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13.8 Photodamage

Solar (Actinic) Keratoses are pre-malignant, but transformation to in-situ or invasive squamous cell carcinoma (SCC) is rare. Patients must be referred if diagnosis is uncertain or if lesions become painful and thickened or tender. See the National Dermatology referral and management pathway for Solar (Actinic) Keratoses and Bowen’s Disease for referral criteria and the Primary Care Dermatology Society Treatment Pathway of Actinic (solar) Keratosis 2012 for more information.

Diclofenac 3% in sodium hyaluronate gel (Solaraze^®)
Dose: Small non-tender keratoses, apply thinly twice daily for 60-90 days; max. 8g daily.

Ingenol mebutate gel ▼ 150micrograms/g and 500micrograms/g
Dose: For application to the face and scalp, apply the contents of one 150micrograms/g tube daily to the affected area for 3 consecutive days.

Dose: For application to the trunk and extremities, apply the contents of one 500micrograms/g tube to the affected area daily for 2 consecutive days.

Please see NICE Evidence Summary 14: Actinic keratosis: ingenol mebutate gel for more information.

Fluorouracil 5% cream (Efudix^®)
Dose: Non-tender thin to moderately thick keratoses, apply thinly to the affected area once daily (max. area of skin treated at one time 500cm² (e.g. 22cm x 22cm) for 3 to 4 weeks. Warn patient of expected inflammatory response and that it may be necessary to have a 1 week “break” during a course to let inflammation subside, and to choose to treat smaller areas at a time.

Diclofenac 3% gel, ingenol mebutate gel and fluorouracil 5% cream are all field treatments, to be applied over a whole affected area (to clear subclinical as well as evident solar keratoses). If inadequately effective, imiquimod 5% cream (Aldara^®) may be appropriate for prescribing under the direction of a dermatologist for actinic keratosis according to SMC advice. Click here for the local protocol.

To treat individual solar keratoses, liquid nitrogen cryotherapy is the best established treatment. Other cryogens (such as Histofreezer^®) are not appropriate alternatives. Fluorouracil 0.5% / salicylic acid 10% Cutaneous Solution (Actikerall^®) may be considered as a spot (rather than field) treatment for mild to moderate actinic keratoses in immunocompetent adults if cryotherapy is not available. This is a newly available preparation and as yet, no controlled studies comparing it with liquid nitrogen cryotherapy have been published. This preparation can be used to treat up to 10 individual lesions as long as the total area of skin being treated at any one time is no more than 25cm² (e.g. 5cm x 5cm).

 Imiquimod 5% cream or Fluorouracil 5% cream may also be used for treating superficial basal cell carcinomas under the direction of a dermatologist.

Photodynamic therapy

Photodynamic therapy in combination with  methyl-5-aminolevulinate 16% cream (Metvix^®) is used by Dermatology specialists for skin conditions requiring photodynamic therapy. It is licensed for treating superficial and confluent, non-hypertrophic actinic keratosis when other treatments are inadequate or unsuitable; it is particularly suitable for multiple lesions, for periorbital lesions, or for lesions located at sites of poor healing. It is also licensed for treating superficial, nodular basal cell carcinomas when other treatments are unsuitable in combination with photodynamic therapy.

Photodynamic therapy in combination with  5-aminolevulinic acid 7.8% gel (Ameluz^®) is licensed for treatment of actinic keratosis of mild to moderate intensity on the face and scalp (Olsen grade 1 – 2).

Photodynamic therapy in combination with  5-Aminolevulinic Acid 20% cream [unlicensed] is also used by Dermatology specialists for skin conditions requiring photodynamic therapy.

For further information on photodynamic therapy refer to the Photodynamic Therapy Patient Information Leaflet and Guidelines for topical photodynamic therapy: update

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