5FU-Cal Treatment

Introduction

This leaflet has been written to help you understand more about using the combination of 5-fluorouracil (Efudix) cream and calcipotriol (Dovonex) ointment (‘5FU-Cal’) for treating actinic keratoses.  It tells you what these treatments are, how they should be applied to your skin and what side effects to expect.

What are actinic keratoses (AKs)?

AKs are very common. They are pink or red, scaly, rough patches on the skin that are due to sun damage. They are more common in older people who burn easily or have had a lot of sun exposure and are also more common in people who have impaired immune systems. They usually appear on the face, scalp, neck, backs of the hands and forearms and lower legs. They are not themselves cancerous but are pre-cancerous and can very occasionally change into a type of skin cancer called squamous cell carcinoma (SCC). When multiple AKs affect an area of skin, this is sometimes referred to as pre-cancerous field change.

What is 5-fluorouracil (Efudix) cream?

5-fluorouracil is a type of chemotherapy cream which has been used for more than 50 years to treat AK. It is the most effective treatment for AK and there have been studies showing that it can reduce the risk of developing SCC. It is usually used once or twice a day for 2-4 weeks. It usually causes skin redness, itching, scaling and sometimes crusting, weeping and soreness or pain. This is known as a ‘local skin reaction’). Local skin reactions can last for about 2 weeks after treatment finishes. As a general rule, the more sun-damaged your skin, the greater the local skin reaction will be after applying 5-fluorouracil.

What is calcipotriol (Dovonex) ointment?

Calcipotriol is a vitamin D ointment that has been used for 30 years to treat psoriasis (a condition in which the skin is affected by scaly red patches). It is usually applied once or twice a day for 6 weeks or more to treat psoriasis. It is not used on its own to treat AKs.

5-fluorouracil and calcipotriol combination treatment:  5FU-Cal

A few years ago, it was found that the combination of 5-fluorouracil and calcipotriol (5FU-Cal) was more effective for treating AK than 5-fluorouracil on its own. Treatment time with 5FU-Cal is also reduced from 4 weeks to approximately 4 days which most people find more convenient.

How should I apply 5FU-Cal combination treatment?

Flu-Cal combination treatment should be applied to the area of skin where you have AKs, as directed by your doctor.

You should mix equal amounts of the 5-Fluorouracil cream and calcipotriol ointment and then spread a thin layer over the whole area of skin where you have AKs. You should then rub the mixture in well.

At what time of day should I apply 5FU-Cal and for how long?

• You should apply 5FU-Cal at the same time in the morning and again at night.
• You should continue for 4 days of the face and 6 days on the arms or legs

If you have very thick AKs in places such as the backs of the hands, you may need to apply for longer but do not do this unless specifically advised to do so by your doctor.

If you have a lot of AKs on your skin you may be advised to treat a relatively small area first, e.g. just the scalp, or forehead, or cheeks, or backs of the hands (rather than all areas at once).

When should I not use 5FU-Cal?

• Avoid areas very close to the eyes or lips, unless specifically advised to do so by your doctor 
• Do not apply 5FU-Cal if you are pregnant or breastfeeding.
• Do not use 5FU-Cal if you are allergic to any of their ingredients.

What are the common side effects of 5FU-Cal?

• Local skin reactions: Flu-Cal can cause the same kind of local skin reaction as 5-fluoruracil cream on its own.  The skin will become red and it may continue to get redder for up to 10 days after stopping treatment. It may then peel a little and after that will settle and go back to normal. The amount of skin reaction that you experience is variable and is not always possible to predict. As a general rule, the more sun-damaged your skin, the greater the local skin reaction from applying Flu-Cal. 
• 5-fluorouracil cream can make your skin more sensitive to sunlight and you should avoid significant sun exposure during and after treatment until the skin has healed. 
• Calcipotriol ointment can cause skin irritation. It is recommended that application on skin creases is avoided.

If the local skin reaction is severe, it may crust or even weep and it can become painful. A severe skin reaction is not a bad thing because it will mean the pre-cancerous cells are being destroyed. However, there may be some stinging or pain for a few days until the reaction settles. Usually, the skin will be back to normal and not be red or sore within two weeks of starting treatment. If the skin becomes very sore or uncomfortable, stop using the treatments. Bathe the area with water, dab the skin dry and apply petroleum jelly (Vaseline) daily. If you are uncertain about whether you should continue or re-start treatment, get in touch with your doctor who can advise you on your treatment schedule.

What are the less common side effects of 5FU-Cal?

• If you have a severe reaction to 5-fluorouracil cream, there is a risk of delayed healing. Occasionally this may cause an ulcer to develop, particularly on the lower legs. This is less likely with 5FU-Cal combination treatment because it is only used for 4-6 days. 
• Following a severe reaction, there is also a small risk of altered skin colour and scarring.
• Skin infections at the site of application of 5-fluorouracil cream are rare. If you have concerns about the severity of the skin reaction, get in touch with your doctor.
• Very rarely, patients can be allergic to 5FU-Cal. This usually causes a severe local skin reaction. If you have any concerns about the severity of your reaction to 5FU-Cal, get in touch with your doctor. Seek immediate medical advice if you notice any symptoms of a serious allergic reaction
• including a rash at other sites, itching/swelling (especially of the face/tongue/throat), severe dizziness or trouble breathing.
• Like all medications, 5-fluorouracil cream and calcipotriol ointment should be kept out of reach of children and pets. There are reports of pets being harmed from licking their owner’s skin after 5-fluorouracil has been applied or from consuming the cream from the tube. Calcipotriol ointment is also harmful to some pet animals, such as dogs, if eaten.
• Over-use of topical vitamin D such as Calcipotriol can cause raised blood calcium levels so the recommended weekly limit of 100g should never be exceeded. You are very unlikely to exceed this limit with 5FU-Cal combination treatment for AK.