Keratoses treatment

The most common areas for psoriasis in human are shown on the scalp[3, 4], Initially, a series of classical treatment is used to treat this disease but that attempt has been failed. Today, phototherapy and PDT have become a regular modality and effective way for psoriasis and actinic keratoses treatment[4]. In spite of the various by topical treatments available for the treatment of superficial skin disease in scalp skin, many patients not succeed to respond adequately or may develop side effects. The goal of PDT treatment of psoriasis and actinic keratoses is to cure or locally control the disease while minimizing complications in normal tissues and reducing pain regarding therapy by investigation the influence of optical properties of skin and hair. 

Actinic keratoses were the first skin lesions to be treated topically with all-frans-retinoic acid. In various clinical trials, retinoids have been shown to be active in chemoprevention and treatment or prevention skin malignancies [2]. 

Vitamin D3 (VD3) and retinoids synergistically inhibit the growth and progression of squamous cell carcinomas and actinic keratoses in chronically sun exposed skin. One reason for this synergism may be the direct influence of VD3 on the isomerization and the metabolism of RA. Here, VD3 inhibits the isomerization of 13-cis-RA to the more receptor active all-trans and 9-cis-isomers. Moreover, the VD3 derivative secocholestra-trien-l,3,24-triol (tacalcitol), used for the treatment of severe keratinizing disorders inhibits 4-hydroxylation of all-ri ans-RA. 

Griffin TD, Van Scott EJ (1991) Use of pyruvic acid in the treatment of actinic keratoses a clinical and histopathologic study. Cutis 47 325-329 Halasz CL (1998) Treatment of warts with topical pyruvic acid with and without added 5-fluoruracil. Cutis 62(6) 283-285... 

Epidermal growths such as actinic keratosis, lentigines or thin seborrheic keratoses can all be treated effectively with 25-35% TCA peels. Thicker epidermal growths or growths involving the dermis will be more resistant to treatment such as hypertrophic actinic keratoses and thicker seborrheic keratoses and may even be resistant to a medium-depth peel. Resistant lesions many times are best treated with a combination of a medium-depth chemical peel and other modalities such as manual dermasanding or CO, laser. 

Chiarello SE (2000) Cryopeeling (extensive cryosurgery) for treatment of actinic keratoses an update and comparison. Dermatol Surg 26 728-732... 

Lawrence et al. [66] in a split face study, compared the efficacy and safety of Jessner s solution and 35% TCA with 5% fluorouracil in the treatment of widespread facial actinic keratoses. Fifteen patients were treated. Both treatments reduced the number of visible actinic keratoses by 75%. Similarly, both caused equivalent reductions in keratinocyte atypia, hyperkeratosis, and parakeratosis. Compared to fluorouracil, only one application of the peel was necessary. 

Actinic keratosis For the topical treatment of clinically typical, nonhyperkeratotic, nonhypertrophic actinic keratoses on the face or scalp in immunocompetent adults. Genital and perianal warts Treatment of external genital and perianal warts/condyloma acuminata in patients 12 years of age and older. 

Fluorouracil (Efudex, Fluoroplex) is an antimetabolite used for the topical treatment of actinic keratoses. It is also useful for the treatment of superficial basal cell carcinomas when conventional surgical modalities are impractical. Local inflammatory reactions characterized by erythema, edema, crusting, burning, and pain are common (and, some would argue, desirable) but may be minimized by reduced frequency of application or use in combination with a topical corticosteroid. 

Fluorouracil is used in several combination regimens in the treatment of breast cancer. It also has palliative activity in gastrointestinal adenocarcinomas, including those originating in the stomach, pancreas, liver, colon, and rectum. Other tumors in which some antitumor effects have been reported include carcinomas of the ovary, cervix, oropharynx, bladder, and prostate. Topical 5-fluorouracil cream has been useful in the treatment of premalignant keratoses of the skin and superficial basal cell carcinomas, but it should not be used in invasive skin cancer. 

Fluorouracil, a fluorinated pyrimidine antimetabolite is used topically for the treatment of multiple actinic keratoses and intralesionally for keratoacanthomas. 

Imiquimod is an immune response modifier shown to be effective in the topical treatment of external genital and perianal warts (ie, condyloma acuminatum see Chapter 61). The 5% cream is applied three times weekly and washed off 6-10 hours after each application. Recurrences appear to be less common than after ablative therapies. Imiquimod is also effective against actinic keratoses, and possibly, molluscum contagiosum. Local skin reactions are the most common side effect these tend to resolve within weeks after therapy. However, pigmentary skin changes may persist. Systemic adverse effects such as fatigue and influenza-like syndrome have occasionally been reported. 

Imiquimod (Aldara) is an immunomodulator approved for the treatment of external genital and perianal warts in adults, actinic keratoses on the face and scalp, and biopsy-proven primary basal cell carcinomas on the trunk, neck, and extremities. The mechanism of its action is thought to be related to imiquimod s ability to stimulate peripheral mononuclear cells to release interferon- and to stimulate macrophages to produce interleukins-1, -6, and -8, and tumor necrosis factor- (TNF-k). 

Imiquimod should be applied to the wart tissue three times per week and left on the skin for 6-10 hours prior to washing off with mild soap and water. Treatment should be continued until eradication of the warts is accomplished, but not for more than a total of 16 weeks. Recommended treatment of actinic keratoses consists of twice-weekly applications on the contiguous area of involvement. The cream is removed after approximately 8 hours with mild soap and water. Treatment of superficial basal cell carcinoma consists of five-times-per-week application to the tumor, including a 1-cm margin of surrounding skin, for a 6-week course of therapy. 

Fluorouracil is a fluorinated pyrimidine antimetabolite that resembles uracil, with a fluorine atom substituted for the 5-methyl group. Its systemic pharmacology is described in Chapter 54. Fluorouracil is used topically for the treatment of multiple actinic keratoses. 

A topical 3% gel formulation of the nonsteroidal anti-inflammatory drug diclofenac (Solaraze) has shown moderate effectiveness in the treatment of actinic keratoses. The mechanism of action is unknown. As with other NSAIDs, anaphylactoid reactions may occur with diclofenac, and it should be given with caution to patients with known aspirin hypersensitivity (see Chapter 36). 

Imiquimod (Aldara , a heterocyclic imidazoquinoline amide (the structure of which is shown in Fig. 2), is an immune response modifier that has potent antiviral and antitumor activities [12-16]. Imiquimod and resiquimod (the structure of which is also shown in Fig. 2) have been shown to be topical immune response modifiers [17]. Imiquimod is approved for the treatment of actinic keratoses, superficial basal cell carcinomas and warts it has also... 

Tear duct fibrosis develops in one of six patients with excessive lacrimation from fluorouracil (66). The eversion of the lower eyelid is reversible with conservative management (68) while the tear duct fibrosis may not be (69). Persistent lacrimation has been described in six patients receiving intravenous fluorouracil weekly for 6-10 months (69). Lacrimation persisted in five patients after the withdrawal of fluorouracil, suggesting an irreversible dacryostenosis. Lacrimal duct stenosis has also been reported (70). Bilateral cicatricial ectropion was also reported in a patient after topical administration of fluorouracil for the treatment of multiple facial actinic keratoses (71). If ectropion and tear duct stenosis progress, surgical correction may be required. 

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