Download Actinic Keratosis January 2015

Management of Actinic (Solar) Keratoses in Primary and Secondary Care
Actinic keratoses are common sun-induced skin lesions which have a small potential to progress to squamous
cell carcinomas. There is a high rate of spontaneous regression and a low rate of transformation (<1 in 1,000
per year). The British Association of Dermatologists (BAD) states that that there is inadequate evidence to
justify treatment of all AKs to try to prevent malignant change. Treatment should be considered on an individual
basis, according to signs, symptoms and history.
Identify high risk patients:

Immunosuppressed patient
Red flag

Past history of skin cancer

Lesions that are rapidly growing

Extensive evidence of sun damage

Lesions that have a firm and fleshy base

Patients with previous history of phototherapy

For very young patients

Patients with xeroderma pigmentosium

Previous failure to respond to first line therapies in
primary care
and/or are painful

Lesions that do not respond to treatment
Priority cancer referral to secondary care
Consider referral to secondary care or to GP with Specialist
Interest in dermatology.
If patient is not at high risk or they do not have any red flag signs, consider treatment in primary care.
Treatment choice should be based on a range of factors:

The grade of the lesion(s)

The surface area of skin to be treated

Whether the lesion(s) have been previously treated with cryotherapy or topical drug application
Step1: Grade the lesion according to table
Step 2: Refer to table 2 for appropriate formulary choices depending on grade of actinic keratosis.
Step 3: Refer to table 3 for information in relation to the cost of individual topical treatments.
General measures
Information applicable to all patients and may be all that is needed for management.
•
AK are a marker of sun damage, examine other areas of the skin
•
Encourage prevention: sun screen and protection
•
Advise patients to report changes
•
Consider use of emollients for symptom control
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Table 1. Clinical grading of actinic keratosis (Olsen 1991).
Grade I
Flat, pink maculae without signs
of hyperkeratosis and erythema
often easier felt than seen. Flat
erythematous macules with or
without scale and possible
pigmentation
Grade II
Moderately thick hyperkeratosis
on background of erythema that
are easily felt and seen
Grade III
Very thick hyperkeratosis, or
obvious AK, differential
diagnosis cutaneous horn
Field damage
Large areas of multiple AKs on a
background of erythema and
sun damage
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Table 2. Formulary choices depending on grade of actinic keratosis.
Grade I
Single or few
lesions. Often
easier felt than
seen.
First line
treatments



Second line
treatments
General notes
on therapy





Liquid nitrogen1
Diclofenac 3%
(Solareze)
Ingenol2 (Picato)
Grade II
Moderately thick
hyperkerototic
lesions that are
easily felt and
seen.
Background
erythema.
 Liquid
nitrogen
 5%
Fluorouracil
(5-FU)
(Efudix)
 0.5% 5-FU +
10% salicylic
acid
(Actikerall)
 Photodynamic
therapy
 Imiquimod
(Aldara or
Zyclara)
Grade III
Very thick
hyperkeratotic
lesions
Field change
Large areas of multiple
AKs with marked
background damage



Liquid nitrogen
Curettage

Diclofenac 3%
(Solareze)
5% Fluorouracil (5FU) (Efudix)

Photodynamic
therapy (with Metvix)
 Imiquimod (Aldara or
Zyclara)
 Ingenol
mebuate(Picato)
Refer to the BNF and manufacturer’s instructions for information on dose and use.
All topical treatments cause inflammation as part of their desired action against abnormal
cells patients should be warned to expect such side-effects. If severe then treatments
may be stopped until the reaction has subsided and then restarted. Fluorouracil and
imiquimod produce a more marked inflammatory reaction than diclofenac but lesions
resolve faster.
It may be preferable to divide larger areas into smaller ones and treat sequentially.
Complete clearance can be delayed for up to several weeks following completion of
topical therapies.
None of the topical treatments apart from Actikerall have a license for non-facial sun
exposed areas (for example, backs of hands) but there is no clinical reason why they
should not be used on such sites.
1. Cryotherapy is more efficacious than topical drug therapies and is the treatment of
choice for discreet areas of AK if available.
2. Ingenol mebuate (Picato) is not suitable for use on a lesion following cryotherapy
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Table 3. Cost and product licenses for the pharmacological treatments available
Licensed use and
Price per unit
Course length
maximum
application area
Diclofenac 3% gel
AK
50g = £38.30
60-90 days
(Solaraze)
Max. 8g daily
(400cm2) (0.5g =
5cm x 5cm)
Fluorouracil 5%
AK
40 g = £32.90
Usual duration of
cream (Efudix)
Max. 500 cm2
initial therapy, 3–4
(approximately 23 x
weeks
23 cm).
Ingenol cream
Non-hyperkeratotic, 150 micrograms/g,
3 days for face and
(Picato)
non-hypertrophic
3 × 0.47-g singlescalp
AK in adults
use tubes = £65.00;
Max: 25 cm2 (e.g. 5
cm x 5 cm).
500 micrograms/g,
2 × 0.47-g single2 days for trunk and
use tubes = £65.00 extremities
0.5% 5-FU + 10%
Slightly palpable
25 mL = £38.30
Up to 12 weeks
salicylic acid
and/or moderately
solution (Actikerall)
thick hyperkeratotic
AK(grade I/II)
Max.25 cm2 (5 cm x
5 cm).
Imiquimod (Aldara)
Clinically typical,
12-sachet pack =
4 weeks
nonhyperkeratotic,
£48.60.
Course may be
nonhypertrophic
repeated after a 4
AKs on the face or
week treatment-free
scalp in
interval if lesions
immunocompetent
persist.
adult patients when
Max. 2 courses.
size or number of
lesions limit the
efficacy and/or
acceptability of
cryotherapy and
other topical
treatment options
are contraindicated
or less appropriate.
Imiquimod (Zyclara) Clinically typical,
28-sachet pack =
2 x 2 week courses
nonhyperkeratotic,
£113.00.
separated by a 2
nonhypertrophic,
week treatment free
visible or palpable
interval.
AK of the full face or
Max. 2 sachets
balding scalp in
daily
immunocompetent
adults when other
topical treatment
options are
contraindicated or
less appropriate.
Estimated cost
£76.60
£32.90 to
£65.80
£65
£38.30 to
£76.60
£48.60 to
£97.20
£113 to
£226
Doses are for general comparison and do not imply therapeutic equivalence.
Costs based on prices contained in the British national Formulary no.68.
Licensing and indications based on the Summary of Product Characteristics for each agent.
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Document reference
Author
Consulted with
Approved by
Date approved
Next review date
ActinicKeratosesGUI201501v1.0final
Clare Drain, Pharmacy Technician, Broomfield Hospital Pharmacy
Erum Haq, Senior Pharmacist, Mid Essex CCG
Prof.Peter Dziewulski, Broomfield Hospital
Mid-Essex Area Prescribing Committee
Jan 2015
Jan 2017
Previous version
Guideline for the Management of Actinic
(Solar) Keratoses in Primary and Secondary
Care (no version number)
ActinicKeratosesGUI201501v1.0 final
Key changes
Document Management added.
Included Picato as a new yellow drug to formulary.
Solaraze and Imiquimod moved to yellow formulary
drugs.
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