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Actinic keratoses (AKs) are red or brown flat scaly lesions that are rough to touch. They occur when sufficient chronic sun exposure allows for genetically damaged epidermis to exhibit clinical lesions. All of the skin is affected (field change) with the most damaged areas expressed as discrete lesions of variable thickness and scale. AKs can be itchy, scaly, rough, sore or bleed. Shallow ulceration can develop as well as persistent sterile pustulation. An uncertain but small percentage transform into squamous cell carcinoma (SCC). This is more likely to happen in immunocompromised patients, those with a previous SCC, elderly patients and extensive moderate / severe AKs. Not all AKs need treating but they should be identified.
Advice on available treatments, sun protection, risk of skin cancer and skin self-examination should be given. Since AKs are a marker for all types of skin cancer, the patient should be inspected on the arms, lower legs, chest, upper back, neck and head as a bare minimum examination.
All year round regular sun protection (which may include sunblock) will reduce the frequency of new visible lesions developing and mild lesions will regress.
The vast majority of AKs can be managed in primary care. To properly manage AKs, it is best to separate field change from separate lesions and stratify into mild, moderate and severe cases.
Red flag signs that should prompt referral to secondary care are immunosuppressed patients, Bowen's disease, painful lesions, cutaneous horns, rapidly growing lesions, deeply ulceration lesions and solitary lesions without convincing evidence of surrounding chronic sun damage. Pigmented facial lesions may also be very difficult to tell apart from lentigo maligna.
Areas of treatment should not exceed 5cm x 5cm. Divide into sections for larger fields.
Sun-protection and Self-examination advice should be given to all patients
Differential diagnosis: seborrhoeic keratosis; dermatitis; Bowen's and SCC
Fluorouracil cream 5%
Fluorouracil cream 5%
Methyl-5-aminolevulinate cream (Metvix®) with Photodynamic therapy (PDT)
April 2020: The European Medicine Agency's safety committee has confirmed that ingenol mebutate gel (Picato) may increase the risk of skin cancer and concluded that the risks of the medicine outweigh its benefits. Ingenol mebutate gel is no longer licensed for use. Patients who have been treated with ingenol mebutate gel should look out for unusual skin changes or growths, which may occur from weeks to months after use, and seek medical advice if any occur.
Sun-protection and self-examination advice
Fluorouracil 5mg/g with salicylic acid 10mg/g cutaneous solution (Actikerall®)
Curettage and cautery (with pathology)
Combination therapy should be used when the patient presents with both individual AKs and field change, although most topical agents will deal with mild to moderate individual lesions.