II. Epidemiology
- Most common premalignant skin lesion
- Responsible for 60% of Squamous Cell Carcinoma involving the skin
-
Prevalence: White skin (increases with age)
- Age 20-29: 10%
- Age 80-89: 75%
III. Pathophysiology
- Superficial keratotic tumor
- Previously considered distinct premalignant changes
- Now thought to be very early Squamous Cell Carcinomas
IV. Risk Factors
- Fair-skinned, blue-eyed persons
- Living in sunny climate
- Cummulative extensive Sun Exposure
- Older persons
V. Symptoms
- Typically asymptomatic
- May be pruritic or burning
VI. Signs
- Characteristics: Rough Scaly patches
- Distribution: Sun exposed areas
- Face and neck
- Left more common (Car driver's window side)
- Dorsal hands
- Forearms
- Face and neck
VII. Diagnosis
- Diagnosis by "feel": Rough
- Palpated more easily than seen
- Biopsy is rarely indicated
VIII. Management: Procedures
-
Cryotherapy with Liquid Nitrogen
- Debride hyperkeratotic lesions first
- Freeze, slowly thaw and then refreeze
- Efficacy increases with duration of freeze time
- Freeze 5 seconds: 39% cure rate
- Freeze 20 seconds: 83% cure rate
- Curettage
- Infiltrate area with Local Anesthetic
- Consider for hyperkeratotic lesions
- Adjuncts
- Trichloroacetic acid (TCA) before curettage
- Electrosurgery post-curettage to destroy residual tissue
- Photodynamic therapy
- Photosensitizer applied to skin followed by exposure to specific light source
- Protocols
- Aminolevulinic Acid (Levulan Kerastick): Exposure to blue light after 14 hours
- Methyl aminolevulinate (Metvixia): Exposure to red light after 3 hours
IX. Management: Topical Treatments with Keratolytics
- Indicated when numerous lesions (e.g. >15 lesions present)
- Topical 5-Flourouracil (5-FU)
- Preparations
- Fluorouracil cream 5% (Efudex) - preferred, most effective at lowest cost
- Fluorouracil cream 1% (Fluoroplex)
- Fluorouracil microspore cream 0.5% (Carac)
- Adverse effects
- Healing may require 2 months
- Photosensitivity (protect from direct sun)
- Dryness, erythema, irritation, crusting, pealing and even disfigurement on the face
- Irritation more common with 5% cream; 0.5% appears better tolerated (but less effective)
- Apply Skin Lubricants frequently (consider petrolatum at night)
- May apply cool compresses to soothe skin
- Technique
- Use twice daily to twice weekly for 2-4 weeks until marked inflammation and lesion crusts over
- Consider 0.5% cream for one week prior to Cryotherapy
- Wait 30 min before applying Sunscreen or makeup
- If excessive response occurs, stop for 2-3 days and then restart for total of 2-4 cummulative weeks
- Efficacy
- 5-Fluorouracil 5% cream more effective, less re-treatement than Imiquimod, ingenol and Phototherapy
- 5-FU 5% cream is also among the most cost effective options (<$100 per course)
- However lower concentrations (e.g. Carac) having more limited efficacy, at 10 times the cost
- Jansen (2019) N Engl J Med 380:935-46 [PubMed]
- 5-Fluorouracil 5% cream more effective, less re-treatement than Imiquimod, ingenol and Phototherapy
- Preparations
- Topical Diclofenac 3% gel in 2.5% hyaluronic acid (Solaraze)
- Technique: Apply twice daily for 90 days
- Efficacy
- Complete resolution in 50% of cases
- Less effective than Imiquimod (Aldara), 5-Fluorouracil (5-FU) or ingenol (Picato), yet >$600 per course
- Adverse Effects
- Reference
-
Imiquimod 5% Cream (Aldara)
- Applied 3-4 times weekly at bedtime and wash off in AM; use for up to 16 weeks
- Efficacy
- Complete response in up to 57% of patients
- Partial response (75% reduction) in up to 72% of patients
- Adverse effects
- Cosmetic outcomes not studied
- Severe erythema (80%)
- Severe erosions (40%)
- Alternative preparation
- Zyclara (2.5 to 3.75% cream) used for 2 weeks on and 2 weeks off cycles (at 10 times the cost of Aldara)
- References
- Ingenol mebutate (Picato gel)
- Technique: Total course is 2-3 days
- Adverse effects
- Skin irritation (erythema, flaking or crusting)
- Efficacy
- Similar to Imiquimod and 5-Fluorouracil, but very expensive ($1000)
- Tirbanibulin (Klisyri) 1% Ointment
- Released in 2021
- Only 5 day course, but with no evidence of benefit over 5-FU in efficacy or tolerability and at 10 times the cost (>$1000)
- (2021) Presc Lett 28(7): 41
-
Chemical Peels for face (applied by dermatology)
- Similar efficacy to Fluorouracil
- Preparations
- Jessner's Solution (Resorcinol, Lactic Acid, Salicylic acid)
- Trichloroacetic acid 35% (Tri-Chlor)
- References
X. Management: Adjunctive measures
-
Niacinamide
- Indicated if Actinic Keratosis patient with 2 or more Nonmelanoma Skin Cancers
- Decreases risk of new Actinic Keratosis lesions and Nonmelanoma Skin Cancers
- Dose: 500 mg orally twice daily ($5/month)
XI. Prevention
- See Sun Exposure (lists general preventive measures)
- See Sunscreen
XII. Course
- Spontaneous resolution in 25-50% of lesions over 12 months
- Progression to squamous cell cancer: 6-10% over 10 years
- Actinic Keratoses are a marker of invasive SCSS
- Malignant transformation rate may be as high as 20% per year
- Malignant transformation of Actinic Keratoses are responsible for 60% of CSCC cases
- Higher risk of Squamous Cell Carcinoma progression in thick tumors (especially on scalp), Immunosuppression
XIII. References
- (2019) Presc Lett 26(5)
- Habif (2004) Dermatology p. 736-43
- Mcintyre (2007) Am Fam Physician 76(5):667-71 [PubMed]
- Stulberg (2004) Am Fam Physician 70:1481-8 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MSH) | White or pink lesions on the arms, hands, face, or scalp that arise from sun-induced DNA DAMAGE to KERATINOCYTES in exposed areas. They are considered precursor lesions to superficial SQUAMOUS CELL CARCINOMA. |
| Definition (CHV) | precancerous thick and scaly patches of skin |
| Definition (CHV) | precancerous thick and scaly patches of skin |
| Definition (CHV) | precancerous thick and scaly patches of skin |
| Definition (NCI) | A precancerous lesion of the skin composed of atypical keratinocytes. It is characterized by the presence of thick, scaly patches of skin. Several histologic variants have been described, including atrophic, acantholytic, and hyperkeratotic variants. |
| Definition (NCI_NCI-GLOSS) | A thick, scaly patch of skin that may become cancer. It usually forms on areas exposed to the sun, such as the face, scalp, back of the hands, or chest. It is most common in people with fair skin. |
| Concepts | Neoplastic Process (T191) |
| MSH | D055623 |
| ICD9 | 702.0 |
| ICD10 | L57.0 |
| SnomedCT | 856006, 201106002, 267858008, 201096007, 201107006, 156398007, 267860005, 156395005, 201098008, 156400006, 201101007, 201097003, 46795000 |
| English | Keratosis, Actinic keratosis, Keratinocytic intraepidermal neoplasia, actinic keratosis (diagnosis), actinic keratosis, Actinic Keratoses, Keratosis, Actinic, Keratoses, Actinic, Actinic Keratosis, Actinic keratoses, Keratosis NOS, Keratosis, Actinic [Disease/Finding], Solar hyperkeratosis, Senile hyperkeratosis (disorder), senile keratosis, solar keratosis, Solar keratosis, Senile keratosis, Senile hyperkeratosis, Senile keratoma, AK - Actinic keratosis, Atrophic keratosis, Hyperplastic keratosis, SK - Solar keratosis, Actinic keratosis (disorder), Actinic keratosis (morphologic abnormality), Senile keratoma (disorder), keratosis, actinic, hyperkeratosis; senile, keratoma; senile, keratosis actinica, keratosis; actinic, keratosis; senile, keratosis; sunshine, actinic; keratosis, senile; hyperkeratosis, senile; keratoma, senile; keratosis, sunshine; keratosis, Actinic (Solar) Keratosis, Senile Hyperkeratosis, Senile Keratosis, Solar Keratosis, keratosis, solar hyperkeratosis |
| Dutch | seniele keratosis, seniel keratoom, zonkeratosis, stralingskeratose, actinisch; keratose, hyperkeratose; seniel, keratoom; seniel, keratose; actinisch, keratose; seniel, keratose; zonnestraling, seniel; hyperkeratose, seniel; keratoom, seniel; keratose, zonnestraling; keratose, Keratosis actinica |
| French | Kératome sénile, Kératose sénile, Kératose solaire, Kératose actinique |
| German | solare Keratose, Keratoma senile, senile Keratose, Aktinische Keratose, Keratose, aktinische, Keratosis actinica |
| Italian | Cheratosi senile, Cheratoma senile, Cheratosi solare, Cheratosi attinica |
| Portuguese | Queratose senil, Queratose solar, Ceratoma senil, Ceratose Actínica, Ceratose Solar, Queratose actínica |
| Spanish | Queratosis senil, Queratoma senil, Queratosis solar, neoplasia intraepidérmica queratinocítica, Queratosis Actínica, Queratosis Solar, hiperqueratosis senil, queratoma senil (trastorno), queratoma senil, queratosis actínica (anomalía morfológica), queratosis actínica (trastorno), queratosis actínica, queratosis hiperplásica, queratosis senil, queratosis solar, Queratosis actínica |
| Japanese | 老人性角化症, 老人性角化腫, ﾛｳｼﾞﾝｾｲｶｸｶｼｮｳ, ﾆｯｺｳｶｸｶｼｮｳ, ﾆｯｺｳｶｯｶｼｮｳ, ﾆｯｺｳｾｲｶｸｶｼｮｳ, ﾛｳｼﾞﾝｾｲｶｯｶｼｮｳ, ﾛｳｼﾞﾝｾｲｶｸｶｼｭ, 角化症-光線, 紫外線性角化症, 角化症-日光, 紫外線角化症, 日光角化症, 光線角化症, 日光性角化症, 角化症-紫外線, 光線性角化症 |
| Czech | Aktinická keratóza, Senilní keratom, Solární keratóza, Senilní keratóza, keratóza aktinická |
| Korean | 광선 각화증 |
| Russian | KERATOZ FOTOKHIMICHESKII, КЕРАТОЗ ФОТОХИМИЧЕСКИЙ, KERATOZ AKTINICHESKII, КЕРАТОЗ АКТИНИЧЕСКИЙ |
| Swedish | Keratos, aktinisk |
| Polish | Rogowacenie słoneczne |
| Croatian | KERATOZA, AKTINIČKA, AKTINIČKA KERATOZA |
| Hungarian | Keratosis actinica, Senilis keratoma, Keratosis senile, Solaris keratosis |
| Norwegian | Keratosis actinica, Aktinisk keratose, Solar keratose |
