SDPA Fall | Live Blog | Shifting the Paradigm of Actinic Keratoses
Actinic keratoses (AKs) are part of a biologic continuum ending in squamous cell carcinoma. At the SDPA’s 14th Annual Fall Dermatology Conference, Dr. George Martin, MD relayed the difficulty of treating actinic keratoses lies in the intolerability of the current treatment regimens available for patients. It may require that clinicians change their approach to what is an effective, tolerable treatment rather than what method has the highest clearance rate.
Next, Dr. Martin discussed the efficacy rates and “down time” for the various treatment options for AKs. Dr. Martin reported ALA-PDT has the least amount of downtime for patients. He states that pain is the most common limiting factor for treatment with photodynamic therapy (PDT), with up to 60% of patients reporting moderate to severe pain. His alternative to the current guidelines for PDT is his method of “painless PDT” where patients incubate for a much shorter period of time and treat under the light for a longer period of time. In his study, he found equal efficacy and less pain for his patients when compared to the current regimen. Further, Dr. Martin stated that a new gel alternative to ALA will be available shortly in the US.
In addition to PDT, Dr. Martin discussed the different formulations of 5-FU and imiquimod topical treatment for patients. He presented his alternative dosing and duration regimens with imiquimod that he uses with excellent long term clearance rates. For chest actinic keratoses, Dr. Martin prefers treatment with ingenol mebutate or 5-fluorouracil. With ingenol mebutate, he cautions that patients need to be prepared for pain and recommends prescribing analgesics and silvadene cream. Furthermore, Dr. Martin urges against use of imiquimod for actinic keratoses on the chest due to scarring and depigmentation.
Most providers will agree that actinic cheilitis presents a difficult to manage presentation of actinic keratoses. Dr. Martin reminded us that none of the topical medications have been approved for use on the lips. He has had the most success with CO2 lasers, imiquimod creamand diclofenac gel. Next, Dr. Martin conveyed treatment regimens for the difficult to treat actinic keratoses on the hands through use of combining products imiquimod and 5-fluorouracil creams with proven efficacy, though due to pain, “it is not for the faint of heart”. Finally, Dr. Martin recommended against using imiquimod in immunosuppressed patients or those with autoimmune disease.
Byline: Sarah Patton, PA-C, MSHS
PostedL November 6, 2016