Table 1. Prescription only-topical therapies for actinic keratosisa3
RegimeIndicationPossible complications/ Tips on treatmentSuccess rate
Diclofenac 3% gel Twice daily for 60–90 days, maximum 8 g per day.Grade 1 AK with or without field change.Pruritus (41%), rash (40%), xerosis, and erythema.Caution – Usually well tolerated but after the course has been completed AK tend to recur.19%–70%
5-flurouracil 5% cream Once daily for 3–4 weeks or twice daily for up to 3 weeks (lower limbs may require longer treatment duration).Cycle can be repeated a month later if AK persists.All grades of AK with or without field change.Local irritation, pain, dryness, erythema, erosion, or oedema.Tip - Test on a small area first and then, if tolerated, treat further sections of field damage.Tip - Side effects can be minimalised by reducing the frequency of application, taking short breaks in the course of treatment or, if needed, applying topical corticosteroid such as clobetasone butyrate.Tip – Application of urea-based emollients before applying 5-flurouracil can enhance the effect.Caution – Ulceration and slow healing are possible on lower legs.70%–78%
5-flurouracil 0.5% cream with salicylic acid 10% Once daily for up to 12 weeks (maximum area of treatment is 25 cm2 at one time).Grade 2 and 3 AK without field change.Moderately thick hyper-keratotic AK lesions.Local inflammatory reaction.Caution - Patients with severe hand arthritis or limited hand dexterity will find it difficult to use the applicator to apply the treatment and peel off the film.55%–77%
Imiquimod (5% cream)Apply at night and washed off 8 hours later, three times a week for 4–6 weeks.Non-hyper-keratotic and non-hypertrophic AK on face and scalp in immunocompetent patients.Second line treatment for AK resistant to 5-flurouracil.Severe erythema, scabbing, crusting, erosions, ulceration, and flu-like symptoms (rare).Tip - Side effects can be minimalised by reducing the frequency of application, taking short breaks in the course of treatment, using lower strength 3.75% imiquimod cream, or applying a topical corticosteroid such as clobetasone butyrate.50%–84%
  • a All topical treatments, except for imiquimod 5% cream, may be initiated by GPs depending on the local area prescribing policy. Imiquimod 5% cream is a specialist-initiated treatment in the UK. All treatments can be applied by patients at home by themselves or with help from family. Please refer to manufacturer’s instructions as to the maximum area of application of the treatment.