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.