BI04: Short sharp shock or slow burn: immunocompromised patient perspectives on treatment of actinic keratoses with 5-fluorouracil 5% cream monotherapy versus 5-fluorouracil/calcipotriol ointment combination therapy

Muhammad Hyder Junejo,¹ Sibel Demirel,² Rubeta N. Matin,³ Charlotte Proby² and Catherine Harwood¹

¹Department of Dermatology, Royal London Hospital, London, UK; ²Department of Dermatology, Ninewells Hospital, Dundee, UK; and ³Department of Dermatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Actinic keratoses (AK) are a common problem in immunocompromised patients and are associated with an increased risk of cutaneous squamous cell carcinoma (cSCC). The current standard of care is 5-fluorouracil 5% cream (5-FU) monotherapy for 4 weeks. However, 5-FU cream and calcipotriol ointment (5-FU–Cal) combination therapy for 4–6 days may be more effective, although the original randomized controlled trials (2017/2019) excluded immunosuppressed patients. We surveyed immunosuppressed patients’ experiences of using both 5-FU monotherapy and combination 5-FU–Cal to evaluate their perspectives on real-world use of both topical AK treatments. Immunosuppressed patients attending specialist dermatology clinics who had received combination 5-FU-Cal over the past 12 months for treatment of AK and had previously been treated with at least one course of 5-FU monotherapy were identified in three specialist centres. We administered a clinician-delivered, structured questionnaire, which included details of previous therapy for AK and skin cancer history. Patients were asked about experience with combination 5-FU–Cal vs. 5-FU monotherapy in terms of convenience of use, effectiveness, severity and duration of local skin reactions (LSRs) and preferences for AK treatment. A total of 32 immunosuppressed patients were surveyed (25 men and seven women; mean age 66 years). This included organ transplant recipients (n = 28); patients with chronic lymphocytic leukaemia (n = 3); and one patient with Crohn disease on azathioprine (n = 1). Twenty-seven (84%) had a history of skin cancer. All had previously used 5-FU and 31 of 32 (97%) had received at least one other intervention for AK (cryotherapy, n = 28; surgery, n = 18; 5-FU/salicylic acid cutaneous solution, n = 11; imiquimod, n = 6; ingenol mebutate, n = 3; diclofenac gel, n = 2; photodynamic therapy, n = 4). Most patients (n = 26/32; 81%) reported that combination 5-FU–Cal was more effective than 5-FU monotherapy. LSRs for 5-FU–Cal vs. 5-FU monotherapy were reported as more severe in 15 of 32 (47%), equivalent in eight of 32 (25%) and less severe in seven of 32 (22%). The duration of LSR with 5-FU–Cal vs. 5-FU monotherapy was reported as shorter in 17 of 32 (53%), equivalent in nine of 32 (28%) and longer in four of 32 (12%). Overall, 28 of 32 (87%) preferred combination 5-FU–Cal vs. 5-FU monotherapy. This is the first evaluation of patient perspectives on the use of combination 5-FU–Cal in immunocompromised patients. The majority (81%) found that that combination 5-FU–Cal was more effective than 5-FU monotherapy and, despite 47% reporting worse LSRs, most would prefer to use the 5-FU–Cal combination in the future. These data provide a rationale for the inclusion of combination 5-FU–Cal therapy in future studies using topical AK treatments for cSCC prevention in immunosuppressed individuals.