At the 2025 ODAC Dermatology Conference, Dr. C. William Hanke, MD, MPH, Professor of Dermatology, Marian University COM in Indianapolis, and triple board-certified in Dermatology, Pathology, and Micrographic Dermatologic Surgery, presented on procedural treatments for preventing nonmelanoma skin cancer (NMSC). His lecture highlighted innovative approaches to reducing this risk through various cosmetic and therapeutic interventions.
Fibroblasts and Aging Skin
Dr. Hanke began by discussing the role of fibroblasts in aging skin. Recent studies have shown that aging skin fibroblasts exhibit a decrease in insulin-like growth factor 1 (IGF-1), a factor crucial for inhibiting UVB-damaged keratinocyte growth. Cosmetic treatments that cause controlled injury to the skin, such as lasers and dermabrasion, have been found to increase IGF-1 levels in fibroblasts, thereby aiding in the prevention of NMSC.
For aging patients with extensive actinic damage, Dr. Hanke recommended the aggressive use of agents like photodynamic therapy (PDT), chemical peels, dermabrasion, and topical chemotherapy agents. These treatments not only improve cosmetic appearance but also decrease the overall risk of cutaneous carcinoma.
Photodynamic Therapy
Photodynamic therapy is an effective treatment for actinic keratosis, and Dr. Hanke has found that frequent utilization significantly reduced the annual incidence of NMSC in his patients. The process involves the application of aminolevulinic acid (ALA) followed by blue or red light exposure. Aminolevulinic acid is converted to protoporphyrin IX, which is activated by light exposure, leading to the oxidative death of cells with ultraviolet damage.
However, significant discomfort can be a limitation of this procedure. Dr. Hanke highlighted several variables that can be modified to make the procedure more tolerable:
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- Incubation Time with ALA: Originally recommended at 14-18 hours in 1999, it has been reduced to as little as 30 minutes in recent years, significantly reducing discomfort while maintaining efficacy.
- Wavelength: Red light penetrates deeper but causes more discomfort compared to blue light.
- Distance to Light Source: Moving patients further away from the light source can reduce discomfort.
- Cold Air Anesthesia: While it has been reported to reduce the effectiveness of PDT by about 30%, it can be utilized to alleviate discomfort and encourage patient compliance.
Lasers
Fractional Lasers
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- Non-Ablative: Dr. Hanke cited a 2023 study showing that non-ablative fractional laser treatment is associated with a decreased risk of subsequent facial keratinocyte carcinoma development by 20.9% in treated patients compared to 40.4% in the control group.
- Ablative: While not as aggressive as CO2 ablative lasers, these can be performed under topical anesthesia and yield improved skin quality, including tighter skin, reduced rhytides, and improved dyschromia.
CO2 Ablative Laser
Dr. Hanke quoted Dr. Susan Weinkle, noting that CO2 ablative lasers can remove up to 10 years of aging from the skin, outperforming facelifts, which typically remove about 5 years. However, caution is necessary to avoid overtreating, as this can result in scarring.
He cautioned against the general use of aggressive lasers on the chest, such as the erbium laser, or CO2 laser, due to the risk of scarring and hypopigmentation. Medium-depth peels should also be avoided on areas other than the face.
Chemical Peels
Dr. Hanke discussed the effectiveness of various chemical peels in reducing actinic keratoses and NMSC incidence. For those interested in learning more, he recommended the International Peeling Society as a valuable resource.
A notable 2006 randomized controlled trial compared the efficacy of 5-FU, CO2 laser, and 30% TCA peel in reducing AKs. The results showed an impressive 83-92% reduction in AKs in the experimental groups compared to control, with the TCA group exhibiting the lowest rate of NMSC.
Chemical peels are categorized based on their depth of penetration:
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- Superficial Peels: Affect the epidermis. Examples include 70% glycolic acid, Jessner’s solution, and 10-20% TCA.
- Medium Depth Peels: Affect the whole epidermis down to the papillary dermis. Dr. Hanke cautioned that medium-depth peels can cause scarring if not performed carefully. To minimize risks, he advised aiming for a “patchy white frost” endpoint rather than the traditional “solid white frost.” Examples include solid CO2, 35% TCA, Jessner’s solution with 35% TCA, and 70% glycolic acid with 35% TCA.
- Deep Peels: Affect the entire epidermis and can penetrate down to the reticular dermis. Examples include Baker’s or Hetter’s phenol, both of which can be used with or without occlusion.
As a practical tip, Dr. Hanke suggested starting with phenol peels for actinic cheilitis of the lips for those looking to introduce phenol peels into their practice. This approach allows practitioners to become familiar with the technique prior to applying to the entire face.
Dermabrasion
Dermabrasion can improve the appearance of aging skin and decrease the incidence of NMSC. Dr. Hanke frequently uses dermabrasion with a nerve block for patients with extensive actinic damage and a history of NMSC on the nose.
In conclusion, Dr. Hanke’s presentation underscored the potential of procedural treatments in preventing NMSC. From the use of PDT and dermabrasion to the application of various lasers and chemical peels, these methods not only improve skin appearance but also play a critical role in reducing cutaneous carcinoma risk. As dermatology continues to evolve, Dr. Hanke’s insights highlight the importance of personalized and effective treatments for patients at risk of skin carcinoma.
This information was presented by Dr. C. William Hanke during the 2025 ODAC Dermatology Conference. The above session highlights were written and compiled by Dr. Vixey Silva.
