http://img.medscape.com/article/770/959/770959-fig1.

jpg
Case Report
in Actinic
Keratosis

Remando, Charmaine Elaine R.

MEDICINE III
HISTORY OF PRESENT ILLNESS

K.P.
52 y/o male
Fair-skinned construction worker
From Dublin, Ireland
Increasing number of small, reddish-colored blemishes on his hands,
forearms, and scalp
Spends much of the day outside on construction sites
Often take off their shirts during summer months
Does not apply sunscreen to any part of his body
PAST MEDICAL HISTORY

-Insignificant

FAMILY HISTORY

-father-lung cancer 3 years ago

http://img.medscape.com/article/770/959/770959-fig1.jpg
PHYSICAL EXAM

(+) Lesions:
.4 lesions on hands and forearms
.Size ranges from 4mm to 12mm
.9 lesions on top of his head
.Appears to have a light, white/silver crust
.Rough patches at the edge of his scalp( no
lesions visible)
.1 lesion is particularly hard
.Erythematous base extending outward
ACTINIC KERATOSIS

Aka solar keratosis

Results from direct absorption of UV radiation
Presents as a rough, scaly patch on skin
Induces changes to the structure and function of keratinocytes in the
epidermis
Commonly found on the face, lips, ears, back of hands, forearms, scalp or
neck
Older adults
Risk for progressing to invasive SCC
Risk Factors

Prolonged sun exposure

Geographic proximity to the equator

Age over 60 years (risk increasing with older age)

Fitzpatrick skin types I and II and associated features (eg, freckles, red hair,
light eyes)

Personal history of prior skin malignancies

Suppressed or impaired immune system

Clinical Variants

Hypertrophic (hyperkeratotic)
Atrophic
AK with cutaneous horn
Pigmented AK
Actinic cheilitis
Bowenoid AK
Pathogenesis
Management

Treatment goals:

Eradicate visible lesions

Minimize recurrence and development of new lesions
from dysplastic cells
Reduce the risk for progression to SCC
Lesion-directed
therapy

Topical Field-
directed therapy

Field-directed
Photodynamic
therapy

Visible lesion

Visible and subclinical

lesions

Solitary or few lesions

Multiple lesions

Lesions near the eyes

or mouth

Lesions in difficult to
reach areas

Thicker

Table 2. Suitability of treatment approaches for different types of AK lesions

Non-pharmacologic

Cryosurgery
Electrodessication and curettage
Photodynamic therapy
Pharmacologic

Medications
.5-fluorouracil
.Imiquimod
.Diclofenac
5-Fluorouracil

Classification

Anti-metabolite

Brand Name

Efudix, Actikerall

Mechanism of Action

A suicide inhibitor and works through irreversible inhibition of thymidylate

synthase

Indication

Used to treat pre-cancerous and cancerous skin growths

Therapeutic dose

5-FU 5% cream

Dosage Regimen

Rubbed gently onto the lesion areas OD/BID for 2-4 weeks

Contraindication

Hypersensitivity to drug or its components, pregnancy and lactation, bone

marrow suppression

Adverse effect

N/V, headache, alopecia, photosensitivity, maculopapular eruption,

irritability, anxiety, itchiness, stinging

Special considerations

Remember to wash hands thoroughly after using the cream

Only use fluorouracil on the skin

Stay out of direct sunlight as much as possible or use sun cream with high
SPF

Drug Interaction

Warfarin, allopurinol, sorivudine

Imiquimod

Classification

Immunomodulator

Brand Name

Aldara

Mechanism of Action

Stimulates release of inflammatory cytokines and proliferation/migration

of immune cells

Indication

Treatment of clinically typical, nonhyperkeratotic, nonhypertrophicactinic

keratosis on the face or scalp in immunocompetent adults

Therapeutic dose

5% cream 50mg/g

Dosage Regimen

Apply OD, 2-3 days a week for 4 weeks

Contraindication

Immunosuppressed, hypersensitivity to drug

Adverse effect

Skin weeping, malaise, fever, nausea

Special considerations

Wash hands before and after application

Apply to the entire treatment area and rubbed in until cream is no

longer visible

Avoid exposure to sunlight

Should be left on the skin for approximately 8 hours

Drug Interaction

Immunosuppressants
Diclofenac

Classification

NSAID

Brand Name

Solaraze

Mechanism of
Action

Potent inhibitor of inducible COX-2, resulting to decreased

prostaglandin synthesis

Indication

To treat actinic keratosis

Therapeutic dose

3% Diclofenac in 2.5% HyaluronanGel

Dosage Regimen

Apply to affected area BID for 60-90 days

Contraindication

Hypersensitivity to drug or other NSAIDs, asthma, heart

failure, kidney disease, liver disease, pregnancy and lactation

Adverse effect

Redness, itching, swelling, pain, burning sensation,headache

Special
considerations

Avoid exposure to sunlight

Wear protective clothing

Use high SPF suncream

Wash hands before and after application

Drug Interaction

Warfarin, cyclosporine, lithium, methotrexate, diuretic, ACE

inhibitors
ESSA Criteria

Drug

Efficacy

Safety

Suitability

Affordability

Total

5-FU

+++

+++

+++

10

Imiquimod

++

++

++

Diclofenac

+++

++

7
5-Fluorouracil 5% cream (Efudex) tube

Twice a day for 4 weeks #1

Sig. Apply only to the affected areas. Wash hands

thoroughly before and after application. Return for follow-
up checkup after 4 weeks (Sept 9, 2016).

REMANDO, CHARMAINE ELAINE R., M.D.

INTERNAL MEDICINE-DERMATOLOGY

Makati Medical Center

AmorsoloSt., Makati City

Clinic Room No. 143 BldgB

Mon & Wed 10am-12nn; Thurs & Fri 1pm-4pm

Phone: 12345678910

Name:K. P__________ Age: 52, M

Address: Dublin, IrelandDate: August 12, 2016_____

Refill Info: 0__

chamremando

REMANDO, CHARMAINE ELAINE R.

License No. 0123456789

S2 No. 987654321
References:

Foley, Peter A., Cases in Actinic Keratosis, the Often Overlooked Condition,
2012, www.medscape.org
http://www.aetna.com/cpb/medical/data/500_599/0567.html
MIMS Philippines
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989823/
Burns, Tony et. al., Rooks Textbook of Dermatology, 8thedition, John Wiley
& Sons, Ltd., Publication, 2010
James, William D. et. al., Andrews Diseases of the Skin: Clinical
Dermatology, 12thedition, Elsevier Inc., 2016