Actinic (Solar) Keratosis

Scope

An Actinic Keratosis (AK) is a common sun-induced scaly or hyperkeratotic lesion, which has the potential to become malignant. NICE estimates that over 23% of the UK population aged 60 and above have AK. Although the risk of an AK transforming into a squamous cell carcinoma (SCC) is very low, this risk increases over time, in the immunocompromised, those with previous SCCs and with larger numbers of lesions. The presence of ten AK is associated with a 14% risk of developing an SCC within five years.

  • AK are a consequence of cumulative long-term sun-exposure:
    • Lesions are very uncommon under the age of 45 years
    • The incidence increases with age
    • The exceptions are patients with xeroderma pigmentosum and albinism who can develop AK at a very young age
  • Genetic factors play a role and individuals with fair skin, blue eyes and blonde hair are at higher risk, whereas lesions are exceedingly rare in patients of skin types IV-VI
  • Artificial UV radiation such as UVB and PUVA, used to treat psoriasis and a number of other skin conditions, as well as the use of sun beds, increase the risk
  • Men are more affected than women (2:1)

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.

Referral Criteria:

The majority of patients can be managed in primary care

Consider referral to accredited GPwSI or secondary care

  • Past history of skin cancer
  • Those with extensive UV damage
  • Immunosuppressed patients
  • The very young

Refer as 2WW

Lesions that are

  • Rapidly growing
  • Have a firm and fleshy base and/or are painful
  • Are not responding to treatment

Assessment

Signs and Symptoms

  • Lesions are normally asymptomatic
  • Recent growth, pain / tenderness, bleeding or ulceration are suggestive of transformation into an SCC
  • There is often a background of significant sun-damaged skin with pigment irregularity, telangiectasia, erythema and collagenosis (a yellow papularity of the skin)
  • Distribution ◦ This reflects the intensity of sun-exposure with the greatest number of lesions occurring on the head, neck, forearms and hands
  • Lesions usually take on a similar appearance
  • Seldom exceed more than 1 cm in diameter
  • Rough surface scale - usually white, although in patients with skin type I AK are often more easily felt than seen
  • Often termed as flat, but some lesions can have significant amounts of scale (hypertrophic or Bowenoid AK)

Red Flags

Red flag signs that should prompt referral to secondary care are:

  • Immunosuppressed patients
  • Bowen's disease
  • Painful lesions
  • Cutaneous horns
  • Rapidly growing lesions
  • Deep 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
  • Potential of SCC

Referral

Referral Criteria

The majority of patients can be managed in primary care

Consider referral to accredited GPwSI or secondary care

  • Past history of skin cancer
  • Those with extensive UV damage
  • Immunosuppressed patients
  • The very young

Refer as 2WW

Lesions that are

  • Rapidly growing
  • Have a firm and fleshy base and/or are painful
  • Are not responding to treatment

Supporting Information

For more information on actinic keratosis refer to:

Evidence

The Primary Care Dermatology Society

North and East Devon formulary guidance - Skin

Pathway Group

This guidance has been signed off by the Eastern Locality on behalf of NEW Devon CCG

Publication date: 30 January 2017

 

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