From the Guidelines
Imiquimod 5% cream yields the lowest recurrence rate for facial actinic keratoses, with 76% of patients maintaining clearance at 12 months. This is based on a three-armed RCT between cryosurgery, 5-FU 5%, and imiquimod, which showed that imiquimod had the highest proportion of patients maintaining clearance at 12 months 1. The treatment involves applying imiquimod 5% cream at night and washing it off in the morning 8 hours later, three times a week for 4 weeks, which can be repeated for a further 4 weeks if needed.
Key Points
- Imiquimod 5% cream is a topical immune-response modifier that is licensed for use in clinically typical, non-hyperkeratotic, non-hypertrophic AKs on the face or scalp in immunocompetent adults 1.
- A meta-analysis of five RCTs demonstrated a 50% complete clearance rate with imiquimod 5% cream 1.
- Imiquimod 5% cream has been shown to have a lower recurrence rate compared to other treatments, including cryosurgery and 5-FU 5% 1.
- Side-effects of imiquimod 5% cream are generally well tolerated, but patients should be counseled carefully to anticipate potential extreme clinical reactions 1.
Comparison to Other Treatments
- 5-FU 0.5% in 10% salicylic acid has been shown to have a lower recurrence rate compared to diclofenac 3% gel, but it is not as effective as imiquimod 5% cream in terms of maintaining clearance at 12 months 1.
- Cryosurgery has been shown to have a lower proportion of patients maintaining clearance at 12 months compared to imiquimod 5% cream, and it may cause scarring 1.
From the FDA Drug Label
INDICATIONS AND USAGE: Fluorouracil Cream USP is recommended for the topical treatment of multiple actinic or solar keratoses. The success rate with Fluorouracil Cream USP is approximately 93%, based on 113 lesions in 54 patients. Eighty-eight lesions treated with the cream produced 7 failures.
The treatment for facial actinic (solar) keratoses that yields the lowest recurrence rate is not directly stated in the provided drug labels. However, based on the available information, Fluorouracil Cream USP has a success rate of approximately 93% 2.
- The recurrence rate is not explicitly mentioned in the provided drug labels.
- Methyl aminolevulinate (TOP) does not provide direct information on recurrence rates in the given text.
From the Research
Treatment Options for Facial Actinic Keratoses
- Photodynamic therapy (PDT) with methyl aminolevulinate (MAL) is an effective first-line treatment for actinic keratosis (AK) 3, 4, 5
- Ablative fractional laser-assisted MAL-PDT (AFL-PDT) has shown significant benefit for the treatment of AK, with a lower recurrence rate compared to conventional MAL-PDT 3, 6
Recurrence Rates
- The recurrence rate was significantly lower for 3h-AFL-PDT (7.5%) than for 3h-MAL-PDT (22.1%) at 12 months 3
- FL-PDT showed a lower lesion recurrence rate than MAL-PDT (9.7% vs. 26.6%) 6
- No significant difference in recurrence rates was observed between ALA-PDT and MAL-PDT at either 6 or 12 months after treatment 7
Efficacy and Cosmetic Outcomes
- 3h-AFL-PDT was significantly more effective than 2h-AFL-PDT and 3h-MAL-PDT, with differences in efficacy remaining significant at the 12-month follow-up 3
- FL-PDT was significantly more effective than MAL-PDT at treating all AK grades (86.9% vs. 61.2%) 6
- Excellent or good cosmetic outcome was reported in >90% cases for FL-PDT 6
- No significant difference in cosmetic outcomes was observed between ALA-PDT and MAL-PDT at 12 months after treatment 7