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Background: Photodynamic therapy (PDT) is a recognized treatment for superficial basal cell carcinoma (sBCC). Conventional PDT (C-PDT) has a relatively high clearance rate but is time-consuming and painful. Simulated daylight PDT (SDL-PDT) has the potential advantage of causing less pain, but its effectiveness has not been investigated thoroughly., Objectives: To determine whether SDL-PDT is non-inferior to C-PDT in the treatment of clinically diagnosed sBCC and to assess adverse events during treatment and patient preferences., Methods: In this single-centre, non-inferiority, randomized controlled trial, adult patients with sBCCs of any size and located on anatomical sites suitable for PDT were recruited. Lesions were randomized to two sessions of either SDL-PDT or C-PDT using aminolevulinic acid as the photosensitizer. Patient-perceived pain was measured using a numeric rating scale (NRS) ranging from 0 to 10. Self-report forms were used to measure patient preferences. Patients were evaluated after 3 months to assess early treatment failure and after 1 year to determine overall clearance rates., Results: In total, 78 participants with 193 sBCCs were treated. Most lesions (47.2%) were located on the trunk and were diagnosed solely through dermoscopic evaluation (64.2%). After 1 year, the clearance rate was 62.4% for SDL-PDT and 91.8% for C-PDT (p < 0.001) disproving non-inferiority. Illumination was reported to be more painful during C-PDT (mean NRS score of 3.5 at session 1 and 3.7 at session 2) compared with SDL-PDT (mean NRS score of 0.1 at both sessions) (p < 0.001). Immediately after treatment, 87.5% of respondents expressed a preference for SDL-PDT., Conclusions: SDL-PDT is less effective than C-PDT but is also less painful. Due to the lower clearance rate, this study does not support SDL-PDT as a primary treatment option for sBCC. The randomized controlled trial was registered at http://www.researchweb.org/ (project 264721)., (© 2025 The Author(s). Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology.)

The high prevalence of basal cell carcinoma (BCC) entails a substantial burden on healthcare systems. Interest in non-surgical treatment methods for low-risk BCCs, including destructive treatments, is increasing. Dermatologists often highlight suboptimal cosmetic outcomes as drawbacks of destructive treatments, also for non-facial lesions. Patient perspectives regarding scarring and cosmetic outcomes in relation to other relevant factors are largely unknown, yet important to consider in shared decision-making when choosing treatment. This study investigates patient perceptions of scarring following destructive treatments and explores important factors in treatment decisions for non-facial BCCs. Through a mixed-methods design, cosmetic outcomes, patient satisfaction, scarring concerns, and treatment preferences were evaluated within an ongoing randomized clinical trial on destructive treatments for low-risk BCCs. Overall, 157 patients with 425 non-facial scars were assessed. Most patients were not concerned about scar appearance, highlighting a discrepancy compared with dermatologists' general concerns regarding inferior cosmetic outcome. Instead, when opting for specific treatments, patients listed clearance rates as the most important factor, followed by convenience and time consumption. We believe the results are important both in the context of patient-centred care and in "choosing wisely" when deciding between BCC treatments.

Competing Interests: Conflicts of interest None disclosed.