From the Guidelines
The recommended treatment for actinic keratosis with mild to moderate dysplasia is topical 5-fluorouracil (5-FU) cream or imiquimod 5% cream, with cryotherapy being an effective alternative for individual lesions. According to the guidelines of care for the management of actinic keratosis 1, strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery.
Treatment Options
- Topical 5-fluorouracil (5-FU) cream applied once or twice daily for 2-4 weeks
- Imiquimod 5% cream applied 2-3 times weekly for 4-16 weeks
- Cryotherapy with liquid nitrogen for individual lesions
- Photodynamic therapy (PDT) for patients with multiple lesions, involving application of aminolevulinic acid followed by light activation
Key Considerations
- Sun protection is essential during and after treatment, including daily use of broad-spectrum sunscreen (SPF 30+) and protective clothing
- Follow-up examinations are recommended every 6-12 months to monitor for recurrence or development of new lesions
- Patients with actinic keratosis have increased risk for skin cancer, and treatment selection should be based on patient characteristics, preferences, and treatment-related factors 1
Evidence-Based Recommendations
The guidelines of care for the management of actinic keratosis 1 provide strong recommendations for the use of topical 5-fluorouracil, imiquimod, and cryosurgery, with conditional recommendations for photodynamic therapy and diclofenac. The British Association of Dermatologists' guidelines for the care of patients with actinic keratosis 2017 1 also support the use of these treatments, with consideration of patient-specific factors and lesion characteristics.
From the FDA Drug Label
INDICATIONS AND USAGE: Fluorouracil Cream USP is recommended for the topical treatment of multiple actinic or solar keratoses. In two double-blind, vehicle-controlled clinical studies, 436 subjects with AK were randomized to treatment with either imiquimod cream or vehicle cream 2 times per week for 16 weeks.
The recommended treatment for actinic keratosis with mild to moderate dysplasia is topical treatment with creams such as fluorouracil or imiquimod.
- Fluorouracil is recommended for the topical treatment of multiple actinic or solar keratoses 2.
- Imiquimod has been shown to be effective in the treatment of actinic keratosis, with complete clearance rates of 46% and 44% in two clinical studies 3.
From the Research
Treatment Options for Actinic Keratosis with Mild to Moderate Dysplasia
The treatment of actinic keratosis (AK) with mild to moderate dysplasia is crucial to prevent the progression to squamous cell carcinoma (SCC) [(4,5,6,7,8)]. Several treatment options are available, including:
- Topical medications such as 5-fluorouracil (5-FU), imiquimod, and diclofenac [(5,7,8)]
- Photodynamic therapy (PDT) [(5,7,8)]
- Cryotherapy [(4,5,7,8)]
- Ablative and surgical methods [(6,8)]
- Laser ablation 7
Recommendations for Treatment
The Guidelines of Care for the Management of Actinic Keratosis provide evidence-based recommendations for the treatment of AK 7. Strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-FU, and cryosurgery. Conditional recommendations are made for the use of PDT and diclofenac, both individually and as part of combination therapy regimens.
Efficacy of Treatment Options
A systematic review of treatment options for AK found that PDT, cryotherapy, imiquimod, ingenol mebutate, 5-FU, trichloroacetic acid, and ablative fractional laser were all non-inferior to one another in terms of percent clearance of AKs 8. However, the lowest rates of clearance were seen with diclofenac sodium. The review also found that combination treatments, such as PDT with other modalities, may be more effective than single treatments.
Considerations for Treatment
When selecting a treatment option for AK with mild to moderate dysplasia, several factors should be considered, including the patient's individual risk factors, the location and number of lesions, and the potential side effects of treatment [(5,6,7,8)]. A multidisciplinary approach to treatment, including education on sun exposure prevention, may also be beneficial 5.