management

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  • established lesions - lesion specific treatment ie a few lesions or larger numbers that are widely distributed (ie dotted around the face, scalp and hands etc) - treat the individual lesions and not the surrounding skin:
    • physical treatment e.g. cryotherapy, curettage, local excision (1,2)
      • cryotherapy - involves a single freeze-thaw cycle of approximately ten seconds; in order to avoid the risk of ulcers then avoid the gaiter area (3)
    • topical treatment options include:
      • topical cytotoxic preparations (e.g. 5-fluorouracil), imiquimod cream, topical retinoids, salicylic acid in emulsifying ointment, topical diclofenac gel (this is licensed for treatment of actinic keratosis in the UK)
      • regimes include:

        • 5-fluorouracil (5-FU) cream (Efudix®) used twice daily for 3-4 weeks.
        • Wash hands thoroughly after application. Leave treated areas uncovered and wash the following morning. Patients should be advised to expect a relatively mild degree of redness and discomfort during the treatment period

        • 5-FU 0.5% and salicylic acid 10% (Actikerall®) licensed for treating moderately thick hyperkeratotic actinic keratosis. It should be used once a day for 6-12 weeks

        • 3% diclofenac gel in sodium hyaluronate (Solaraze®) used twice a day for 12 weeks

    • guidance suggests a strategy for management of multiple lesions (3) - AK widely considered a field disease that is rarely limited to a single clinically apparent lesion. Field-directed therapy aims to treat not only clinically visible lesions, but also subclinical lesions within the treatment area, lesions thought to exist along the same continuum as AKs and SCCs
      • field change
        • areas of skin that have multiple AK associated with a background of erythema, telangiectasia and other changes seen in sun-damaged skin
          • these areas are probably more at risk of developing SCC, especially if left untreated and, as such, it is recommended that they should be treated more vigorously
          • (3)
            • treatments should be applied to the whole area of field change and not just the individual lesions
        • primary aim of treatment is to reduce the total number of lesions that the patient has at any one time, the fewer lesions a patient has the less risk they have for developing an SCC
        • treatment courses will need to be repeated from time to time
        • all field based treatments will elicit local skin responses, which are expected as part of the treatment. The length of time a patient has to endure local skin responses varies widely between the treatments referred to below, and this needs to be discussed with the patient to aid them with the decision making
        • options for smaller areas of field change (eg an area the size of a palm or most of the forehead) include:
          • 5% imiquimod cream
            • use three nights a week
              • apply overnight and wash off the following morning. After four weeks stop the treatment and consider the use of a mild topical steroid for two to four weeks to help settle down any inflammation. Follow up three months after the treatment was started, repeat the treatment if needed
            • advantages - generally very effective in terms of clearance, and cosmetic appearance once inlammation resolved
            • disadvantages - patients should be warned to expect marked erythema with crusting of the skin. Timing of the treatment is important and is best avoided during holidays and important social occasions. Some patients develop flu-like symptoms during treatment
          • 5-FU cream
            • once a day for four weeks
              • apply thinly in an evening with a gloved finger, alternatively wash the finger after application
              • treated area should be washed the following morning. After four weeks stop the treatment and consider the use of a mild topical steroid for two to four weeks to help settle down any inflammation
              • follow up three months after the treatment was started
            • similar advantages and disadvantages similar to 5% imiquimod cream although patients do not develop flu-like symptoms
          • ingenol mebutate - formulations 150 µg/g or 500 µg/g
            • similar outcomes to the above
              • also very short treatment period and recovery phase when compared to the other topical treatments
            • face and scalp - apply the 150 µg/g formula for 3 consecutive days only
            • trunk and extremities - apply the 500 µg/g formula for 2 consecutive days only
            • note that an MRHA alert has noted an increased incidence of skin tumours in some clinical studies when using ingenol mebutate

            - and now the licence of ingenol mebutate has been suspended as a precautionary measure while the European Medicines Agency (EMA) continues to investigate concerns about a possible increased risk of skin malignancy (4,5)

          • photodynamic therapy
            • single treatment often provides an effective treatment for an area of field change
            • skin settles down within a few days of treatment
            • cosmetic outcomes are good
        • for larger areas of field change consider then options include 3% diclofenac in sodium hyaluronate or 3.75% imiquimod cream

  • screening - for other skin lesions that are more common in patients with marked sunshine exposure e.g. squamous cell carcinoma, basal cell carcinoma, melanomas
  • prophylaxis - sun avoidance - e.g. sunscreens such as 4% mexenone (Uvistat (R))

Systemic therapies (only used by specialists) include treatments such as oral retinoids are used for chemoprevention of non-melanoma skin cancers in high-risk patients for both immunocompetent and immunosuppressed patients, including patients with genodermatoses, such as xeroderma pigmentosum.

Reference:

  1. Dermatology in Practice (2001); 9 (4): 26-9.
  2. Berman B. New developments in the treatment of actinic keratosis: focus on ingenol mebutate gel.Clin Cosmet Investig Dermatol. 2012;5:111-22.
  3. Primary Care Dermatological Society. Actinic Keratosis (Accessed 9/3/2020)
  4. MHRA.Ingenol mebutate gel - increased incidence of skin tumours seen in some clinical studies.Drug Safety Update volume 13, issue 3: October 2019: 1
  5. MHRA Drug Safety Update (February 2020). Ingenol mebutate gel (Picato): suspension of the licence due to risk of skin malignancy

Last edited 03/2020 and last reviewed 09/2020

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