In this session, Brian Berman, MD, PhD, and Darrell Rigel, MD, MS, provided an overview of available therapies for actinic keratoses (AKs), emphasizing combination therapies and delivering individualized patient care. Patients with AK have a 1.9 times higher risk of developing cutaneous squamous cell carcinoma (cSCC) each year and an 11.4% greater cumulative incidence compared to those without AKs, highlighting the importance of having an array of treatments to reduce cSCC risk. There are treatment options available, which are discussed in the lecture, including cryotherapy, tirbanibulin, 5-fluorouracil (5-FU), imiquimod, diclofenac, and photodynamic therapy (PDT). 

The American Academy of Dermatology guideline efficacy reports of tirbanibulin, imiquimod, 5-FU, and diclofenac indicated that imiquimod and 5-FU had the highest efficacy rates with 80% partial and 52% to 54% complete clearance rates. Tirbanibulin, which was a close third, was recently FDA approved for field treatment of 100 cm² with similar efficacy and safety compared to its previous FDA approval for 25 cm² treatment areas. 

The presenters explored optimal treatment regimens for AK treatment with PDT. Combining aminolevulinic acid (ALA) with PDT significantly enhances PDT efficacy compared to PDT monotherapy, however treatment is known to be painful. The presentation highlighted alternative methods to improve patient comfort during PDT by using "short contact ALA." This modified regimen, where ALA is applied followed by immediate blue light PDT, was found to be equally effective and significantly less painful. 

Given the risk of AK progression to cSCC, the presenters underscored the need for patient-tailored therapy and integration of both lesion-targeted and field-directed treatments. When used first, lesion-directed therapy first reduces AK burden prior to field therapy, but topical field therapy may identify subclinical lesions prior to more targeted therapy. Dermatologists should consider the benefits and drawbacks of the order in which lesion and field-directed treatments are applied.