Picato gel.

A good treatment for small sun spots but relatively expensive.

Picato gel is the latest skin cancer topical.

Picato is a newish topical for solar keratosis & skin cancer

What is Picato gel?

Picato® gel (Ingenol Mebutate) is the newest of the topical treatments for Solar Keratosis. Its main attraction is that the course of treatment is just 2 or 3 days. Side effects often last 1-2 weeks although this is a shorter time than with other topicals.  As with any new medication, it takes times for its role to become established as experience increases and new studies are released.

A two to three day course of treatment is attractive compared with a two to three weeks of efudix. The downside is that it only treats a small area and is over twice the cost of Efudix or Aldara.

How effective is Picato gel?

The high quality randomised controlled trial upon which the licensing of Picato was published¹ in 2012. As with most new medications, the trials compared the medication with a placebo rather than comparing the medication with established treatments.

The clearance rate at 8 weeks is quoted in the trials as:

  • Face & Scalp: Complete Clearance in 42% of participants, Partial Clearance in 64%, and an average reduction of lesions 83%
  • Rest of Body: Complete Clearance in 34% of participants, Partial Clearance in 49%, and an average reduction in lesions 75%

The recurrence of Solar Keratosis at 12 months is 54% for the face/scalp and 56% for the rest of the body.

So there’s no simple answer – this is a changing field, and different thought-leaders will give different opinions.

As with any new medication, it takes times for its role to become established as experience increases and new studies are released, but Picato gel looks promising.

How is Picato gel used?

The gel must be kept refrigerated. The gel comes in two different strengths with the lower strength preparation being appropriate for use on the face and scalp.

  • 0.05% Picato Gel for the trunk and limbs. Applied once per day for 2 days.
  • 0.015% Picato Gel for the face and scalp. Applied once per day for 3 days.

Your Skin Cancer doctor will advise your which area to treat. It should not be used near the eye and not applied to healing wounds. The maximum treatment area is 5cm by 5cm.

The gel is applied to dry skin and left on for at least 6 hours. Do not use it in the 2 hours leading up to bedtime. Most people will therefore find it most convenient to apply it in the morning. Keep the skin dry for at least 15 minutes after application. You should wash your hands after use.

Be particularly careful when applying Picato gel anywhere near the eye because there have been reports of severe eye injuries. Be careful that the Picato doesn’t get transferred to the eye by sweating or washing / showering.

What are the side effects of Picato gel?

The side effects may be:

  • Itching, Pain – each in around 8%, Irritation in around 3%
  • Redness – very common, to be expected
  • Flaking / Scaling or Crusting – to be expected
  • Blisters or Pustules – common
  • Erosion or ulceration: Least common

Localised skin reactions²

  • Usually occur within 1 day of starting treatment
  • Peak in intensity up to 1 week after finishing treatment
  • Usually resolve within 2 weeks of starting treatment on the face or scalp, and within 4 weeks of starting treatment elsewhere

Rarely non-local symptoms such as headache may occur.

There have been rare reports of severe allergic reaction (anaphylaxis)³.

References
1: Mark Lebwohl et al; N Engl J Med 2012; 366:1010-1019
2: Picato Gel, medicines.gov.uk, updated 29/4/16
3: Picato Safety Warning, FDA 2015

Refer to full product information & follow directions from your doctor. The areas treated and duration of treatment, in particular,  will vary from patient to patient.

WRITTEN BY: Dr Richard Beatty
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