Efficacy and safety of ALA/MLA photodynamic therapy for superficial and nodular basal cell carcinoma: a systematic review and meta-analysis

Background: Basal cell carcinoma (BCC) is the most prevalent non-melanoma skin cancer, with surgical excision as the gold standard-though it carries risks of cosmetic scarring and functional impairment. Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) emerges as a non-invasive alternative, yet evidence on its relative efficacy across superficial (sBCC) and nodular (nBCC) subtypes remains inconsistent. Methods: This systematic review and meta-analysis adhered to PRISMA 2020 guidelines, with a comprehensive search of PubMed, Embase, Cochrane Library, and Web of Science up to December 31, 2025. Eligible studies included randomized controlled trials (RCTs) and single-arm studies evaluating ALA-PDT/MLA-PDT for histologically confirmed sBCC or nBCC. Study quality was assessed via the Methodological Index for Non-Randomized Studies (MINORS) scale, and statistical analyses were performed using Review Manager 5.4. Results: A comprehensive literature search identified 3832 records, with 55 eligible studies (41 for sBCC, 34 for nBCC) ultimately included, involving 2123 patients and 2995 lesions. For sBCC, the pooled complete response (CR) rate was 0.88 (95% CI: 0.85-0.91, p