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CLINICAL
Treating actinic keratoses
PRACTICE
with imiquimod
• There are many options for managing actinic Case study
keratoses. Percentage complete clearance of lesions Anthony Dixon
with cryotherapy is in the order of 80%, topical imiquimod 70% and 5 fluorouracil 50%.2–5 • Some patients will find some of the options more tolerable than others. Consider trying alternative approaches for patients with the treatment very uncomfortable and can being treated on each visit. He develops lesions faster than lesions are treated.
Mr KC now presents with numerous hyperkeratotic
lesions on his face (Figure 1
). Biopsies were taken
of the clinically most suspicious actinic lesions. This
is done to identify which, if any, lesions are SCCs.
(These are surgically excised.) Numerous actinic
keratoses still covered most of his face including
most of his left forehead.

He was keen to try imiquimod for his residual actinic
keratoses. We divided his face up into regions about
the size of a playing card. In turn he treated each
region with an application of imiquimod three times per
Figure 1. The patient’s face is covered with actinic lesions, week for 6 weeks. This is the recommended protocol especially the forehead. The lesions marked with pen are all SCCs and were surgically excised. There was further for usage of imiquimod for actinic keratoses.
SCC on the right eyebrow, also surgically excised The final section of face skin to be treated was the right forehead. Mid treatment the area was red and angry looking, as part of the expected immune response induced by the imiquimod1 (Figure 2). This erythema and irritation was never disturbing to the patient. If imiquimod causes excess irritation, the clinician can advise the patient to leave out a dose or two. Upon completion Mr KC had no apparent actinic lesions on his face or forehead (Figure 3).
Summary of important points
• Treat malignant lesions before benign lesions. It is
the SCCs that can metastasise and potential y kil Figure 2. The skin is typically red and angry looking for the patients. Once the SCCs are excised, the focus can duration of imiquimod management of actinic keratoses. Imiquimod was only commenced following all surgical excisions Reprinted from Australian Family Physician Vol. 36, No. 5, May 2007 341
CLINICAL PRACTICE Treating actinic keratoses with imiquimod Numerous actinic keratoses
There are five characters of an actinic keratosis that should be considered upon
examination:
Hyperkeratosis: to what extent does the keratosis extend above the skin
Full thickness: when the lesion is manipulated with your fingers upon
examination, does it appear to be deeply into the skin or very much a surface • Surrounding induration: is there enhanced thickness in the tissue adjacent to
Surrounding erythema: is the immediate adjacent skin clearly redder than the
Tenderness: is the lesion causing the patient any degree of discomfort?
Does the patient withdraw when you touch one or more lesions in the field of The more of these characteristics an individual lesion has, the more likely the lesion is to be a malignant SCC rather than a premalignant lesion. In patients with large numbers of keratoses, consider biopsy of the lesions that have the greatest number of these features. Regardless of the number of keratoses a patient suffers, lesions with three or more of these five features should be biopsied.
If any lesion demonstrating several of these features does not respond to cryotherapy, biopsy rather than treating repeatedly with cryotherapy or References
1. Vidal D. Topical imiquimod: mechanism of action and clinical applications. Mini Rev Med Chem 2006;6:499–503.
2. Tutrone WD, Saini R, Caglar S, Weinberg JM, Crespo J. Topical therapy for actinic keratoses, I: 5-fluorouracil and imiquimod. Cutis 2003;71:365–70.
3. Del Rosso JQ. New and emerging topical approaches for actinic keratoses. Cutis 2003;72:273–6, 279.
4. Falagas ME, Angelousi AG, Peppas G. Imiquimod for the treatment of actinic keratosis: a meta-analysis of randomised control ed trials. J Am Acad Dermatol 2006;55:537–8.
5. Gupta AK, Davey V, McPhail H. Evaluation of the Figure 3. Following treatment there is no apparent effectiveness of imiquimod and 5-fluorouracil for the treatment of actinic keratosis: Critical review and meta-analysis of efficacy studies. J Cutan Med Surg 2005;9:209–14.
6. Dixon AJ. Multiple superficial basal cel carcinomata: topical imiquimod versus curette and cryotherapy. Aust • Imiquimod is approved in Australia for field actinic keratoses only on the face and forehead. The patient applies a ful sachet three times per week to an area of skin equivalent to the forehead on one side. One sachet wil cover a field about this size. Once one region has completed management, a new region may be commenced. Conflict of interest: none declared.
CORRESPONDENCE email: afp@racgp.org.au
342 Reprinted from Australian Family Physician Vol. 36, No. 5, May 2007

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