From the Guidelines
The best management for an 81-year-old male with suspected skin cancer and actinic damage should begin with a prompt dermatology referral for a complete skin examination and biopsy of suspicious lesions, as recommended by the most recent guidelines 1. The patient should undergo a thorough assessment including dermoscopy of concerning areas to determine the specific type of skin cancer (basal cell carcinoma, squamous cell carcinoma, or melanoma). Treatment options will depend on the diagnosis but typically include:
- Surgical excision with appropriate margins
- Mohs micrographic surgery for high-risk areas like the face
- Topical therapies, such as 5-fluorouracil cream (5% applied twice daily for 2-4 weeks) or imiquimod (applied 2-3 times weekly for 4-16 weeks depending on the formulation), which have been shown to be effective for treating actinic keratoses and superficial basal cell carcinoma 1. For actinic damage, treatment may also include field therapies such as photodynamic therapy. Sun protection is essential and should include:
- Daily application of broad-spectrum SPF 30+ sunscreen
- Wearing protective clothing
- Wide-brimmed hats
- Avoiding peak sun hours (10 AM to 4 PM) 1. Regular follow-up skin examinations every 3-6 months are necessary due to the patient's age and history, as older patients with actinic damage have a higher risk of developing additional skin cancers 1. This comprehensive approach addresses both the immediate concern of suspected skin cancer and the underlying sun damage that predisposes the patient to future malignancies. Some key considerations for reducing the risk of future skin cancers include:
- Counseling the patient on sun protection and avoidance of tanning beds
- Recommending routine use of sunscreens in combination with other sun-protective behaviors
- Considering the use of oral nicotinamide, which has shown some evidence of reducing the risk for subsequent keratinocyte carcinoma in nonimmunosuppressed individuals with a history of such carcinomas 1.
From the FDA Drug Label
When fluorouracil is applied to a lesion, a response occurs with the following sequence: erythema, usually followed by vesiculation, desquamation, erosion and re-epithelialization. Apply cream twice daily in an amount sufficient to cover the lesions. Medication should be continued until the inflammatory response reaches the erosion stage, at which time use of the drug should be terminated. Complete healing of the lesions may not be evident for 1 to 2 months following cessation of fluorouracil therapy. Superficial Basal Cell Carcinomas Only the 5% strength is recommended. Apply cream twice daily in an amount sufficient to cover the lesions. Treatment should be continued for at least 3 to 6 weeks.
The best course of management for an 81-year-old male patient with suspected skin cancer and signs of actinic damage may involve topical treatments such as 5-fluorouracil (TOP) 2. The patient's lesions, including the 1 cm irregularly shaped lesion on the left shoulder and multiple lesions on the forearms, may be treated with 5-fluorouracil cream applied twice daily until the inflammatory response reaches the erosion stage.
- The treatment duration may vary from 2 to 4 weeks for actinic keratosis and at least 3 to 6 weeks for superficial basal cell carcinomas.
- It is essential to monitor the patient's response to treatment and adjust the therapy as needed.
- A dermatology consult is also recommended to further evaluate and manage the patient's condition.
From the Research
Management of Suspected Skin Cancer and Actinic Damage
The patient's presentation of a non-healing lesion on the back, a suspicious lesion on the left shoulder, and multiple lesions on the forearms, along with signs of actinic damage, suggests the need for a comprehensive management plan.
- The patient's age and multiple lesions make surgical options challenging, and therefore, topical treatments may be considered as an alternative or adjunct therapy 3, 4, 5, 6.
- Imiquimod, an immune response modifier, has been shown to be effective in treating basal cell carcinoma (BCC) and actinic keratosis, with a clinical cure rate of 80-85% at 12 months 5.
- Combination topical therapy with imiquimod, 5-fluorouracil, and tretinoin, along with intermittent cryotherapy, has been reported to effectively treat invasive squamous cell carcinoma in a select patient who deferred surgery 3.
- A meta-analysis comparing the efficacy of imiquimod and 5-fluorouracil for the treatment of actinic keratosis found that imiquimod may have higher efficacy than 5-fluorouracil for lesions located on the face and scalp 7.
Treatment Options
Considering the patient's presentation and the available evidence, the following treatment options may be considered:
- Topical imiquimod therapy for the treatment of basal cell carcinoma and actinic keratosis 4, 5, 6.
- Combination topical therapy with imiquimod, 5-fluorouracil, and tretinoin for the treatment of invasive squamous cell carcinoma 3.
- Cryotherapy as an adjunctive treatment for actinic keratosis and squamous cell carcinoma 3, 6.
Monitoring and Follow-up
Regular monitoring and follow-up are crucial to assess the response to treatment and detect any potential recurrences or new lesions.