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    Best practices for treating severe sun damage

     

    Common scenarios

    Dr. Jambusaria offers a few scenarios that dermatologists might typically encounter in practice.

    Scenario #1: A patient with diffuse actinic keratosis/field cancerization on the face, many of which are hyperkeratotic, who failed treatment with topical 5 fluorouracil.

    Treatment options include multimodality treatment with curettage of hyperkeratotic actinic keratosis, followed by five days of 5 fluorouracil twice daily, followed by photodynamic therapy with 1 hour incubation. The patient most likely failed treatment because of hyperkeratotic lesions, which made it impossible for the medication to penetrate below the scaling, she says. Another potential problem is many patients do not adhere to topical 5 fluorouracil treatment because of the therapy’s side effect profile, Dr. Jambusaria says. 

    “This multimodality treatment allows to direct aggressive treatment to the most hyperkeratotic areas by curettage and limits the length of therapy and time that the skin will be red/inflamed by priming the skin with topical 5 fluorouracil before photodynamic therapy,” she says. “Most patients are red/inflamed for 14 days total, with the worst being three days after PDT. This is in stark contrast to the anticipated three to four weeks quoted by most dermatologists who prescribe topical 5 fluorouracil (assuming a two-week use followed by [a] one-to-two week recovery period).”

    Scenario #2: Patient develops five to 10 SCCs in one area in the past 12 months.

    Treatment options include cyclic photodynamic therapy. In this treatment, patients get blue light photodynamic therapy with one hour incubation every four to eight weeks, for an extended period of time, according to Dr. Jambusaria.

    “In a clinical trial of high-risk patients, cyclic PDT caused a 95 percent reduction in squamous cell carcinomas at the 2 year mark,” she says.

    Another option is the use of oral retinoids. Based on anecdotal experience, patients who develop more than five SCCs in a 12-year period are good candidates to go on Soriatane (acitretin, Stiefel). In a study of 38 patients3 with multiple SCCs, half who were treated with Soriatane and half with placebo, Two of the 19 (or 11 percent) in the treatment group versus nine of 19 (47 percent) in the placebo group developed SCC during the study period.

    Soriatane must be taken long term because if it is stopped, the rate of SCC development increases to what it was before the drug was started, according to Dr. Jambusaria.

    Patients must be counseled on Soriatane risks and their lab work closely monitored, she says.

    NEXT: Derms know best

    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.

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