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Skin Care and Diseases

Actinic Keratosis

03/23/2000

Question:

Can I just watch actinic keratosis or should I have it removed? Different doctors have told me different things. Does EFUDEX work, and when should you use this instead of freezing? Thsnk you.

Answer:

Actinic keratoses are premalignant skin lesions that usually develop at the site of solar damaged skin. They are seen most frequently on the face, ears, neck, upper chest, upper back, upper arms, forearms, and top of the hands. They occur in skin that has been exposed to solar radiation for many years. There is frequently a history of frequent sunburn. The fairer the skin of the individual the more likely they are to have significant damage and it is in this setting that the keratoses develop. Histologically these are characterized by abnormalities within the cells that are characterized as premalignant. The literature is vague on the number of these lesions that can be expected to turn into frank squamous cell carcinoma. The figures range as high as one in a thousand, to as little as one in ten thousand. Those figures vary directly with the location within the country. Those individuals who live in Florida, the very most southern parts of the United States and in the desert southwest seem to have the highest frequency of not only sun damage but keratoses that progress to squamous cell.

Once the keratoses have developed there are several ways to deal with them. For those lesions that are nodular with keratotic horn like projections on them surgical removal is usually indicated. Deep freezing with liquid nitrogen can be used for those that are less advanced. The use of topical anticancer drugs has been shown to be helpful in decreasing the number of keratoses and squamous cell carcinomas. The drug most frequently used if 5 Fluorouracil, Efudex being one of the trade designations for that drug. 5 Fluorouracil comes as a 1% cream and as a 5% cream. Some manufacturers have different vehicles and there are gels as well. These medications are applied once or twice a day for a month to six weeks, and in some cases for several months, and they destroy rapidly peripherating cells that are found within the keratoses. Following a satisfactory regimen there is usually a decrease in the frequency of new keratosis formation and decrease in the frequency of squamous cell carcinoma in the area treated. The treatments may have to be repeated every two to three years since the use of 5 Fluorouracil preparations topically does not totally reverse the process that has led to the development of the keratoses. It is helpful, however. If you have been offered this drug it probably means that your physician is concerned about the frequency with which you are developing these premalignant lesions and/or other skin cancers. I would urge you to consult with your physician carefully, understand all of the implications and prognosis related to your skin disorder, and use their recommendation to select the form of treatment best suited to your care.

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Response by:

University of Cincinnati Charles L Heaton, MD
Professor
Department of Dermatology
College of Medicine
University of Cincinnati