management

Last edited 05/2022 and last reviewed 02/2023

• General measures for all patients (1):
• moisturisers two to three times a day to help differentiate early AK from dry scaly arease of normal skin
• larger number of AK lesions – Nicotinamide 500 mg BID, which has shown to reduce number of AK and non-melanoma skin cancer
• Lesion specific treatment – few lesions or larger numbers that are widely distributed (ie dotted around the face, scalp and hands etc) (1):
• treat the individual lesions and not the surrounding skin
• cryotherapy - involves single freeze-thaw cycle of approximately ten seconds; in order to avoid the risk of ulcers, avoid the gaiter area
• 5-fluorouracil (5-FU) cream (Efudix®) twice daily for 3-4 weeks
• Patients should be advised to expect a relatively mild degree of redness and discomfort during the treatment period
• 5-FU 0.5% and salicylic acid 10% (Actikerall®) moderately thick hyperkeratotic actinic keratosis, used once a day for 6-12 weeks
• 3% diclofenac gel in sodium hyaluronate (Solaraze®)  twice a day for 12 weeks
  

• field change – multiple AK associated with a background of erythema, telangiectasia and other changes seen in sun-damaged skin (1)
• treatments should be applied to whole area of field change and not just the individual lesions
• smaller areas of field change (e.g. an area the size of a palm or most of the forehead)
• 5% imiquimod cream (Aldara cream) – use three nights a week; generally effective in terms of clearance, and cosmetic appearance
• 5- FU cream (Efudix cream) – once a day for four weeks
• Photodynamic therapy (PDT) – single treatment often provides effective treatment

NOTE: MHRA alert has noted an increased incidence of skin tumours in some clinical studies when using ingenol mebutate; as of February 2020, licence of ingenol mebutate has been suspended as a precautionary measure while the European Medicines Agency (EMA) continues to investigate the concerns about a possible increased risk of skin malignancy (2,3)

• For larger areas of field change consider:
• 3% diclofenac gel – use twice daily fior 8-12 weeks; generally well tolerated
• 3.75% imiquimod cream (Zyclara cream) – once daily for two weeks, followed by two week treatment-free, then once daily for two weeks

Systemic therapies (only used by specialists) include treatments such as oral retinoids are used for chemoprevention of non-melanoma skin cancers in high-risk patients for both immunocompetent and immunosuppressed patients, including patients with xeroderma pigmentosum

References:

• (1) Primary Care Dermatological Society. Actinic Keratosis. https://www.pcds.org.uk/clinical-guidance/actinic-keratosis-syn-solar-keratosis (Accessed 27/01/2022)
• (2) MHRA.Ingenol mebutate gel - increased incidence of skin tumours seen in some clinical studies.Drug Safety Update volume 13, issue 3: October 2019: 1
• (3) MHRA Drug Safety Update (February 2020). Ingenol mebutate gel (Picato): suspension of the licence due to risk of skin malignancy (Accessed 27/012022)