Photodamage/Actinic Keratosis

NHSL Medicines Guidance
NHS Lanarkshire

Prescribing Notes: Actinic Keratosis of Face/Scalp

Single scattered lesions

FLUOROURACIL 5% cream

or

FLUOROURACIL 0.5% AND SALICYLIC ACID 10% solution

Small field (25cm2) / clusters

FLUOROURACIL 5% cream

or

IMIQUIMOD 5% cream in single-use sachets

Large field (25 – 200cm2)

FLUOROURACIL 5% cream

or

DICLOFENAC 3% gel

or

IMIQUIMOD 3.75% cream in single-use sachets

Prescribing Notes: Actinic Keratosis of Trunk/Limbs

Single scattered lesions

FLUOROURACIL 5% cream

Small field (25cm2) / clusters

FLUOROURACIL 5% cream

Large field (25 – 200cm2)

DICLOFENAC 3% gel

or

FLUOROURACIL 5% cream

DO NOT PRESCRIBE: Ingenol Mebutate for Actinic Keratosis

Ingenol mebutate 150micrograms/g and 500micrograms/g (Picato®) gel has been removed from the formulary. This is following MHRA Drug Safety Update February 2020 and EMA review April 2020.

Advice for healthcare professionals:

  • Stop supplying the above products immediately. Quarantine all remaining stock and return it to your supplier using your supplier’s approved process.
  • Stop prescribing Picato® and consider other treatment options as appropriate. For patients who have recently been prescribed Picato®, advise patients to be vigilant for any skin lesions developing and to seek medical advice promptly should any occur.
  • Reminder - report any suspected adverse reactions via the Yellow Card Scheme website or search for MHRA Yellow Card in the Google Play or Apple App Store.

Preparations

Preferred list (P)

FLUOROURACIL 5% cream (Efudix®)

Total list (T)

FLUOROURACIL WITH SALICYLIC ACID (Actikerall®) solution

  • Fluorouracil 0.5% with salicylic acid 10%.
  • Indication - treatment of slightly palpable and/or moderately thick hyperkeratotic actinic keratosis (grade I/II) in immunocompetent adult patients.

DICLOFENAC SODIUM 3% gel (Solaraze®)

  • Duration of therapy is from 60 to 90 days. Complete healing of the lesion(s) or optimal therapeutic effect may not be evident for up to 30 days following cessation of therapy.
  • A maximum of 8 grams daily should not be exceeded. Long term efficacy has not been established.

Specialist initiation (S1)

IMIQUIMOD 5% cream (Aldara®)

  • Indication - clinically typical, nonhyperkeratotic, nonhypertrophic actinic keratoses on the face or scalp in immunocompetent adult patients when size or number of lesions limit the efficacy and/or acceptability of cryotherapy and other topical treatment options are contraindicated or less appropriate.

IMIQUIMOD 3.75% cream (Zyclara®) 

  • Indication - clinically typical, nonhyperkeratotic, nonhypertrophic, visible or palpable actinic keratosis of the full face or balding scalp in immunocompetent adults when other topical treatment options are contraindicated or less appropriate.
  • SMC restriction: for the treatment of large field actinic keratosis (>25cm2).

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.