What are the treatment options for actinic keratosis on the face?

From the Guidelines

Actinic keratosis on the face can be treated with several effective options, with strong recommendations for the use of UV protection, cryosurgery, topical imiquimod, and 5-fluorouracil, as stated in the guidelines of care for the management of actinic keratosis 1. The most common treatments include:

• Topical medications such as 5-fluorouracil (Efudex, Carac) applied twice daily for 2-4 weeks,
• Imiquimod (Aldara, Zyclara) applied 2-3 times weekly for 4-16 weeks,
• Ingenol mebutate (Picato) applied once daily for 2-3 days,
• Diclofenac gel 3% (Solaraze) applied twice daily for 60-90 days. For individual lesions, cryotherapy with liquid nitrogen is highly effective and can be completed in a single office visit, though it may cause temporary discoloration, as recommended by the guidelines 1. Photodynamic therapy is excellent for multiple facial lesions, involving application of aminolevulinic acid followed by light activation, and is conditionally recommended for the treatment of AK, both individually and as part of combination therapy regimens 1. Chemical peels, laser therapy, and curettage with electrodesiccation are additional procedural options. Treatment choice depends on the number and location of lesions, patient preferences, and skin type. Sun protection with broad-spectrum SPF 30+ sunscreen, protective clothing, and avoiding peak sun hours is essential during and after treatment to prevent recurrence, as UV exposure is the primary cause of actinic keratosis, as emphasized in the guidelines of care for the management of actinic keratosis 1. The British Association of Dermatologists and British Photodermatology Group guidelines for topical photodynamic therapy 2018 also recommend offering topical PDT as a treatment option to people with AK, particularly for cosmetically sensitive skin sites, multiple lesions, and large-area lesions 1.

From the FDA Drug Label

1.1 Actinic Keratosis Imiquimod Cream is indicated for the topical treatment of clinically typical, nonhyperkeratotic, nonhypertrophic actinic keratoses on the face or scalp in immunocompetent adults. 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 studies enrolled subjects with 4 to 8 clinically typical, visible, discrete, nonhyperkeratotic, nonhypertrophic AK lesions within a 25 cm2 contiguous treatment area on either the face or scalp.

The treatment options for actinic keratosis on the face include:

• Topical imiquimod cream applied 2 times per week for 16 weeks, as indicated in the FDA drug label 2 and 2. Key points:
• Imiquimod cream is indicated for the topical treatment of clinically typical, nonhyperkeratotic, nonhypertrophic actinic keratoses on the face or scalp in immunocompetent adults.
• The treatment area can be of any dimensions, but should not exceed 25 cm2.
• The complete clearance rate, defined as the proportion of subjects with no clinically visible AK lesions in the treatment area, was 46% and 44% in the two clinical studies, respectively 2.

From the Research

Treatment Options for Actinic Keratosis on the Face

• Topical therapies, including 0.5% and 5-fluorouracil concentrations, photodynamic therapy, 3% diclofenac sodium gel, and imiquimod 5% cream, are indicated in the treatment of actinic keratosis 3.
• Imiquimod 5% cream is approved for the treatment of actinic keratosis of the face or scalp and has been shown to be effective in managing the disease 3, 4.
• 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 actinic keratosis lesions located on the face and scalp 4.
• Photodynamic therapy (PDT) is also an effective treatment option for actinic keratosis, particularly for individual lesions, and has been shown to have better cosmetic outcomes than cryotherapy and 5-fluorouracil 5, 6, 7.
• A study on the treatment of actinic keratoses with sequential combination of 5-fluorouracil and photodynamic therapy found that 90% of treated lesions had resolved at 1 month and 1 year post-treatment 6.
• PDT has also been shown to have esthetic effects, removing not only the lesion but also photoaging manifestations like wrinkles and lines, leaving a smooth skin 7.

Field-Directed Treatments

• Field-directed treatments, such as 3% diclofenac in 2.5% hyaluronic acid, 0.5% 5-fluorouracil, 5% imiquimod, and 0.025% to 0.05% ingenol mebutate, have been shown to be effective in treating actinic keratosis 5.
• These treatments have similar efficacy, but their associated adverse events and cosmetic outcomes are different 5.

Individual Lesion-Based Treatments

• Individual lesion-based treatments, such as photodynamic therapy, have been shown to be effective in treating actinic keratosis, particularly for individual lesions 5, 6, 7.
• PDT has been shown to have better cosmetic outcomes than cryotherapy and 5-fluorouracil 5, 7.