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.

Advantages

  • Very effective in treating AKs

  • May give skin more youthful appearance

  • Side effects usually disappear in 4 to 7 days

Disadvantages

  • Visible reddening, blistering, crust formation and peeling over treated areas that remains for 4 to 7 days

  • Discomfort

  • May require local anesthesia

  • Patient downtime


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.

Advantages

  • Cure rate of approximately 98%

  • Research shows effective
    in removing as well as preventing recurrence

  • Well tolerated by most patients

  • Side effects rare

  • Local anesthetic usually
    not required

  • Widely available

  • Economical

  • Quick

Disadvantages

  • Pain during procedure

  • Healing time may be slower than with other treatment options

  • May cause skin discoloration

  • Scarring possible

  • May require prescription medication to protect against bacterial and viral infection

  • Patient downtime


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.

Advantages

  • Can obtain a specimen to determine if squamous cell carcinoma present

  • Removes the entire lesion

  • Complete in 1 office visit

Disadvantages

  • Invasive procedure

  • Requires local anesthesia

  • Scarring possible

  • Patient downtime


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.

Advantages

  • Well tolerated

  • Patients usually go 5 or more years without developing new AKs

Disadvantages

  • One of the more complicated procedures

  • Requires local anesthesia

  • May require prescription medication to protect against bacterial and viral infection

  • May require prescription medication to relieve pain
    and soreness

  • Patient downtime


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.

Advantages

  • Well tolerated

  • Easy to use (patients can self treat)

  • May treat lesions that are not clinically apparent

  • Good cosmetic effects
    (no scarring or skin discoloration)

  • No patient downtime

  • Minimal side effects that resolve when treatment stopped

  • Appears to be as effective as topical chemotherapy, without the burning and irritation

  • May be effective in preventing AKs; long-term research needed to determine

Disadvantages

  • Long treatment time (60 to
    90 days)

  • Patient must be complaint

  • Potential allergic reaction


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 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.

Advantages

  • Well tolerated

  • Non-invasive

  • Excellent to good cosmetic results

  • Can clear AKs not yet visible, causing them to appear and clear

  • Little scarring

  • No skin discoloration

  • Good option for treating face, where may be
    difficult to perform more invasive therapy

  • No patient downtime

Disadvantages

  • Irritation usually develop on treated skin - redness, flaking, and scabbing typical

  • Not effective for all patients

  • Patient must apply medication as directed

  • Longer treatment time

  • Cost of imiquimod


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.

Advantages

  • Allows dermatologist to more precisely control amount of tissue removed

  • Can treat multiple lesions

  • Good cosmetic effects

  • Low risk of scarring and other complications when treated by a physician who is skilled in using the laser and experienced in treating AKs

Disadvantages

  • Expensive

  • Not widely available

  • Requires local anesthesia

  • Longer healing time

  • Series of office visits may be necessary


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.

Advantages

  • Noninvasive

  • Can treat large area

  • Good cosmetic results

  • Few side effects

  • Does not permanently discolor skin

Disadvantages

  • Severe stinging and burning during treatment in some cases

  • Two-step process

  • Costly

  • Not widely available

  • May require multiple sessions


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.

Advantages

  • Can obtain sample to determine if squamous cell carcinoma present

  • High success rate

  • Removes entire lesion

  • Complete in 1 office visit

Disadvantages

  • Invasive procedure

  • Scarring possible

  • Often limited to treating single lesion


Topical Chemotherapy
The topical chemotherapy agent that is FDA approved for treatment of AKs is 5-Fluorouracil (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)

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

Advantages

  • Cure rates exceed 90% with 100% patient compliance

  • Non-invasive

  • No patient downtime

  • Lesions usually heal within 2 weeks after treatment stopped and a smooth complexion appears

  • No scarring

  • No skin discoloration

Disadvantages

  • Requires 100% patient compliance to be effective
    (If dose missed, patient cannot double next dose to comply.)

  • Failure rate high as 60% when patient not compliant

  • Patient must endure some unsightly and painful side effects, such as severe redness and burning of the skin, to complete therapy

  • Allergic reaction can occur, and it may be difficult for patient to distinguish between expected side effects and allergic reaction



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.


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Various treatments are available for actinic keratoses.  The course of treatment depends on the nature of the lesion as well as the patient's age and overall health.

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