Actinic Keratoses

TREATMENT

Nightly application of a thin layer of imiquimod and 5-FU (any order) until a brisk reaction occurred across at least 80% of applied area (average was 11 days). At follow up (mean 7 months), all patients experienced at least 75% reduction in AKs (mean 90%). 38316257

These are protocols designed to decreased side effects while maintaining efficacy and also improve convenience for the patient. Instead of application of a sensitizing agent (usually ALA), a long incubation period, and then exposure to a red or blue light device, the sensitizing agent is applied and then exposed to ambient sunlight.
One protocol utilizing ALA demonstrated similar clearance rates between daylight PDT (95.5%) and conventional PDT (96.8%). 30336290 However, the protocol described included microneedling and also was confusingly written, possibly due to a language barrier (Chinese authors). The protocol included:
- Application of chemical sunscreen with SPF 30 (15min incubation)
- Gentle removal of scales, and crusts
- Microneedling
- Application of 10% ALA (30min incubation)
- 2 hours of daylight exposure.

Class I: Limited to 1–4 actinic keratoses (AK).
- Treatment: Cryotherapy, Topical 5-fluorouracil (5-FU).
Class II: Field cancerization with multifocal AK or history of 1 keratinocyte carcinoma (KC).
- Treatment: Photodynamic therapy. 5-FU or imiquimod. Chemowraps if on extremities
Class III: Two or more low-risk KCs.
- Treatment: Niacinamide (Vitamin B3) 500 mg twice daily.
Class IV: Two or more low-risk KCs within one year (IVa); Five or more lifetime KCs (IVb).
- Treatment: If BCC predominant, imiquimod cycle or cyclical photodynamic therapy. If SCC predominant, acitretin 10–20 mg.
Class V: Two or more high-risk skin cancers (BWH T2b) or four or more high-risk skin cancers (BWH T2a or higher).
- Treatment: Capecitabine in conjunction with oncology.