End of this Round

My cheek is finally finished peeling, almost three weeks after I stopped the 4-week application of Efudex. This was a much longer and stronger reaction than when I only used the Efudex for two weeks, and I think it is more likely to have been effective. Here is what the final week looked like:

12 days after stopping Efudex

13 days after stopping Efudex

16 days after stopping Efudex. All clear except faint redness.

This will be the final entry for this round. I have another appointment with my dermatologist at the end of June and might start another "Efudex experiment" on my cheek after that.

Four weeks and done

I kept applying the Efudex to my cheek twice per day for four weeks, which ended a week ago. When I did it 4 months ago, I only applied it for two weeks, which didn't seem to be long enough. This time, I got about the same reaction in the first two weeks -- the skin turned very red and peeled in a few places. There wasn't as much additional change in the second two weeks as I expected, although there were a few spots that started to ooze blood, especially an area right below my eye, and there was extensive peeling. During the week since I stopped the Efudex, the bleeding areas have scabbed over and the the other areas have continued peeling. The peeling is much more extensive than when I only used the Efudex for two weeks, and it is easier to picture that it is actually shedding the layers of sun-damaged skin cells.

18 days of Efudex

4 weeks - Last day of Efudex

One week after stopping Efudex

This second application on my cheek seems to have achieved the reaction that most people describe. I think my dermatologist is just too conservative when she recommends only two weeks and says that it is done when it turns red. Other users, and even the official web site for the Efudex product, talk about a treatment of 3 to 4 weeks and a "destruction" phase when the skin ulcerates and peels. In any case, I will probably do another "Efudex experiment" after my next derm appointment at the end of June to see if the cheek reacts to a third application. If the sun damage is really removed, it shouldn't react so strongly the next time!

On my own for this experiment

I sent the email with the picture from the previous post to my dermatologist last Sunday, called on Tuesday, and finally got hold of her on Friday. So it had been almost two weeks since I started the "Efudex experiment," and I wanted some professional advice. The area on my scalp continued to have only a mild reaction, which makes sense if the previous Efudex treatment had removed most of the sun-damaged cells. But the area on my left cheek had continued its strong reaction, and was burning to the extent that I had started to apply vaseline over it to ease the burning.

I was a little surprised by what she said. Apparently she had just returned from a conference at which she had discussed my experiment with  a few of her colleagues. And whereas at our last appointment she had agreed that reapplying Efudex to an area that had recently been treated should not yield a significant reaction, her colleagues had convinced her that it would probably react even if the previous treatment had been effective. Well this makes no sense to me. In the original treatment, some areas reacted, presumably because those areas contained rapidly-dividing, sun-damaged cells. And other "normal" areas didn't react. So if the previous Efudex treatment really removed most of the rapidly-dividing, sun-damaged cells the treated skin should now be "normal" and there shouldn't be a strong reaction to a subsequent efudex treatment. Right? But she said that nobody has ever done such an experiment! Why not? Because 1) most people don't like to use the Efudex again, 2) if the skin looks smoother after the Efudex treatment, it must have worked, and 3) the condition is not life threatening anyway.

So she didn't see any point in continuing the Efudex on my cheek. It was previously treated for two weeks to the point that it turned red, it looks smooth on the outside, so it's fine. And even if it's not fine, it wouldn't be life-threatening anyway. On the other hand, I think that the strong reaction this time must indicate that there is still significant sun damage and that I might as well treat it for a while longer to try to remove that sun damage. She warned me not to go too long since it could become a mess and get infected, and we said goodbye.

So it appears that I am on my own for the rest of this experiment. I've stopped applying Efudex to the area on my scalp, since that area did not react. But I will continue for a while longer on my cheek. But perhaps not too much longer since it has already reacted more than the first time, with a few spots starting to ooze. Perhaps one more week? We'll see how it progresses.

Did the Efudex work? An Efudex experiment

I'm trying an "Efudex experiment" in which I reapply Efudex to a few small areas that were treated a few months ago to see if they react. My dermatologist agreed that if the first treatment really removed most of the sun-damaged cells, then the skin should not "light up" in response to a second treatment. So a week ago I started applying Efudex twice a day to my left cheek and to a small area (about two square inches) on my scalp.

What happened? The area on my scalp only had a small reaction. But my cheek lit up just as fast and intensely as during the original Efudex treatment. I can also feel it starting to burn like the first time.

What does this imply? Clearly, whatever property of the skin on my cheek made it react to the Efudex was not changed by the first Efudex treatment. In other words, if the reaction is due to sun damaged cells, then there are still a lot of sun-damaged cells there.

What to do next?  I sent an email to my dermatologist with this picture to see what she advises. I proposed to keep applying the Efudex, but go longer than last time -- perhaps 3-4 weeks instead of just two.

Day 86 (Recovery Day 72)

It's been over 10 weeks since I stopped the Efudex. Here's what I look like now:

Red area still present on left cheek at site of AK, but has sprouted no new keratin pillars

I'm surprised that the Efudex-treated areas are still a little redder than the untreated skin. This is mainly visible around the eyes, where whiter skin adjacent to the eye is surrounded by redder skin -- kind of a raccoon effect. 

Did it work? Well, the red area on my left cheek is still red, although no new keratin pillars have appeared in that area. And I do have a new keratosis on my forehead within the treated area. It doesn't seem that a new keratosis should appear so soon in an area where the sun damage has supposedly been removed. But it still seems that the best test will be to reapply the Efudex in some areas and see if they light up again. My next dermatology appointment isn't until March 8, so I might email the doc to see what she thinks about testing a few areas ahead of the appointment.

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.