, Volume 27, Issue 6, pp 451–464

Pharmacoeconomic Considerations in Treating Actinic Keratosis

  • Marjorie V. Neidecker
  • Mary Lynn Davis-Ajami
  • Rajesh Balkrishnan
  • Steven R. Feldman
Leading Article


Actinic keratosis is among the most commonly treated skin conditions in the outpatient setting. Its prevalence spans the globe, with greater distribution in fair skinned individuals and the immunocompromised. With high prevalence, increasing incidence and the risk of transformation to a cancerous lesion, prevention and timely treatment present opportunities to rein in costs.

The purpose of this article is to review published economic studies relating to the treatment of actinic keratosis, to summarize results discussing the cost drivers of current treatment modalities and to identify parameters most likely to influence the cost effectiveness of treatment.

We systematically conducted a published literature search for pharmacoeconomic research of actinic keratosis using title, abstract or full-text searches with the following search terms ([actinic OR solar] AND [keratosis OR keratoses]) AND (economic OR cost OR pharmacoeconomics OR decision). We included published articles referencing actinic keratosis in a standalone study or in a broader study referencing non-melanoma skin cancer and articles evaluating cost-of-illness, cost-of-treatment, cost minimization, cost effectiveness, cost utility, cost-benefit analysis and cost consequence.

Our review of the literature found nine studies devoted to pharmacoeconomic considerations of actinic keratosis treatments, with one article investigating both cost-of-illness and cost-of-treatment, two measuring cost-of-illness, two evaluating cost-of-treatment, one focusing on cost minimization, and three focusing on cost effectiveness. The literature compared a broad range of actinic keratosis treatments including topical medications, cryotherapy, photodynamic therapy, excision and a combination of treatment modalities. The direct cost of actinic keratosis management in the US was estimated at $US1.2 billion per year, with indirect costs totalling $US295 million (year 2004 values). The primary drivers of cost were physician office visits and associated procedures.

Pharmacoeconomic research defining standards, outcomes and areas of efficiencies in the treatment of actinic keratosis is in its infancy. To move towards more comprehensive analysis, research needs to focus on updating epidemiological data, evolving evidence-based standards, delineating cost drivers in immunocompetent and immunocompromised populations, and on health outcomes.


  1. 1.
    Moy RL. Clinical presentation of actinic keratoses and squamous cell carcinoma. J Am Acad Dermatol 2000 Jan; 42 (1 Pt 2): 8–10PubMedCrossRefGoogle Scholar
  2. 2.
    National Center for Health Statistics. National Ambulatory Health Care Survey (NAMCS), public use data files: 2008 [online]. Available from URL: [Accessed 2008 Aug 15]Google Scholar
  3. 3.
    Frost CA, Green AC. Epidemiology of solar keratoses. Br J Dermatol 1994 Oct; 131 (4): 455–64PubMedCrossRefGoogle Scholar
  4. 4.
    Marks R, Ponsford MW, Selwood TS, et al. Non-melanotic skin cancer and solar keratoses in Victoria. Med J Aust 1983 Dec 10–24; 2 (12): 619–22PubMedGoogle Scholar
  5. 5.
    Green A, Beardmore G, Hart V, et al. Skin cancer in a Queensland population. J Am Acad Dermatol 1988 Dec; 19 (6): 1045–52PubMedCrossRefGoogle Scholar
  6. 6.
    Frost C, Williams G, Green A. High incidence and regression rates of solar keratoses in a Queensland community. J Invest Dermatol 2000 Aug; 115 (2): 273–7PubMedCrossRefGoogle Scholar
  7. 7.
    Karagas MR, Zens MS, Nelson HH, et al. Measures of cumulative exposure from a standardized sun exposure history questionnaire: a comparison with histologic assessment of solar skin damage. Am J Epidemiol 2007 Mar 15; 165 (6): 719–26PubMedCrossRefGoogle Scholar
  8. 8.
    Marks R, Rennie G, Selwood TS. Malignant transformation of solar keratoses to squamous cell carcinoma. Lancet 1988 Apr 9; 1 (8589): 795–7PubMedCrossRefGoogle Scholar
  9. 9.
    Dodson JM, DeSpain J, Hewett JE, et al. Malignant potential of actinic keratoses and the controversy over treatment: a patient-oriented perspective. Arch Dermatol 1991;127 (7): 1029–31PubMedCrossRefGoogle Scholar
  10. 10.
    Chen GJ, Feldman SR, Williford PM, et al. Clinical diagnosis of actinic keratosis identifies an elderly population at high risk of developing skin cancer. Dermatol Surg 2005 Jan; 31 (1): 43–7PubMedCrossRefGoogle Scholar
  11. 11.
    Housman TS, Feldman SR, Williford PM, et al. Skin cancer is among the most costly of all cancers to treat for the Medicare population. J Am Acad Dermatol 2003 Mar; 48 (3): 425–9PubMedCrossRefGoogle Scholar
  12. 12.
    Diepgen TL, Mahler V. The epidemiology of skin cancer. Br J Dermatol 2002 Apr; 146 Suppl. 61: 1–6PubMedCrossRefGoogle Scholar
  13. 13.
    Green A. Changing patterns in incidence of non-melanoma skin cancer. Epithelial Cell Biol 1992 Jan; 1 (1): 47–51PubMedGoogle Scholar
  14. 14.
    Roberts WE. Dermatologic problems of older women. Dermatol Clin 2006 Apr; 24 (2): 271–80, viiiPubMedCrossRefGoogle Scholar
  15. 15.
    de Berker D, McGregor JM, Hughes BR. Guidelines for the management of actinic keratoses. Br J Dermatol 2007 Feb; 156 (2): 222–30PubMedCrossRefGoogle Scholar
  16. 16.
    Helfand M, Gorman AK, Mahon S, et al. Actinic keratoses: final report. Agency for Healthcare Research and Quality; 2001 May 19. Report No.: contract 290–97-0018, task order no. 6 [online]. Available from URL: [Accessed 2009 Jun 28]
  17. 17.
    McIntyre WJ, Downs MR, Bedwell SA. Treatment options for actinic keratoses. Am Fam Physician 2007 Sep 1; 76 (5): 667–71PubMedGoogle Scholar
  18. 18.
    Gold MH. Pharmacoeconomic analysis of the treatment of multiple actinic keratoses. J Drugs Dermatol 2008 Jan; 7 (1): 23–5PubMedGoogle Scholar
  19. 19.
    Dinehart SM. The treatment of actinic keratoses. J Am Acad Dermatol 2000 Jan; 42 (1 Pt 2): 25–8PubMedCrossRefGoogle Scholar
  20. 20.
    Stockfleth E, Kerl H. Guidelines for the management of actinic keratoses. Eur J Dermatol 2006 Nov-Dec; 16 (6): 599–606PubMedGoogle Scholar
  21. 21.
    Agency for Healthcare Research and Quality, 2008 [online]. Available from URL: [Accessed 2008 Jul 8]
  22. 22.
    American Academy of Dermatology, 2008 [online]. Available from URL: [Accessed 2008 Jul 8]
  23. 23.
    Higashi MK, Veenstra DL, Langley PC. Health economic evaluation of non-melanoma skin cancer and actinic keratosis. Pharmacoeconomics 2004; 22 (2): 83–94PubMedCrossRefGoogle Scholar
  24. 24.
    Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. 3rd ed. New York: Oxford University Press, 2005Google Scholar
  25. 25.
    Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ 1996 Aug 3; 313 (7052): 275–83PubMedCrossRefGoogle Scholar
  26. 26.
    Muston D, Downs A, Rives V. An economic evaluation of topical treatments for actinic keratosis. J Dermatolog Treat 2009 Jan; 1: 1–10. Epub ahead of printGoogle Scholar
  27. 27.
    The Society for Investigative Dermatology and The American Academy of Dermatology Association. The burden of skin diseases: 2005. Falls Church (VA): The Lewin Group, 2005 [online]. Available from URL: [Accessed 2008 Aug 25]
  28. 28.
    Warino L, Tusa M, Camacho F, et al. Frequency and cost of actinic keratosis treatment. Dermatol Surg 2006 Aug; 32 (8): 1045–9PubMedCrossRefGoogle Scholar
  29. 29.
    Gupta AK. The management of actinic keratoses in the United States with topical fluorouracil: a pharmacoeconomic evaluation. Cutis 2002 Aug; 70 (2 Suppl.): 30–6PubMedGoogle Scholar
  30. 30.
    Streeton CL, Gospodarevskaya E, Harris AH. How are solar keratoses treated by general practitioners in Australia? Int J Dermatol 2006 Mar; 45 (3): 272–6PubMedCrossRefGoogle Scholar
  31. 31.
    Caekelbergh K, Annemans L, Lambert J, et al. Economic evaluation of methyl aminolaevulinate-based photodynamic therapy in the management of actinic keratosis and basal cell carcinoma. Br J Dermatol 2006 Oct; 155 (4): 784–90PubMedCrossRefGoogle Scholar
  32. 32.
    Annemans L, Caekelbergh K, Roelandts R, et al. Real-life practice study of the clinical outcome and cost-effectiveness of photodynamic therapy using methyl aminolevulinate (MAL-PDT) in the management of actinic keratosis and basal cell carcinoma. Eur J Dermatol 2008 Sep-Oct; 18 (5): 539–46PubMedGoogle Scholar
  33. 33.
    de Roos KP, Beljaards RC. The Delphi panel in the economic evaluation of photodynamic therapy for actinic keratosis and basal cell carcinoma: poor results? Br J Dermatol 2007 Jun; 156 (6): 1393–4PubMedCrossRefGoogle Scholar
  34. 34.
    Caekelbergh K, Annemans L. Interest in interests in photodynamic therapy: reply from the authors [letter]. Br J Dermatol 2007 Jun; 156 (6): 1393CrossRefGoogle Scholar
  35. 35.
    Weston A, Fitzgerald P. Discrete choice experiment to derive willingness to pay for methyl aminolevulinate photodynamic therapy versus simple excision surgery in basal cell carcinoma. Pharmacoeconomics 2004; 22 (18): 1195–208PubMedCrossRefGoogle Scholar
  36. 36.
    Braathen LR, Szeimies R-M, Basset-Seguin N, et al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. J Am Acad Dermatol 2007; 56 (1): 125–43PubMedCrossRefGoogle Scholar
  37. 37.
    Halpern AC, Hanson LJ. Awareness of, knowledge of and attitudes to nonmelanoma skin cancer (NMSC) and actinic keratosis (AK) among physicians. Int J Dermatol 2004 Sep; 43 (9): 638–42PubMedCrossRefGoogle Scholar
  38. 38.
    American College of Physicians. Information on cost-effectiveness: an essential product of a national comparative effectiveness program. Ann Intern Med 2008 Jun 17; 148 (12): 956–61Google Scholar
  39. 39.
    Tunis SR. Why Medicare has not established criteria for coverage decisions. N Engl J Med 2004 May 20; 350 (21): 2196–8PubMedCrossRefGoogle Scholar
  40. 40.
    Ginsburg ME. Cost-effectiveness: will the public buy it or balk? Health Aff (Millwood) 2004 Jan-Jun; Suppl. Web Exclusives: W4–297-9Google Scholar
  41. 41.
    Ulrich C, Hackethal M, Ulrich M, et al. Treatment of multiple actinic keratoses with topical diclofenac 3% gel in organ transplant recipients: a series of six cases. Br J Dermatol 2007 May; 156 Suppl. 3: 40–2PubMedCrossRefGoogle Scholar
  42. 42.
    Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med 2003 Apr 24; 348 (17): 1681–91PubMedCrossRefGoogle Scholar
  43. 43.
    Ulrich C, Schmook T, Nindl I, et al. Cutaneous precancers in organ transplant recipients: an old enemy in a new surrounding. Br J Dermatol 2003 Nov; 149 Suppl. 66: 40–2PubMedCrossRefGoogle Scholar
  44. 44.
    Palm MD, O’Donoghue MN. Update on photoprotection. Dermatol Ther 2007 Sep-Oct; 20 (5): 360–76PubMedCrossRefGoogle Scholar
  45. 45.
    Heckman CJ, Coups EJ, Manne SL. Prevalence and correlates of indoor tanning among US adults. J Am Acad Dermatol 2008 May; 58 (5): 769–80PubMedCrossRefGoogle Scholar
  46. 46.
    Moyal DD, Fourtanier AM. Broad-spectrum sunscreens provide better protection from solar ultraviolet-simulated radiation and natural sunlight-induced immunosuppression in human beings. J Am Acad Dermatol 2008 May; 58 (5 Suppl. 2): S149–54CrossRefGoogle Scholar
  47. 47.
    Lim HW, Cooper K. The health impact of solar radiation and prevention strategies: report of the Environment Council, American Academy of Dermatology. J Am Acad Dermatol 1999 Jul; 41 (1): 81–99PubMedCrossRefGoogle Scholar
  48. 48.
    Mettlin CJ. Skin cancer and ozone depletion: the case for global action. J Surg Oncol 2001 Jun; 77 (2): 76–8PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2009

Authors and Affiliations

  • Marjorie V. Neidecker
    • 1
  • Mary Lynn Davis-Ajami
    • 1
  • Rajesh Balkrishnan
    • 1
    • 2
  • Steven R. Feldman
    • 3
  1. 1.Division of Pharmacy Practice and AdministrationOhio State University College of PharmacyColumbusUSA
  2. 2.Division of Health Services, Management, and PolicyOhio State University College of Public HealthColumbusUSA
  3. 3.Center for Dermatology Research, Departments of Dermatology, Pathology, and Public Health SciencesWake Forest University School of MedicineWinston SalemUSA
  4. 4.WFU DermatologyWinston SalemUSA

Personalised recommendations