Optimal treatment of actinic keratoses

Figures & data

Table 1 Field-directed therapeutic options for actinic keratoses

Treatment modality	Formulation	Treatment regimen	Advantages	Side effects	Molecular target	Efficacy	Cost*
Patient-administered treatments
5-fluorouracil	0.5%–5% cream, solution	5% cream twice daily or 0.5%–1% cream daily for 3–4 weeks	Over 50 years of data to support usage, high cure rate with compliance, good cosmetic result 2 weeks after therapy	Burning, pruritus, erythema, peeling, scaling, potential scarring	Inhibition of thymidylate synthetase, reducing DNA synthesis and increased cell death	58% patients achieved 100% clearance while 75% patients achieved 75% clearance with 5% cream^2	0.5% cream 30 g: $228.89 1% cream 30 g: $279.97 5% cream 40 g: $345.99 (name brand); $249.98 (generic) 5% solution 10 cc: $126 (name brand); $101.99 (generic)
Imiquimod	3.75%, 5% cream	Twice a week for 16 weeks using 5% cream. Daily for one week, then off a week, then on for a week using 3.75% cream daily	Believed to induce immune memory that may prevent recurrence, milder erythema than 5-fluorouracil	Erythema, crusting, pruritus, induration, scaling; rarely flu-like symptoms, fever, fatigue, angioedema	Toll-like receptor-7 agonist that induces interferon-γ, interleukin-12, and tumor necrosis factor	45% patients achieved 100% clearance 8 weeks posttreatment with 5% cream while 60% achieved 75% clearance^Citation24,Citation25 35% patients achieved 100% clearance 8 weeks posttreatment with 3.75% cream while 60% achieved 75% clearance^Citation24,Citation25	3.75% one box (28 each): $601.01 5%, $650.82 three packages for one treatment course (name brand); $434.38 (generic)
Diclofenac	3% cream in 2.5% hyaluronan gel	Nightly for 60–90 days	Limited irritation and erythema	Allergic reaction to those allergic to aspirin or NSAIDS, contact sensitization erythema	Inhibits cyclooxygenase-2	50% patients achieved 100% clearance after 60–90 days treatment^Citation29	1% gel 100 g tube: $559.97
Ingenol	0.015% gel for face and scalp; 0.05% gel for trunk and extremities	Daily application for 3 days face and scalp; 2 days for trunk and extremities	Short treatment application duration for patient	Redness, scaling, vesiculation, dyspigmentation, swelling, pruritus, crusting	Macrocyclic diterpene ester with nonspecific cellular necrosis and neutrophil-mediated antibody-dependent cellular cytotoxicity	42.2% patients achieved 100% clearance with 0.015% gel on face and scalp; 63.9% had 75% clearance at 8 weeks^Citation31 34.1% patients achieved 100% clearance with 0.05% gel on body; 49.1% had 75% clearance at 8 weeks^Citation31	0.05% gel two packets: $608.06 0.015% gel three packets: $608.06
Physician-administered treatments
PDT/blue light	ALA incubated 1–2 hours, blue light exposure 16 minutes 40 seconds	1–3 treatment sessions every 4–6 weeks	High clearance rates and compliance; photorejuvenation with good cosmetic results	Pain, erythema, edema, stinging, crusting may last up to 4 weeks after treatment; must practice strict sun protection 24–48 hours after treatment	Free radicals are produced after light activation of protoporphyrin IX	66% patients achieved complete clearance 8 weeks after ALA/PDT treatment^Citation47 65% patients achieved complete clearance 3 months after MAL/PDT treatment^Citation34	Average $550 per treatment session $165.31 per ALA stick
Chemical peels	Trichloroacetic acid 35% or 50%, with or without Jessner’s solution	Every 4 weeks	Photorejuvenation with excellent cosmetic results	Pain, erythema, edema, stinging; initially effective but recurrences high; requires skill and user experience	Nonspecific cell necrosis	Not established	Average $125–$250 per session
Dermabrasion		Not clearly established	Low incidence recurrence, good cosmetic results	Pain, erythema, edema, stinging; requires skill and user experience	Nonspecific physical destruction	Not established	Average $100–$500 per session
Laser	Carbon dioxide, Erb:YAG	Not clearly established	Added cosmetic photorejuvenation	Pain, erythema, bruising, dyschromia, scarring; requires user experience; low clearance rates	Laser target specific to each laser	Not established	Dependent on office and laser type

Note:

* Epocrates Essentials (ePocrates Rx). ePocrates, Inc; Ver 4.5.

Abbreviations: ALA, aminolevulinic acid; Erb:YAG, erbium-doped yttrium aluminum garnet; MAL, methyl 5-aminolevulinate; NSAIDs, nonsteroidal antiinflammatory drugs; PDT, photodynamic therapy.

Table 2 Lesion-targeted versus field-directed therapies

	Lesion type targeted	Approaches	Advantages	Disadvantages
Lesion-targeted therapy	Isolated, singular lesions	Liquid nitrogen, electrodessication and curettage	– Localized side effects – Less downtime after treatment – High efficacy – Cheap – Readily available	– Addresses only clinically apparent lesions – Can require multiple treatments – Efficacy is technique dependent – Painful during procedures – Can leave scarring
Field-directed therapy	Diffuse clinical and subclinical lesions	5-fluorouracil, imiquimod, diclofenac, ingenol, photodynamic therapy, chemical peels, dermabrasion, laser	– Field cancerization treatment – Improved cosmetic outcome – More diffuse and larger areas can be treated at once	– More diffuse side effects – Unpredictable patient response – Patient compliance with patient administered therapies – Longer downtime – More expensive and not all covered under insurance plans – Potential for scarring

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