Journal of Clinical and Aesthetic Dermatology

Updates on Psoriasis & Cutaneou Oncology

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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S24 P r o c e e D i n G s JCAD jOUrnAl Of ClInICAl And AEsthEtIC dErMAtOlOgy september 2017 • volume 10 • number 9 • supplement should treatment begin? and 2) What is the role (and timing) of prevention? the cascade of precipitating events that occurs in the etiology of aK occurs at diderent stages at multiple sites, such that photodamage, early aK, aK, and scc may occur in close proximity in the same feld. the paradigm in aK treatment has changed in recent years, such that it is now deemed important to treat the entire feld rather than the visible lesions alone. 123 the classical pathway for aK development begins with photodamaged skin, which leads to a down-regulation of cutaneous immune response and continually expands the keratinocyte intraepidermal neoplasia (Kin). it had previously been accepted that this classical pathway involved several sequential steps, from aKi to aKii, aKiii, and fnally scc, but new evidence suggests that steps can be skipped, such that aKi can advance directly to scc without the intervening stages. 125 in fact, in Germany, aK is accepted by clinicians as a form of carcinoma in situ. the treatment algorithms for aK vary depending on whether solitary lesions or the entire feld is treated (figure 3). 127 surgery remains the primary treatment for malignant melanoma and scc, while noninvasive procedures are the frst-line approach to aK. 126 Photodynamic therapy (PDt) as feld therapy for aK is an edective therapeutic option, but its clinical utility is limited by associated pain. so painful is PDt that it averages 7.8 on an analog pain scale where 0 is no pain and 10 is the worst pain imaginable. as an alternative to conventional PDt, so-called "daylight PDt" has been developed. regardless of the algorithm, the goal of aK treatment is to address the aK present and prevent scc in the feld with fewer side edects, better safety, enhanced eecacy (low recurrence rate, prevention of development of invasive scc), cost-edectiveness, and with a product that optimizes patient adherence (e.g., easy to apply in a short period of time). the presence of solitary aKs indicates that the patient's skin is photodamaged and that he or she is at risk for developing skin cancer. thus, a topical immune response modifer (irM) may be appropriate for feld treatment in that it treats existing lesions, subclinical aK, and may prevent aK from developing into scc. nExtMgEnErAtIOn IMIQUIMOd new drugs are being developed for the safe, edective treatment of feld cancerization, such as resiquimod, a next-generation imiquimod product aimed at treating aK. 1 28 resiquimod is an imidazoquinoline that acts by cytokine secretion from monocytes and macrophages and has been shown to be edective in Bcc and scc in both immunocompetent and immunosuppressed patients. 129 resiquimod is 100-fold more potent than imiquimod and can be used topically at 0.03% with a 90-percent complete clearance rate. 130 in fact, szeimies et al 130 showed that more than 70 percent of patients achieved complete clearance after a single course of treatment. resiquimod is applied topically for two or three days only. adverse edects are the development of gu-like symptoms that may last up to 15 days; these were reported by 0 (0.01% gel), 3 percent (0.03% gel), 13 percent (0.06% gel), and 12 percent (0.1% gel) of patients. 130 resiquimod may also be edective in the treatment of cutaneous lymphoma. topical ingenol mebutate gel may be used to treat aK. in one study, patients were treated for three days with ingenol mebutate gel 0.015% on the face or scalp or for two days on the trunk or extremities with 0.05% gel. 131 of those patients who achieved complete clearance of the face or scalp lesions, most were enrolled in a 12-month study to evaluate recurrence rates. figure 3. actinic keratoses (aK) treatment algorithms reproduced with permission from eggert stockgeth, MD. copyright © 2012

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