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The ability of AKs to eventually form a squamous cell carcinoma is well recognised and it is for this very reason that more widespread part treatment protocols are calling for all AKs to be treated.

Is there anything we can do better? Should we be looking at different preventative strategies or should we be educating patients differently in order to minimize these risks of subsequent recurrence? UV radiation is really the predominant trigger for all of this and probably is one of the bigger focuses for us in preventative medicine for this particular dermatological condition. AKs have a lifecycle of their own and in some instances do improve or regress without active intervention. But the message is not to leave it. A milestone study performed in Australia took almost 600 patients and they gave them sunscreen or a base cream, which had no UV filters in them, and they gave these to the patients for a period of six months. They were required to apply the product once a day. It had an SPF rating of 17 but it was a broad-spectrum cover. They were asked to be manage their sun behaviours, avoiding peak day sun use, and wearing appropriate UV protective clothing.

In terms of the number of baseline lesions that spontaneously resolved, 25 had resolution of their baseline count. There were 508 new lesions in the non-sunscreen group vs 330 in the sunscreen group, that's a 34% variance in the number of new presenting lesions if you just apply sunscreen. So the takeaway here is it is an intervention that has absolutely zero adverse event profile, and it reduces your risk of development of new AKs. It certainly requires us to use this as one of our principle treatment options and prevention options for patients at risk or with current AKs.

The reason why this trial (ONTRAC) is such a welcome addition to our understanding is that it was driven by the Australians who themselves felt that current treatment options were not only expensive in terms of a whole, national health budget. The trial showed a significant reduction in the incidence of AKs and even nonmelanoma skin cancers by the daily consumption of one gram of nicotinamide. This trial was run over a one-year period and these reductions in AKs and nonmelanoma skin cancers occurred rather early.

However, the effect or the benefit of this oral supplementation was lost the minute the patient stopped taking the treatment. It's a programme you stay on because the mechanism of action of nicotinamide is to increase the available energy, the mitochondrial ATP levels, which helps drive DNA mutation correction, should you take the fuel away from the vehicle. Oral nicotinamide, although effective, although inexpensive and does require ongoing supplementation. Some sunscreen is better than nothing. But if you aren't going to use it correctly, you also are not going to realise the full benefit of what this particular treatment modality can do for us in terms of remission.

You'll see that using the correct quantity of sunscreen over a, this was the six-month trial, you can see a 25% reduction in the sunscreen user and only a 15% regression in the base cream user. We know that sunscreen reduces AKs and squamous cell carcinomas. It does not reduce BCCs and is questionable on melanoma. We've learned about some preventative pharmacology, sometimes oral, sometimes topical. And then we've learned hopefully a little bit more about a really important preventative aspect of all of these skin conditions, which is of course, photoprotection and photorepair.