What is the treatment for an ulcerated actinic keratosis?

Treatment for Ulcerated Actinic Keratosis

For ulcerated actinic keratosis, surgical treatment with curettage followed by histological examination is the recommended first-line approach to rule out invasive squamous cell carcinoma and provide definitive treatment. 1, 2

Treatment Options Based on Lesion Characteristics

Surgical Approaches (First-line for Ulcerated Lesions)

• Curettage with histological examination is the preferred treatment for ulcerated actinic keratosis to rule out invasive squamous cell carcinoma 1
• For hyperkeratotic or ulcerated lesions, two or three cycles of curettage may be necessary to ensure adequate treatment, especially when there is diagnostic uncertainty 1
• Formal excision may be preferred when there is high suspicion of squamous cell carcinoma, particularly on high-risk areas such as the ear 3

Cryosurgery

• Cryosurgery shows a 75% complete response rate for actinic keratoses, with better efficacy for thick lesions (69% complete response) compared to other treatments 1
• A double freeze-thaw cycle is more effective than a single cycle, with response rates of 75% versus 68% 1
• Cryosurgery is strongly recommended by the American Academy of Dermatology as first-line treatment for isolated non-ulcerated actinic keratoses 3

Special Considerations for Specific Anatomical Sites

High-Risk Areas

• For lesions on the ear, histological biopsy is essential due to the higher risk of transformation into squamous cell carcinoma 2
• For periorbital lesions, cryotherapy with a contact probe is preferable to avoid contact with the eye 2
• For lesions on the legs, photodynamic therapy presents less risk of unfavorable scarring compared to other physical therapies 2

Treatment for Resistant Lesions

• Larger lesions (>1 cm) and painful lesions are more likely to be resistant to standard treatments 4
• For treatment-resistant actinic keratoses, combination therapy may be more effective 4
• Simultaneous therapy with topical 5-fluorouracil and imiquimod creams has shown success in treating refractory actinic keratoses 4

Field Treatment for Multiple Lesions

• 5-fluorouracil (5-FU) at 5% applied twice daily for 3-4 weeks is effective in reducing about 70% of actinic keratoses for up to 12 months 2
• Imiquimod 5% applied three times a week for 16 weeks shows a complete response rate of 47% 2
• Photodynamic therapy is particularly effective for confluent actinic keratoses of the scalp and difficult-to-treat areas 2

Important Clinical Considerations

• Failure of an ulcerated lesion to respond to initial therapy indicates a need for further evaluation, including formal excision 2
• The risk of progression of actinic keratosis to squamous cell carcinoma varies from less than 0.1% to 20%, with higher risk on the ear 3
• Regular use of high-index sunscreen reduces the appearance of new actinic keratoses 2
• Patient education on potential side effects is essential, as many treatments cause redness, pain, and sometimes crusts 2

Treatment Algorithm for Ulcerated Actinic Keratosis

1. Perform curettage with histological examination to rule out invasive squamous cell carcinoma 1, 2
2. If histology confirms actinic keratosis without invasion:
   • For isolated lesions: Complete treatment with additional curettage or cryosurgery 1
   • For multiple lesions in the same area: Consider field therapy with 5-fluorouracil or imiquimod after healing of the ulcerated lesion 2, 3
3. If histology suggests or confirms squamous cell carcinoma:
   • Proceed with formal excision with appropriate margins 3
4. For recurrent or resistant lesions:
   • Consider combination therapy approaches such as 5-FU with imiquimod or 5-FU followed by cryotherapy 2, 4