My Efudex Experience

My name is Jim. I am a fellow patient, not a doctor. If you are reading this, you have probably just seen a dermatologist and he or she has diagnosed a pre-cancerous skin condition and has prescribed Efudex for you. You are probably curious and a bit apprehensive about the Efudex treatment plan. I was too. I wanted to know just how bad it would get and how soon, so I searched the web for Efudex pictures. I found plenty of clinical information about Efudex but almost no pictures of Efudex patients. I decided that I would take a picture of myself every day and create an Efudex photo journal showing the results of my treatment with Efudex. Here is my story (with lots of Efudex pictures) or skip to the bottom line if you're busy.
 

For several months I had two spots of scratchy skin on my face. One was below my left eye and the other was just left of center high on my forehead. They weren't really bothering me, but I was concerned because they weren't healing either. At a recent physical exam, my doctor suggested I see a dermatologist about them just to be safe.

I saw Dr. Marc E. Grossman, a dermatologist in White Plains, New York, on January 24, 2007. He immediately diagnosed the spots as Actinic Keratosis (AK), a precancerous condition also known as solar keratosis, the result of prolonged exposure to sunlight. I guess all those summer days at Jones Beach took their toll. When I was a kid, they did not have effective sunscreens like we have today and the so-called suntan lotion was just to help you cook to a nice even brown color. Unfortunately my fair Norwegian skin is not known for its ability to tan, and I can remember getting some pretty painful sunburns.

Actinic keratoses, though relatively harmless themselves, must be taken seriously because they are considered warning signs of skin cancer and should be treated immediately to prevent them from developing into something much more serious.

Dr. Grossman treated the AK spot under my eye with liquid nitrogen. After an initial stinging sensation, surprisingly it did not hurt at all. But he felt that I had more damage on my forehead than just the one visible AK. Therefore, to treat my entire forehead at once he prescribed Efudex 5%. Efudex is fluorouracil, one of several topical chemotherapy drugs. I was instructed to apply Efudex to my forehead only, from my eyebrows up to my hairline, two applications per day (morning and bed time) for thirty days.

Dr. Grossman warned me that my skin would turn red and would blister and peel, and would look and feel really bad for a while, but should clear up all the AKs in about four weeks. He reiterated that it would look really ugly before it got better. I said not to worry, I could handle it. He said don't be so sure about that, because he has had patients come back crying after two weeks begging to stop the Efudex treatment and for him to clear up their skin.

Maybe he was trying to scare me or to toughen me up for what he knew was to come, but I laughed because it reminded me of the scene in Star Wars: The Empire Strikes Back where Luke says about his upcoming Jedi training "I'm not afraid." and Yoda says in a menacing voice "You will be. You will be!"

With his dire warning in mind but thinking that no matter how bad it got in the interim, I would be better in six weeks, I began the Efudex treatment on January 25, 2007.

	January 29, 2007. Efudex Day 5. The first few days I noticed little to no change. Unfortunately I did not think to take a "Before" picture. This picture was taken on January 29, 2007 which was Day 5 of my Efudex treatment. Some small red spots are visible on my forehead. Based on the doctor's warning I expected my entire forehead to turn red immediately. Is this it? How can I tell if the Efudex is working? Notice the AK below my left eye. This is about as bad as it looked. It blistered up after a couple of days and totally cleared up in two weeks, as you will see in subsequent pictures.
	February 3, 2007. Day 10. Five days later and lots more red spots on my forehead. I don't look very happy, but it is still not too unpleasant at this point. The AK below my left eye is nearly healed. Efudex makes your skin very sensitive to sun exposure. Luckily it is winter so I am not outdoors much and when I am, the sun is not too strong. I am glad I'm not doing this in the summer. If I don't want anyone to see my forehead, I can always wear a hat and pull it down to my eyebrows.
	February 8, 2007. Day 15 I look like I have the measles or chicken pox. Earlier in the week I was feeling a little self conscious and I wore a hat at work but it was just too itchy, and besides, everyone was asking me why I was wearing a hat around the office. So I took off the hat and explained to my coworkers what was going on, and probably most important to them, that I was not contagious! The good news is the AK spot below my left eye is totally healed.
	February 11, 2007. Day 18. The red spots on my forehead are coming together and my forehead is turning a solid ugly red. I get a lot of stares now from people who haven't seen me recently. There are still a few scattered white spots amid the redness on my forehead, especially near my scalp on the left and right side. I wonder if they will eventually turn red also? It is very itchy and standing in the shower is about the only relief I can get.
	February 15, 2007. Day 22. I am now three weeks into my Efudex treatment. One more week to go. What a difference a couple of days make. My forehead is now a very dark red. At this point it is torture to apply the Efudex. It is like rubbing acid on my tender skin. My skin feels like a really bad sunburn. It is starting to blister and peel. Even washing it is painful now. If you are really interested, you can click to see what I look from the left and the right side.
	February 19, 2007. Day 26. My forehead has gotten very crusty. It blistered and the blisters are weeping fluid. It's really gross. Click here for a close-up if you dare! I try not to look in the mirror. When I do, I take off my glasses and my face looks like a red blur. I feel sorry for people who have to look at me. I know it looks really disgusting. The skin around the inside of my eyes, especially my left eye, has gotten very puffy. I'm not sure why. It doesn't hurt nor does it affect my vision. At least the acne pimple by my nose is clearing up.
	February 21, 2007. Day 28. Today it has started to crack and bleed. It is very sore and my forehead doesn't even feel like my skin anymore. I try not to make any facial expressions that involve wrinkling my forehead, because it hurts so much. As bad as it looks from the front, I think it looks worse from the left and right.
	February 23, 2007. Day 30. Aren't I a pretty sight? Touching the skin on my forehead feels like I am touching a football and it hurts all the time. Washing it used to feel good; now it is torture. Applying the Efudex is just a matter of gritting my teeth and bearing the pain. Too bad it is not Halloween because I would make a good zombie with my skin flaking off, or maybe a devil. I'd only have to apply red makeup to the lower half of my face. It's really awful, but I think the end is near. I'm going back to the dermatologist this afternoon. I have spoken to him several times but have not seen him since my treatment began. I hope he tells me I'm done with the Efudex. I noticed I was looking a little scruffy so I trimmed my beard and I shaved for the first time in a month. That made me feel a little more human. Here is a close-up of my forehead, and my left and right sides.
	February 24, 2007. Good news! Yesterday Dr. Grossman told me I'm done with the Efudex and now it is time for my skin to heal. He also told me that my reaction was one of the worst he had ever seen in his thirty years of practicing dermatology, so most likely your reaction will not be as bad as this. However, my reaction did validate his original diagnosis that my entire forehead was one big AK, and that spot-treating with liquid nitrogen would have been a waste of time. The doctor gave me prescriptions for two topical creams, Mupirocin 2%, an antibiotic, and Fluticasone Propionate 0.05%, a corticosteroid. The latter is better known as the active ingredient in Flonase, an anti-inflammatory nasal spray used to treat allergies! Three times per day for the next two weeks I will mix and apply these creams to my forehead. As I later learned, I am going to look a lot worse before I get better, but then I will improve rapidly. Keep reading and don't get discouraged. The end results are worth it.
	February 25, 2007. Healing Skin Day 2. This is Day 2 of healing time for my skin after the Efudex treatment. I have been using the two topical Rx creams three times per day as directed. The basic idea is to use an antibiotic to prevent infection, and an anti-inflammatory to reduce pain and swelling. If your doctor did not prescribe anything, ask your pharmacist for recommendations for OTC (over the counter) medications. Prescription medications are stronger, but anything will help. My skin has started to crack and bleed. It stings all the time. My eyes are still grotesquely swollen but the doctor said this swelling is normal and will shrink in time.
	February 27, 2007. Healing Phase Day 4. My forehead is really bloody and surprisingly I look even worse now than I did when I was applying the Efudex. It is quite painful. My skin feels very dry and tight. The creams are soothing for an hour or two but then the pain returns. It is too itchy and messy to wear a hat. I'm glad its not too cold out. I've been using Tylenol occasionally to help with the pain.
	March 1, 2007. Healing Phase Day 6. Here is a face only a mother could love! This is brutal. My forehead is a bloody mess and it hurts like hell all the time. At least it doesn't hurt as much as road rash, broken ribs, and a broken clavicle, but that is another story. My old damaged skin is all cracked and flaking off and I can see new skin growing in its place. But its so disgusting I try not to look in the mirror too often. I don't know how my coworkers can look me in the eye. I get a lot of horrified looks from strangers. I really don't want anyone to see me like this. I wore a hat to my son's hockey game last night, uncomfortable as it was. I'm just tired of people staring at me or asking what's wrong with me. Maybe I should hang a sign around my neck that says "Use Sunscreen!"
	March 3, 2007. Healing Phase Day 8. Wow, I think I am finally starting to look better! The skin on my forehead is still very dry and very tight, but not as bloody as it was only a day or two ago. See left and right. Every time I wash my face large flakes of old skin come off and I can see a lot more new pink skin emerging. It even feels a bit better today, still itchy but it does not hurt like it did.
	March 5, 2007 Healing Phase Day 10. In case you lost track, it has been forty days since I began the Efudex treatment and ten days since I stopped. I am still applying Mupirocin and Fluticasone Propionate three times daily. The changes just in the last two days have been remarkable. And when I look at the picture from only four days ago, I can't believe how much better I look today! My eyes, especially the left, are still puffy and the skin on my forehead is very tender and sensitive. It's also itchy, but I don't even think of scratching it. Touching it gently is relief enough. I can finally see light at the end of the tunnel. I think in another week or two this will all be just a bad memory. Until next time, whenever that is.
	March 7, 2007. Healing Phase Day 12. It is incredible how fast my skin is regenerating. Everyone tells me how good I look (well my forehead anyway!). Today is the first day in over a month that I felt like I was back to normal. See left, right, forehead. My skin is still pink and there are still some red marks, but every day there are less and less. It is still itchy, but actually feels good to gently massage it with soap and water. If you met me now for the first time you might just think I had scraped my head. Even my eyes seem less swollen.
	March 9, 2007. Healing Phase Day 14. Today is the first day in several weeks that: my forehead didn't bleed.   I started looking people in the eye again.   I looked in the mirror and smiled! Today is also the last day that I apply the mixture of Mupirocin and Fluticasone Propionate, and after today I am officially done with the skin cancer treatment on my forehead! It's not quite that simple though. As you can see, my forehead is still very pink. See left and right sides. My new skin is still quite itchy and rather tender. But it is more annoying than painful at this point. The doctor said the pink color will fade in a couple of months. He wants to see me for a follow-up exam in six months.
	March 13, 2007. Four days later and the change is remarkable. The dark pink has faded to a light pink that almost looks normal. I still have one red spot high on my forehead between my left eye and my nose. It still itches, but nowhere near as bad as it did.
	March 16, 2007. The pink continues to fade, but there is still a noticeable difference between my forehead and the rest of my face. Today is one week after the treatment ended, 21 days after I stopped applying Efudex, and 51 days since I started the Efudex treatment. See left, right, forehead. There is still some mottled looking skin near my scalp on both sides. My skin is still tender, but the itching is mostly over.
	March 24, 2007. Another week has gone by and the difference in color between my forehead and the rest of my face is even less. See left and right. I look like maybe I got a little sunburn or windburn from skiing. In fact I went skiing twice this past week and someone remarked that I looked like I got a little color. True, but he did not know about my Efudex ordeal. My forehead does not itch anymore and it is no longer tender. It finally feels like my skin again! Today is two months since I started using Efudex, so I think this validates what the doctor said, that I would be more or less back to normal in six to eight weeks.
	March 31, 2007. My entire face looks a little red today, but that is because I just got back from a hard 55 mile bike ride. I look tired because I am. I'll sleep well tonight. The past couple of weeks I have finally felt normal again. Even the mottling near my scalp has faded and is barely noticeable. See left, right, forehead. In case you are still keeping track, today is 66 days since I began my Efudex treatment, 36 days since I stopped applying Efudex and my skin began healing, and 22 days since I stopped applying the healing and soothing antibiotic cream. In round numbers, it has been two months since I first applied Efudex. If you are trying to schedule your treatment around work, vacation, or important family events like weddings, give yourself two months to be safe unless you want your vacation or wedding album photos to look like mine. Also, I highly recommend that you do this treatment in the winter if possible. The sun is not as strong, you tend to be indoors more, and you can wear a hat or hood when you do go outdoors. You don't want to be using Efudex when its sunny and hot because then you will be sweating and even more uncomfortable. Unfortunately, teachers will most likely want to do this over summer vacation so that their students don't see them like this. It can be a good teaching moment for older kids, but might be scary for the younger ones.
	May 3, 2007. Fast forward one month. I'd need a calendar to calculate days or even weeks, but there is no need to be so precise anymore. It is a little over three months since I began the Efudex treatment. My normal skin tone is slightly pink and at this point even I can barely see a difference between my forehead and the rest of my face. I'd say I'm 95% back to a uniform color. See left and right. I think I'm done posting pictures of myself. Updating this web page today and looking back at the pictures from several weeks ago it's all like a bad memory. I can't believe how awful I looked two months ago and how good I look now. If you're a woman, treat yourself and buy a big floppy hat and wear it whenever you are out in the sun. Women have a much better selection of hats than men do. Baseball caps don't offer much sun protection for the face, and do nothing for the back of the neck. I have never worn any other kind of hat, but I think that will have to change. I plan to look for a hat with a wide brim for myself, or maybe one of those hats with the flap in the back like you see in the old movies with the French Foreign Legion soldiers. I think you know what I mean.
	November 2008 update: I get a lot of emails from this web page, and I answer every one. Someone recently asked me what I look like now, so I took this picture today. It has been a year and a half since my Efudex treatment. My skin is soft and smooth. I'm very happy with the long term results, and the short term pain is largely forgotten. Feel free to email me no matter how silly you think your question is, or email me if you just want to talk to someone who has been there. I have running dialogs with many patients and I try to help in any way I can. Sometimes it's actual advice, and sometimes it's just moral support. My name is Jim.
	November 2011 update: Wow, has it really been three years since my last update? Yes, and it has been almost five years since my Efudex treatment. I'm doing well and my skin is great. I see Dr. Grossman annually for a full body exam and I have had no additional skin cancer issues since 2007. I keep expecting him to treat the rest of my face, but so far he has said that further treatment is not indicated. However, my skin is very oily and I have been prone to persistent acne breakouts for the past forty years. I'm 55 years old but I have the skin of a teenager! I discussed this with Dr. Grossman and he recommended a course of low-dose Accutane (isotretinoin). I could find nothing on the internet about the use of low-dose isotretinoin by older patients. Isotretinoin is typically prescribed for people half my age as a last resort for severe, chronic acne. Thus I have decided to document my experience and you can about read my ongoing Accutane story here. Finally, I had PVP surgery for BPH (male urinary problem) in September, 2011. I am fully recovered and the results are remarkable. If you are a fellow old guy with an enlarged prostate, read about my BPH experience and please email me if you have any questions.
Click here to see Elie's Carac diary. (Internet Explorer recommended. May not display correctly in other browsers. Sorry, I need to fix this.)
So what is the bottom line on this Efudex treatment? You should have stayed out of the sun or used sunscreen (or both), but it's too late to cry about it now. Face it, you have no choice. Just tough it out and apply the Efudex and you will get better. After six to eight weeks the redness will fade and it will all be just a bad memory. You will have fresh, new, pink cancer-free skin! Just keep telling yourself that. Treatment with Efudex will hurt, maybe even hurt a lot, but not as much as a broken collar bone. The entire process takes six to eight weeks, but it will only look really bad for a total of about four weeks, starting two weeks after beginning Efudex application and for two weeks after your skin begins to heal. The ugly red skin and the pain is only temporary. Don't worry about how bad you will look in the short term. You are beating skin cancer and that's what is important. After you stop applying Efudex, you will actually look worse for a week or so before you start getting better. After that, you will improve rapidly. Unless you are applying Efudex to a part of your body normally covered when you are at work, the worst part of the treatment is the reaction of other people when they see your face. Explain to friends, neighbors, and coworkers what is going on. You will be surprised how many people have been treated for skin cancer or know someone who has. Be an advocate for the use of sunscreen and for sensible exposure to the sun, especially with children. Look at the calendar, not at the mirror. You will be back to normal and cancer free in about 8 weeks. Treatment with Efudex is better than the alternative, getting skin cancer. Skin cancer would be a really stupid way to die. Unfortunately, many people die from skin cancer every year. Finally, the sun is not your friend. Enjoy the outdoors, but be sensible. Cover up, wear a hat, and always use sunscreen. Good Luck! (And if you skipped right to the bottom line, you really should go back and look at my Efudex pictures.)
USE SUNSCREEN! YOU DO NOT WANT TO GO THROUGH THIS TORTURE!
I am happy to provide this information for free, so please do not feel obligated, but it does cost me money to maintain this website. If I've helped you and you'd like to say thanks with a small donation, I really do appreciate it.

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