The Prescription Face Cream You Might Just Need

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By Cheryl Wischhover 

Most face creams don’t really deliver on their marketing promises. In fact, they under-deliver. This is not the case with fluorouracil, which arguably punches way, way above what its simple, clinical-looking tube might suggest. But you won’t find this miracle worker in your local Sephora, because, well, it’s chemotherapy. Wait, don’t run away! If your generational culture touchstones range anywhere on the spectrum from black rubber bracelet-era Madonna to Reality Bites, it might be time to ask your dermatologist about it.

“These are my favorite buzzwords about fluorouracil: it's diagnostic and therapeutic,” says Dr. Elizabeth Hale, my dermatologist and a clinical associate professor of dermatology at the New York University Langone Medical Center. This means that the act of applying it helps to diagnose precancerous lesions, because they “light up” (turn very pink). Then it obliterates them, preventing them from turning into full-blown skin cancers. The superficial, and very welcome, side effect of this obliteration is that it can make your skin look smoother, clearer, and just generally nicer. It’s unique in that it can diagnose, treat, and maybe even beautify your face, all within a few weeks of application. 

It’s not a new treatment, but lately you can find posts like this about it on TikTok and Instagram.

Fluorouracil (pronounced floro-YUR-asil), also called 5-FU, is a chemotherapy that was developed in the 1970s. Here’s how it works: Cancer cells divide and grow quickly. Fluorouracil is an anti-metabolite type of chemo, meaning it “interferes with cell production and DNA synthesis,” which prevents cancer cells from rapidly reproducing, according to Dr. Hale. In the course of giving patients IV 5-FU for their cancers, doctors discovered that certain spots on the skin were lighting up and then peeling off, leaving clear, smooth skin in its wake. They soon determined that the 5-FU was killing off actinic keratoses (AKs), skin lesions that can be precursors to certain types of non-melanoma skin cancers. (It’s important to note that fluorouracil can’t identify or treat melanomas, so get your skin checked annually.) 

When applied topically, fluorouracil causes an inflammatory reaction on the skin only where AKs or precancerous lesions exist. “The idea is to treat them so that they don't progress into squamous cell carcinoma,” Dr Hale says. 

I didn’t know any of this when Dr. Hale told me a few years ago that she was prescribing me 5-FU to put near my face. I was familiar with the drug, because I’ve administered it to patients in its IV form back when I was a pediatric oncology nurse. It had all the usual chemo side effects; we wore gloves and masks to administer it. 

I played softball in a ponytail all through middle school and high school, resulting in many blistering burns on the tops of my ears. I had noticed that for several months, the skin on the top of my left ear felt really dry and sandpapery. No amount of lotion or Aquaphor could touch it. She prescribed me the cream to apply for several days. It got pretty inflamed and peeled off, and now the skin is soft and normal. 

Actinic keratoses are “usually pinkish to brownish scaly lesions. When they're really early stages, they're gritty, rough patches that you don't necessarily see, and they can wax and wane,” says Dr. Hale. “[There are] subclinical AKs, which means they aren't yet visible but they're definitely damaged keratinocytes under the surface of the skin.” 

While you can burn off a visible lesion or two with liquid nitrogen, topical fluorouracil will get the lesions that you can’t even see yet, making it good for treating larger surface areas like the face, hands/arms, chest, and scalp. Once the skin heals after treatment, visible lesions will be gone, too, leaving your skin looking more clear and smooth. Another caveat: 5-FU won’t remove benign sun spots — those require laser treatments to eliminate. 

You’ll need a prescription for fluorouracil cream. It is not a treatment for the faint of heart, though it’s a lot less nightmarish than it used to be. While interfering with the rapidly dividing abnormal cells, it causes an inflammatory response, per Dr. Hale. This manifests as inflamed skin, a feeling of warmth/burning, and peeling. “The downtime was so intolerable, patients hated using it. You looked like you were burned,” she says. 

But in the last few years, there’s been a breakthrough. Fluorouracil can now be combined with a topical vitamin D analog called Dovonex, or calcipotriol generically. Instead of several weeks of treatment, a four-day course on the face is all that’s required. While the exact mechanism isn’t known, the vitamin D is thought to calm down the inflammation by modulating the immune reaction. Certain compounding pharmacies can combine the creams into one tube, but it’s also fine to just mix them in your hand to apply. You will still experience side effects, but not as severe and for a shorter period of time. Dr. Hale counsels that fluorouracil is safe to use on darker skin tones, but says that if there’s a lot of inflammation, there is a risk of hyperpigmentation, so she will also prescribe cortisone to decrease that risk. 

And as usual, wear sunscreen, friends. Here are some good ones. 

xxx