Cryopeeling (extensive cryosurgery) for treatment of actinic keratoses: an update and comparison

A Review of Existing Therapies for Actinic Keratosis: Current Status and Future Directions

Actinic keratosis (AK) is a chronic skin disease in which clinical and subclinical cutaneous lesions coexist on sun-exposed areas such as the head and neck region and the extremities. The high prevalence of AK means the disease burden is substantial, especially in middle-aged and elderly populations. Evidence indicates that AK may progress into invasive cutaneous squamous cell carcinoma, so the European guidelines recommend treatment of any AK regardless of clinical severity. Given the aging population and therefore the increasing incidence of AK and cutaneous field carcinogenesis, further updates on the long-term efficacy of current therapies and new investigational agents are critical to guide treatment choice. Patients often have difficulty adequately applying topical treatments and coping with adverse local skin reactions, leading to less than optimum treatment adherence. The development of associated local skin symptoms and cosmetic outcomes for the area of interest are also relevant to the choice of an appropriate therapeutic strategy. Treatment is always individually tailored according to the characteristics of both patients and lesions. This review focuses on the therapeutic approaches to AK and illustrates the currently available home-based and physician-managed treatments.

Cryopeeling versus trichloroacetic acid peeling in the treatment of solar lentigines: Effect on epidermal Langerhans cells

Trichloroacetic acid (TCA) peeling may be effective in solar lentigines, but with concerns regarding potential tumorigenesis. Cryopeeling would be better with improving the whole sun-damaged skin. We aimed to compare the efficacy and safety of cryopeeling and TCA 35% peeling for treatment of solar lentigines and assess their influence on the number of epidermal Langerhans cells (LC). Twenty-five patients were treated with TCA 35% and cryopeeling on the right and left hands, respectively. Two sessions were done 3 weeks apart. Evaluations were scheduled at weeks 0, 3, and 6. Skin biopsies, taken before and after treatment, were evaluated histologically and immunohistochemically for the number of CD1a + epidermal LCs. Lentigines decreased after cryopeeling from the first session (p < .001), but after the second session with TCA peeling (p = .004). Cryopeeling produced significant lightening, compared with TCA (p = .015). Blistering, hyper/hypopigmentation were reported with cryopeeling, whereas only hyperpigmentation was noted after TCA peeling. The LCs remained at about the pretreatment number after cryopeeling (p = .058), though they decreased after TCA (p = .002). Cryopeeling provided faster and superior improvement of lentigines compared with TCA peeling. Furthermore, TCA seems to suppress LCs raising the concern for carcinogenic potential.

Comparison of the Treatment Guidelines for Actinic Keratosis: A Critical Appraisal and Review

There are currently several reputable guidelines on the treatment of actinic keratosis (AK) from groups in Canada, the United Kingdom, and Europe. These recommendations, based on evidence or expert consensus, offer clinicians a variety of treatment options for the different clinical presentations of AKs. Although the guidelines are similar in some regards, variations exist in treatment options, duration, and strength of recommendation. Some guidelines also lack input on specific therapies and certain types of AK, such as hypertrophic or thin presentations. The purpose of this article is to review and compare guidelines published by Canadian, UK, and European groups for the management of AKs in patients.

Long-term use of a new topical formulation containing piroxicam 0.8% and sunscreen: efficacy and tolerability on actinic keratosis. A proof of concept study

INTRODUCTION

Cyclooxygenase (COX) 1 and 2 enzyme up-regulation is involved in the pathogenetic process of actinic keratosis (A.K.) and non-melanoma skin cancers. Diclofenac, a non-steroidal anti-inflammatory (N.S.A.I.D.) drug, is used as topical treatment of A.K. Piroxicam is a N.S.A.I.D. characterized by a high COX-1 inhibition activity.

STUDY AIM

We conducted an 18 month exploratory open-label study on A.K., to assess the efficacy and tolerability of a new topical formulation of piroxicam and sunscreen in A.K.

PATIENTS

Enrolled subjects applied a galenic formulation of piroxicam 0.8%, vehiculated in a topical product containing sun filters with high (50+) and broad spectrum (UVA) actions, twice a day for 6 months. Subjects were then followed up for additional 12 months. Thirty-eight subjects with a total of 69 A.K. lesions participated in the trial. The primary outcome was the evolution of the Actinic Keratosis Erythema Scale Atrophy (A.K.E.S.A) score assessing erythema, scale, and atrophy of a target A.K. lesion. Secondary outcomes were the percentage of treated lesions with complete (100%) or partial (≥75%) clearance and the evaluation skin tolerability.

RESULTS

A.K.E.S.A. mean (S.D.) score at baseline was 7.5 (1.2). After 6 months of treatment, A.K.E.S.A. score decreased to 0.9 (1.1), a -88% reduction versus baseline. At the end of follow-up, A.K.E.S.A. score was 0.8 (1.2). A complete response was achieved in 38 of the 69 lesions (55%, 95% C.I.: 43% to 66%) and clearance was maintained 1 year post-treatment. A partial clearance was observed in 57 of 69 treated lesions (83%, 95% C.I.: 73% to 91%). Adverse events were limited to mild local irritation.

CONCLUSION

Our experience suggests that 6 month topical piroxicam 0.8% is efficacious and well tolerated in A.K. Clinical efficacy is maintained 1 year post-treatment. The main limitation of our study is that it was an open label non-controlled trial. Future controlled trials are warranted in order to compare the efficacy and tolerability of this topical piroxicam preparation with standard treatments in the management of A.K.

Evaluation of Resource Utilization and Treatment Patterns in Patients with Actinic Keratosis in the United States

OBJECTIVE

To compare health care resource utilization and treatment patterns between patients with actinic keratosis (AK) treated with ingenol mebutate gel (IngMeb) and those treated with other field-directed AK therapies.

METHODS

A retrospective, propensity-score-matched, cohort study compared refill/repeat and adding-on/switching patterns and outpatient visits and prescriptions (health care resource utilization) over 6 months in patients receiving IngMeb versus those receiving imiquimod, 5-fluorouracil, diclofenac sodium, and methyl aminolevulinate or aminolevulinic acid photodynamic therapy (MAL/ALA-PDT).

RESULTS

The final sample analyzed included four matched treatment cohort pairs (IngMeb and comparator; n = 790-971 per treatment arm). Refill rates were similar except for imiquimod (15% vs. 9% for imiquimod and IngMeb, respectively; P < 0.05). MAL/ALA-PDT treatment repetition rates were higher than IngMeb refill rates (20% vs. 10%; P < 0.05). Topical agent add-on/switch rates were comparable. PDT had higher switch rates than did IngMeb (5% vs. 2%; P < 0.05). The IngMeb cohort had a significantly lower proportion of patients with at least one AK-related outpatient visit during the 6-month follow-up than did any other cohort: versus imiquimod (50% vs. 66%; P < 0.0001), versus 5-fluorouracil (50% vs. 69%; P < 0.0001), versus diclofenac sodium (51% vs. 56%; P = 0.034), and versus MAL/ALA-PDT (50% vs. 100%; P < 0.0001). There were significantly fewer AK-related prescriptions among patients receiving IngMeb than among patients in other cohorts.

CONCLUSIONS

Results based on the first 6 months after treatment initiation suggested that most field-directed AK therapies had clinically comparable treatment patterns except imiquimod, which was associated with higher refill rates, and PDT, which was associated with significantly more frequent treatment sessions and higher switching rates. IngMeb was also associated with significantly fewer outpatient visits than were other field-directed therapies.

[Cryosurgery in dermatology]

This article provides information on the clinical development of skin reactions after cryosurgery/cryotherapy and the indications, complications and contraindications of skin cryosurgery. Successful skin cryosurgery requires rapid freezing and slow thawing, minimum tissue temperature of -25 to -60℃ and, in malignant lesions, repetition of the freeze-thaw cycle. Frozen tissue reacts with peripheral erythema immediately after thawing, followed by edema, bulla formation, exudation and mumification. Lesions usually heal with a fine atrophic scar after approximately 4 weeks. Nowadays, cryosurgery is considered the treatment of choice in hypertrophic scars and keloids, granuloma annulare, small capillary infantile hemangioma and isolated actinic keratoses. It is also a valuable alternative therapy for various other skin diseases, including common warts, solar lentigo, superficial basal cell carcinoma and Kaposi's sarcoma. Cryosurgery is a safe regimen with relatively few adverse effects and contraindications. Pain during and/or shortly after treatment, bulla formation and local edema are the major temporary adverse effects; lesional hypopigmentation and/or peripheral hyperpigmentation is the most common long-term complication.

5-Fluorouracil "Chemowraps" in the Treatment of Multiple Actinic Keratoses: A Norwich Experience

Introduction

Topical 5-fluorouracil (5-FU) has been used to treat actinic keratosis for decades. It has been an important and effective treatment which the patient can self-administer, but is limited by the surface area of skin to be treated (according to the manufacturer’s guidelines) of 500 cm². Other topical treatments can be painful, or require hospital/health care professional input. The use of 5-FU under occlusion (chemowraps) for large areas of sun-damaged skin on the arms or legs has been described and is a potentially useful treatment option. We describe our experiences with this technique in the Norfolk and Norwich University Hospital Dermatology Department (Norwich, UK).

Methods

Five patients were recruited into this pilot study. Topical 5-FU was applied to sun-damaged limbs under occlusion, and reviewed weekly for response, and local or systemic side effects. Treatment duration was 12–14 weeks. Clinical photography was undertaken prior to, during, and after treatment to document response.

Results

We show that there was substantial clinical improvement in the treated skin in our patients. Experienced dermatologists reviewed all the patients, and documented the changes photographically, and by counting lesions. All patients were satisfied with their treatment regimen, and also with the end result; although two did not complete the treatment regimen due to complications not directly attributable to the treatment.

Conclusion

Topical 5-FU under occlusion (chemowraps) may be a valid treatment option for large areas of sun-damaged skin with field cancerization changes, due to low systemic and local toxicity, and acceptability to patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-015-0082-5) contains supplementary material, which is available to authorized users.

Histological comparison of two cryopeeling methods for photodamaged skin

Background. Cryopeeling is a technique that uses cryotherapy not only on actinic keratoses lesions, but also all over the photodamaged skin. Objectives. To investigate the histological changes induced by two cryopeeling methods (liquid nitrogen (LN) and portable system (PS)). Methods. Sixteen patients (n = 16) with multiple actinic keratoses on the forearms were treated with cryopeeling technique using LN for one forearm and PS for the other, randomly. Skin biopsies were taken before and after the procedures. Results. There was no statistical difference between the epidermal and Grenz zone thicknesses or density of elastic fibers after treatments. The amount of melanin pigment was lower after PS treatment (P < 0.05). In a blind analysis of paired pre- and postprocedure slides, it was not possible to identify cases which underwent treatment, both in global analysis of quality of the skin and in specific analysis (considering only the aspect of stratum corneum). Discussion. The results indicate the inconsistency of histological improvement after treatments, and, likely, since the method causes superficial exfoliation, a reliable marker was not found in the analysis. Conclusions. Despite cosmetic benefits on photodamaged skin and efficient treatment of actinic keratoses lesions, cryopeeling was not able to induce measurable histological changes in solar elastosis, epidermal organization, or epidermal and Grenz zone thicknesses. One should keep in mind the possibility of hypopigmentation risk of the method.

Solar keratoses: photodynamic therapy, cryotherapy, 5-fluorouracil, imiquimod, diclofenac, or what? Facts and controversies

Actinic keratosis is a common dermatologic condition that may regress, remain stable, or progress to squamous cell carcinoma. Some question whether all actinic keratoses should be routinely treated, whereas others contend that the unpredictable natural history of this disease necessitates treatment to prevent malignant transformation. Available treatments include photodynamic therapy, cryotherapy, 5-fluorouracil, imiquimod, and diclofenac. Each of these options has its advantages and disadvantages, although they all have a place in the management of actinic keratosis. An overview of these treatment modalities is presented, as are the controversies surrounding the treatment of actinic keratosis.

Update on non-melanoma skin cancer and the value of dermoscopy in its diagnosis and treatment monitoring

Dermoscopy has become an integrative part of the clinical examination of skin tumors. This is because it significantly improves the early diagnosis of melanoma and non-melanoma skin cancer (NMSC) including basal cell carcinoma and keratinocyte skin cancer compared with the unaided eye. Besides its value in the noninvasive diagnosis of skin cancer, dermoscopy has also gained increased interest in the management of NMSC. Dermoscopy has been used in the preoperative evaluation of tumor margins, monitoring of the outcomes of topical treatments and post-treatment follow-up. This article provides an update on NMSC with special emphasis on dermoscopy in the diagnosis and management of basal cell carcinoma, actinic keratosis, Bowens' disease and squamous cell carcinoma.

Pharmacotherapy of actinic keratosis: an update

INTRODUCTION

Actinic keratosis (AK) represents the initial intraepidermal manifestation of abnormal keratinocyte proliferation, with the potential of progression to squamous cell carcinoma (SCC). Few visible AKs lead to the use of lesion-directed treatments, including ablative and/or surgical procedures. Multiple and/or the suspicion of subclinical (non-visible) AKs lead to the use of field-directed therapies, including topical and ablative treatments. Predicting which AK will progress to SCC is difficult, and so all are treated. The goals of treatment are to eliminate visible AKs and to treat subclinical (non-visible) AKs, minimizing their risk of progression to invasive SCC, while pursuing good cosmesis.

AREAS COVERED

This review discusses the prevention of AKs (such as ultraviolet light avoidance, sunscreen use, protective clothing, and frequent self-examinations, in addition to chemoprevention with retinoids, eflornithine, silymarin, and others). It also covers lesion-directed treatments (e.g., cryotherapy, electrodessication and curettage, and surgery). Field-directed treatments are also mentioned (including laser resurfacing, dermabrasion, chemical peels, topical immunomodulators (imiquimod and diclofenac), topical chemotherapeutic agents (5-fluorouracil and retinoids), and photodynamic therapy). Finally, newer and investigational treatments are discussed (including ingenol mebutate).

EXPERT OPINION

There is no panacea in the treatment of AKs. The current best approach is the sequential treatment with a lesion-directed and a field-directed therapy. Several combinations seem to work well; they just need to be selected based on the evidence and adjusted to patient needs, preferences and dermatologist expertise.

The role of ingenol mebutate in the treatment of actinic keratoses

Actinic keratoses (AK) are the most common premalignant pathology seen in dermatological practice and represent a burgeoning burden upon health services. Increasingly recognized is the damage to surrounding, perilesional skin, forming the premise for field-directed therapy. Ingenol mebutate gel is a novel agent for field-directed treatment of AK, requiring only 2 or 3 days of application. Following an overview of existing treatment modalities, the authors review recent trials and safety data pertaining to the use of ingenol mebutate gel and discuss its role in the treatment of AK.

Cryopeeling for treatment of photodamage and actinic keratosis: liquid nitrogen versus portable system

BACKGROUND

Cryopelling uses diffuse cryotherapy not only on lesions of actinic keratosis but all over the photodamaged skin.

OBJECTIVES

The aim of this study was to compare two cryopeeling methods (liquid nitrogen- LN and portable system - PS) and demonstrate their efficiency in the treatment of actinic keratoses, patient tolerance, researcher and patient preference and aesthetic results.

METHODS

Sixteen patients (N = 16) with multiple actinic keratoses on the forearms were subjected to cryopeeling with LN on one of the forearms and PS on the other, randomly.

RESULTS

In the treatment of actinic keratoses, LN obtained 74% efficiency and PS, 62% (p = 0.019). The mean visual analogue scale (0-10) was 5.7 ± 1.61 with LN and 4.3 ± 1.44 with PS (p = 0.003). There was no significant statistical difference between the two methods in terms of researcher and patient preference. An analysis of the photos showed improvement of the skin appearance with both treatments (p <0.001). Treatment with LN obtained some degree of improvement in 62.5% of the cases, while treatment with PS obtained some degree of improvement in 52% of the cases (p> 0.05).

DISCUSSION

Treatment with the PS showed better tolerance, but was less efficient than LN. Although LN has been the preferred method, there was no statistical difference between the methods.

CONCLUSIONS

The cryopeeling technique may be an option in the treatment of photodamage. The PS can be an interesting alternative in clinical practice with good tolerance and acceptable results in the treatment of actinic keratoses.

Imiquimod 3.75% cream (Zyclara) for the treatment of actinic keratoses

INTRODUCTION

actinic keratosis is a premalignant disease with a high incidence and is a strong predictor for the development of squamous cell carcinoma. Various treatment options have been established over recent years, including topical treatment with imiquimod, 5-fluorouracil, diclofenac or photodynamic therapy, cryotherapy and surgical procedures.

AREAS COVERED

this review covers basic and clinical experiences with imiquimod 3.75% for topical treatment of actinic keratosis of the face and balding scalp and its comparators with special focus on imiquimod 5%. It also covers pharmacology of imiquimod 3.5% and its contribution to the current treatment options of actinic keratoses.

EXPERT OPINION

imiquimod 3.75% is an interesting, safe and well-tolerated treatment option for actinic keratoses of the face or balding scalp especially in respect of compliance, as it is indicated for daily use for a shorter time period (2 times, 2-week cycles) and approved for use on larger areas compared with imiquimod 5%. Data from current trials indicate lower efficacy compared with imiquimod 5% cream when applied three times a week for 16 weeks or for two 4-week cycles with a 4-week no-treatment interval, but indicate similar efficacy when compared with a twice-weekly schedule for 16 weeks. An additive effect was observed when combining cryosurgery followed by imiquimod 3.75%.

Non-surgical treatments of primary, non-melanoma eyelid malignancies: a review

The diagnosis and management of periocular cutaneous malignancies are essential components of an ophthalmologist's practice. Skin cancers comprise nearly one-third of newly diagnosed malignancies. Furthermore, the incidence of skin cancer appears to be increasing. Multiple treatment modalities exist for periocular cutaneous malignancy. Surgical extirpation, often with the combined expertise of a Mohs micrographic surgeon, is typically the first line therapy and is often curative in the periocular region, depending on a variety of factors, including tumour histology, specific location, depth of invasion and surgical technique. However, there are instances where a less invasive, non-surgical treatment option is warranted, including patients who are poor surgical risks or those with diffuse disease. The purpose of this article is to review the literature and describe the non-surgical treatment options, indications and efficacies for non-melanoma primary eyelid malignancies.

5-Fluorouracil superficial peel for multiple actinic keratoses

BACKGROUND

Chronically photodamaged skin usually presents with multiple, widespread, actinic keratoses (AKs), and treatment of the entire affected area is recommended.

METHODS

We report our experience with a combination of Jessner's solution or 70% glycolic acid (GA) with 5% 5-fluorouracil (5-FU) solution for superficial pulse peeling used in the treatment of widespread AKs in 31 patients. Pulse peelings were performed at biweekly intervals. The endpoint for treatment was complete or maximum clearance of the lesions at clinical evaluation. Pre- and post-skin biopsy and histopathologic examination were performed in three patients for the purpose of demonstrating the pulse peel effects.

RESULTS

All patients achieved a satisfactory result, including the complete regression, or at least 80% clearing, of AK lesions and an overall improvement of photodamaged skin.

CONCLUSION

We consider this superficial 5-FU pulse peel to be a safe, well-tolerated, very effective, and highly inexpensive therapeutic option for the treatment of multiple, diffuse AKs. Its benefit/cost ratio will be of interest to public health services, mainly in developing countries.

Clinicopathological study of 21 cases of eyelid actinic keratosis

BACKGROUND

Actinic keratosis (AK) is an intraepidermal malignancy precursor form of cutaneous squamous cell carcinoma (SCC), which generally occurs in fair-skinned individuals with long-term sun exposure. We present a case series of AKs on the eyelid.

METHODS

This was a retrospective study. Data of patients seen from 1994 to 2005 were used in the analyses.

RESULTS

There were 21 cases of eyelid AKs in 18 patients, 11 men, and seven women, with a mean age of 70 (range 43-80) years. Most tumors were located on the upper eyelid. The mean size was 0.8 +/- 0.4 cm. The most frequent AK type was type I (76.2%). Men had bigger lesions and more frequent free-margin eyelid involvement.

CONCLUSIONS

In our series, tumors were more frequent and had worse clinical and histopathological features in men. AKs are closely related to SCC and need to be removed before they turn into SCC. They can be safely and effectively removed, and therapy is therefore warranted.

Long-Term Efficacy of Carbon Dioxide Laser Resurfacing for Facial Actinic Keratosis

PURPOSE

To evaluate the efficacy and long-term effectiveness of carbon dioxide laser resurfacing in the treatment of patients with facial actinic keratosis.

PATIENTS AND METHODS

A retrospective chart analysis was conducted of 31 patients who underwent full face carbon dioxide laser resurfacing for facial actinic keratosis from July 1998 to November 2002.

RESULTS

Of 31 patients, 18 (58%) were free of lesions at their longest visit. The average actinic keratosis free period, excluding 2 deceased patients, was 27.4 months.

CONCLUSION

Carbon dioxide laser resurfacing is an effective tool in the management of patients with facial actinic keratosis.

Does progression from actinic keratosis and Bowen's disease end with treatment: diclofenac 3% gel, an old drug in a new environment?

Progression from actinic keratosis (AK) and Bowen's disease (BD) to invasive disease involves a complex cascade of events. The preparation of diclofenac 3% gel (Solaraze; Shire Pharmaceuticals) has been shown to be efficacious and well tolerated in AK. The inhibition of the COX enzymes results in a decrease in downstream by-products of arachidonic acid metabolism. These metabolites have been shown to play a pivotal role in promoting epithelial tumour growth. Given its mechanism of action, we hypothosize that diclofenac 3% gel may have potential to halt the progression of actinic keratoses (AKs) in the setting of field cancerisation and BD. We report a series of five patients with BD, all treated with diclofenac 3% gel with clinical and histological clearance.

Guidelines for the management of actinic keratoses

These guidelines stemmed from a consensus meeting held by the British Photobiology Group (BPG) in 1999. Following this meeting one of the authors (J.M.M.) was invited to draw up guidelines for the management of actinic keratoses by the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Relevant evidence was sought using the search terms 'solar keratosis' and 'actinic keratosis' in Medline from 1966 onwards. Additional and earlier literature was reviewed on the basis of references within post-1966 publications. All articles of apparent relevance were reviewed independently of the nature of the publication. The quality of the evidence elicited has been indicated. The National Ambulatory Medical Care Survey (U.S.A.) was used for further data on topical chemotherapy. Papers were reviewed and discussed by the contributors to the BPG Workshop (see Acknowledgments). Recommendations are evidence based where possible. Strength of recommendation is coupled with quality of evidence. Strength of recommendation includes consideration of apparent cost-benefit and practical considerations. Quality of evidence reflects the nature of the trial structure that provides data of efficacy.

Different inflammatory mediators induce inflammation and pain after application of liquid nitrogen to the skin

The application of liquid nitrogen to the skin induces inflammation and pain. However, there is little data on the role of inflammatory mediators in the production of these symptoms. We have developed an experimental model to study some aspects of the inflammatory response and its mediators following the application of cold. We have applied liquid nitrogen jets to subcutaneous air pouches in the dorsal skin of rats to study the kinetics of the migration of inflammatory cells; also to the ear for histopathological analysis and on the paws for edema and pain. Inflammatory mediators were identified by pharmacological means. The results showed that the cellular inflammatory response was characterized by persistent cell migration, mainly of granulocytes. Histopathology of the ears confirmed these findings. Histamine and sympathomimetic mediators were mainly responsible for the resultant swelling. However, the hypernociception that resulted involved other mediators including IL-1 and eicosanoids. These data suggest that interference with the release of inflammatory mediators might reduce the side effects of cryosurgery and prevent hyperalgesia and inflammation at the site of application of cold.

Basal cell carcinoma mistaken for actinic keratosis

Increasing age and UV exposure are well-known associations with precancerous and cancerous skin lesions, including actinic (solar) keratosis, and squamous and basal cell carcinomata. This report describes a patient with a facial skin lesion close to an eye that was initially believed to be actinic (solar) keratosis but was subsequently diagnosed as a basal cell carcinoma (BCC). The diagnosis of BCC was helped pre-operatively by manipulation of the surrounding facial skin, which revealed the characteristic rolled edges and telangiectasis. Referral to his general medical practitioner (GP) resulted in surgical excision of the lesion. This procedure was performed inexpensively by the local GP as the lesion was not large and was in an accessible position. The lesion and the course of recovery over four weeks were documented photographically. The lesion was surgically excised and the diagnosis of basal cell carcinoma was confirmed by pathological examination. The wound healed well and the final cosmetic result was excellent. This patient illustrates the importance of careful observation and photo-documentation of suspicious skin lesions. A review of the treatment options for these lesions is included in this report.

Kryochirurgische Behandlung aktinischer Keratosen mit evidenzbasierter �bersicht

BACKGROUND

Actinic keratoses are focal epithelial carcinomas in situ, which are considered precursors of squamous cell carcinoma and must therefore be treated. In the USA, cryosurgery is the most frequent surgical procedure for the treatment of actinic keratoses and considered the treatment of choice.

METHODS

Our own results of cryosurgical treatment of actinic keratoses were evaluated. Original publications and reviews on the treatment of actinic keratoses with cryosurgery were retrieved from MEDLINE and classified according to their evidence level.

RESULTS

Two months after the procedure, 97.0% of the lesions (n=99) were considered sufficiently treated. Local pain during and shortly after treatment (15%) and pigmentary changes (5%) were the most frequent side effects. Recurrences were detected in 2.1% of the lesions during the 1st year and in 11,5% after 3 years. In 2 further monotherapy studies recurrences occurred in 1,2-9% of the lesions after one year in 30% after 3 years. Literature data suggest that photodynamic therapy is equally or even more effective than cryosurgery after a 3-month follow-up. The cryosurgical results were strongly dependent on the attending physician.

CONCLUSIONS

Cryosurgery is beneficial in the treatment of actinic keratoses. This method is equivalent to photodynamic therapy.

A prospective study of the use of cryosurgery for the treatment of actinic keratoses

BACKGROUND

Actinic keratoses are the most common actinic lesions on Caucasian skin. Cryosurgery with liquid nitrogen is commonly used to treat actinic keratoses, but there have been few studies examining the true rate of cure in everyday dermatologic practice.

AIM

To determine prospectively the true efficacy of cryosurgery as a treatment for actinic keratoses in everyday dermatologic practice.

METHODS

A prospective, multicentered study (a subsidiary study of a photodynamic therapy trial) was performed. Patients with untreated actinic keratoses greater than 5 mm in diameter on the face and scalp were recruited. Eligible lesions received a single freeze-thaw cycle with liquid nitrogen given via a spray device and were reviewed 3 months thereafter. Each center used their preferred freeze time. The only treatment criterion was complete freezing of actinic keratoses and a 1-mm rim of normal skin. Treated lesions were assessed as complete response or noncomplete response. The influence of the duration of freeze, cosmetic outcomes, and adverse events were examined.

RESULTS

Ninety adult patients from the community with 421 eligible actinic keratoses were recruited. The overall individual complete response rate was 67.2%[SEM = +/-3.5%; 95% confidence interval (CI) = 60.4-74.1%]. Complete response was 39% for freeze times of less than 5 s, 69% for freeze times greater than 5 s, and 83% for freeze times greater than 20 s. Cosmetic outcomes were good to excellent in 94% of complete response lesions. The main adverse events were pain, stinging, and burning during treatment, and hypopigmentation after healing.

CONCLUSIONS

Cryosurgery is an effective treatment for actinic keratoses. The true complete response rate is significantly lower than that previously reported. The freeze duration influences successful treatment. Adverse events are mild and well tolerated.

Full face laser resurfacing: Therapy and prophylaxis for actinic keratoses and non-melanoma skin cancer

BACKGROUND

Although there are many effective treatment modalities for individual actinic keratoses (AKs), widespread lesions on the photoaged face pose a challenge due to inefficient and ineffective therapy resulting in high rates of recurrence after local destruction. Full face laser resurfacing offers an effective and efficient treatment option that successfully reduces the number of AK's on diffusely damaged skin and may show a prophylactic benefit for preventing non-melanoma skin cancers.

OBJECTIVE

To assess the efficacy of full face laser resurfacing in reducing the number of facial AK's by comparing preoperative and postoperative numbers of lesions present and to observe the incidence of non-melanoma skin cancer after full face laser resurfacing.

STUDY DESIGN

A retrospective chart review of 24 patients with widespread facial AK's (greater than 30) treated with full face UPCO(2) and/or Er:Yag laser resurfacing was performed. All patients were a minimum of 1 year post-operative following facial laser resurfacing. The recurrence of AK's and the occurrence of facial non-melanoma skin cancers in these patients was assessed through chart analysis.

RESULTS

Widespread AK's were effectively eliminated in all patients. Twenty-one patients (87%) remained lesion free for at least 1 year. Fourteen of the 24 patients (58.3%) showed no new lesions during a 2-year follow-up. There was an overall 94% reduction in total number of AK's. Adverse effects included transient perioral scarring in one patient, S. aureus infection in two patients, and dyschromia in two patients.

CONCLUSIONS

Full face laser resurfacing provides long-term effective prophylaxis against AKs and may reduce the incidence of AK related squamous cell carcinoma.

Management of actinic keratoses

Actinic keratoses are quite common. Since they represent the initial stage in the evolution of squamous cell carcinoma, recognition and treatment are important. Recently, new treatment modalities have become available including immune modulators, photodynamic therapy, and topical nonsteroidal anti-inflammatory agents.

Delayed wound healing after three different treatments for widespread actinic keratosis on the atrophic bald scalp

BACKGROUND

Actinic keratosis is an exceedingly common premalignant lesion that can develop into squamous cell carcinoma. There is an increasing prevalence of actinic keratosis with increasing age. Numerous treatment options are available for the treatment of actinic keratosis on the scalp. Although we know that atrophic skin heals slowly, one should be careful but should not hesitate to treat.

OBJECTIVE

We present three patients with widespread actinic keratotic lesions on the atrophic bald scalp who received different treatments.

METHODS

Patient 1 was treated with medium-depth chemical peel, patient 2 with cryopeel, and patient 3 with CO2 laser resurfacing. In all patients, the entire surface area was treated.

RESULTS

Despite the different treatment methods used, all three patients had severely delayed wound healing as a complication. Remarkably, all patients had a prolonged period of re-epithelialization.

CONCLUSION

Care has to be taken in patients with widespread actinic keratosis on the atrophic bald scalp when treating the entire surface area regardless the treatment modality.

Topical and light-based treatments for actinic keratoses

Actinic keratosis is currently believed to be an early stage in the evolution of squamous cell carcinoma. Active and intensive treatment of actinic keratosis may prevent the formation of invasive squamous cell carcinoma and potential metastases. While destructive methods of treatment of actinic keratosis remain the gold standard for the eradication of visible and palpable actinic keratoses, new medical therapies may accomplish this goal more comfortably and reliably for the patient. Newer topical medications, light therapy and photodynamic therapy are generating promising results that presage more widespread use in the future. These novel therapies for the early treatment of actinic keratosis may be administered in combination or serially, with the locus of treatment at any given time possibly restricted to a region of affected skin. Treatment of incipient or subclinical lesions may mitigate the risk of future squamous cell carcinomas lesions. Widespread actinic keratosis constitutes a persistent medical problem that requires long-term management. The role of traditional and novel treatments in the routine treatment of actinic keratosis will be determined by the efficacy, limitations and the practicality of each of these methods in individual patients. As the first stage of squamous cell carcinoma, actinic keratosis is worthy of prompt evaluation and active treatment.

Topical 3.0% diclofenac in 2.5% hyaluronan gel in the treatment of actinic keratoses

BACKGROUND

Actinic keratoses (AKs) are epidermal skin lesions with the potential to develop into invasive squamous cell carcinoma (SCC). Treatment at an early stage may prevent development of SCC. Current treatment options are highly destructive and associated with significant side-effects. Early studies with topical diclofenac were encouraging and led to its evaluation for the treatment of actinic keratosis. Previous studies have demonstrated that 3% diclofenac in 2.5% hyaluronan gel is effective and well tolerated in the treatment of AK. The present study was designed to further explore the therapeutic potential of this gel.

METHODS

This randomized, double-blind, placebo-controlled trial involved outpatients with a diagnosis of five or more AK lesions contained in one to three 5 cm(2) blocks. Patients received either active treatment (3% diclofenac gel in 2.5% hyaluronan gel) or inactive gel vehicle (hyaluronan) as placebo (0.5 g b.i.d. in each 5 cm(2) treatment area for 90 days). Assessments included the Target Lesion Number Score (TLNS), Cumulative Lesion Number Score (CLNS), and Global Improvement Indices rated separately by both the investigator (IGII) and patient (PGII).

RESULTS

Results obtained from 96 patients at follow up (30 days after end of treatment) indicated that a significantly higher proportion of patients who received active treatment had a TLNS = 0 compared to the placebo group (50% vs. 20%; P < 0.001). There was also a significant difference between the two groups in CLNS, with 47% of patients in the active treatment group having a CLNS = 0 compared with only 19% in the placebo group (P < 0.001). The proportion of patients with an IGII score of 4 (completely improved) at follow-up was 47% in the active treatment group compared with only 19% in the placebo group (P < 0.001); for PGII these values were 41% vs. 17%, P < 0.001. Both treatments were well tolerated, with most adverse events related to the skin.

CONCLUSIONS

Topical 3% diclofenac in 2.5% hyaluronan gel was effective and well tolerated for the treatment of AK.