Table 1.

Pearls to enhance therapeutic response and patient adherence to treatments for actinic keratoses

Treatment	Practical approach	Pearls to enhance therapeutic response	Pearls to improve patient adherence
Photoprotection	Use of sunscreens containing DNA-photolyase	Daytime use of a topical product (medical device) with DNA repair function paired with high sun protection in fluid presentation is an excellent option for patients with scalp lesions and alopecia	Light texture of the product allows perspiration and ensures adhesion especially among men, who may be more reluctant to use daily sun creams
5-FU	5-FU is a cost-effective treatment (more effective and less costly)	Use chemoprevention of squamous cell carcinoma (SCC) with 5% 5-FU twice daily for 1 month in high-risk patients	Short treatment duration (1 month) and fast improvement of FC signs If no available commercial formulations of 5-FU, it can be formulated in a Vaseline or Beeler base
PDT	PDT is an extremely versatile form of therapy	Gauze abrasion, scrub soaps, microdermabrasion or sandpaper are mechanical techniques to disrupt the stratum corneum and enhance skin penetration of the photosensitizer for a uniform and effective incubation Ablative fractional laser and microneedle can increase drug delivery and can shorten incubation time	To reduce pain:  Daylight-PDT as a first-choice procedure  Cold analgesia  Momentary interruption of PDT  Local nerve block  Single dose of NSAID prior to PDT  Listening to music or talking during the procedure
Imiquimod	Imiquimod is an effective form of immunotherapy	A 12-day uninterrupted course of imiquimod 5% instead of the intermittent scheme of 3 nights per week for 4 weeks can be an effective protocol for managing AK	A 12-day uninterrupted course of imiquimod 5% may increase adherence to therapy in clinical practice
Chemical peels	Chemical peels can be cost-effective when compared to invasive procedures	30–45% TCA is the most-used peel for treatment of FC Synergistic effect of glycolic acid peels and 5-FU. Glycolic acid can enhance penetration of 5-FU, as it decreases corneocyte cohesion	Choosing the right chemical peel, alone or in combination, is crucial to achieve good tolerance and predictability of results
Combined treatments in the clinic	Several procedures or in-home-treatments could be combined to optimize FC management approach	At-home treatments could be combined with in-clinic procedures Pretreatment with topical 5% 5-FU twice daily for 7 days prior to daylight-PDT can enhance therapeutic responses Chemical peels or fractionated ablative lasers could be combined with PDT to improve results	Use a repairing cream immediately after the procedure as a “fire extinguisher” (cooling effect) Keep creams in a refrigerator or immerse them in ice water before the procedure. Products containing triterpenes of Gotu kola Centella asiatica associated with rosehip oil are the best options Use of non-ablative energy devices, such as intense pulsed light or non-ablative Erbium-Glass 1550 nm laser, in patients in whom the recovery time due to their occupation needs to be minimal
Oral therapy	Nutricosmetics can be an excellent alternative in patients who do outdoor activities, as an adjuvant to topical photoprotection in susceptible populations	Nutricosmetics with Polypodium leucotomus, Vitis vinifera and green tea extract allows non-photoadapters to respond to therapeutic doses of daylight-PDT giving better tolerance to sun exposure and increasing the minimum erythemal dose Similar to PDT or topical therapy	Preferable to use nutricosmetics that can be prescribed once daily

FC Field cancerization, 5-FU 5-fluorouracil, PDT photodynamic therapy, SCC TCA trichloroacetic acid