Actinic keratosis
Right Decision Service: Actinic keratosis
Generally, no treatment indicated except for emollients and sunscreen. Consider treatment for patients with high risk disease.
Apply 1-2 times a day for 3-4 weeks (usual duration of initial therapy), apply thinly to the affected area, maximum area of skin 500 cm2 (e.g. 23 cm × 23 cm) treated at one time, alternative regimens may be used in some settings
Can be used in immunocompetent patients with slightly palpable and/or moderately thick hyperkeratotic actinic keratosis (grade I/II). It is an alternative to first line options of fluorouracil cream where the addition of salicylic acid 10% is deemed beneficial. For use in patients with <10 isolated lesions of actinic keratoses where cryotherapy is unsuitable.
Apply once daily for up to 12 weeks, reduced to 3 times a week if severe side-effects occur and until side-effects improve, to be applied to the affected area, if treating area with thin epidermis, reduce frequency of application and monitor response more often; maximum area of skin treated at one time, 25 cm2 (e.g. 5 cm x 5 cm).
Apply 3 times a week for 4 weeks, to be applied to lesion at night, and left on the skin for approximately 8 hours, assess response after a 4 week treatment-free interval; repeat 4-week course if lesions persist, maximum 2 courses.
Prescribing Notes:
- Actinic keratosis (AK) are pre-malignant but transformation to squamous cell carcinoma is rare. Patients must be referred if diagnosis is uncertain or if lesions become thickened or tender. See the Right Decision Service: Actinic keratosis.
- Skin inflammation is common with topical fluorouracil and the concomitant use of a moderate/potent topical corticosteroid can be used.
- Imiquimod 5% cream (Aldara) can be used on specialist advice based on the size or number of lesions which may limit the efficacy and/or acceptability or following unsuccessful treatment with cryotherapy, diclofenac 3% gel or fluorouracil cream. It should be used for nonhyperkeratotic, nonhypertrophic AK on the face or scalp.
History Notes
15/12/2021
East Region Formulary content agreed.
Smaller areas of field change (e.g. an area the size of a palm or most of the forehead)
Apply 1-2 times a day for 3-4 weeks (usual duration of initial therapy), apply thinly to the affected area, maximum area of skin 500 cm2 (e.g. 23 cm × 23 cm) treated at one time, alternative regimens may be used in some settings
Apply once daily for up to 12 weeks, reduced to 3 times a week if severe side-effects occur and until side-effects improve, to be applied to the affected area, if treating area with thin epidermis, reduce frequency of application and monitor response more often; maximum area of skin treated at one time, 25 cm2 (e.g. 5 cm x 5 cm).
Apply once daily for 5 consecutive days, consider other treatment options if treated area does not show complete clearance after about 8 weeks.
Apply 3 times a week for 4 weeks, to be applied to lesion at night, and left on the skin for approximately 8 hours, assess response after a 4 week treatment-free interval; repeat 4-week course if lesions persist, maximum 2 courses.
Prescribing Notes:
- Actinic keratosis (AK) are pre-malignant but transformation to squamous cell carcinoma is rare. Patients must be referred if diagnosis is uncertain or if lesions become thickened or tender. See the Right Decision Service: Actinic keratosis.
- Skin inflammation is common with topical fluorouracil and the concomitant use of a moderate/potent topical corticosteroid can be used.
- Fluorouracil 0.5% / salicylic acid 10% cutaneous solution (Actikerall) can be used in immunocompetent patients with slightly palpable and/or moderately thick hyperkeratotic actinic keratosis (grade I/II). It is an alternative to first line options of fluorouracil cream where the addition of salicylic acid 10% is deemed beneficial. For use in patients with <10 isolated lesions of actinic keratoses where cryotherapy is unsuitable.
- Imiquimod 5% cream (Aldara) can be used on specialist advice based on the size or number of lesions which may limit the efficacy and/or acceptability or following unsuccessful treatment with cryotherapy, diclofenac 3% gel or fluorouracil cream. It should be used for nonhyperkeratotic, nonhypertrophic AK on the face or scalp.
- Imiquimod 3.75% cream (Zyclara) is restricted for initiation by a specialist for the treatment of large field actinic keratosis (>25cm2).
History Notes
05/10/2022
ERFC May addition of tirbanibulin.
15/12/2021
East Region Formulary content agreed.
Care should be taken when prescribing diclofenac gel. Only the 3% strength (Solaraze) is licensed for use in actinic keratosis.
Apply thinly twice daily for 60-90 days; max 8g daily.
Apply once daily for up to 12 weeks, reduced to 3 times a week if severe side-effects occur and until side-effects improve, to be applied to the affected area, if treating area with thin epidermis, reduce frequency of application and monitor response more often; maximum area of skin treated at one time, 25 cm2 (e.g. 5 cm x 5 cm).
Prescribing Notes:
- Actinic keratosis (AK) are pre-malignant but transformation to squamous cell carcinoma is rare. Patients must be referred if diagnosis is uncertain or if lesions become thickened or tender. See the Right Decision Service: Actinic keratosis.
- Skin inflammation is common with topical fluorouracil and the concomitant use of a moderate/potent topical corticosteroid can be used.
- Imiquimod 3.75% cream (Zyclara) is restricted for initiation by a specialist for the treatment of large field actinic keratosis (>25cm2).
History Notes
05/10/2022
Change to generic Diclofenac sodium 3% gel
15/12/2021
East Region Formulary content agreed.
See product literature
See product literature
Prescribing Notes:
- Actinic keratosis (AK) are pre-malignant but transformation to squamous cell carcinoma is rare. Patients must be referred if diagnosis is uncertain or if lesions become thickened or tender. See the Right Decision Service: Actinic keratosis.
- Aminolevulinic acid (as hydrochloride) (Ameluz) or methyl aminolevulinate (Metvix) can be used for treatment of actinic keratosis of mild to moderate intensity on the face and scalp (Olsen grade 1 to 2) where photodynamic therapy (PDT) would be beneficial. As this treatment involves PDT, its use is restricted to secondary care only.
History Notes
15/12/2021
East Region Formulary content agreed.