Day 36 (Recovery Day 22)

There was quite a bit of peeling of my scalp for a few days this past week. If I rubbed my hand over my head a shower of skin particles fell on my desk. Other than that, things look pretty much the same as last week. My face looks normal from a distance, but there is a residual redness left over in the Efudex-treated areas. And the areas that were the most red during the treatment (my upper cheeks, just under my eyes,  and the AK on my left cheek) are still redder than the rest.

Day 29 (Recovery Day 15)

Happy Thanksgiving to those in the USA!

My face now looks normal at a casual glance. And it feels normal too; showers and towel drying feel fine. But a closer look around the eyes shows that the Efudex skin is still significantly pinker than the untreated skin. Also, the areas that were reddest during the Efudex are still redder and they are still peeling. So presumably, that deepest sun damage is still being shed.

Now looking pretty normal overall

Still peeling on forhead

AK on left cheek still peeling

Day 24 (Recovery Day 10)

Things are feeling much closer to normal now. I don't think people even notice anything strange about the appearance of my face. And this morning when I took a shower I left the temperature at full hot and let the spray fall on my head without problems. The skin is a little tender but doesn't burn anymore. In addition to feeling somewhat itchy, it also feels a little "tight" when I smile or grimace. But the skin really is much smoother!

Much less contrast now between red and normal areas

So is there anything I would do differently next time? I found that the most painful times were in the final days of applying the Efudex and, in particular, in the 2-4 hours before reapplying. The moisture of the Efudex had evaporated or soaked in, leaving dry burning skin. But it turns out that vaseline petroleum jelly that my dermatologist had me use after finishing with the Efudex does a great job of restoring the moisture and relieving the burning. Other people's blogs have noted that it is OK to apply vaseline or Aquaphor two hours after applying the Efudex, and I think that would probably have eliminated the most painful times. So next time, if my derm approves, I will apply vaseline two hours after the Efudex and then reapply during the day to keep it moist until the next Efudex application.

This is the area of the AK on my left cheek. It is still redder than the surrounding skin, but now has a divot toward the lower left where damaged skin was perhaps removed. I still plan to wait a while and then test the area by hitting it area again with Efudex to see if it lights up.

Divot in area of AK on left cheek

I will probably wait to post again until the redness is all gone,  until I've tested if the AKs on my cheek and scalp are really gone, or until something else interesting happens.

How does Efudex work?

I think it's pretty fascinating how Efudex works - even though I don't have the background in cell biology to fully understand the process. Efudex is just one of the brand names for 5-Flourouracil. (Carac is another brand.) As the name implies, flouro-uracil is a modified form of the molecule uracil with an extra flourine atom stuck on. And uracil is one of the basic building blocks of RNA. It also plays a key role in the cell's synthesis of DNA.

Flourouracil

Although the full description of what happens is apparently quite complicated, the essence appears to be that the flourouracil molecule is similar enough to uracil that the cell incorporates flourouracil in processes where it would usually incorporate uracil. So, as the cell prepares to divide, it builds the intermediate molecules that lead to new RNA and DNA using flourouracil instead of uracil. But the molecules built using flourouracil don't function properly! That additional flourine atom, riding along like the soldier inside a Trojan Horse, spoils the operation. And since the cells have evolved to be good team players, when the cell somehow recognizes that something is seriously wrong with the RNA and DNA that it is producing, it commits suicide (apoptosis) rather than hurt the team (the whole person) by spawning defective offspring.

Since the process primarily affects cells that are dividing, it preferentially kills cells that are dividing more rapidly than normal - including cancerous and pre-cancerous cells (including actinic keratoses). The result is that the areas that contain lots of those types of cell become inflamed and eventually shed the dead skin cells through peeling, and the dead cells are replaced by new, undamaged cells.

Day 23 (Recovery Day 9) - Peeling Skin

In the last two days my face has gotten much less red and much less tender. This morning I was actually able to dry my head by wiping it with a towel, rather than blotting it, and also able to shave the top of my head. Instead of burning, the main thing I feel now is itching.

Face is much less red that just two days ago.

But, even better, my skin is definitely peeling. (Probably why it itches!)  This means that I used the Efudex long enough to kill at least some of the sun-damaged skin cells;

Peeling skin on left temple. It itches!

Day 21 (Recovery Day 7)

This morning I noticed that there was actually peeling and flaking skin on my right forehead and cheek. It was visible first thing in the morning where the vaseline had rubbed off of my face overnight. The loose skin was gone after a shower, and any new peeling probably won't be visible until the new layer of vaseline rubs off tonight. But maybe the Efudex has worked, after all.

Day 20 (Recovery Day 6)

My skin is definitely getting less red. But that may not be not good news! In fact, I'm worried that my dermatologist stopped me too soon. After the inflammation phases, there is supposed to be an "erosion" phase in which the damaged skin peels, scabs, or is otherwise destroyed. I don't see much evidence of any of that. So far I've seen one small spot of blood on my left temple, some peeling on the bridge of my nose, and increased itching all over, which may correspond to skin flaking under the vaseline. Here's what I look like now:

I'm thinking that if the AK on my cheek is still visible after the overall redness goes away, I'll ask my dermatologist if I should try again but go for 3-4 weeks. If the cheek AK appears to be gone, I might apply Efudex to just that area for a week or two. If the area "lights up" again, that would indicate that the damage is still there. I could try the same thing on a part of my scalp to see if the AKs up there are really destroyed. It would be pretty sad if I went through this for nothing because I stopped too soon.

Day 17 (Recovery Day 3)

Today I rode our bike club's 200K. This was the same route that I rode as a checkout last weekend when I wasn't sure if I'd be able to wear a helmet this weekend. But it turns out that my scalp is not too sensitive compared to my face, so I decided to ride again. The main problem was applying sunscreen. Last weekend that felt OK, but this weekend - Ouch! I first tried applying Coppertone Sport SPF 50 to my forehead and suddenly felt like a dozen bees had just stung my forehead. So I then tried Neutrogena Ultrasheer Dry-Touch SPF 55 on the lower part of my face. The Neutrogena is an "Ultra Light - Clean Feel" sunblock that I use on week days since it isn't as slimy as the Coppertone Sport. Perhaps it is more gentle as well? Wrong! It stung just as badly as the Coppertone. After walking around for a few minutes waiting for the burning to subside, I finally applied vaseline over the whole mess, resulting in this very attractive look:

Face coated with two different sunscreens and vaseline before all-day bike ride

The ride itself actually felt pretty good on my face because I had nice cool 40-55 degree air blowing over it all day. Before the inside pizza party at the end of the ride, I washed off the worst of the sunscreen and reapplied a layer of vaseline. The next few hours at the party felt OK as long as I periodically reapplied vaseline to the "hot spots" that developed on my cheeks and temples.

Day 15 (Recovery Day 1) - Ouch!

This was the first day after stopping the Efudex and, as others have noted in their experiences, felt (and maybe looked) worse than while I was still applying it. Vaseline really helps manage the burning, but looks pretty bad. This is what I looked like at work and at the viewings for my mother-in-law at the funeral home. I hope that I was at least a walking advertisement for using sunscreen.

Covered with Vaseline to ease the burning one day after stopping Efudex

Those rosy cheeks burn the most. They feel hot to the touch.

I carried around the container of Vaseline because if any areas started to dry off  - usually my cheeks - they would start to feel like they were on fire. And the red skin really is hot - when I placed my palms against my cheeks to get some temporary relief, the skin on my cheeks felt  hot to my palms. By the end of the day, I was reapplying the Vaseline every hour or two. And cold air felt SO much better that I walked outside of the funeral home a few times to cool off my face and get some relief. I also have never enjoyed taking the trash can down to the street as much as  tonight. The cold air blowing across my face was WONDERFUL!

I'm really hoping that things will start feeling better in the next few days. I'll probably ride my bike club's 200K in two days. (Same route that I rode as a checkout last weekend.) The cool air in the morning should feel good on my face, as long as the helmet doesn't hurt too much. Just have to give it a try.

Day 14 - Fully Cooked!

I had my two-week appointment with my dermatologist this afternoon, and she said that I am fully cooked! I should stop the Efudex! I was surprised because I thought she had planned for another two weeks, so I asked her three different times if she was sure that I had had enough. I definitely didn't want to go this far and stop too soon to get the full benefit. But she said that on her scale of mild to severe reaction I was close to severe, so additional use would just add more pain for no gain.

What a relief! I didn't want to say it there, because I didn't want her to stop me too soon, but the burning had been getting tough to take the last couple of days. The worst times were actually in the 2-3 hours BEFORE it was time to apply the Edudex. The act of applying the Efudex had gotten painful because of the tender skin, and then it would burn for 10-15 minutes after the application. But then the moisture of the Efudex would have a soothing effect so that it wasn't too bad for the following 8 hours or so. But after about 8 hours the Efudex would be absorbed into the red skin leaving the skin burning and dry. So in those 2-4 hours before the next application, it was getting increasingly hard to take, especially in the raw skin above my mustache and on my temples. Today at work, my reading glasses were starting to hurt my nose, so I copied another Efudex blogger and put gauze between my nose and the glasses. It looked pretty stupid, but it worked. I also found that holding my fingers or hand gently against the skin gave some relief, so the entire time that I was waiting for my dermatologist appointment (which was two hours before the next application was due) I was moving my hands around to different areas of my face to relieve the burning.

Now I am just supposed to apply petroleum jelly over the area, so one of the first things I did when I got home was to smear Vaseline over the entire area. After about 20 minutes it felt SO MUCH better. Now I have the moisturizing without the burning! And the skin can start healing. Others have said that the days right after stopping the Efudex can be the worst, so I'm ready for it to get a little worse before it feels better, but I'm headed in the right direction. My next appointment is in 4 months.

So this is what I look like fully cooked. Unfortunately, this is what I will look like at my mother-in-law's viewing and funeral over the next couple of days. It seems somewhat disrespectful to look like this at such an event, but nothing can be done about it.

AK on left cheek and raw, painful area in nasal fold and above mustache

Day 11

I did the bike ride yesterday. In the morning, before the ride, I applied the Efudex and then a coating of Coppertone Sport SPF50 sunscreen over the Efudex. I felt like a slimy mess. I was also worried about how much it would hurt to wear a helmet, but with a soft winter skull cap between me and the helmet it wasn't bad at all.

It seems that a bunch of smaller spots popped out on my face and nose during the ride:

New spots appeared across my cheeks and nose, and the red is getting darker

Other people have said that wetness accelerates the effect of the Edudex, so maybe the sweat and sunscreen during the bike ride moved things along a little quicker.

The initial tube of Efudex (actually generic 5-Flourouracil) is almost empty. I might be able to stretch it out until the next appointment with my dermatologist in three days, but will need another tube if she wants me to continue the applications.

I definitely want to continue the Efudex long enough for it to do the job. But the whole business is starting to be a little painful and irritating. I probably should have been more careful to avoid getting Efudex into the folds at the sides of my nose, because that area is now the most irritated of all. But I wanted to be sure to coat the red skin just above the moustache and it was hard to get that area without some getting into the nasal fold.

Day 9 - Starting to Feel the Burn

Here's how things are looking on Day 9:

Looking like a bad rash

Worst damage is on upper forehead and temples

I think I missed putting suncreen right over the moustache

I think there's less damage on top because of the previous Efudex treatment

The extent of sun damage on my forehead is a bit of a surprise. I originally mentioned Efudex to my dermatologist because of the AK on my left cheek, and she thought it would also be good for all of the noiticeable pink AKs on top of my head. But my forehead didn't look bad. I suggested using it there because I had seen a couple of keratin pillars growing out, and she just said "OK, if you want to." I think she'll be surprised by how much it "lit up" when I go back in 5 days.

I thought the "rash" was getting noticeable enough that I spoke up at a group meeting at work to say that 1) It's not an infectious disease; it's just a creme to remove sun damage and 2) It's probably going to look worse before it looks better.

Although I felt some tenderness on previous days, it's getting more noticeable now. Pulling a t-shirt over my head did not feel good! Tomorrow I'm doing a 200K bike ride and hoping that the helmet doesn't hurt too much. I'm actually doing the ride a week early partly because I'm afraid I wouldn't be able to stand the helmet in another week.

Day 4 - Starting to see some red areas

Just starting to see some reddening now and feeling a very slight irritation.  It's hard to see in the pictures, but there is a line between the whiter area on the top of my head where I previously used Efudex (10-15 years ago) and the redder area on my forehead, presumably because the previous treatment already removed much of the sun damage on the top.

Looking like a mild sunburn

Might be significant damage here

AK on cheek is reddening

Areas just appearing on forehead

Unlike some of the other people who have posted their Efudex experience, I have never really liked being in the sun. But in the 1950s and 1960s there didn't seem to be any real sunscreen. Instead they had "sun tan lotion." So every year when I went to the ocean with my parents I would get sunburned so bad that I would feel on fire on the ride home and then the burned skin would peel off over the next week. (Sound familiar?) I also spent two summers painting houses, one working on road construction, and one as a letter carrier - all without much protection. So I think most of my skin problems now are related to sun exposure before I was 20. There have been a few more recent  exceptions, like the time I hiked to the top of Yosemite Valley and forgot to wear sunscreen -- or even a hat! Ouch!

I now do bike rides which sometimes last from before dawn until after dusk. But I use Coppertone Sport SPF 50 sunscreen, which is truly amazing stuff. I apply it once in the morning, and even after sweating all day long, it keeps on working and I don't get even a hint of sunburn.

Anyway, the next few days should reveal how much sun damage actually exists on my face. Maybe just a few isolated areas? Halloween is tomorrow, so it's too bad that I didn't start this a week earlier. I could go to a party without any additional mask needed.

Day 1

The Efudex is supposed to be applied twice a day, which I will do at around 4AM and 4PM. I apply it to all of my scalp and face that is not covered with hair or beard. A mirror helps see the part of the bald scalp that extends down the back of my head. I tried to be sure to include the skin right above the moustache because I think I have been missing that spot with sunscreen and it seems to always be red over the past year or so.

Nothing will probably happen for the next few days, so I'll wait for a change before another post.

Day 0 - Before Efudex

This is what I look like before the Efudex treatment:

Area where I previously used Efudex

This is the AK on my left cheek that I hope will "light-up" and be destroyed by the Efudex. There is a small keratin pillar or horn that grows out of the red patch for a few months, then dissappears to be followed by another one in a different location within the patch. Two attempts to freeze it with liquid nitrogen failed. The cat came back after each attempt.

AK on my cheek with keratin pillar

Background

I'm currently 59 years old. Over the past 15 years I've had three basal cell carcinomas (BCCs) and three squamous cell carcinomas (SCCs) removed from various places on my face, leg, arm, and shoulder. About 10-15 years ago I used Efudex on my scalp to remove actinic keratoses (AKs) that result from sun damage and are considered pre-cancerous with a small probability of turning into SCC.

When I recently had a red scaly patch removed from my arm that turned out to be SCC, I noted that it had looked very similar to the red scaly patch that was developing on my left cheek over the past year or two. And since getting a patch cut out of my cheek sounded much less pleasant than a patch out of my arm, I asked my dermatologist if another round of Efudex might be worthwhile. She gave me a prescription and originally suggested putting it just on my scalp and left cheek. But I decided to use it on my entire face and scalp, as well as on an AK on my ear. After all, the right cheek has been exposed to the same amount of sun as the left one. And one of the neat things about Efudex is that it only "lights up" sun-damaged skin. So it seemed a waste not to determine (and fix)  the whole pattern of sun damage on my face.

I can't really remember much about my last experience with Efudex except for people staring at the red blotches on my scalp. I don't remember it being especially painful and my dermatologist says that it shouldn't hurt. But every other blog I've seen talks about it hurting alot. So we'll see what happens this time. Hopefully, adding my experience with Efudex to the others that have been published will help other people know what to expect.