This handout is for actinic keratosis & keratinocyte carcinoma (bcc + cscc, dermatology lens). Your care team identified this based on: rough, scaly, sandpapery erythematous macules/papules on chronically photodamaged skin (face/scalp/ears/dorsal hands/forearms) — actinic keratosis on a cancerised field (aad 2018 cscc pmid 29331386).
Other reasons your team may use this plan: pearly, rolled-border telangiectatic papule or a non-healing/bleeding sore — basal cell carcinoma (aad 2018 bcc pmid 29331385); indurated, tender, rapidly growing, hyperkeratotic or ulcerated lesion → biopsy pivot for invasive cscc (aad 2018 cscc pmid 29331386); prior keratinocyte carcinoma / multiple aks / heavy cumulative photodamage — high recurrence + new-primary field (aad 2018 bcc pmid 29331385).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| cryotherapy_liquid_nitrogen_lesion_directed | — | — | — | AAD 2018 cSCC (PMID 29331386) — lesion-directed cryotherapy is highly effective for discrete AKs; does not treat the surrounding cancerised field, so combine with field therapy when field cancerisation is present. |
| fluorouracil | 5% (or 4%/0.5%) cream | topical | once–twice daily ×2–4 wk per regimen | AAD 2018 cSCC (PMID 29331386); four-treatment AK RCT (Jansen NEJM 2019 PMID 30855743) — topical 5-FU had the highest sustained efficacy of the four field treatments; brisk inflammatory reaction is expected and therapeutic. |
| imiquimod | 5% (or 3.75%) cream | topical | per regimen (e.g., 5% 2–3×/wk ×4 wk cycles; 3.75% daily ×2-wk cycles) | AAD 2018 BCC (PMID 29331385) + cSCC (PMID 29331386) — TLR7 agonist field therapy for AK and an option for low-risk superficial BCC where surgery is undesirable; expect a robust local inflammatory response. |
| tirbanibulin | 1% ointment | topical | once daily ×5 consecutive days | AAD-era newer agent — short 5-day field course for AK of the face/scalp with a favourable tolerability profile; recurrence may necessitate retreatment. |
| diclofenac | 3% gel (in hyaluronic acid) | topical | BID ×60–90 days | AAD 2018 cSCC (PMID 29331386) — topical diclofenac is a lower-irritation field option with slower onset and a longer course; modest clearance vs 5-FU. |
| calcipotriol | compounded with 5-FU (calcipotriol 0.005% + 5-FU 5%) | topical | BID ×4 days (immune-priming combination) | Short-course calcipotriol+5-FU drives a TSLP-mediated T-cell immune priming of the field with high short-course AK clearance and possible cSCC-protective immunity; combination field-immunotherapy adjunct. |
| photodynamic_therapy_field_directed | — | — | — | AAD 2018 cSCC (PMID 29331386) + BCC (PMID 29331385) — aminolevulinate/methyl-aminolevulinate photodynamic therapy gives excellent field clearance and cosmesis for AK, Bowen disease and superficial BCC where surgery is undesirable. |
Plan: AK & keratinocyte carcinoma — continuum-directed ladder (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386; advanced systemic routed to oncology)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Lifelong derm continuity: scheduled total-body skin exams (prior NMSC ≈ strongest predictor of the next; substantial cumulative new-primary risk), structured skin self-examination, rigorous photoprotection counselling, chemoprevention adherence (nicotinamide, acitretin for high-risk/transplant), field-cancerisation re-treatment as needed, transplant-team immunosuppression-modulation continuity, and Gorlin/xeroderma-pigmentosum familial/genetic counselling. Re-stage and re-route to oncology on recurrence/locally-advanced progression; reconcile any checkpoint-inhibitor cutaneous irAE with derm.drug-eruption.core.v1.
Guideline: AAD 2018 Guidelines of care for the management of basal cell carcinoma (Kim et al, JAAD; PMID 29331385, DOI 10.1016/j.jaad.2017.10.006) + AAD 2018 Guidelines of care for the management of cutaneous squamous cell carcinoma (Kim et al, JAAD; PMID 29331386, DOI 10.1016/j.jaad.2017.10.007) + comparative AAD/NCCN/ASTRO US-guideline analysis (Mittal & Mittal, J Skin Cancer 2024; PMID 38370137, DOI 10.1155/2024/3859066); trial anchors cemiplimab EMPOWER-CSCC (Migden NEJM 2018 PMID 29863979), vismodegib ERIVANCE (Sekulic NEJM 2012 PMID 22670903), nicotinamide ONTRAC (Chen NEJM 2015 PMID 26488693), four-treatment AK RCT (Jansen NEJM 2019 PMID 30855743), Mohs vs excision 5-yr RCT (Mosterd Lancet Oncol 2008 PMID 19010733), transplant keratinocyte-cancer cohort (PMID 28615224)