What is actinic keratosis?
Actinic keratosis is a scaly spot found on sun-damaged skin. It is also known as solar keratosis. It is considered precancerous or an early form of cutaneous squamous cell carcinoma (a keratinocyte cancer).
Who gets actinic keratoses?
Actinic keratoses affect people that have often lived in the tropics or subtropics and have predisposing factors such as:
Other signs of photoageing skin
Fair skin with a history of sunburn
History of long hours spent outdoors for work or recreation
Defective immune system
What causes actinic keratoses?
Actinic keratoses are a reflection of abnormal skin cell development due to DNA damage by short wavelength UVB.
They are more likely to appear if the immune function is poor, due to ageing, recent sun exposure, predisposing disease or certain drugs.
What are the clinical features of actinic keratosis?
Actinic keratosis may be solitary but there are often multiple keratoses. The appearance varies.
A flat or thickened papule or plaque
White or yellow; scaly, warty or horny surface
Skin coloured, red or pigmented
Tender or asymptomatic
Actinic keratoses are very common on sites repeatedly exposed to the sun, especially the backs of the hands and the face, most often affecting the ears, nose, cheeks, upper lip, vermilion of the lower lip, temples, forehead and balding scalp. In severely chronically sun-damaged individuals, they may also be found on the upper trunk, upper and lower limbs, and dorsum of feet.
Complications of actinic keratoses
The main concern is that actinic keratoses predispose to squamous cell carcinoma. It is rare for a solitary actinic keratosis to evolve to squamous cell carcinoma (SCC), but the risk of SCC occurring at some stage in a patient with more than 10 actinic keratoses is thought to be about 10 to 15%. A tender, thickened, ulcerated or enlarging actinic keratosis is suspicious of SCC.
Cutaneous horn may arise from an underlying actinic keratosis or SCC.
Because they are sun damaged, people with actinic keratoses are also at risk of developing actinic cheilitis, basal cell carcinoma (BCC, which is more common than SCC), melanoma and rare forms of skin cancer such as Merkel cell carcinoma.
What is the treatment for actinic keratoses?
Actinic keratoses are usually removed because they are unsightly or uncomfortable, or because of the risk that skin cancer may develop in them.
Treatment of an actinic keratosis requires removal of the defective skin cells. Epidermis regenerates from surrounding or follicular keratinocytes that have escaped sun damage.
Tender, thickened, ulcerated or enlarging actinic keratoses should be treated aggressively. Asymptomatic flat keratoses may not require active treatment but should be kept under observation.
Physical treatments are used to destroy individual keratoses that are generally symptomatic or have a thick hard surface scale. The lesions may recur in time, in which case they may be retreated by the same or a different method.
Cryotherapy using liquid nitrogen
Shave, curettage and electrocautery
Creams are used to treat areas of sun damage and flat actinic keratoses, sometimes after physical treatments have been carried out. Field treatments are most effective on facial skin. Pretreatment with keratolytics (such as urea cream, salicylic acid ointment or topical retinoid), and thorough skin cleansing improves response rates.
Prevention of actinic keratoses
Actinic keratoses are prevented by strict sun protection. If already present, keratoses may improve with a very high sun protection factor (50+) broad-spectrum sunscreen applied at least daily to affected areas, year-round.
The number and severity of actinic keratoses can also be reduced by taking nicotinamide (vitamin B3) 500 mg twice daily.
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