Una puesta al día en el tratamiento de las queratosis actínicas / An update on the treatment of actinic keratosis

Las queratosis actínicas son una de las causas más frecuentes de consultas dermatológicas. Están consideradas como lesiones premalignas que pueden evolucionar a carcinoma espinocelular invasor. Constituyen un marcador de fotodaño y actualmente se consideran como modelo de cancerización de campo. Existen diversos tipos de tratamientos que se clasifican en terapias dirigidas a la remoción de la lesión (crioterapia y / o quirúrgicos) y terapias dirigidas al campo de cancerización que incluyen: inmunomoduladores tópicos (imiquimod y diclofenaco), agentes quimioterapéuticos (5-Fluorouracilo y retinoides), Ingenol mebutato, dermoabrasión, peelings químicos, láser, terapia fotodinámica y terapias combinadas entre otras. El principal objetivo de esta revisión es realizar una actualización de las terapias dirigidas al campo de cancerización de las queratosis actínicas con sus respectivas indicaciones, ventajas y desventajas.

Actinic keratosis are one of the most common causes of dermatological consultation. Considered as premalignant lesions that can progress to invasive squamous cell carcinoma. Constitute a marker of photodamage and actually considered as a model of field cancerization. There are several types of treatments classified as therapies targeting the removal of the lesion (cryotherapy and / or surgery) and targeted therapies of field cancerization that include topical immunomodulators (imiquimod and diclofenac), chemotherapeutic agents (5-fluorouracil, and retinoids), ingenol mebutate, dermabrasion, chemical peels, laser, photodynamic therapy and combination therapies among others. The main objective of this review is to update therapies of field cancerization for actinic keratosis with their respective indications, advantages and disadvantages.

Pain evaluation in the cryosurgery of actinic keratoses.

BACKGROUND: Background: Actinic keratosis is a frequently-encountered premalignant lesion occurring in areas exposed to sunlight in fair-skinned elderly or middle-aged people. Cryosurgery with liquid nitrogen is the most common method for treating the lesions. OBJECTIVES: The primary objective of this study was to measure the intensity of pain during cryosurgery by using the Visual Analog Scale (VAS). We also sought to identify the pain level deemed appropriate by the patient, to assess the proportion of patients who considered it necessary to reduce the pain and, finally, to gauge whether or not additional analgesia was required. METHODS: Cross-sectional study with patients referred for cryosurgical treatment of actinic keratoses to the Sanitary Dermatology Outpatient Clinic. We applied a questionnaire to 112 patients [48 men (42.8%) and 64 women (57.2%)] after their treatment for actinic keratoses, asking them to assess the intensity of pain experienced during surgery and the pain that they considered to be bearable or appropriate for the procedure. RESULTS: The mean referred pain during surgery was 32.85 mm on the Visual Analog Scale, while the mean pain deemed appropriate by the patients was 23.01 mm. The difference between the two means was statistically significant (p <0.05). 30.4% of the patients reported in the direct and objective questionnaire that they needed the pain to be reduced. CONCLUSIONS: Although the level of pain considered to be appropriate by the patients was statistically lower than the referred pain, it did not reach the level at which it would be judged necessary to provide additional analgesia in this type of intervention.

Avaliação da dor em criocirurgia de ceratoses actínicas / Pain evaluation in the cryosurgery of actinic keratoses

FUNDAMENTOS: a ceratose actínica é lesão pré-maligna frequente, que ocorre em áreas expostas à luz solar, em pessoas idosas ou adultas de meia-idade e pele clara. A criocirurgia com nitrogênio líquido é a modalidade mais comum para o tratamento de ceratoses actínicas. OBJETIVOS: o objetivo primário deste estudo foi medir a intensidade da dor durante a criocirurgia, por meio da Escala Visual Análoga. Também buscou-se identificar o nível de dor considerado adequado pelo paciente, avaliar a proporção de pacientes que consideram necessária a diminuição da dor sentida e verificar a necessidade ou não de analgesia suplementar. MÉTODOS: Estudo transversal com pacientes encaminhados para terapêutica criocirúrgica de ceratoses actínicas no Ambulatório de Dermatologia Sanitária. Foram avaliados 112 pacientes, após tratamento de ceratoses actínicas, aplicando-se um questionário com perguntas sobre a intensidade da dor sentida durante o procedimento cirúrgico, assim como a dor considerada confortável ou adequada ao procedimento. RESULTADOS: participaram 48 homens (42,8 por cento) e 64 mulheres (57,2 por cento). A média da dor referida durante o procedimento cirúrgico, medida em milímetros na Escala Visual Análoga, foi de 32,85 mm; a média da dor considerada adequada pelos pacientes foi de 23,01 mm. A diferença entre as duas médias foi estatisticamente significativa (p<0,05). Em questionário objetivo e direto, a percentagem de pacientes que referiu ser necessária a diminuição da dor foi 30,4 por cento. CONCLUSÕES: embora a dor considerada adequada seja menor estatisticamente do que a sentida, não alcança níveis suficientes para que seja atribuída a necessidade de método de analgesia suplementar neste tipo de intervenção.

BACKGROUND: Background: Actinic keratosis is a frequently-encountered premalignant lesion occurring in areas exposed to sunlight in fair-skinned elderly or middle-aged people. Cryosurgery with liquid nitrogen is the most common method for treating the lesions. OBJECTIVES: The primary objective of this study was to measure the intensity of pain during cryosurgery by using the Visual Analog Scale (VAS). We also sought to identify the pain level deemed appropriate by the patient, to assess the proportion of patients who considered it necessary to reduce the pain and, finally, to gauge whether or not additional analgesia was required. METHODS: Cross-sectional study with patients referred for cryosurgical treatment of actinic keratoses to the Sanitary Dermatology Outpatient Clinic. We applied a questionnaire to 112 patients [48 men (42.8 percent) and 64 women (57.2 percent)] after their treatment for actinic keratoses, asking them to assess the intensity of pain experienced during surgery and the pain that they considered to be bearable or appropriate for the procedure. RESULTS: The mean referred pain during surgery was 32.85 mm on the Visual Analog Scale, while the mean pain deemed appropriate by the patients was 23.01 mm. The difference between the two means was statistically significant (p <0.05). 30.4 percent of the patients reported in the direct and objective questionnaire that they needed the pain to be reduced. CONCLUSIONS: Although the level of pain considered to be appropriate by the patients was statistically lower than the referred pain, it did not reach the level at which it would be judged necessary to provide additional analgesia in this type of intervention.

Cryopeeling for treatment of photodamage and actinic keratosis: liquid nitrogen versus portable system.

BACKGROUND: Cryopelling uses diffuse cryotherapy not only on lesions of actinic keratosis but all over the photodamaged skin. OBJECTIVES: The aim of this study was to compare two cryopeeling methods (liquid nitrogen- LN and portable system - PS) and demonstrate their efficiency in the treatment of actinic keratoses, patient tolerance, researcher and patient preference and aesthetic results. METHODS: Sixteen patients (N = 16) with multiple actinic keratoses on the forearms were subjected to cryopeeling with LN on one of the forearms and PS on the other, randomly. RESULTS: In the treatment of actinic keratoses, LN obtained 74% efficiency and PS, 62% (p = 0.019). The mean visual analogue scale (0-10) was 5.7 ± 1.61 with LN and 4.3 ± 1.44 with PS (p = 0.003). There was no significant statistical difference between the two methods in terms of researcher and patient preference. An analysis of the photos showed improvement of the skin appearance with both treatments (p <0.001). Treatment with LN obtained some degree of improvement in 62.5% of the cases, while treatment with PS obtained some degree of improvement in 52% of the cases (p> 0.05). DISCUSSION: Treatment with the PS showed better tolerance, but was less efficient than LN. Although LN has been the preferred method, there was no statistical difference between the methods. CONCLUSIONS: The cryopeeling technique may be an option in the treatment of photodamage. The PS can be an interesting alternative in clinical practice with good tolerance and acceptable results in the treatment of actinic keratoses.

Criopeeling para tratamento de fotodano e ceratoses actínicas: comparação entre nitrogênio líquido e sistema portátil / Cryopeeling for treatment of photodamage and actinic keratosis: liquid nitrogen versus portable system

FUNDAMENTOS: O criopeeling utiliza a crioterapia difusa não somente nas lesões de ceratose actínica, mas em toda a pele fotodanificada. OBJETIVOS: Comparar dois métodos de criopeeling (nitrogênio líquido e sistema portátil de éter dimetílico, propano e isobutano) quanto à eficiência no tratamento de ceratoses actínicas, tolerabilidade do paciente, preferência do paciente e do pesquisador e resultado estético. MÉTODOS: Dezesseis pacientes (n=16) com múltiplas ceratoses actínicas nos antebraços foram submetidos ao criopeeling com nitrogênio líquido em um dos antebraços e com o sistema portátil no outro, randomicamente. RESULTADOS: No tratamento das ceratoses actínicas, o nitrogênio líquido obteve 74 por cento de eficiência e o sistema portátil, 62 por cento (p=0,019). A média da escala visual analógica (0-10) foi 5,7±1,61 com o nitrogênio líquido e 4,3±1,44 com o sistema portátil (p=0,003). Não houve diferença estatística entre os métodos quanto à preferência do paciente e do pesquisador. Na análise das fotos, observou-se melhora do aspecto da pele nos dois tratamentos (p<0,001). Com o nitrogênio líquido, em 62,5 por cento das vezes houve algum grau de melhora; com o sistema portátil, em 52 por cento (p>0,05). CONCLUSÕES: A técnica de criopeeling pode ser uma opção no tratamento de fotodano. O sistema portátil pode ser uma alternativa interessante na prática clínica, com boa tolerância e resultados aceitáveis no tratamento de ceratoses actínicas.

BACKGROUND: Cryopelling uses diffuse cryotherapy not only on lesions of actinic keratosis but all over the photodamaged skin. OBJECTIVES: The aim of this study was to compare two cryopeeling methods (liquid nitrogen- LN and portable system - PS) and demonstrate their efficiency in the treatment of actinic keratoses, patient tolerance, researcher and patient preference and aesthetic results. METHODS: Sixteen patients (N = 16) with multiple actinic keratoses on the forearms were subjected to cryopeeling with LN on one of the forearms and PS on the other, randomly. RESULTS: In the treatment of actinic keratoses, LN obtained 74 percent efficiency and PS, 62 percent (p = 0.019). The mean visual analogue scale (0-10) was 5.7 ± 1.61 with LN and 4.3 ± 1.44 with PS (p = 0.003). There was no significant statistical difference between the two methods in terms of researcher and patient preference. An analysis of the photos showed improvement of the skin appearance with both treatments (p <0.001). Treatment with LN obtained some degree of improvement in 62.5 percent of the cases, while treatment with PS obtained some degree of improvement in 52 percent of the cases (p> 0.05). Discussion: Treatment with the PS showed better tolerance, but was less efficient than LN. Although LN has been the preferred method, there was no statistical difference between the methods. CONCLUSIONS: The cryopeeling technique may be an option in the treatment of photodamage. The PS can be an interesting alternative in clinical practice with good tolerance and acceptable results in the treatment of actinic keratoses.