I've seen some horrible looking pics posted on the internet from patients that had horrific responses to treatment with FU-5 - they said the pain, oozing (sometimes bleeding) was almost more than they could stand for 2-4 wks. What is a ballpark cost for Photodynamic therapy @ treatment - not sure if my insurance will pay for this but I need to do something about the actinic keratosis on my face and forearms - more extensive than than would be practical for cryosurgery - according to my Dermatologist.
Photodynamic Therapy Vs Efudex - Best Treatment for Actinic Keratosis?
Doctor Answers 5
PDT as effective as Efudex
There have been at least one head to head study with Efudex and they had similar efficacy. Patients seem to like PDT better as it is almost always completely healed at Day 8 or 9. Most patients pay less out of pocket for photodynamic therapy than they do for efudex at the pharmacy.
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5-FU versus Photodynamic Therapy
There is no question that 5-FU can have some ugly downtime.
Other topical choices for treatment of actinic keratoses would include Aldara, or photodynamic therapy using amino levulonic acid.
Aldara can be used a little more 'conservatively' by applying fewer times per week for a longer period. Unfortunately, though, it (like 5-FU) can cause oozing and crusting with discomfort and irritation.
The use of a topical photosensitizing agent (ala) with a red light has less down time and fairly successful results. Several studies show reduction rates of some 90%, after a couple of treatments.
Most people have only a sunburned appearance with some flaking, and occasional swelling and mild to moderate discomfort- much less of an effect on your social life than 5-FU or Aldara.
The only negative with this procedure is the absolute need to remain out of the sun (basically any direct daylight from the sun) for some 24-36hrs.
A severe burn can be elicited with sunlight hitting the treated areas. The two topical preparations used are Aminolevulinic Acid and Methyl Aminolevulinate.
These products are applied and allowed to "incubate" for up to several hours, depending on the product and the treatment site. A light using near infra-red to infra red is used to activate the product. The procedure is generally repeated somewhere between one week and one month.
A recent article by Gold showed that after one year, photodynamic therapy led to a greater clearing of actinic keratoses than Efudex. It should be noted that this finding was applicable if the patient had two photodynamic treatments. Another recent study demonstrated that the use of Aldara (imiquimod) for one month before and a month after photodynamic therapy gave even more outstanding results.
The treatment can cause a sunburn-like reaction, sometimes even with oozing, but this problem is short-lived.
Insurance covers this treatment in most cases. If you do not have insurance, the Kerastick (containing the Levular) costs $135 and the treatment $115.
Incidentally, the improvement in photoaging is well documented, and though off-label, many physicians offer PDT for this reason.
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Chemoprevention of precancerous lesions and the concept of Preventive Dermatology
Several chemopreventive modalities to treat actinic keratoses and prevent skin cancer are available and should be aggressively pursued. An experienced board-certified dermatologist with keen interest in Preventive Dermatology and Chemoprevention can outline pros and cons of topical 5-flurouracil, imiquimod, photodyanimc therapy, chemical peel, laser resurfacing, even oral acitretin (Vitamin A).
Deciding factors of utilizing any of above suggested modalities depend on location to be treated, one's priorities and schedules. For example, topical chemopreventive creams such as 5-flurouracil (e.g. Carac, Efudex) or imiquimod (Aldara) are more amenable to areas such as arms, chest of women or scalp in men as the 'down time' could last 3-4 weeks but can be covered up with clothing or hat. Whereas photodynamic therapy (PDT), chemical peel, Fractional CO2 laser resurfacing are more appropriate for the face where the 'down time' typically does not exceed one week.
Keep in mind that the extent of inflammation associated with these chemopreventive modalities is correlated with the extent of underlying sun damage. In other words, if there is minimal sun damage in areas treated, there should not be significant irritation. However, if there is significant precancerous lesions, it is better for them to be brought out to the surface and be dealt with before they turn cancerous and require surgical excision. The irritation/inflammation from topical chemopreventive creams and PDT are not only diagnostic (e.g. identifying the locations of precancerous changes) but also therapeutic.
For women and men who want to get some cosmetic benefits while addressing medical concerns of sun damage and precancerous changes, TCA chemical peels and Fractional CO2 laser resurfacing can be fantastic options.
Treatment for AK's
Both methods are effective for the treatment of AK's but Efudex is the "gold standard". It is not easy to use, but you do not have to become one of those pictures you mention in your question. I have patients use Efudex until they get a response, meaning until they start to get a little irritated and crusty. That may take 2 to 4 weeks or that may only take a few days depending on how sun damaged you are.
Once you start to react to the Efudex, stop. Do not continue to apply it or you will look like the horrible pictures. Once you stop the Efudex it will take about a week for your skin to calm down. If you still have a lot of AK's, then do it again, but for a little bit longer. This is a more gentle way of using Efudex to get to the same clinical endpoint without suffering.