Efudex (fluorouracil) diary

In early 2016 I was treated for possibly precancerous cells on my face with a topical chemotherapeutic cream called Efudex (actually I used a generic version called fluorouracil).

Anyone who has been exposed to the sun for a number of years has some skin damage. Eventually we might develop actinic keratoses (precancerous patches of skin) and/or basal cell carcinomas (skin tumors).

While seeing my dermatologist for another problem, I mentioned that I had a few spots on my cheeks that seemed to be permanently scaly/scabby. Unlike normal scabs that eventually fall off, these never fell off. These were actinic keratoses. This was not surprising since I was 53 years old and fair-skinned, and had gotten a normal amount of sun exposure throughout my life, including a few bad sunburns. He prescribed Efudex and told me to apply it twice a day for two weeks. (Treatment duration normally ranges from two to six weeks. I assume that the greater the skin damage and/or the thicker the skin, the longer the treatment. Facial skin is thinner than the skin on most other areas, plus my skin damage wasn't severe, so this could be why my treatment duration was relatively short.)

Efudex is an effective way of treating abnormal cells without scalpels (which leave scars), lasers, or systemic drugs. In a nutshell, Efudex kills rapidly growing cells by blocking an enzyme that is necessary for DNA replication. Abnormal cells multiply more rapidly than most normal cells, which is why they are so vulnerable to this sort of drug.

If you Google "efudex", you will see some nasty images of red, blotchy faces that look like their owners are suffering from bad allergic reations or chemical burns. My photos are very similar, so brace yourself. Different people react differently because only abnormal cells react to Efudex, and the reaction severity is proportional to the amount of skin damage.

I did my first Efudex application on the evening of January 11, 2016. We'll call that "Day 0". Thereafter I applied it twice a day, every day, until the evening of January 25. I put it all over my forehead, nose, cheeks, sides of my face, and lower eyelids. I did not put it on my jawline, chin, or around my mouth (maybe I should have?).

Following is a day-by-day account of the treatment process. All photos were taken early in the morning, after washing my face but before applying the cream.

Day 1 - January 12. Here is how I looked at the start of the treatment process. Although you can't see them, I had some small actinic keratoses on my cheeks and nose.

Day 2 - January 13

Day 3 - January 14

Day 4 - January 15

Day 5 - January 16. Upper cheeks and nose starting to react. I assume that those areas tend to get the most sun, which would mean that the areas with the most damage are the first to react.

Day 6 - January 17. Started taking side photos as well, in order to fully document the process. Photos for today, day 7 and day 8 were taken at my girlfriend's house where the lighting is different.

Day 7 - January 18. Mild pain. Several spots tingled. Washing and drying hurt some and burned for a while afterward. I was surprised that my nose creases were reacting.

Day 8 - January 19. No more pain than yesterday but redness spread. Mild discomfort when I scrunched up my cheeks and nose. Skin was burning for a while after applying the cream because I rubbed my skin, but that eventually went away. Notice in the side photos that the skin in the upper sideburn areas did not react to the treatment. I've been cutting my own hair and keeping my hairline above the ears since about the mid-1990s, which shows that 20 years of exposure didn't do much skin damage. The only areas that reacted to the treatment were those that had been exposed during my youth. Also, I wrestled today for the first time since my face started reacting, and as expected it was painful when my face rubbed against someone else's clothing and hair.

Day 9 - January 20. A bit more pain but not bad. When my face was dry it hurt some to move it; but when my face was moist after applying the cream, moving it caused less pain. Applying the cream hurt more than yesterday. Took two sets of photos: row 1 in my bedroom (where photos for days 1-5 were taken), and row 2 in my bathroom. It shows how lighting makes a difference.

Day 10 - January 21. Skin is tight when dry. A little more pain today when moving my dry face, and the pain was diminished but still there when I moved my face after applying the cream. Still not much pain when I don't move my face. A few spots on my upper cheeks and bridge of my nose bled or weeped a bit after washing, as the top layer of skin came off.

Day 11 - January 22. Skin is even tighter when dry, like a steel mask. Mild pain, burning and itching when my face is still, and some pain when it moves. By the end of the day my upper cheeks and part of the bridge of my nose were crusty. Maybe this means that the skin has stopped reacting and is starting to heal? Also, notice how the areas where my hair has receded did not react. Again, only skin that was exposed in my youth reacted.

Day 12 - January 23. Some itching and a little needles-and-pins, but not bad. Just lightly touching it makes the sensations stop, at least for a little while. Still hurts to wash my face and skin is still tight when it's dry. Lighting in second row of photos is way different from previous days, probably because I took them in the daylight (the shade behind me is translucent) and my iPhone camera automatically adjusted itself. (There was a blizzard by the way.)

Day 13 - January 24. Face felt okay while shoveling my driveway because the sweat kept it moist. Stings when it's dry but feels okay after applying the cream. This stuff does a good job of moisturizing the skin all day - better than many lotions I've tried. Forehead, bridge of nose, upper cheeks, outside corners of eyes, and the crevices where the outside of my nostrils meet my upper lip are very dry and stiff. All those areas except my forehead are crusty or scabbed, and hurt when moved/rubbed while dry. Photos in second row were taken in a different part of my bathroom because the light streaming in through the shade was preventing good photos.

Day 14 - January 25. Less pain and burning today. My face has never looked worse, but that's because it's scabbing and crusting, which is exactly what you want during this treatment. This is the erosion phase, and it's when Efudex treatment should stop because it's done all it can do. This will be my last day of treatment.

Recovery day 1 - January 26. Mild to moderate burning, pain, and itching. Annoying but not unbearable. Cheeks look not only very red but also puffy. The most unsightly day so far. Washing stung and so did applying moisturizer. Anything that gets the face wet hurts, but it has to be done because without moisturizer the skin is very dry and subject to cracking. The stinging went away in a matter of minutes.

Normal mosturizer didn't work for long because once its water content evaporated, my skin became dry and painful again. I found that petroleum jelly works much better since it doesn't evaporate.

For the past 2 or 3 days the skin under my eyes has felt constantly wet, maybe because it's weeping. There seems to be some aching underneath it too.

I fashioned a mask out of an old T-shirt in order to spare people the shock of seeing me. Unfortunately the plasma and blood that oozed from my skin dried and stuck to the mask, and it was painful to pull it off. I won't be doing that again.

Recovery day 2 - January 27. Upper cheeks and skin under/around the eyes did a lot of oozing and crusting overnight. They don't hurt unless I stretch the skin. Some itching on forehead. Redness seems to be starting to subside. During the day my temples and nose creases crusted somewhat. The petroleum jelly kept everything moist so the crusting was soft. Occasional pins-and-needles. My lower eyelids ache when I close my eyes, and my cheeks ache when I bend over. Skin is still tight when dry, but a little less painful than a few days ago.

Recovery day 3 - January 28. Upper cheeks and skin under/around the eyes oozed and crusted a little less but hurt more. Those areas are still puffy and more achy than yesterday. They also have the sensation of being wet even when they're dry. Redness seems to have increased. Eyes are irritated and watering. Used some Clear Eyes drops. Face is hot and moderately painful when dry, and putting on the petroleum jelly hurt. (Actually I'm now using an antibiotic ointment, which has a petroleum jelly base.) Face had a moderate burning sensation for a few hours after washing and applying ointment. Burning and aching were mostly gone by afternoon. The photos in the third row were taken after the burning mostly died down. The lighter areas around my eyes, on my cheeks, and in my nose crevices are new crusting that formed in the first few hours after washing. By late afternoon there were some light-colored, painful spots on my lower cheeks, especially on the right side. I've read in other diaries that some of people's worst days were during the third week of treatment, or several days after they stopped applying Efudex, so I'm not surprised that today is painful and unsightly. There is no way around the fact that the skin has a painful, messy healing process to go through. Have not used any corticosteroids (yet) because I've read that they can suppress immune responses and delay healing.

Recovery day 4 - January 29. Haven't slept well this week due to frequent discomfort. Nothing overwhelming, but the itching, pain, and burning grab enough of my attention to disturb my sleep. Slept maybe 3 hours last night. Didn't wash my face this morning; just wiped some petroleum jelly and wet crusting off. Face is still painful when dry, so applied the petroleum jelly right after taking the photos. Face didn't burn too much afterward. Definitely a better morning than yesterday: no more aching in lower eyelids, and there is less aching in my cheeks when I bend over. The skin around my eyes and on my upper cheeks is very sensitive. Still some crusting and a tiny amount of bleeding going on, and occasional needles-and-pins. Lower right cheek still has those painful spots. Lower nose creases are still crusty but less painful to move. Face is looking less red. Temples and sides of face are flaring up, with weeping, pins-and-needles, and itching. After work I showered and OMG it was like hot razors on all my sensitive spots. Quickly put on ointment afterward. It helped somewhat but spots would take turns sending pain signals. These spots are red and raw. Eventually the pain subsided, but came back later. I felt like a chemical burn victim.

Recovery day 5 - January 30. Back at my girlfriend's place for recovery days 5-7. Very little crusting overnight. Definitely less red. Temples, sides of cheeks, and outside corners of eyes still burned after blotting off some of the ointment and also after applying more. There's still some crusting below the outsides of the nostrils. Areas just beneath my cheekbones are sore, with a little blood on the right side. That night there was some itching and peeling on my nose and the sides of my face.

Recovery day 6 - January 31. Temples and cheek points are still very tender. They stung after applying ointment. Left lower eyelid crusted a bit overnight, and hurts when I close it. In the afternoon I shaved for the first time in 4 days. Was able to shave everything except my cheekbone areas. Nose and sides of my face peeled some.

Recovery day 7 - February 1. No change noticeable from yesterday. Still sore in the same spots. Just as red.

Recovery day 8 - February 2. Still red but less painful. Temples itch a little. In the afternoon my face itched and peeled a bit. Pay no attention to the spot below my left ear - that is a scaly patch that I discovered on my last day of treatment, and I've been treating it since then.

Recovery day 9 - February 3. No pain except left lower eyelid, which is somewhat sore and puffy. Cheeks are just a bit tender to the touch. Don't need moisturizer anymore. Forehead is smooth but face still feels a little dry. Unfortunately my iPhone camera's lighting is inconsistent so it doesn't always give a good indication of how I look from one day to the next. For example, look at the second row of photos for today versus yesterday. The middle and left photos make me look redder today, but the right photo makes me look less red. Notice how the color of the shade behind me has changed in the right photo.

Recovery day 10 - February 4. Just as red if not redder than yesterday, but that might be because I wrestled last night for the first time in 2 weeks and got my face rubbed, which hurt some. No pain at all this morning, and my face is not sensitive when touched (if anything, touching it makes it itch a little). It seems as though the nerves are a bit "deadened" right now. Maybe they were damaged by the treatment, or perhaps my body put extra cells around them to protect them.

Recovery day 11 - February 5. A tiny bit itchy. The areas that reacted the most are now sort of scaled over with a thin, flat layer of dead, dry cells. I assume these will eventually flake away, revealing new, soft skin.

Recovery day 12 - February 6. White skin flakes sloughing off, like when recovering from a sunburn. Took these photos after sunrise. Row 1 photos seem to have a different lighting from other days. Took row 2 photos in another part of the bathroom to prevent sunlight from affecting them. Did the same thing on recovery day 13. The different lighting angle seems to make me look less red.

Recovery day 13 - February 7. Still shedding. Spot below left ear has scabbed so I'll stop treating it.

Recovery day 14 - February 8. Still shedding. Red spot on chin is a pimple and has nothing to do with Efudex. Back to original bathroom spot for second row of photos, where the different lighting angle makes me look more red. Face did not hurt at wrestling practice.

Recovery day 15 - February 9. No change. Still pink.

Recovery day 16 - February 10. Area below left ear is in full scab mode and only hurts a little when touched.

Recovery day 17 - February 11

Recovery day 18 - February 12. Abrasions on nose and forehead are from last night's wrestling practice.

Recovery day 19 - February 13. Progress has slowed so from now on I'll take photos weekly or semi-weekly.

Recovery day 25 - February 19

Recovery day 29 - February 23

Recovery day 35 - February 29

Recovery day 39 - March 4

Recovery day 47 - March 12

Recovery day 51 - March 16. Although the redness has mostly disappeared, exercise makes my face red. The first row of photos was taken before my workout, the second row after.

Recovery day 55 - March 20

Recovery day 64 - March 29

Recovery day 68 - April 2

Recovery day 78 - April 12

Recovery day 88 - April 22

Recovery day 99 - May 3

Recovery day 106 - May 10

Recovery day 114 - May 18

Recovery day 129 - June 2

Recovery day 134 - June 7

Recovery day 144 - June 17

Recovery day 164 - July 7

Recovery day 219 - August 31

All in all the process was not as painful as I'd heard. The first several days of recovery were the worst, but still not horrible (it would have been a lot worse without petroleum jelly). Some people have written in their Efudex diaries that the pain was "unbearable". I wonder: did they have more sun damage than I did? Or are they just not as tolerant to pain? Maybe their skin stayed drier than mine did - there was definitely a lot more pain and burning when my face was dry.

I missed a few social events, though the ones I did go to were not problematic because I explained what was going on and everyone was very supportive and understanding. I also missed a few wrestling practices for obvious reasons. The blizzard couldn't have come at a better time because the 4 days I spent alone were some of the most unsightly.

As expected, the areas that reacted the most (i.e., the most sun-damaged areas) were the upper cheeks, the skin around the eyes, and the bridge of my nose; and there was a later reaction on my temples and the sides of my cheeks. Surprisingly, my nose creases reacted strongly. My forehead and sides of my face also had some damage, but they did not weep/crust nearly as much as the other areas.

This process would have been excruciating without petroleum jelly. Some Efudex users recommend certain products in order to ease the pain. One is Aquaphor. Well, if you read the small print, its "active ingredient" is petrolatum. That's petroleum jelly. Does it work any better than straight petroleum jelly? Well, I tried it and I can honestly say no. Its much higher cost seems unwarranted. Another recommended product is hydrocortisone cream. Well, I tried that too, and it didn't seem to help. But that's just me - your mileage may vary.

Would I recommend this sort of treatment? If it gets the job done, yes. A month of discomfort and unsightliness is a small price to pay for long-lasting health and beauty. Now, is it better than laser or other treatments? That is something to both research on your own and discuss with your dermatologist.