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

Treatment Options for Actinic Keratosis on the Face

For actinic keratosis on the face, cryosurgery is strongly recommended for isolated lesions, while 5-fluorouracil or imiquimod are recommended as first-line field-directed therapies for multiple lesions. 1

Treatment Selection Based on Number of Lesions

For Isolated Lesions:

• Cryosurgery is the first-line treatment with high efficacy (clearance rates between 57% and 98.8%) and the convenience of a single office visit 1
• Curettage may be warranted for thicker lesions, especially when there is suspicion of early squamous cell carcinoma, with histology always being obtained 1
• Photodynamic therapy (PDT) with ALA-red light is another effective option with complete clearance rates of 77.1% at 12 weeks 1

For Multiple Lesions (Field-Directed Therapy):

• 5-fluorouracil (5-FU) at 5% is strongly recommended, applied twice daily for 3-4 weeks, with effectiveness in reducing about 70% of actinic keratoses for up to 12 months 2
• Imiquimod 5% is strongly recommended, applied three times a week for 16 weeks, with a complete response rate of 47% 2
• Tirbanibulin is strongly recommended with high certainty evidence, applied once daily for 5 consecutive days with complete clearance rates of 49.3% at day 57, and has the advantage of a much shorter treatment duration 1
• Diclofenac gel 3% offers moderate efficacy with low morbidity for mild actinic keratoses, applied for 60-90 days 2

Photodynamic Therapy Options

• AMELUZ (aminolevulinic acid), in combination with photodynamic therapy using BF-RhodoLED® or RhodoLED® XL lamp, is FDA-indicated for both lesion-directed and field-directed treatment of actinic keratoses of mild-to-moderate severity on the face and scalp 3
• PDT with ALA-blue light is conditionally recommended with moderate quality evidence 1
• PDT with ALA-daylight is conditionally recommended as less painful but equally effective as ALA-red light PDT 1
• PDT appears more effective for individual lesions and has better cosmetic outcomes than cryotherapy 4

Combination Approaches

• 5-FU + Cryosurgery is conditionally recommended over cryosurgery alone with moderate quality evidence 1
• Imiquimod + Cryosurgery is conditionally recommended over cryosurgery alone with low quality evidence 1
• Diclofenac + Cryosurgery is conditionally recommended against compared to cryosurgery alone 1
• PDT followed by imiquimod twice a week for 16 weeks is more beneficial than PDT alone 2

Treatment Algorithm

1. Assess number and distribution of lesions:

   • Isolated lesions: Use cryosurgery as first-line treatment 1
   • Multiple lesions in a contiguous area: Use field-directed therapy 1

2. For field-directed therapy, select based on:

   • Highest efficacy: 5-fluorouracil 1
   • Shorter treatment duration: Tirbanibulin 1
   • Better tolerability for mild lesions: Diclofenac 3% gel 2

3. For special considerations:

   • Thicker lesions: Consider curettage with histological examination 1
   • Cosmetically sensitive areas: Consider PDT for better cosmetic outcomes 4

Important Considerations and Pitfalls

• Actinic keratoses have a high recurrence rate (up to 50% within the first year), necessitating ongoing monitoring and treatment 1
• The risk of progression to squamous cell carcinoma varies from less than 0.1% to 20%, requiring vigilant follow-up 1
• UV protection is strongly recommended for all patients to prevent new lesions 1
• Failure of an individual lesion to respond to therapy indicates a need for further evaluation, including possible excision 2
• Patient education on potential side effects is essential, as many treatments cause redness, pain, and sometimes crusting 2