It can take up to 5-7 days before this treatment ‘kicks in.’ For the first few days most patients will not notice much, unless you are a ‘brisk reactor.’ This is the typical timeline of Efudex therapy, so don’t worry if you are not noticing any changes in the first few days.

• Day 0-5: Some mild redness, increasing as days go by. V. mild irritation
• Day 5-10: Significant redness, itch, crusting & irritation
• Day 10-14+ as above, some patients have erosions. Uncomfortable, stinging
• Healing: over 5-14 days or longer. Residual redness for a few months.

Your GP, skin cancer GP or dermatologist will arrange a follow up with you weeks to months post treatment. Comparison photos are used to gauge success. In some cases a skin biopsy is required to exclude skin cancer (resistant areas).

Fluorouracil may cause redness, soreness, scaling, & peeling of affected skin even after ceasing this medication. It can take up to 4-6 months before redness settles. In some cases topical chemotherapy can cause persistent redness.

The success rate of treating sunspots or solar keratosis is around 89%. To this day, it still remains as one of the best treatments for sun damage. Lasers & PDT (photodynamic therapy) has a similar clearance rate(slightly less), however the remission rate of Efudex – Efudix is higher. Needless to say, this chemotherapy in a tube is still a favourite amongst many dermatologists.

Many pluses here including-

• Cost effectiveness – one tube cost between 40 to 80 AUD
• Good efficacy & cure rate
• Readily available
• Long safety record

Several downsides of this topical including-

• Significant downtime of 2-8 weeks (red, scaly)
• Prolonged symptoms (itchy, sensitive, red, burning)
• Persistent redness for 2-6 months
• Does not address other factors such as pigmentation

In my practice I prefer laser therapy of solar keratosis as laser provides comparable clearance rates of 80-90%. The upside of laser is the quick recovery rate of 5-7 days, with less persistent redness (1-2 weeks).

Healing creams & ointments can be used after Efudex.

Your doctor will have their favourite topical. Sensible options include Vaseline- petrolatum, mineral oil, emollients & hydrating agents Most dermatologists will prescribe a short course of topical corticosteroids to reduce inflammation. A sensible CS is hydrocortisone ointment, 1% applied 3-4 times a day for 5 days only.The treated area can be pink for several months and is more susceptible to getting sunburned. Sunscreen is paramount.

There are multiple ways to manage  sun spots including Bowens/IECs. Treatment modalities will depend on the location and size of the cancer, the number of lesions, the degree of functional impairment and costs.  Each modality has both advantages and disadvantages.

Cryotherapy or liquid nitrogen

Liquid nitrogen can be an excellent method of treating IECs. Most cases will require a double –freeze cycle of cryotherapy. This treatment is not recommended for IECs below the knee, as poor healing may occur. Solar keratosis can be treated with this modality.

Creams

Imiquimod (Aldara), or 5-fluorouracil (Efudix) are effective in the treatment of Bowen disease & solar keratosis. Clinical studies have shown cure rates approaching 80-90%. Treatment appears to be most successful when these creams are applied for 6-16 weeks.

Curettage and Electrocautery

When small patches of IECs are present they may be treated via curettage and cautery. A local anaesthetic is given prior to the procedure to prevent pain and discomfort. Hypertrophic sun spots are also treated with this method.

Photodynamic therapy (PDT)

Photodynamic therapy or PDT can be an excellent non-surgical method of treating skin cancers such as Bowen’s/ IEC’ as well as sun spots. PDT uses  a photosensitive cream called 5-aminolevulinic acid or methyl aminolevulinate, that is applied to the skin cancer. The cancerous cells of Bowens/ IEC take up this chemical over a period of 3 hours. A low-level laser light then activates the chemical, and destroys the skin cancer cells. Patients will require two treatments spaced a week or two apart.

PDT is ideal for IECs on cosmetically sensitive areas such as the face, or for IECs that occur on the legs where healing can be a problem. PDT can also be used for multiple or large IECs. The benefit of PDT is that it selectively targets neoplastic cells without affecting the surrounding epidermis. This results in improved cosmetic outcomes, and faster healing times.

Laser therapy

Ablative lasers such as CO2 or erbium can be used to treat sun spots, precancerous lesions & IECs.

Surgery

Surgery is the ideal method of treating IECs in certain areas including-

• IECs associated in terminal hair bearing areas, such as the scalp or brows
• IECs that occur in the nail (periungual IECs)
• IECs that occur on the lip
• Recurrent IECs that fail to respond to other treatments.

Surgery has the highest cure rate for Bowens/ IECs but is an overkill for the mangement of sun spots.

Radiotherapy

Consider referral for consideration of radiotherapy for poor surgical candidates, or patients with multiple lesions.

Peels

I do perform medium to deep peels including Jessner-TCA or phenol croton oil peels for field changes, including solar keratosis. Mild sun damage can be treated with high strength AHA-glycolic acid 70%.

Efudex, which is used to treat actinic keratoses, a precancerous form of squamous cell carcinoma, can improve some age spots including pigmented solar keratosis. Other types of age spots such as flat warts, raised warts & sebaceous (oil) spots will not improve with Efudex. This is why I prefer 1927 Thulium high density laser resurfacing as lasers treat both sun damage, & age spots.

Natural remedies are not advised in the management of cancer & precancer lesions.  The followup data on natural remedies that contain sanguinarine (*such as Black salve, red salve & cansema) is lacking.  These remedies work by chemical destruction of the lesion. It is advisable to see a medical professional such as your GP, skin cancer GP or a medical dermatologist prior to treatment.

The best ‘natural’ treatment for precancerous lesions & intraepithelial cancers- superficial BBCs is dermabrasion. Sand is natural correct? Sanding down the layers of skin to the dermis will have a good remission rate. Sea salt dermabrasion is also natural. Discuss this technique with your naturopathic practitioner.

* Disclaimer: I do not treat pre-cancers with creams, my practice is procedural, namely laser, deep peels & injectables.

Discuss treatment options with your general practitioner. They can discuss treatment options with you. A referral to a dermatologist can be generated should you want to discuss other treatment options.