Criteria for guidelines
According to Dr. Stockfleth, the global AK guidelines were formulated under very rigorous conditions and were based on the clinical data from over 500 papers that were included in the extensive Cochrane review. The evidence in the papers was critically reviewed for quality, and the level of evidence for each modality was assessed and graded, the results of which were used to help generate different treatment recommendations for specific clinical scenarios, including patients with solitary AK lesions, multiple lesions (<5 AKs/region, and field cancerization), as well as high-risk AK lesions (i.e., high-risk location or occurring in immunosuppressed individuals such as organ transplant recipients).
The clinical data was vetted and therapeutic recommendations were made and based on a 5-point GRADE (Grading of Recommendations Assessment, Development and Evaluation) scale that included the range:
- Strong recommendation for use (“we recommend”)
- Weak recommendation for use (“we suggest”)
- No recommendation (“we cannot make a recommendation with respect to”)
- Weak recommendation against (“we suggest not to”)
- Strong recommendation against (“we recommend not to”)
“These global guidelines for AKs represent the highest level of evidence-based work that has ever been done on the subject of AKs. The goal of the S3 actinic keratosis guidelines program was to develop a deeper insight into what AKs are and to look at the safety and efficacy of the myriad of new drugs that are currently being used to treat actinic keratoses, as well as to provide a heightened global awareness of AKs and the optimal treatment modalities at our disposal,” Dr. Stockfleth says.
Choosing a treatment option
The development of AKs is a clear biologic signal that the patient has received too much cumulative sun exposure over the years. In these cases, not only can AKs arise, but basal cell carcinoma (BCC) and melanoma can develop as well. When presented with AKs, wary physicians will perform a thorough skin exam regularly, depending on the clinical presentation of the patient.
Therapy for actinic keratosis can basically be divided into lesion-directed treatment options (i.e., cryotherapy, electrodessication and curettage, laser surgery), and field-directed treatment options (i.e. imiquimod, ingenol mebutate, 5-FU, diclofenac, and PDT).
According to Dr. Stockfleth, all of the agents currently available are effective, and choosing the most effective agent and treatment regimen can depend on different factors, including:
- Severity/extent of the clinical presentation
- Downtime and tolerability
Need-to-know: 6 important trends in PDT treatment for AK
Disclosures: Dr. Stockfleth reports no relevant disclosures.
1. Werner RN, Jacobs A, Rosumeck S, Erdmann R, Sporbeck B, Nast A. Methods and Results Report - Evidence and consensus-based (S3) Guidelines for the Treatment of Actinic Keratosis -International League of Dermatological Societies in cooperation with the European Dermatology Forum. J Eur Acad Dermatol Venereol. 2015;29(11):e1-66.