Actinic Keratosis

Clinical diagnosis is usually sufficient for a typical rough, scaly lesion on chronically sun-exposed skin, but dermoscopy is useful when morphology is uncertain or when documenting response and recurrence. Dermoscopy improves diagnostic assessment but does not replace histopathology when invasive SCC, pigmented malignancy, or another mimic remains plausible. PubMed+2PubMedActinic keratoses: review of clinical, dermoscopic, and therapeutic aspects☆☆☆PubMedDigitally Enhanced Methods for the Diagnosis and Monitoring of Treatment Responses in Actinic Keratoses: A New Avenue in Personalized Skin CareccjmActinic keratosis: A clinician's guide to diagnosis and treatment

Perform biopsy before routine destructive or field treatment for a lesion larger than 1 cm, bleeding, ulcerated, indurated, rapidly enlarging, or prominently erythematous. These features raise concern for progression to SCC or an alternative diagnosis. Biopsy is also appropriate for intense pruritus or pain, marked hyperkeratosis, palpable thickening, pigmentation, unusual morphology, or failure to respond to usual AK treatment. PubMedPubMedActinic keratoses: review of clinical, dermoscopic, and therapeutic aspects☆☆☆

Treat a persistent suspicious lip lesion as a separate high-risk problem: actinic cheilitis may clinically resemble AK, yet lesions presumed premalignant can prove to be SCC on histology. Biopsy is the diagnostic standard for a persistent suspicious lesion on the lip; SCC arising on the lip has higher metastatic potential than SCC at many other cutaneous sites. PubMedPubMedActinic Cheilitis - StatPearls - NCBI Bookshelf

Choose lesion-directed treatment for a limited number of discrete lesions. Liquid-nitrogen cryotherapy is a standard destructive option; curettage with or without electrodesiccation is another destructive approach listed for AK management. Surgical excision is a lesion-directed option when tissue diagnosis or definitive removal is needed, particularly when SCC cannot be excluded clinically. BMJ+1BMJActinic keratosis - Symptoms, diagnosis and treatment | BMJ Best Practice USccjmActinic keratosis: A clinician's guide to diagnosis and treatment

Choose field-directed therapy for multiple AKs or recurrent lesions within a contiguous sun-damaged area because visible lesions coexist with subclinical disease in the cancerization field. Field options include topical 5-fluorouracil, imiquimod, tirbanibulin, diclofenac, and photodynamic therapy. BMJ+3BMJActinic keratosis - Symptoms, diagnosis and treatment | BMJ Best Practice USScienceDirectRandomized comparative study of 5-Fluorouracil 4%, tirbanibulin ...ScienceDirectClinical and histopathological study of actinic keratosis treatment with photodynamic therapy VS 5-fluorouracil for face cancerization - ScienceDirectccjmActinic keratosis: A clinician's guide to diagnosis and treatment

Do not interpret short-term clearance comparisons as proof that one field treatment is universally best. In relapsing AK after diclofenac, a prospective randomized comparison of 5-fluorouracil 4%, tirbanibulin, and PDT found no statistically significant short-term differences in clearance or recurrence; the study was not powered to establish equivalence. Individualize selection around site, number of lesions, expected inflammation, treatment duration, access, and cosmetic preference. ScienceDirectScienceDirectRandomized comparative study of 5-Fluorouracil 4%, tirbanibulin ...

Topical 5-fluorouracil is a field-directed option for AK. In a split-face study of facial field cancerization, 5-fluorouracil was applied twice daily for 15 days; this is a study regimen rather than a universal regimen. Select topical therapy only when the patient can apply treatment to the defined field and return for reassessment of persistent lesions. ScienceDirect+1ScienceDirectClinical and histopathological study of actinic keratosis treatment with photodynamic therapy VS 5-fluorouracil for face cancerization - ScienceDirectccjmActinic keratosis: A clinician's guide to diagnosis and treatment

Topical 5-fluorouracil plus calcipotriene is an off-label short-course field strategy. Reported courses are commonly 4 to 7 days, intended to augment a T-cell-mediated response against dysplastic keratinocytes while reducing treatment duration compared with traditional 5-fluorouracil monotherapy. Anticipate erythema, crusting, and localized irritation; assess residual focal lesions after reaction resolves. ccjmccjmActinic keratosis: A clinician's guide to diagnosis and treatment

Imiquimod and tirbanibulin are additional field-directed topical options. Their principal operational advantage is avoidance of an in-office light procedure; their limitation is that successful treatment depends on adherence to the prescribed application schedule and recognition of local treatment reactions. Current AK guidance includes a focused update addressing tirbanibulin. BMJ+3BMJActinic keratosis - Symptoms, diagnosis and treatment | BMJ Best Practice USaadWe’ve got new AK guidelines with CME creditaadActinic keratosis - American Academy of DermatologyccjmActinic keratosis: A clinician's guide to diagnosis and treatment

Photodynamic therapy is a field procedure using a topical photosensitizer and light activation. Methyl aminolevulinate-PDT has been compared with liquid-nitrogen cryotherapy in a multicenter randomized study, and PDT is used for AKs with an established reputation for efficacy and cosmetic results. Consider PDT when a procedure-based field treatment is preferable to prolonged topical application. NEJM+2NEJMActinic Keratosis: Photodynamic Therapy or Cryotherapy? | NEJM ClinicianScienceDirectClinical and histopathological study of actinic keratosis treatment with photodynamic therapy VS 5-fluorouracil for face cancerization - ScienceDirectccjmActinic keratosis: A clinician's guide to diagnosis and treatment

At each follow-up, examine the treated field for persistent thick, tender, indurated, ulcerated, bleeding, or enlarging lesions and direct these lesions to biopsy. Dermoscopy can support serial assessment of clinical response and recurrence, particularly in patients with numerous lesions where routine biopsy of each site is impractical. PubMed+1PubMedActinic keratoses: review of clinical, dermoscopic, and therapeutic aspects☆☆☆PubMedDigitally Enhanced Methods for the Diagnosis and Monitoring of Treatment Responses in Actinic Keratoses: A New Avenue in Personalized Skin Care

Explain the reason to treat and surveil: AKs may progress to invasive SCC. A retrospective electronic-record study estimated that approximately 10% of AKs progress to SCC and that mean time to progression among transforming lesions was 24.6 months; this estimate should inform vigilance, not lesion-specific prediction. WileyWileyThe Kinetics of Skin Cancer: Progression of Actinic Keratosis to Squamous Cell Carcinoma - FUCHS - 2007 - Dermatologic Surgery - Wiley Online Library

Prescribe ongoing UV protection as a core prevention strategy for patients with AK or ongoing risk. A contemporary clinician review also identifies oral nicotinamide as a preventive strategy that can reduce lesion formation and recurrence; determine use in the context of the patient's broader skin-cancer risk profile and concurrent care. aad+1aadWe’ve got new AK guidelines with CME creditccjmActinic keratosis: A clinician's guide to diagnosis and treatment