DEPARTMENTS: Teledermatology Viewpoint
The store-and-forward feature of teledermatology allows patient medical information (including history and visual data) obtained from one provider’s location to be electronically transferred to a provider in another location (Roman & Jacob, 2014). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
Pruritus and pain of the forehead onset within the last 10 days.
History of Present Illness
A 62-year-old gentleman presents 10 days after initiation of twice-daily 5-fluorouracil (5-FU) 5% cream application. He has a history of nonmelanoma skin cancer and has had cryotherapy for actinic keratosis in the past. His primary symptom: pruritus and soreness. He is concerned about his appearance. Prior biopsy: none.
Image Quality Assessment
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided, showing discrete erythematous, inflamed, scaled, and crusted papules involving the left temple and forehead (Figure 1). There are notable areas of sparing and primary involvement in sun-exposed skin.
Interpretation of Images
There appears to be an appropriate inflammatory response to the 5-FU in the areas of actinic damage and keratosis. There is no evidence of infection.
Skin Care and Treatment Recommendations
Please reassure patient that this response is appropriate. Given that he has used the 5-FU for 10 days, he may discontinue use at this time. He may apply cool compresses and a ceramide-containing emollient to the affected area to promote healing. Spot treatment with a midpotency topical corticosteroid may be used twice daily for 3–5 days for symptom control. Continue to keep the treated area protected from the sun.
No referral to dermatology needed. Recommend follow-up with referring provider at 3–4 months.
Actinic keratoses (AKs) are precancerous lesions commonly caused by nonionizing radiation, notably ultraviolet radiation. As these lesions may progress to squamous cell carcinomas, field (area) treatment may be indicated when AK counts or frequency of presentation is high (Ingham & Weightman, 2014). Cryotherapy is considered the first-line standard of treatment for isolated lesions. Common side effects of cryotherapy are mild, including pain, scarring, and change in pigmentation. Limited side effects and complete clearance rates up to 88% at 6 months make cryotherapy a preferred treatment (Dréno et al., 2014).
For multiple lesions involving >1% body surface area, cryotherapy becomes an unsuitable treatment, and chemopreventive topical therapy may be considered. Topical 5-FU is a cytotoxic agent that irreversibly binds to thymidylate synthase—destroying rapidly dividing cells—and is commonly used to treat multiple widespread lesions (Dréno et al., 2014). It has been shown to significantly reduce AK counts (3.0 vs. 8.1, p < .001, at 6 months) and extend time between need for spot treatments over 2 years (Pomerantz et al., 2015). Side effects of field treatment include irritation, erosion, dryness, pruritus, burning, pain, and edema at the site of application (Kaur, Alikhan, & Maibach, 2010).
Dréno B., Amici J. M., Basset-Seguin N., Cribier B., Claudel J. P., … AKTeam. (2014). Management of actinic keratosis
: A practical report and treatment algorithm from AKTeamTM
expert clinicians. Journal of the European Academy Of Dermatology & Venereology
, 28(9), 1141–1149. doi:10.1111/jdv.12434
Ingham A. I., Weightman W. (2014). The efficacy and safety of topical 5% 5-fluorouracil
in renal transplant recipients for the treatment of actinic keratoses. Australasian Journal of Dermatology
, 55(3), 204–208. doi:10.1111/ajd.12158
Kaur R. R., Alikhan A., Maibach H. I. (2010). Comparison of topical 5-fluorouracil
formulations in actinic keratosis
treatment. Journal of Dermatological Treatment
, 21(5), 267–271. doi:10.3109/09546630903341937
Pomerantz H., Hogan D., Eilers D., Swetter S. M., Chen S. C., Jacob S. E., … Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) Trial Group. (2015). Long-term efficacy of topical fluorouracil cream, 5%, for treating actinic keratosis
: A randomized clinical trial. JAMA Dermatology
, 151(9), 952–960. doi:10.1001/jamadermatol.2015.0502
Roman M., Jacob S. E. (2014). Teledermatology: Virtual access to quality dermatology care and beyond. Journal of the Dermatology Nurses’ Association
, 6(6), 285–287. doi:10.1097/JDN.0000000000000086
1The standardized teledermatology reader report format is available for authors on the journal’s Web site (www.jdnaonline.com) and on the submissions website online at http://journals.lww.com/jdnaonline/Documents/Teledermatology%20Column%20Template.pdf.