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

Treatment Options for Actinic Keratosis on the Face

Cryosurgery is strongly recommended as first-line treatment for isolated actinic keratoses on the face, while field-directed therapies like 5-fluorouracil, imiquimod, or tirbanibulin are recommended for multiple lesions. 1, 2

Lesion-Directed Treatments

• Cryosurgery: Strongly recommended for individual actinic keratoses with clearance rates between 57% and 98.8% depending on follow-up duration. Longer freeze times (>20 seconds) achieve higher clearance rates (83%) compared to shorter freeze times (<5 seconds, 39% clearance). 1

• Curettage: Warranted for thicker actinic keratoses, especially when there is suspicion of early squamous cell carcinoma. Histology must be obtained in these cases. 2, 3

Field-Directed Treatments

For multiple actinic keratoses in a contiguous area, field-directed therapies are recommended:

• 5-Fluorouracil (5-FU): Strongly recommended with high efficacy rating. 5% concentration applied twice daily for 3-4 weeks can reduce about 70% of actinic keratoses for up to 12 months. 2, 3

• Imiquimod: Strongly recommended at 5% concentration, applied three times weekly for 16 weeks, with complete response rates of approximately 47%. 2, 3

• Tirbanibulin: Strongly recommended (new FDA-approved treatment as of 2020) with high certainty evidence. Applied once daily for 5 consecutive days with complete clearance rates of 49.3% at day 57. Has the advantage of a much shorter treatment duration compared to other topical agents. 1

• Diclofenac gel: Conditionally recommended at 3% concentration for mild actinic keratoses, applied for 60-90 days with moderate efficacy and low morbidity. 3

• Photodynamic therapy (PDT): Conditionally recommended, particularly effective for confluent actinic keratoses. Options include:

  • ALA-red light PDT: Complete clearance rates of 77.1% at 12 weeks 1
  • ALA-blue light PDT: Conditionally recommended with moderate quality evidence 1
  • ALA-daylight PDT: Conditionally recommended as less painful but equally effective as ALA-red light PDT 1

Combination Approaches

• 5-FU + Cryosurgery: Conditionally recommended over cryosurgery alone with moderate quality evidence. 1, 2

• Imiquimod + Cryosurgery: Conditionally recommended over cryosurgery alone with low quality evidence. 1, 2

• Diclofenac + Cryosurgery: Conditionally recommended against compared to cryosurgery alone. 1

Treatment Selection Algorithm

1. For isolated lesions: Use cryosurgery with liquid nitrogen as first-line treatment. 1, 2

   • For thicker lesions or when suspecting early squamous cell carcinoma, consider curettage with histological examination. 2, 3

2. For multiple lesions or field cancerization:

   • First-line options: 5-fluorouracil, imiquimod, or tirbanibulin 1, 2
   • Consider patient factors:
     • For patients needing shorter treatment duration: Tirbanibulin (5 days) 1
     • For patients who can tolerate longer treatment: 5-FU (3-4 weeks) or imiquimod (16 weeks) 3
     • For patients with mild lesions or who cannot tolerate other options: Diclofenac gel 3

3. For difficult-to-treat areas or confluent lesions: Consider photodynamic therapy. 3

Important Considerations and Pitfalls

• Actinic keratoses have a high recurrence rate (up to 50% within the first year), requiring ongoing monitoring and treatment. 2

• The risk of progression to squamous cell carcinoma varies from <0.1% to 20%, with higher risk in certain anatomical locations. 2, 4

• UV protection is strongly recommended for all patients with actinic keratoses to prevent new lesions. 2, 3

• Patient education regarding potential side effects is essential, as many treatments cause redness, pain, and sometimes crusts. 3

• Failure of a lesion to respond to therapy indicates a need for further evaluation, including possible excision and histopathological examination. 3

• Actinic keratosis lesions can spontaneously regress in 15-25% of cases over a one-year period. 3