Actinic Keratosis When UV Protection Has Not Reduced Lesion Counts: What Comes Next
Clinical Scenario
In patients with actinic keratosis, UV protective measures are the first management step. When those measures do not achieve a sufficient reduction in lesion counts or prevent the emergence of new lesions over a 6-month period, escalation to active treatment is warranted.
Previous Step — Goal Not Reached
The initial approach — minimising exposure to both natural and artificial UV sources, wearing sun-protective clothing, and applying broad-spectrum sunscreen blocking UVA and UVB — targets a reduction in actinic keratosis lesion counts and a decrease in the appearance of new lesions over 6 months. Failure to achieve these outcomes prompts the next treatment step.
Active Treatment — Overview
Guidelines strongly recommend active topical field treatment or, for individual isolated lesions, a procedural approach. The full evidence-based regimen — specifying which modality to use, in which situation — is available in the complete protocol.
Treatment Goal
Complete clearance of actinic keratosis lesions, assessed at 6 months.
References
DOI: 10.1016/j.jaad.2021.02.082
- The literature on AK treatment supports a strong recommendation for field treatment with either 5-fluorouracil (5-FU) or imiquimod (Table III).
- A large, placebo-controlled randomized trial showed field treatment of AKs on the face with 5% 5-FU treatment twice daily for 4 weeks to be more effective than placebo for complete AK clearance at 6 months (38% vs 17%, respectively; P < .01; Supplemental e-Table 1a).
- Studied in concentrations of 5%, 3.75%, and 2.5%, most data on the efficacy of topical imiquimod for the management of AKs were derived from 8 RCTs studying 5% imiquimod cream applied 2 to 3 times a week for 1 to 2 treatment courses.
- The Work Group strongly recommends cryosurgery as a treatment approach for individual AKs as good practice (Table III).
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