorescence. The electron returns to singlet ground level (S1) or can move to the triplet form (T3) by the process known as intersystem crossing (ICS) (Fig. 2)30. T3 state is an excited and stable state of PS. From the T3 state photosensitizers can reach the S1 state following two pathways named Type 1 and Type 230,31.
Figure 2: Schematic representation of PDT
Type 1: In Type 1 excess electron photosensitizers get transferred to a substrate i.e. biomolecules of cancerous cells32. The reaction occurs between photosensitizers and biomolecules which leads to the liberation of free radicals. The free radicals get reacted with oxygen present in the body and create (ROS) reactive oxygen species like hydrogen peroxide, and alkyl radicals in the cancerous cell which creates oxidation stress in DNA and induces cell death33.
Type 2: In type 2 photosensitizers transfer energy to oxygen present in the cells. The O2 present is in the triplet and excited state. This triplet O2 gets converted to a singlet O2 which is unstable. The singlet O2 interacts with cancerous cells and produces oxidized radicals which lead to the denaturation of cells (Fig.3) [33,34]. PDT can also send the conduction and release the antigens that trigger the immune system. The generated immune response can kill the cancer cells and helps in tissue replacement and refinement33,34.
In accession to the type 1 and type 2 process, Hamlin and researchers proposed the photochemical type 3 process. In the type 3 process, the photosensitizing agent must itself target the biomolecule of cancerous cells which results in the killing of target cells 35. This process occurs in the excitation state of PS, rather than returning to its ground position without the involvement of oxygen 6,33,34,35. NBEX (Nanoparticles Based Photodynamic Therapy) is used as a Type 3 photosensitizer which applies radio sensitizers X-ray that excites chemotherapeutic effect36. By use of nanomaterials as a PS researchers believe to accomplish fine and moral tumor killing, better PS targeting, and promoting reactive oxygen species production36. The objective of photosensitizer NBEX is to increase the efficacy of PDT by compelling it with X-ray waves resulting in improved cancer therapy results7,34,36. Perhaps NBEX PS is still in improvement and research and their accessibility may change 37. Lamentably PS with fundamental targeting features is rare, hence PS practicing type 3 procedures are terrifying and persistent subtle goal37.
PDT resolves the destruction of cancer cells following three mechanisms: Reactive oxygen species generated by psychogalvanic response can kill cancer cells by promoting apoptosis38. PDT induces immune reaction which produces inflammatory responses like the release of interferons and interleukins against the cancer cells and tissues38,39,40. PDT also induces spoliation of the lump-associated parenchymal tissues and nearby healthy arteries leading to the obtrusion in nutrient flow and oxygen supply and inevitably resulting in cell ruin because of anoxia39,40.
Malignancy of cells by PDT can result in either a programmed cell death pathway called apoptosis or an unprogrammed pathway called necrosis41. When photosensitizers are emitted the lump is easily vaporized by necrosis42. Necrosis is distinguished by vacuolization of the cell membrane and cytosol malfunction resulting in a release of cytokines and pro-inflammatory receptors due to leakage of cytosolic components43. Comparatively, apoptosis is commenced when less intensified light is emerged44. Apoptosis is distinguished by properties like liquefaction of chromatins, shattering of genetic material into fragments, cell wrinkling, and membrane reduction without breakage of the cell membrane (Fig.4)45.
Figure 4: Cancer cell destruction by PDT 45
Antimicrobial photodynamic therapy (APDT) is also referred to as lethal photo-sensitization, photodynamic deactivation, and photodynamic antibacterial chemotherapy which constitutes another approach for antidote-resistant microbes and committed a comeback as an outlook to cure polydrug-resistant diseases46. ADPT along with a broad range of photosensitizing agents is more efficient in the inactivation of gram-positive bacteria in contrast to gram- negative bacteria47. This difference arises due to the cell structure of both bacteria. The cytoplasmic layer of gram +ve microbes is permeable, covered by the lipo-teichoic acid and peptidoglycan that permits photosensitizer to pass over the membrane46,47. Gram -ve bacteria consist of a peptidoglycan outer layer and an inner cytosolic membrane distinguished by peptidoglycan consisting of periplasm46,47,48. The outer layer acts as an absorbing barrier that confines the penetration and binding of PS. To overcome this barrier PS is combined used with a permeabilizing medium like EDTA (Ethylene diamine tetra acetic acid) or polymyxin nanopeptide had made APDT helpful besides Gram -ve microbes48. PS is active against a broad spectrum of microorganisms including fungi, parasites, viruses, and bacterial spores 48. Methylene blue, and toluidine blue are phenotiazinium-based dyes, porphyrin-based dyes like 5 aminolevulinic acid-induced protoporphyrin IX (ALA-PpIX) and chlorine combined with polyethyleneimine, neutral red are hematoporphyrin originated dye used as PS8,45,46,48.
Skin is the major obstacle to the body preventing the external attack. The healing process after injury in the skin consists of a series of processes including the release of cytokines, showing an inflammatory reaction, and involvement of multiple cells49. Connective tissue fibroblast is distinguished into myofibroblast, and continued tissue repair is processed to heal wound injury and restore the nature of the skin49. So far, recently recommended dermatological mark of APDT includes Bowen's illness (squamous cells dermis cancer), basal-cell skin cancer, and actinic keratosis50. Acute leg blisters are usual but at the same time challenging and PDT is applied to acute leg blisters by use of 20% ALA photosensitizers in liposome gel (Fig.5)
50,51. The treatment is carried out in three sessions once a week51. Dermatophyte, Trichophyton rubrum is a common APDT moderated by methylene blue and inhibits the growth of hyphae and spores of Trichophyton rubrum52. PS which are porphyrin based are important in binding to the cell membrane of Candida albicans. PS penetrates the cytoplasm resulting in the death of cells. Candida albicans are responsible to cause different skin infections50,51,52.
Figure 5.: 20% ALA as photosensitizers to treat leg blisters 50,51
The basic and most important component of PDT is photosensitizers. PDT was accidentally pioneered by observing that the emission of light kills microorganisms 7,10. An ideal and appropriate PS should have enough energy power at the triple level so that it can transfer the e- at ground state, must have prolonged life at the triplet level, must possess fine photochemistry, and must have appropriate stability33,34,35. There are several PS and microbes used in PDT (Table.1)53.
|
Microorganisms |
Photosensitizers |
Outcomes |
|
|
Candida spp |
Indocyanine green (2019) |
APDT confirmed a reduction in the CFU (Colony Formation Unit) count of Candida |
|
|
C.albicans, C. tropicalis, C. glabrate |
Methylene Blue, Photodithazine (2019) |
Reduce the count of C. albicans |
|
|
Bacteria |
Methylene Blue 0.005% (2021) |
Reduction in HSV 1, relives pain and sores |
|
|
Bacteria |
Hematoporphyrin and phenotiazinium dye, ALA |
Cure localized infections |
|
|
Propionibacterium acnes |
Endogenous porphyrins |
Treated Acne vulgaris |
|
|
Corynebacterium minutissimum |
Endogenous porphyrins |
Cure Erythrasma |
|
|
Mycobacterium marinum |
Endogenous porphyrins |
Treat nontuberculosis mycobacterial ulcers |
|
|
Malassezia furfur |
Methyl aminolevulinic acid (MAL) |
Treat malassezia folliculitis |
|
|
Molluscum contagiosum virus |
ALA |
Use to reduce Skin bumps caused by a virus |
|
|
Humanpapilloma virus (HPV) |
ALA |
Helps to reduce skin infections, particularly of feet and hand |
|
|
Staphylococcus aureus |
ALA |
Treat Acne, psoriasis |
|
|
Pseudomonas aeruginosa |
ALA |
Treat wound and skin abrasion |
|
|
Bacteria |
20% ALA |
Cure chronic leg ulcers |
|
|
Pseudomonas aeruginosa, Methicillin resistant S. aureus |
0.5% ALA and 0.005% EDT |
Skin ulcers |
|
PS can be divided into 3 generations since there are many molecular patterns of PS recently in use in PDT55. Hematoporphyrin derivative (HpD) and porfimer sodium are 1st periods PS. 2nd generation PS has developed to overcome the drawbacks of the 1st period referred to as absorption of light at peculiar wavelength56. Examples like derivates of phthalocyanines, chlorins, and bacteriochlorins that have potent work on tumor cells due to the high penetration ability of red light56,57. Lastly, the 3rd generation PS are components with advanced precision and accuracy on tumor part, since conjunction between PS and codocytes or its capsulation into its agents57. Agents or carriers like gold nanomaterials, silica nanomaterials, carbon microtubes, and other agents transport PS to the target place57.
In dermal intimation, PDT is often carried out through topical usage of photosensitizers like 5-ALA i.e. 5 aminolevulinic acid (Fig. 5), or as a substitute MAL i.e. methyl aminolevulinate its ester form58. In Europe country, 3 PS are recently affirmed for being topical usage 5- aminolevulinic acid Ameluz, methyl aminolevulinate Metvix, and 5-aminolevulinic acid AlaCare59. Additionally, topical photodynamic treatment is strongly suggested for the medication of acne vulgaris and photo-revitalization. However, protocols for this still required to be developed58,59.
Figure 6: Molecular structure of Photosensitizer Methylene Blue and Aminolevulinic acid (5-ALA)57,58
A group of chemical dyes is referred to as phenothiazinium60. Methylene blue and toluidine blue are frequently used Chemical dyes. These stains were used against cancer and are involved in 1st generation 55,56.
Table 2: Natural and Chemical PS with Applications
|
Class |
Photosensitizers |
Applications |
||
|
Natural PS |
Chlorophyll |
|
||
|
Hypericin |
Cancer, infections |
viral |
||
|
Curcumin |
Cancer and different conditions |
|||
|
Flavin derivatives |
Cancer and infections |
skin |
||
|
Chemical PS |
Porfimer (Photofrin |
sodium |
Oesophageal and larger cell lung lumps |
|
|
Methylene blue |
Different conditions like cancer and microbial diseases |
|||
|
Rose Bengal |
cancers, ocular dermatological infections |
and |
||
Cationic PS are compounds having a positive charge and are designed in a way to target tumor cells bearing a negative charge61. These include porphporphyrins-related components, phthalocyanines, or other closely related structures. Oppositely are anionic PS which holds a negative charge61. Anionic PS are rarely used as photosensitizers in PDT since the absorption power of cationic PS is high But anionic PS has unique properties to kill the target cell. Anionic PS is designed to target the tumor cell having a positive charge61,62.
Synthetic PS: The dyes produced from fluorescein PS are erythrosine (ERY) and eosin Y which belong to chemical dyes62,63. These dyes absorb light in a wavelength span of 470-560nm with green spectra. The absorption and uptake of cationic photosensitizers are maximum as compared to anionic photosensitizers. Porphyrins are a tetrapyrrole structure chemical PS63. It is widely used as PS because of its advantageous points like maximum frequency, and high ROS production, and easily gets chemically modified. Light gets absorbed in a wavelength of 400-555nm50,56,59,64.
Natural PS: Many components extracted from natural sources like plants and living organisms act as natural and effective PS. This PS absorbs UV- A or white light. Many natural PS are yet to be found and their use is restricted. Commonly used natural PS are curcumin and hypericin64. Curcumin is extracted from Curcuma longa plant roots64. They absorb the light in a range of 400-440 nm. Curcumin has many pharmaceuticals and biological functions as it acts as an antioxidant, antimicrobial, and anti-inflammatory64. Curcumin was found to possess many antimicrobial characteristics in the absence of UV irradiation besides attaching to protein FtsZ (similar to eukaryotic cytosol tubulin) and blocking the arrangement of FtsZ protofibril in Bacillus subtilis64. While Hypericum perforatum is a flowering plant and it is traditionally well-known for healing the wound, burns, and skin injuries65. This also acts as an antiviral, antidepressant, antitumor, and antimicrobial. This PS absorbs the light at a range of 600 nm i.e.orange color light. It has demonstrated that this PS is active against Gram-positive bacteria like Propionibacterium acne, Streptococci mutants, and Lactobacilli mutants. They also show activity against MRSA (methicillin-resistant Staphylococcus aureus)60,61,64.
APDT is the largest multidisciplinary branch that includes biologists, chemists, engineers, physicians, and physicists. ADPT is used to cure many infectious, oncologic, and nononcologic diseases by the release of ROS. PDT plays a significant role in multidrug-resistant approach by use of type 1 and type 2 photosensitizers state. ADPT works in medical therapies as an effective tool against tumors and skin lesions. The future challenge in front of PDT is to improve and show remarkable results through the use of the type 3 approach. Maximum use of different Natural PS is the biggest prospect in PDT with fastidious results along with the involvement of Immune response. PS with Nanomaterials has great scope and importance in PDT. In different localized diseases, oral or intradermal antibiotics aren’t effective in the presence of microbes in cells as a biofilm or rapid multiplication of bacteria into tissues. APDT provides solutions to such problems with the use of fastidious photosensitizers. Researchers are continuously working in advance development and betterment of photodynamic therapy.
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Received on 14.01.2025 Revised on 28.02.2025 Accepted on 03.04.2025 Published on 18.04.2025 Available online from April 22, 2025 Asian J. Res. Pharm. Sci. 2025; 15(2):147-154. DOI: 10.52711/2231-5659.2025.00023 ©Asian Pharma Press All Right Reserved
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