Treatment Options

The following have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of actinic keratoses (AKs). Each treatment has advantages and disadvantages, and what is suitable for one patient may be less than ideal for another. Board-certified dermatologists and dermatologic surgeons have the medical training and experience needed to determine which treatments are appropriate for each patient.

Chemical Peeling
A common skin rejuvenation treatment used to give skin a more youthful appearance; chemical peeling is also effective for treating AKs. Often used when a patient has numerous facial lesions, chemical peeling may be combined with another AK treatment for optimal results.

Procedure: A local anesthesia may be given to ease discomfort. Before the chemical solution is applied, the skin is thoroughly cleansed, and eyes and hair are protected. Then one or more chemical solutions are applied to the lesion(s). The chemical(s) causes the skin to blister and eventually peel. It is common to experience discomfort, reddening and crust formation over peeled areas. These are relieved with medications and moisturizers, and the side effects usually disappear in 4 to 7 days.

How it works: As the treated skin blisters and peels, new skin forms to replace it. Chemical peels work by removing damaged skin at superficial, medium and deep levels. Medium to deep-level peeling is usually required to remove AKs.

Cryosurgery
The most common method for treating AKs in the United States, cryosurgery is used for all forms of AKs. It is best suited for treating a few lesions that are clearly defined. However, a multi-stage treatment plan may be used when skin damage is diffuse or lesions are obscured by other dermatologic conditions.

Procedure: The dermatologist or dermatologic surgeon first applies a cryogenic (extremely cold) substance, usually liquid nitrogen, to the lesion(s). Liquid nitrogen is applied by either 1) dabbing it on with a cotton swab or 2) spraying it on with a special device. The application causes some discomfort, but local anesthesia is usually not required. If the AKs are very thick and scaly, they may be pretreated with a skin-softening cream or chemical peeling agent to “thin” them before the cryogenic substance is applied. Single or multiple lesions may be treated during a single treatment session. Pain and stinging can occur after the procedure.

How it works: The cryogenic substance freezes the surface skin, causing blistering or peeling. As the skin heals, the AK(s) is sloughed off and new skin appears in approximately 3 to 6 weeks. A scab may form during healing.

Curettage (with and without electrosurgery)
This is a common procedure for treating more advanced lesions and is often used for lesions resistant to other treatments.

Procedure: First, a local anesthesia is administered. Once it has taken affect, the dermatologist or dermatologic surgeon uses a curet, a spoon-shaped instrument, to scrape off AKs cells to the level of uninvolved tissue. Scraping may be followed by electrosurgery, a procedure that uses a pencil-shaped instrument to cut, destroy and cauterize the affected tissue with an electric current. Electrosurgery widens the area to ensure all damaged tissue is removed and limits bleeding.

How it works: The entire lesion and a portion of uninvolved tissue are physically removed.

Dermabrasion
Effective in destroying AKs, dermabrasion is well suited for treating extensive AKs.

Procedure: A rapidly moving brush is used to abrade and remove the skin down to the depth required to eliminate the AK(s). Local anesthesia is administered before the procedure to reduce discomfort. After treatment, the treated skin looks as if it has been badly sunburned. Several days are required for healing. Medication can be prescribed to relieve the pain and soreness.

How it Works: The lesion is sanded off to trigger new skin growth.

Diclofenac Sodium Gel
FDA approved in 2002 for treating AKs, this topical medication is used to treat multiple lesions. It should not be used by women who are pregnant or may become pregnant during treatment.

Procedure: Patients apply the non-greasy gel to their lesions twice a day for 2 to 3 months. During this time, the sun must be avoided. Best results are seen about 30 days after the patient stops applying the gel. Residual lesions may be treated with cryosurgery.

How it works: The gel destroys the lesion and accompanying solar damage.

Imiquimod
A topical medication that comes in cream form, imiquimod belongs to a class of drugs called immunomodulators. This means the medication stimulates the patient’s own immune system to fight disease. To be a candidate for imiquimod therapy, a patient must be immunocompetent (have a normal functioning immune system).

Imiquimod may be part of a treatment plan that uses combination therapy — use of more than one treatment method. Cryosurgery, electrosurgery, or surgical removal with a scalpel may be included in a treatment plan that includes imiquimod as may other topical therapies.

In clinical trials conducted to gather the data needed to submit imiquimod to the U.S. Food and Drug Administration (FDA) for approval, AKs on the face and scalp were treated. Nearly half of the patients treated with imiquimod saw all of their treated lesions clear, and the majority of patients treated with imiquimod experienced a clearance rate of 75% or more.

While imiquimod causes skin irritation, patients participating in clinical trials who have used other topical therapies that cause skin irritation reported that imiquimod seems less irritating and more tolerable.

Procedure: Patient applies the cream as directed by a dermatologist. The course of treatment may vary from 4 to 16 weeks, depending on several factors, including the severity of the AKs and patient’s response. The patient is carefully monitored during therapy to determine if the amount of cream being applied is sufficient, or if more or less imiquimod should be used. A rest period (treatment stopped and then resumed) may be given during imiquimod therapy.

How it works: Imiquimod modifies the skin’s immune system, which stimulates the body to reject the UV-damaged cells. When skin inflammation develops, it indicates that the lesion is being destroyed.

Laser Resurfacing
Less common procedure. Used to treat a few localized lesions as well as multiple AKs. Best suited for treating AKs on the lips.

Procedure: Local anesthesia is given, and after it takes effect, a laser is used to remove skin to the depth needed to eradicate the AK cells. Skin redness is the primary side effect. A week or two is needed for healing.

How it Works: The laser removes the skin to the depth required to eliminate damaged tissue.

Photodynamic Therapy
One of the newer treatment methods, it is most appropriate for treating multiple AKs on the face and scalp.

Procedure: A topical medication, 5-aminolevulinic acid (ALA), is applied and left in place for a specified amount of time, usually between 3 and 18 hours. The area is then treated with a blue light source.

How it works: The AK cells are destroyed when protoporphyrin IX--a chemical that is produced when the topical solution interacts with the skin--is exposed to the blue light. Results may be seen as early as the first session; however, re-treatment may be needed.

Surgical Excision
When a lesion is especially large or thick or is resistant to treatment, surgical removal is an option.

Procedure/How it Works: The entire lesion along with some healthy tissue are excised and sent to a dermatopathologist, who performs a microscopic examination to determine if cancer cells are present.

Topical Chemotherapy
The topical chemotherapy agent that is FDA approved for treatment of AKs is 5-fluorouracial (5-FU). It is effective in treating multiple AKs and is one of the most frequently used AK treatments in the United States. This method must not to be used by women who are pregnant or may become pregnant during the course of treatment.

Procedure: Patient applies the topical 5-FU as directed by the dermatologist or dermatologic surgeon. A typical course of treatment requires applying 5-FU twice daily to the AKs for 2 to 4 weeks. However, this may vary depending on the area to be treated and the treatment’s progress. 5-FU causes sun-damaged areas to become irritated. In fact, immediately following application, the patient usually sees a localized red spot that remains for some time and experiences a burning sensation and/or itching at the site. It is critical that the patient prevent direct sunlight from reaching the treated sites as sunlight can cause intense pain. As treatment progresses, patients typically notice the treated AKs begin to form crusts and erode and redness develop.

An allergic reaction may develop, which needs to be reported immediately to the patient’s dermatologist or dermatologic surgeon.

	This patient continued to use 5-FU after an allergic reaction developed. It eventually cleared after he stopped using the medication.
Photo used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides and the Sulzberger Institute for Dermatologic Education.

How it works: 5-FU destroys AK cells by blocking essential biochemical reactions in the cells.

References
AAD Guidelines of Care for Actinic Keratoses (1995).

Callen JP et al. “Actinic keratoses.” J Amer Acad Dermatol 1997; 36:650-653.

Dinehart SM. “The treatment of actinic keratoses.” J Amer Acad Dermatol 2000; 42:S25-S28.

Yu, TC et al. “Actinic Keratoses—Surgical and Physical Therapeutic Modalities.” Cutis, 2003; Vol.71, No. 5:381-384.