HNY Policy and Pathway Repository - York

• Scaly, flat pink, red or brownish lesions, on any sun exposed skin from mid-life onwards.
• Typical areas affected are scalp in balding patients, upper pinna, temples, bridge of nose, anterior upper chest.
• Example images 
• Often multiple, with a dry adherent scale. They occasionally itch.
• Hyperkeratotic scale can form a cutaneous horn.
• The vast majority of actinic keratoses do not progress to squamous cell carcinoma

Evidence suggests that the annual incidence of transformation to SCC is less than <2%. This risk is higher in immuno-compromised patients.

 

• The majority of patients can be managed in primary care.
• There is a field change effect- so if sufficient UV exposure has occurred to trigger 1 actinic keratosis, adjacent skin will not be far behind, and more will likely occur over coming months and years.

• Tender and /or indurated lesions are more likely to be SCCs or other significant pathology.
• Also if bleed spontaneously. Refer if ?SCC or concerns about malignant change

 

• Fluorouracil (Efudix®) is the most cost effective treatment. Its application and use needs care and there are a number of leaflets within the treatment pathway that help to explain this to patients. Apply every night for four weeks. Wash hands thoroughly after application. Leave treated areas uncovered and wash the following morning. Patients should be advised to expect a relatively mild degree of redness and discomfort during the treatment period.
• ONLY IF FLUOROURACIL OUT OF STOCK:
  • Imiquimod 3.5 or 5% is a much more expensive treatment for actinic keratoses, and can be used 3 x per week for 6 weeks. Like efudix, there is usually a degree of redness and discomfort, but this can also be severe on occasion, and/or imiquimod can rarely cause flu like symptoms. If the latter side effect happens, they should avoid the treatment in future.
  • Actikerall is another alternative, containing salicylic acid as well as fluorouracil (aimed usually at viral warts), use as for efudix, once  day for up to four weeks but can be more irritant.
  • Tirbanibulin (klysiri) is a new treatment for actinic keratoses, this is currently a red drug for primary care once a day for 5 days. This is also considerably more expensive. Do not prescribe, unless directed by secondary care or through advice and guidance.
• AKs can regress spontaneously especially if sun exposure is reduced.
• Do a full body examination for other sun induced lesions.
• For all patients advise avoid sun exposure by wearing hats and clothing, use sunscreens (SPF 50+) applied from April to October and reapply frequently on sunnier days or when outside for longer periods. Reinforce this frequently.
• If patient follows this rigorously may need vitamin D measurement or supplementation
• Isolated well defined lesions:
• Cryotherapy – not on lower legs (thermal injury takes too long to heal);  10-20 second freeze, depending on thickness; can be  useful for thicker or resistant lesions

Curettage of difficult lesions can also be carried out in primary care, preferably double curettage and cautery. This should be sent for histology in case SCC is missed.
 

Refer or seek advice and guidance if:

• Diagnostic doubt (actinic keratosis vs SCC)
• Failed more than 2 treatment modalities
• Immunosuppressed patients
• Consider not treating– many regress spontaneously
• cryotherapy – not on lower legs (thermal injury takes too long to heal); • 10-20 second freeze depending on thickness
• Can be useful for thicker or resistant lesions.

Information to include in referral letter

• Previous treatments tried and their effect.
• Photograph (desirable)
• Relevant past medical/ surgical history
• Current regular medication
• BMI/smoking status

Referral Criteria

• Diagnostic doubt.
• Failure of 2 different treatments.
• Immuno-compromised patients

Patient information leaflets

• York Hospital Foundation Trust's leaflet - efudix cream (a one page summarised leaflet)
• Manufacturer Patient Information Leaflet (a more detailed leaflet)
• British Association of Dermatologists' leaflet
   

References

• Primary Care Dermatology Society
   

Appendices

Grade of Actinic Keratosis and Treatment Choices – Table 1

Single or few lesions, better felt than seen
Moderately thick lesions (hyperkeratotic), easily felt and seen
Thick hyperkeratotic or obvious AK, differential diagnosis cutaneous horn
Lesions grouped in same area, with marked background damage

Drug Name	Licensed Indication	Dose Directions	Area	Duration	Costs	Patient leaflet
Fluorouracil 5% cream (40g)	Topical treatment of superficial pre-malignant and malignant skin lesions; keratosis including actinic forms	Apply once or twice daily, start gradually until tolerance established	max. area of skin treated at one time, 500 cm2 (e.g. 23 cm × 23 cm)	3-4 weeks	40g £32.76	British Association of Dermatologists (bad.org.uk)
0.5% Fluorouracil and 10% salicylic acid (25ml)	Topical treatment of slightly palpable and/or moderately thick hyperkeratotic actinic keratosis (grade I/II)	Apply once daily unless side effects severe, then reduce frequency to 3 times a week until side effects improve	max. area of skin treated at one time, 25 cm2 (e.g. 5 cm x 5 cm)	Up to 12 weeks	25ml £38.30	British Association of Dermatologists (bad.org.uk)

 

Drug Name	Licensed Indication	Dose Directions	Area	Duration	Costs	Patient leaflet
Imiquimod   5% 250mg sachets	Topical treatment of actinic keratoses, superficial BCCs,	Apply in regime under duration, unless intense inflammation or flu like side effects. Counsel patient some inflammation is normal and beneficial.	Each sachet is single use up to 25cm2 (5x5cm)   Maximum 2 sachets per day	For AK treatment   3x per week for 4 weeks to area and 1cm around it	£48.90 for 12 sachets	British Association of Dermatologists (bad.org.uk)
Imiquimod   3.75% 250mg sachets				Once a day for 2 weeks, 2 week break then a further 2 weeks if needed	£54.95 for 28 sachets
Tirbanibulin 10mg/ml cutaneous ointment, 250mg sachets	Topical treatment of facial and scalp actinic keratoses, grade I/II	Apply once daily for 5 consecutive days	Each sachet is single use up to 25cm2 (5x5cm).	5 days	5 sachets £59.00 (use if efudix unavailable or patient unable to tolerate other methods)	Tirbanibulin — DermNet (dermnetnz.org)