1MD/MBA/MPH Candidate at Yale University, New Haven, CT, USA
2Baylor College of Medicine, Houston, TX, USA
3Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
4Pacific Dermaesthetics, Vancouver, BC, Canada
Conflict of interest:
Jason Rivers has been a consultant for Almirall; Harrison Nguyen has no conflicts to report.
Actinic keratosis (AK), a common cutaneous lesion with the potential to transform into squamous cell carcinoma, has traditionally been treated with ablative and/or surgical procedures. Recently, a topical formulation combining 0.5% 5-fluorouracil with 10% salicylic acid (5-FU-SA) was introduced in Europe under the trade name Actikerall™ for the treatment of grade I/II AK. In a single randomized phase III trial, 5-FU-SA was shown to be superior to diclofenac 3% gel in hyaluronic acid, as measured by the histological clearance of one defined lesion (72% vs. 59.1%) and by complete clinical clearance (55.4% vs. 32.0%). 5-FU-SA should be applied once daily to a total area of up to 25 cm2, which may include the lesion(s) and a small area of surrounding skin (rim of healthy skin should not exceed 0.5 cm), for up to 12 weeks. The most commonly reported side effects are local inflammation and pruritus at the application site, and no serious adverse effects have been reported to date. Now commercially available in Canada, 5-FU-SA represents a patient-applied therapeutic option for the treatment of both overt and subclinical AK.
- Actinic keratosis (AK) is a lesion considered to be on a continuum with squamous cell carcinoma (SCC).1-6
- Invasive disease occurs in up to 10% of cases over time, which highlights the need for early recognition and adequate treatment of all AK, including subclinical lesions.7
- Although many AK never progress to SCC, their treatment has been recommended to preempt this eventuality.
- Treatment options can generally be stratified based on whether only discrete lesions are treated, or whether subclinical lesions are also targeted, which is referred to as field-directed therapy.
- Lesion-directed therapy has historically consisted of ablative and/or surgical procedures. However, several topical agents have emerged as attractive alternatives in the treatment of AK.
- Examples of topical agents available in Canada include 5-fluorouracil (5-FU), imiquimod (2.5%, 3.75%, and 5% formulations), diclofenac 3%, methylaminolevulinate/aminolevulinic acid (for photodynamic therapy), and ingenol mebutate.8
- In one controlled clinical trial, topical 5-FU applied to AK resulted in a 96% clearance after 4 weeks of twice daily application.9 However, high rates of severe localized tissue reactions with 5-FU have led to reduced patient compliance, and this, in part, may explain why the long-term clearance of AK in clinical practice is around 50%.8
- This problem has resulted in a search for therapeutic agents less likely to induce skin irritation.10
- In 2011, a topical formulation combining 0.5% 5-FU with 10% salicylic acid (5-FU-SA) was introduced to the European market under the trade name Actikerall™ for the topical treatment of grade 1/2 AK (slightly palpable and/or moderately thick hyperkeratotic lesions) in immunocompetent adult patients.11,12 This preparation is not novel as the same agent has been used in Europe for more than 30 years in the treatment of plantar warts (Verrumal®).
In this brief review, we present some of the clinical data to support the use of 5-FU-SA in patient-directed* management of AK and we summarize the salient information that the provider should be aware of when prescribing this product.
*Health Canada has elected to classify Actikerall™ as neither lesion-directed nor field-directed. This was done to support the individual needs of patients; the locational distribution of a patient’s lesions will dictate whether a lesion-directed versus a field-directed approach is preferred.
Evidence from Clinical Trials
- The primary evidence used to support the efficacy of 5-FU-SA in the treatment of AK comes from a single randomized, multi-center, phase 3 trial.13 The study included 470 patients with histologically diagnosed AK on the face, forehead, or bald scalp. Subjects were randomly assigned to 5-FU-SA, diclofenac 3% gel in hyaluronic acid (diclofenac HA), or placebo (5-FU-SA vehicle). Treatment was continued until either complete resolution of the lesions was evident, or for a maximum of 12 weeks.
- Subjects were instructed to apply their assigned intervention directly to their lesions – once daily for the 5-FU-SA and vehicle groups and twice daily for the diclofenac group.
- The primary outcome – histological clearance of one defined lesion within 8 weeks of treatment cessation – was achieved in 72.0%, 59.1%, and 44.8% of patients treated with low-dose 5-FU-SA, diclofenac and placebo, respectively.
- In addition to the histological data, the rate of complete clinical clearance was also highest in the study group (55.4% vs. 32.0% and 15.1% for 5-FU-SA, diclofenac HA, and vehicle groups, respectively).13 Similar to the temporary lesion increase associated with other topical therapies, an ephemeral increase in mean lesion area was observed only in patients treated with 5-FU-SA at week 2.
- However, by the end of the treatment period, reduction in mean lesion area was more evident in the study medication group compared to the comparator and placebo groups.
- In a more recent non-interventional study, a reduction in number and size of AK after 0.5% 5-FU-SA therapy was observed even after a short period of use: target results were achieved in approximately half of patients within 6 weeks of treatment commencement.15
- Another study assessed the efficacy of low-dose 5-FU-SA versus cryosurgery in patients with grade II/III hyperkeratotic AK.16 In this open labelled, randomized trial, patients with histologically confirmed AK received either a 6-week course of once daily topical 5-FU-SA applied directly to lesions or up to two cryosurgical treatments spaced 3 weeks apart.
- 5-FU-SA achieved greater histological clearance as measured by mean lesion area and lower recurrence of lesions compared to cryosurgery at the 6-month follow-up.
- In the phase 3 mentioned above13, about 95% of patients in the study medication group reported treatment-emergent adverse effects (TEAEs), with local inflammation and pruritus at the application site being the most common.
- Approximately 60% of patients in the vehicle group also reported application site burning, suggesting the etiology of this sensation was likely related to dimethyl sulfoxide, which facilitates tissue absorption and is a known irritant present in the 5-FU-SA excipients.
- For patients who have difficulty tolerating the side effects, dosing can be reduced from daily applications to treatment three times a week.
- In spite of the relatively high rate of TEAEs, patients have reported a high level of satisfaction with the use of low-dose 5-FU-SA.15
- No serious adverse effects directly related to 5-FU-SA treatment, including usage as Verrumal® for warts, have been reported in either clinical studies or post-marketing surveillance.
Dosing and Administration
- Actikerall™ is a transparent, colorless to slightly orange-white solution that is packaged in 25 mL glass bottles, accompanied by a nylon brush that allows for easy application. It is recommended for application once daily to a total area of up to 25 cm2, which may include the lesion(s) and a small area of surrounding skin (rim of healthy skin should not exceed 0.5 cm), for up to 12 weeks (Table 1).
|Drug Profile for Actikerall™|
|Form/strength||Solution/0.5% fluorouracil and 10% salicylic acid|
|Nonmedicinal ingredients||Dimethyl sulfoxide, ethanol, ethyl acetate, pyroxyline, poly(butyl methacrylate, methyl methacrylate)|
|Dosing and administration||Apply to AK in an area of up to 25 cm2 once daily until the lesion have completely cleared or for up to a maximum of 12 weeks. Apply directly to lesions and up to 0.5 cm rim of healthy surrounding skin.|
|Contraindications||Hypersensitivity to fluorouracil, capecitabine, or salicylates; contact with the eyes or mucous membranes; pregnant or in the lactation period; renal insufficiency; should not be used in conjunction with brivudine, sorivudine and analogues; known dihydropyrimidine dehydrogenase deficiency|
|Table 1: Summary of drug information20|
- If the lesions are located in areas with thin epidermis, the solution may be applied less frequently (e.g., 3 times per week).
- The solution should be allowed to dry on the skin but prior to re-application on subsequent days, the existing film should be peeled off, which can be facilitated by using warm water.
- A significant reduction in lesions is usually seen within 6 weeks of starting treatment, and patients most likely to benefit from the full 12-week course are those who have failed previous treatments with other modalities.15
- Patients should be advised that lesions may continue to regress for up to 8 weeks after cessation of therapy.
- 5-FU-SA is contraindicated for use during lactation or pregnancy. Other contraindications include renal insufficiency and concurrent usage of brivudine, sorivudine, or similar analogues. Of note, although these agents are structurally similar to acyclovir, which does not inhibit dihydropyrimidine dehydrogenase to any significant extent and is therefore safe to administer concurrently with 5-FU-SA.
- Additionally, instances of phenytoin toxicity related to the concurrent use of topical 5-FU-SA have been reported, so these patients should be tested at monthly intervals for plasma levels of phenytoin when this combination of therapies exists.11
- 5-FU-SA should not be applied on bleeding lesions and has not been evaluated for the treatment of recurrent lesions.
- Patients should be educated on FU-SA’s flammability, propensity to desiccate quickly (the bottle needs to be closed tightly after use and it should be discarded if crystallization occurs), and ability to cause permanent stains on textiles and acrylics.
5-FU-SA represents a new addition to our treatment of AK, especially
for individuals who want to avoid the pain or potential consequences
associated with destructive therapy for isolated lesions. An emerging
role for 5-FU-SA may be in combination therapy with other agents
that have been unsuccessful in clearing hyperkeratotic lesions in the
- Marks R, Rennie G, Selwood TS. Malignant transformation of solar keratoses to squamous cell carcinoma. Lancet. 1988 Apr 9;1(8589):795-7.
- Cockerell CJ. Histopathology of incipient intraepidermal squamous cell carcinoma (“actinic keratosis”). J Am Acad Dermatol. 2000 Jan;42(1 Pt 2):11-7.
- Ehrig T, Cockerell C, Piacquadio D, et al. Actinic keratoses and the incidence of occult squamous cell carcinoma: a clinical-histopathologic correlation. Dermatol Surg. 2006 Oct;32(10):1261-5.
- Quaedvlieg PJ, Tirsi E, Thissen MR, et al. Actinic keratosis: how to differentiate the good from the bad ones? Eur J Dermatol. 2006 Jul-Aug;16(4):335-9.
- Fuchs A, Marmur E. The kinetics of skin cancer: progression of actinic keratosis to squamous cell carcinoma. Dermatol Surg. 2007 Sep;33(9):1099-101.
- Criscione VD, Weinstock MA, Naylor MF, et al. Actinic keratoses: Natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial. Cancer. 2009 Jun 1;115(11):2523-30.
- Stockfleth E, Ortonne JP, Alomar A. Actinic Keratosis and field cancerisation. Eur J Dermatol. 2011 Feb; 21(Suppl 1):3-12.
- Samrao A, Cockerell CJ. Pharmacotherapeutic management of actinic keratosis: focus on newer topical agents. Am J Clin Dermatol. 2013 Aug;14(4):273-7.
- Krawtchenko N, Roewert-Huber J, Ulrich M, et al. A randomised study of topical 5% imiquimod vs. topical 5-fluorouracil vs. cryosurgery in immunocompetent patients with actinic keratoses: a comparison of clinical and histological outcomes including 1-year follow-up. Br J Dermatol. 2007 Dec;157 Suppl 2:34-40.
- Perl M, Goldenberg G. Field therapy in the treatment of actinic keratosis. Cutis. 2014 Apr;93(4):172-3.
- The electronic Medicines Compendium (eMC). Actikerall 5mg/g and 100mg/g cutaneous solution. Summary of product characteristics. Almirall Limited, Uxbridge, Middlesex, UK. Last updated June 4, 2014.
- Olsen EA, Abernethy ML, Kulp-Shorten C, et al. A double-blind, vehicle-controlled study evaluating masoprocol cream in the treatment of actinic keratoses on the head and neck. J Am Acad Dermatol. 1991 May;24(5 Pt 1):738-43.
- Stockfleth E, Kerl H, Zwingers T, et al. Low-dose 5-fluorouracil in combination with salicylic acid as a new lesion-directed option to treat topically actinic keratoses: histological and clinical study results. Br J Dermatol. 2011 Nov;165(5):1101-8.
- Frost C, Williams G, Green A. High incidence and regression rates of solar keratoses in a Queensland community. J Invest Dermatol. 2000 Aug;115(2):273-7.
- Szeimies RM, Dirschka T, Prechtl A, et al. Efficacy of low-dose 5-fluorouracil/salicylic acid in actinic keratoses in relation to treatment duration. J Dtsch Dermatol Ges. 2015 May;13(5):430-8.
- Simon JC, Dominicus R, Karl L, et al. A prospective randomized exploratory study comparing the efficacy of once-daily topical 0.5% 5-fluorouracil in combination with 10.0% salicylic acid (5-FU/SA) vs. cryosurgery for the treatment of hyperkeratotic actinic keratosis. J Eur Acad Dermatol Venereol. 2015 May;29(5):881-9.