Therapeutic strategies for actinic keratoses - a systematic review

An exponentially increasing incidence, malignant potential and economical interest have made actinic keratoses (AKs) a strategic healthcare issue. The debate whether AKs are precursor lesions or in situ cancers with a continuum towards invasive squamous cell carcinoma has faded, given the millions of affected individuals. Cumulative exposure to ultraviolet light and increasing life expectancy, together with an over-aged, therefore increasingly affected population, create responsibilities for clinicians. Guidelines in the UK (2007) and Europe (2011), meta-analyses and overviews of selected treatment options, as well as some selected combined treatment strategies, are available. No comprehensive overview providing explicit details of randomized studies, including the majority of approved and popular treatment options, and designating evidence-based criteria has been published so far, a goal desirable to avoid a biased perspective on therapeutic approaches. This review defines the state of art for destructive and topical treatment options based on randomized trials which meet criteria like > 30 patients in an intention-to-treat analysis, an easily reproducible study design with responses rated towards treatment as the major objective, measured as complete remission. Epidemiological data include grades and location of treated AKs, operational procedures, cryotherapy, laser therapy, 3% diclofenac in 2.5% hyaluronic acid, 2.5%, 3.75% and 5% imiquimod, 0.5% and 5% 5-fluorouracil, photodynamic therapy including ALA-patches. Sequential and combined approaches in daily practice and in developing study design might profit from the details of studies listed here. Divergent and treatment-specific proceedings, response rates after definite time intervals aiding physicians' further guidance and their management of patients are elucidated. Uncommon and new therapeutic options are discussed.