In this feature video, Dr Neal Bhatia shares insights into his session, “What's New and Hot in AK Management,” presented at the 2024 Winter Clinical Hawaii Conference.

Neal Bhatia, MD, is a board-certified dermatologist in San Diego, California, and is a director of clinical dermatology at Therapeutics Clinical Research. He is, also, the president of the Pacific Dermatological Association, secretary-treasurer of the Noah Worcester Dermatologic Society, and vice president-elect of the AAD.

Can you go over what your session will cover regarding actinic keratosis management?

Dr Bhatia: So, my session at the Winter Clinical Conference in January, we'll talk about approaches to actinic keratosis (AK), taking into account the concept of, and with that meaning let's add treatments topically, liquid nitrogen photodynamic therapy, rather than thinking about, or because when we substitute or minimize, you know, the combination approaches, we're not really treating through the disease state or thinking about what's coming. I'm gonna be presenting some data on the large field, use of tirbanibulin which is gonna be very exciting. Tirbanibulin ointment came to market for 25 square centimeters, and now has, data for a hundred square centimeters, which will be great for larger surface areas of the face and scalp, even more. So, again, thinking in terms of when do we use topicals, when do we do live treatment, when do we freeze? And getting the maximum benefit of all the treatment options available to not only keep things away, but reduce skin cancer risk down the road. I'll talk a little bit about some of the chemo prevention strategies as well as, you know, optimizing photo protection. But really my goal is to get dermatologists off the ledge of, you know, not treating aggressively. We need to really think about not just freezing AKs and seeing them back, but treating through the disease state and making things stay away, not just go away.

What are the newest updates for AK management that physicians can look forward to or implement their practice?

Dr Bhatia: So, we're a few years removed from the guidelines for the actinic keratosis management through the academy, but since then there have been a lot of, discussion topics about when do we use photodynamic therapy? How many cycles per year is there good data to keep using PDT, either red light or blue light, and either strength of a LA, that it's optimum. And I'm a big believer in trying to treat at least a couple times a year. I like to treat patients before and after the time change, so that their minimal exposure to sunlight is, is optimized, but even more so, again, just thinking in terms of balancing out, you know, when are we treating around social events, around summer vacations or holidays? We wanna make sure patients don't look blotchy red and, you know, have, you know, downtime when they're in an airplane rather than in home, you know, away from light.

But at the same time, we wanna make sure they can optimize their topical management, and make sure they're getting the most out of managing the local skin reaction. So the focus is gonna be on strategies to minimize the local skin reaction, you know, and optimize tolerability, but still get the most out of treatment. Unfortunately, there haven't been any new therapeutic advances except for the combinations of fluorouracil and calcipotriol outside of tirbanibulin, and we're waiting to see if there's gonna be some new molecules down the road. So really, we have a toolbox that's pretty rich with, you know, ideas for, all different approaches, whether they be fluorouracil, imiquimod, and again, of course some of the destructive modalities we use in the office.

In your experience, what are the challenges and considerations when managing patients with skin cancer particularly in AK management?

Dr Bhatia: So, some of the opticals with AK management are, really not as much of function of, patients as they are my colleagues. I, I just think my, you know, a lot of dermatologists just don't fight for the drugs. They look at access as a pain in the neck to, you know, to try to battle for when really it doesn't take that much to optimize, you know, the specialty, pharmacy angle or, you know, trying to get drugs covered, from the right sources. That being said, I think there's just still a lot of trepidation on how to optimize, you know, the local skin reactions with different healing ointments, you know, topical anesthetics, you know, trying to avoid steroids when we can use other things that are nice for itch. There's a, a strontium based, anti-itch gel with some ceramides that works very well. There's some other, topical agents with promazine but even more so again, it's just when to do what, with patients I can kind of guide, it's like, okay, when are you going on vacation?

When do you have a photo shoot? You know, don't do anything the day before your kid's wedding. You know, things like that that are a little bit more timing based, but most patients don't wanna have skin cancer, and if you put skin cancer in the context of the discussion of the risk of not treating, we really open their eyes a lot more. There's been some surveys shown that 90% of patients will get aggressive with treatment if they hear the word skin cancer versus, versus if the term cancer is not used in the conversation, that compliance rate drops down to 60%. So, it really is an, is an important concept to bring up about why are we treating these spots? Not that they'll be cosmetic or aesthetic in any way. It's more about, okay, let's treat now because you're gonna get 10 more if we don't treat, and let's think about what are we using optimally in our office.

What else would you like to share with your colleagues regarding your session at Winter Clinical Hawaii 2024?

Dr Bhatia: So, when clinical, there's gonna be a lot of discussion about sunscreens, photoprotection. There's gonna be another lecture about photodynamic therapy. I'm gonna cover a, a bits of a, a bit of each of those topics. But I do think photodynamic therapy is really underutilized. There's a lot of misconceptions about the overhead about having a PDT day in your office. The reimbursements for PDT are actually on the rise. The overhead can be easily managed in a group setting. You know, with the consolidation of dermatology, it's easy to have a flow of, you know, one office doing them, or, or at least on a Friday, just having PDT day where you just, you know, wheel patients in and out and have them under the light while they're incubating. I, I just think it's really a, a missed opportunity, not just for the business and of reimbursements, but also just, you know, really comprehensive treatment of the field as well as, you know, treating through the disease.

When we use photodynamic therapy in combination with, you know, liquid nitrogen and topicals, my thinking is, it's a little bit, rough example of dating. You know, you meet people on the first date, you freeze 'em right there when you have them, you set up a next date, and that's the same with putting a dynamic therapy when they can schedule it. But in between time, you think about using topicals to maintain the gains and, and reduce the burden of the, of the next day case. So I think there's really a lot of opportunities there when we can really put things in a framework.