Disseminated Superficial Actinic Porokeratosis :Treatment, Procedure, Cost And Side Effects

Disseminated Superficial Actinic Porokeratosis is a very uncommon skin condition that results in scaly spots, drying, ring-like scaly lesions on the skin which are as large as up to 10 mm each. The condition usually effects the areas of the forearms and legs. It is an inherited keratinisation disorder and is more common among people of European Descent. While the susceptibility to the disorder is inherited, Disseminated Superficial Actinic Porokeratosis is caused due to the thickening of the skin which is due to the result of sun exposure. It is due to the abnormal sun sensitivity leading to pre-cancerous skin cells. It is not a serious condition. If the spots are formed they seem to grow or itch after sun exposure.

The first step to treatment is to find the presence i.e diagnosis of the Disseminated Superficial Actinic Porokeratosis on the patient body. This requires, a skin specialist to examine the area especially thready rim on the edge. There may be a need to have a small shaving of skin removed for the purpose of the biopsy analysis so as to elimante the doubt of skin cancer. Once the diagnosis for the Disseminated Superficial Actinic Porokeratosis on the patient body is done the best thing one can do is avoid further sun damage by wearing long sleeves and using strong sunscreens. Prevention is the only treatment that can provide best relief. Unfortunately, there is no cure for Disseminated Superficial Actinic Porokeratosis. Even on the treatment side of things, there is very little that can be offered. Most patients of the condition undergo no treatment except that they need to avoid sun exposure. The few treatment methods that are available are expensive, temporary, with a lot of side effects and more importantly unnecessary. Some of the other options used for treatment are as follows:

1. Emollients (moisturizers) can be used the reduce the roughness and dryness of the lesions. However, they do nothing to reduce the size of the lesions or papules.
2. Cryotherapy is one possible treatment. Liquid nitrogen is sprayed on the lesion which destroys the abnormal cells in the lesions/papules.
3. Various creams such as 5-fluorouracil or imiquimod creams may be used to destroy the abnormal skin cells in the lesions that have formed due to sun exposure. Application of these creams can induce a remission in the patient.
4. Surgical methods constitute the most drastic option and are used when the lesions are too large to be managed by other simpler methods. It is a procedure conducted while the patient is under the influence of a local anaesthetic. The affected areas (lesions) are scraped off from the skin using a curette (a sharp spoon-like instrument). Surgical methods are necessary when the lesions have undergone malignant deformations.

There is no effective or permanent treatment for Disseminated Superficial Actinic Porokeratosis. The few available ways of treatment are temporary, painful, expensive and often have various side effects.

1. Use of creams such as 5-fluorouracil or imiquimod is one such method. 5-fluorouracil cream is applied regularly to the lesions for a few weeks The cream selectively destroys cells that have been damaged by the sun while not affecting healthy cells. The cream induces inflammation, in the form of redness, oozing, scabs, crusts, and soreness at the affected spot. Over a period of few weeks, the inflammation dies down leaving behind healthy skin. Imiquimod cream affects the immune system of the patient. The cream forces the immune system to recognize the abnormal cells, the immune system induces inflammation to remove the diseased cells.
2. Cryotherapy is another treatment used for DSAP. Liquid nitrogen is used to freeze the lesions. The low temperature destroys the abnormal cells while the targeted nature of the treatment ensures that unaffected cells are not harmed. Most patients also have too many lesions to freeze of all of them, therefore only the largest and the worst of the lesions can be frozen and destroyed.
3. Laser Therapy, also known as Red Light Therapy has become increasingly popular among DSAP patients in recent years as it has shown remarkable effects on patients. Red Light Therapy or photobiomodulation is the usage of light therapy in the form of infrared light which repairs the skin cells by means of increasing blood flow and collagen stimulation. RLT is different from other methods of treatment because it does not simply burn or destroy the damaged cells, the infrared light emitted through lasers stimulates tissue regeneration through augmented cell growth in the treated area. As a result, Red Light Therapy does not leave any scars and can be used as much as required without worrying about external scarring.

5-fluorouracil or imiquimod creams are generally used for patients with a low number of lesions, none of which are at any risk of malignancy. Since the application of these creams does not require any specialised equipment and the creams are readily available, they can be used by any patient. While it varies from case to case, the inflammation process is often painful and therefore should not be used by patients with low pain tolerances. Application of steroid creams may be recommended to reduce the inflammation and fasten the process.

Cryotherapy is used in case of patients where the number of lesions or papules is low which makes individually freezing and destroying the damaged cells an achievable goal. Red Light Therapy is used in case of widespread lesions of damaged skin. RLT is also the only known treatment that has been reported to have no side effects. While the treatment is mostly done in clinics, a variety of home treatment kits are also available. However, Red Light Therapy is still considered experimental and therefore is not covered by any insurance policy.

5-fluorouracil or imiquimod creams are to be used only when the patients have been shown to have no allergies to any of the major ingredients in the creams. A patch test must be administered before use of the creams is permitted. 5-fluorouracil or imiquimod creams have dangerous side effects and hence are not covered by insurance. As such, patients from low-income groups are advised to abstain from this treatment method. Use of cryotherapy is not practical in patients with a large number of lesions or papules as it is not practically viable to individually destroy all lesions. Cryotherapy also leaves behind significant scarring that often look worse than the original lesions. Patients who are bothered by scarring or those who are in no danger of developing malignant lesions could choose to not engage in this treatment method. Red Light Therapy is probably the safest and the least invasive of all treatment methods and therefore there is no specific group of people who should avoid it, however, the treatment is experimental and by no means, an FDA approved method of treatment. Patients who do not wish to dabble in experimental treatment methods should avoid this.

Some of the side effects of the treatment are as follows:

1. Side effects of 5-fluorouracil cream include redness, soreness oozing at the application site, muscle soreness, sun sensitivity etc.
2. Side effects of cryotherapy include excessive scarring at treatment site that may be worse than the original lesions.

Though there are no known side effects of Red Light Therapy. In case any patient reports any other complexity after undergoing the treatment the patient is advised to consult the doctor immediately.

After application of 5-fluorouracil or imiquimod creams, the application area must not be disturbed for 1 – 2 hours. Sun exposure should be avoided until the treatment cycle is completed. After a patient undergoes cryotherapy, there may be blister formation a couple of days later, followed by crusting that lasts for 3 weeks. Patients may be advised to apply a mild to moderately potent topical steroid and antibiotic combination. The treated area should be left open and washed gently with soap and water before being patted dry.

There are as such no post-treatment guidelines for red light therapy. Five minutes under the infrared laser is recommended daily for about two to 4 weeks for maximum effect.

Once the creams are applied, the area must not be disturbed for 1 to 2 hours. The creams must be applied daily for a minimum of two weeks or as recommended by a physician.The treatment recovery time varies from the patient condition to condition and differs from the mode of the treatment opted for the patient.

Recovery time for cryotherapy is about three weeks. The scabs and crusts formed as a result of cryotherapy take three weeks to completely heal. Red Light Therapy has no recovery time. After the recommended amount of time spent under the infrared laser, the patients are free to do and move about as they wish without any fear of ill effects.

5-fluorouracil creams cost about INR 150 will imiquimod creams are slightly more expensive at INR 300 to INR 400. Both creams are readily available in medical stores. Cryotherapy is an expensive treatment with average costs going up to INR 3,000 per treatment. The treatment is available at many dermatological clinics and high-end salons around the country. Red Light Therapy costs range from INR 1,000 to INR 3,500 per session in dermatological clinics and salons. At-home kits are available for INR 2,500 on Amazon.

Unfortunately, DSAP has no known cure. None of its treatments is permanent, most require multiple and frequent sessions in order to make some difference.

Apart from the treatments mentioned above, topical and oral retinoids may be used to decrease the risk of malignancy in the lesions. Calcineurin inhibitors and diclofenac gels, when applied to affected areas have shown some effect in treating DSAP. Surgical excision is the best method when the risk of malignancy is high. Most patients prefer to use precautionary methods such as avoiding sun exposure and consistent use of sunscreens rather than any substantial treatment options.