A Systematic Review and Meta-Analysis of Interventions for Actinic Keratosis from Post-Marketing Surveillance Trials

European consensus-based interdisciplinary guideline for diagnosis, treatment and prevention of actinic keratoses, epithelial UV-induced dysplasia and field cancerization on behalf of European Association of Dermato-Oncology, European Dermatology Forum, European Academy of Dermatology and Venereology and Union of Medical Specialists (Union Européenne des Médecins Spécialistes)

A collaboration of multidisciplinary experts from the European Association of Dermato-Oncology, the European Dermatology Forum, the European Academy of Dermatology and Venereology, and the European Union of Medical Specialists was formed to develop European recommendations on AK diagnosis and treatment, based on current literature and expert consensus. This guideline addresses the epidemiology, diagnostics, risk stratification and treatments in immunocompetent as well as immunosuppressed patients. Actinic keratoses (AK) are potential precursors of cutaneous squamous cell carcinoma (cSCC) and display typical histopathologic and immunohistochemical features of this malignancy in an early stage. They can develop into cSSC in situ and become invasive in a low percentage of cases. AK is the most frequent neoplasia in white populations, frequently occurring within a cancerous field induced by ultraviolet radiation. Since it cannot be predicted, which lesion will progress to cSCC and when treatment is usually recommended. The diagnosis of AK and field cancerization is made by clinical examination. Dermatoscopy, confocal microscopy, optical coherence tomography or line-field confocal-OCT can help in the differential diagnosis of AK and other skin neoplasms. A biopsy is indicated in clinically and/or dermatoscopically suspicious and/or treatment-refractory lesions. The choice of treatment depends on patients' and lesion characteristics. For single non-hyperkeratotic lesions, the treatment can be started upon patient's request with destructive treatments or topical treatments. For multiple lesions, field cancerization treatment is advised with topical treatments and photodynamic therapy. Preventive measures such as sun protection, self-examination and repeated field cancerization treatments of previously affected skin areas in high-risk patients are advised.

Poor Adherence to Self-Applied Topical Drug Treatment Is a Common Source of Low Lesion Clearance in Patients with Actinic Keratosis-A Cross-Sectional Study

BACKGROUND

Many treatments for actinic keratosis (AK) have been proven efficient in clinical trials. However, patients with AK may still experience unsatisfactory therapeutic outcomes in clinical practice.

OBJECTIVES

To investigate patient adherence to self-applied topical interventions for AK and to explore factors associated with adherence in a real-world setting.

METHODS

A cross-sectional study was conducted. Patients presenting with AK were asked to complete a self-administered questionnaire about their last topical AK treatment.

RESULTS

A total of 113 patients participated with a median age of 78.5 years (range 58-94). Fifty-four patients (47.8%) received topical diclofenac, ten (8.8%) imiquimod, nine (8%) 5-fluorouracil, nine (8%) 5-fluorouracil plus salicylic acid, and eight (7.1%) photodynamic therapy. The non-adherence rate was 46.9% (n = 53), and only 30.9% (n = 35) used the topical treatments according to the summary of product characteristics (SmPC). These subgroups were compared. Patients of the non-compliant group were significantly less informed about the application time of the specific topical intervention (p = 0.002) and adjusted the timeframe (p < 0.001) and application frequency of the therapy (p = 0.02) independently of their physician. Conversely, patients reporting a sufficient pre-treatment consultation (p = 0.019) generally complied with the SmPC compliance application.

CONCLUSIONS

A thorough pre-treatment consultation can help to increase treatment adherence and ensure lesion clearance.

The Role and Effectiveness of Photodynamic Therapy on Patients With Actinic Keratosis: A Systematic Review and Meta-Analysis

Actinic keratoses (AKs) are the most common neoplastic lesions and are recognized as a precursor to squamous cell skin cancer. Photodynamic therapy (PDT) is a therapeutic option for multiple AKs in line with field cancerization. The aim of this study was to assess the effectiveness of PDT on patients with AKs using a meta-analysis, in order to evaluate the possible superiority of one treatment over the others. For this purpose, the PubMed, MEDLINE, Scopus, OVID, Science Direct, British Journal of Dermatology, Research Gate, and Embase databases were searched in March 2022. The search terms used were 'photodynamic therapy' and 'actinic keratosis'. We utilized the random-effects meta-analysis model to compare methyl aminolevulinate PDT (MAL-PDT) and the combination of a nanoscale-lipid vesicle formulation with the prodrug 5-aminolevulinic acid (BF-200 ALA) on a complete response (CR) of the lesions. Our meta-analysis indicated that the comparison of BF-200 ALA versus MAL-PDT showed marginally higher CRs than MAL-PDT.

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.

Topical Pharmacotherapy for Actinic Keratoses in Older Adults

Actinic keratosis is caused by excessive lifetime sun exposure. It must be treated, regardless of thickness, because it is the biologic precursor of invasive squamous cell carcinoma, a potentially deadly malignancy. Physical ablative techniques such as cryotherapy, lasers, and curettage are the most used treatments for isolated lesions. Multiple lesions are treated with topical drugs, chemical peelings, and physical techniques. Drug preparations containing diclofenac plus hyaluronate, aminolevulinic acid, and methyl aminolevulinate and different concentrations of imiquimod and 5-fluorouracil are approved for this clinical indication. All treatments have a good profile of efficacy and tolerability although there are relevant differences in the clearance rate, tolerability, and type and frequency of adverse effects. In addition, they have very different mechanisms of action and treatment protocols. No differences in the efficacy and tolerability were found in older patients compared with younger patients, therefore no dose adjustments are needed. That said, older patients often need to be motivated to treat actinic keratoses and a careful attention to expectations, needs, and preferences should be used to obtain the maximal adherence and prevent treatment failure. This goal can be achieved with a careful evaluation not only of published efficacy, toxicity, and tolerability data but also of practical topics such as the frequency of daily applications, the overall duration of therapy, and the need for a caregiver. Finally, particular attention must be paid in the case of frail patients and immunosuppressed patients.

Update aktinische Keratosen – Neuigkeiten und Relevanz für den Alltag

Ziel der Arbeit Die im März 2020 zuletzt überarbeitete Leitlinie „Aktinische Keratosen und Plattenepithelkarzinome der Haut“ hat aufgrund der Zunahme der klinischen Studien zum Thema aktinische Keratosen den höchsten Grad für Methodik (S3) erreicht, da diese nicht nur konsensbasiert sondern auch evidenzbasiert verfasst wurde. Diesen Entwicklungen gerecht zu werden und den klinisch relevanten Teil des aktuellen Stands des Wissens zu vermitteln, ist Ziel dieses Artikels.

Methodik Anhand der aktuellen epidemiologischen Lage wird der dramatisch wachsende Bedarf für das bessere Verständnis der Ätiologie aktinischer Keratosen deutlich. Ebenso gilt es, Patienten mit aktinischen Keratosen und therapiebedürftigen Ko-Morbiditäten vor einem therapiebedingten, erhöhten Risiko für die Entwicklung weiterer aktinischer Keratosen oder Plattenepithelkarzinomen zu bewahren. Die Möglichkeit der Spontanremission aktinischer Keratosen sollte ebenso wenig vernachlässigt werden wie eine mögliche Progredienz in ein Plattenepithelkarzinom. Die kontroverse Diskussion der fortwährend postulierten, sequenziellen Abfolge der histologischen Grade aktinischer Keratosen zum Plattenepithelkarzinom beinhaltet klinische und histologische Fallstricke. Diese sollten bei der Therapieentscheidung ebenso bedacht werden wie die Wünsche und Erwartungen der Patienten an ein Therapieregime. Eine bleibende Schwierigkeit ist die fehlende Standardisierung erhobener Daten zu den zahlreichen zur Verfügung stehenden Therapieoptionen. Das Potenzial dieses Forschungsgebietes für neue Therapiealternativen und präventive Maßnahmen lässt nach wie vor auf weitere, interessante Entwicklungen hoffen.

Ergebnisse Der gut etablierte kausale Zusammenhang zwischen kumulativer UV-Strahlung in der Entwicklung von Plattenepithelkarzinomen und aktinischer Keratosen hat zur Anerkennung berufsbedingter UV-Exposition als Berufserkrankung geführt, die auch die Anerkennung multipler aktinischer Keratosen als Berufserkrankung beinhaltet. Das therapeutische Handeln sollte durch die Gesamtanzahl der aktinischen Keratosen, das Ausmaß der betroffenen Fläche, die Dynamik des Krankheitsgeschehens und den Wunsch des Patienten bestimmt werden. Ein besonderes Augenmerk sollte auf den Patienten liegen, denen die Krankheitseinsicht fehlt oder die nur wenig motiviert zur Therapie sind. Es könnte der Schlüssel zur Verbesserung der Therapieadhärenz und Akzeptanz sein, diese Patienten zu erkennen und ihre Bedürfnisse in das Arzt-Patienten-Gespräch zu integrieren. Die Differenzierung zwischen lokalisierten aktinischen Keratosen und einer Feldkanzerisierung stellt ein wichtiges Entscheidungskriterium für die Wahl der empfohlenen Therapie dar. Die Rücknahme der Zulassung von Ingenolmebutat in der EU durch die EMA im Jahr 2020 hat das Spektrum der lokaltherapeutischen Optionen eingeschränkt. Der periinterventionelle Schmerz ist nach wie vor der limitierende Faktor für die konventionelle photodynamische Therapie, jedoch schreitet die Entwicklung für schmerzärmere Varianten weiter voran. Es ist zu erwarten, dass sich in den kommenden Jahren durch eine bessere Evidenzlage für weitere systemische oder lokaltherapeutische Optionen neue Behandlungsstrategien ergeben werden. Besonders im Fokus wird sicherlich nach wie vor die Präventionsforschung stehen, die v. a. den Erhalt einer erzielten Remission beinhaltet.

Schlussfolgerung Die aktuellen Forschungsergebnisse und -bestrebungen zur Thematik der aktinischen Keratosen sind aufgrund des zukünftig gesteigerten Bedarfes zum einen notwendig und zum anderen sehr ermutigend. Das Ende des therapeutischen Horizonts ist gegenwärtig noch nicht erreicht.

How to Assess the Efficacy of Interventions for Actinic Keratosis? A Review with a Focus on Long-Term Results

Actinic keratoses (AK) are common lesions of the skin caused by cumulative sun exposure. Since AK may progress to invasive cutaneous squamous cell carcinoma (cSCC), guidelines uniformly recommend early and consequent treatment. A variety of interventions are available; however, most randomized controlled trials, meta-analyses, and guidelines focus on outcomes that are usually evaluated 8–12 weeks after the end of treatment. Importantly, these assessments can capture the short-term, transient outcomes, but do not allow any conclusions about long-term results to be drawn and do not reflect the probability of transition towards cSCC. Until now, few studies have assessed the long-term results of interventions for AK. Indeed, finding the most appropriate end-point and adjunct time point for determining the long-term results of interventions for AK remains a challenge. Here, we provide an overview of the different ways of measuring the efficacy of AK treatments, such as using recurrence rates or sustained clearance rates, and discuss methodological aspects. Furthermore, we highlight the importance of evidence from post-marketing surveillance trials for the detection of efficacy values and safety signals. Additionally, we emphasize that a follow-up period of 12 months might not be sufficient to reflect the long-term results and stress the urgent need for a longer follow-up period and regular risk-stratified surveillance.

Local Chemotherapy as an Adjuvant Treatment in Unresectable Squamous Cell Carcinoma: What Do We Know So Far?

Background: Squamous cell carcinoma (SCC) is one of the most common cancers involving skin and oral mucosa. Although this condition's gold-standard treatment is the surgical removal of the lesions, the physician must propose alternative treatments in some cases due to the patient's ineligibility for surgery. Among the available alternative therapies, local chemotherapy may represent an initial treatment in combination with radiotherapy or systemic chemotherapy due to the low frequency of side-effects and the lack of necessity for expensive devices. Methods: In this paper, we review all available literature in various databases (PubMed, Scopus-Embase, Web of Science), proposing local chemotherapy as a treatment for cutaneous and oral SCC. Exclusion criteria included ocular lesions (where topical treatments are common), non-English language, and non-human studies. Results: We included 14 studies in this review. The majority were case reports and case series describing the treatment of non-resectable localized SCC with either imiquimod or 5-fluorouracil. We also analyzed small studies proposing combination treatments. Almost all studies reported an excellent clinical outcome, with a low risk of relapses in time. Conclusions: Resection of the lesion remains the gold-standard treatment for SCC. When this approach is not feasible, local chemotherapy may represent a treatment alternative, and it may also be associated with radiotherapy or systemic chemotherapy.