Actinic Keratosis before undergoing treatment at the #1 Dermatologist in Phoenix, Arizona

What is Actinic Keratosis?

Actinic keratosis (plural, keratoses) is a small, rough, precancerous growth of sun-damaged skin skin. Also caused by repeated use of tanning beds over a long period of time, actinic keratoses usually appear on adults older than 40 who have had sustained exposure to the sun’s ultra-violet (UV) rays. Actinic keratoses are concerning because, left untreated, some of them can develop into skin cancer. Typically once an individual actinic keratosis appears, others will follow, putting you at a higher risk.

What does actinic keratosis look like?

Unlike smoother marks on the skin, such as ordinary moles, actinic keratoses are typically rough or crusty spots or patches of skin that are often slightly raised. They may resemble warts, scabs, or appear as irregularly shaped, discolored spots. They are often described as having a sandpaper texture. Actinic keratoses can appear singly or in clusters, and they vary in color from tan or brown to pink or red. Because they occur on skin exposed to the sun, they are most common on the face, forehead, lips, ears, scalp, neck, forearms, and back of the hands.

What are the risk factors for actinic keratosis?

The biggest risk factor for actinic keratoses is cumulative build-up of UV damage to the skin, i.e., too much exposure to UV radiation over a long period of time. That’s why people over 40 years of age are most affected. However, according to one recent study, the incidence of actinic keratoses continues to rise among younger sun-damaged populations as well. People with fair skin and those who live in hotter, sunnier places (as in countries closer to the equator) also carry more risk, as do males in general and balding males in particular. Increased sensitivity to UV radiation caused by other skin conditions can also make you susceptible to actinic keratosis (1).

Can actinic keratosis turn into skin cancer?

Although only about 1% of actinic keratoses become skin cancer, there is a strong association between actinic keratosis and squamous cell carcinoma (SCC) (1), one of the three main types of skin cancer.

To determine if actinic keratosis is cancerous, some dermatologists use a 3-tiered classification system based on the presence of abnormal, or atypical, cells in the lowest layer of the epidermis (this is called basal atypia). This abnormality in the cells can move upward through the entire thickness of the lesion. However, not all actinic keratoses behave this way. In fact, many lesions will stay in the first benign stage or even regress, while only a few will turn into SCC (2). The critical determination is whether the abnormal cells are present only in the lower levels of the lesion of if the entire thickness is affected, and only your doctor will be able to distinguish the difference.

The good news is that the estimated annual risk of progression from actinic keratosis to SCC for an individual lesion is believed to be small; still, the cumulative risk for a patient with multiple lesions over time is substantial (1).

Signs indicating that actinic keratosis is progressing to SCC include inflammation, swelling, thickening, rapid enlargement of the lesion, bleeding, redness, and ulceration or scabbing/crusting (1). Even if an individual lesion does not show any of these characteristics, it is important to be proactive in monitoring its appearance and the development of new actinic keratoses.

It is not possible to predict if or when an individual actinic keratosis will turn into cancer.

What should I do If I suspect I have actinic keratosis?

Once detected, early identification of the actinic keratosis by a dermatologist is critical to reducing risk. This is especially important for actinic keratoses that appear on the head or neck, the site of more aggressive skin cancers. Confirming that the crusty bump that’s appeared is indeed actinic keratosis will allow your doctor to monitor its development, check for any new lesions, and prescribe the most appropriate treatment.

The particular treatment your dermatologist recommends will depend on whether you have an isolated lesion or widespread activity with multiple lesions. Other considerations are the appearance of the lesion(s), its location and size, and your history of other medical conditions that may make you more vulnerable. Common treatments for actinic keratosis include 1) removal by freezing (cryotherapy); 2) light therapy (photodynamic therapy); 3) topical treatment with medicated creams or ointments; and 4) a combination of therapies.

Cryosurgery is a preferred method for dealing with an isolated lesion. In this method, intensely cold liquid nitrogen (-196ºC) is quickly applied to the lesion by spray or using a cotton swab, which freezes and destroys the tissue.

Phototherapy, also called photodynamic therapy, involves the application of a photosensitizer (a chemical that sensitizes the skin to light; in the United States aminolevulinic acid (ALA ) is commonly used. This is followed by brief exposure to a particular wavelength of light. The light activates the drug, resulting in cell death in the tissue.

Topical treatments for actinic keratosis are widely available in cream or ointment form. Among the most common medicated creams used to treat actinic keratosis are imiquimod, which modifies the body’s immune response; diclofenac, a non-steroidal, anti-inflammatory drug; ingenol mebutate, a drug that induces rapid cell necrosis (cell death); and 5-fluoracil, a drug that disrupts cell division in the tissue.   

Your doctor may recommend a combination therapy of two of these treatments. Typical pairings are 1) cryosurgery and photodynamic therapy, 2) cryosurgery and a topical treatment, and 3) a topical treatment and phototherapy.

In case of suspected cancerous actinic keratosis, surgical techniques may also be recommended.

Shave excision is a minimally invasive procedure whereby your doctor uses a razor to remove the growth layer by layer until no affected tissue remains. 

Curettage is a similar procedure whereby your doctor scrapes away abnormal tissue using a sharp spoon-like tool called a curette.

The topical medications mentioned above have all been approved by the US Food and Drug Administration. While you can apply the prescribed cream at home, it is unwise to use any medicated cream without the supervision of a dermatologist; one cream may be more appropriate for use on the face while another may be prescribed for other parts of the body due to the skin reactions it may cause. Moreover, certain medicated creams are not recommended for use during pregnancy. When treating actinic keratosis at home, it is critical to follow the instructions for use very carefully and to continue treatment throughout the suggested time period. It is also important to refrain from using hydrocortisone or any other corticosteroid treatment to calm your skin while using medicated creams for actinic keratosis.

Many websites promote the use of so-called “natural” remedies over “chemicals” to treat actinic keratosis. Some patients have tried applying natural substances such as apple cider vinegar, virgin coconut oil, and soaked green tea bags to treat sun damage. These treatments are unlikely to provide reliable and repeatable improvement. There is some evidence for use of essential oils and Kanuka honey (3) to treat actinic keratosis, but we do not recommend their use without seeing a dermatologist, and they may need to be used in conjunction with traditional therapy also. It is important to assess the validity and accuracy of any Internet sites you consult. Most claims that seem too be good to be true, are too good to be true! The best course of action is to talk to your dermatologist about how to incorporate natural products into your treatment plan.

Actinic keratoses can go away on their own, especially if you limit exposure to the sun for a long time. However, they may return.

You should never attempt to scrape off or pick at an individual actinic keratosis. Not only can you damage your skin but removal of the lesion will prevent your doctor from evaluating whether it is possibly cancerous or not.

Due to the inability to predict which actinic keratoses will progress to skin cancer, current recommendations suggest that all lesions should be treated (2). For the best outcomes, adhere to the advice of your dermatologist and follow through on your recommended treatment plan. Make it a regular practice to examine your skin for new lesions and get a skin cancer screening at least once a year.  Although cost-effectiveness of treatment is important when making treatment decisions, long-term follow-up is advised.

Final Word on Actinic Keratosis

As the old saying goes, “An ounce of prevention is worth a pound of cure.” To reduce further development of actinic keratosis, be proactive in developing common-sense practices for your outdoor activities. Minimize your sun exposure when the UV rays are most intense, and refrain from tanning altogether, whether in the open air or in a tanning booth. Learn about other measures to protect against sun damage to your skin. It’s worth it in—and for—the long run.

Suggested Resources

Skin Cancer Foundation

National Cancer Institute

American Cancer Society

Healthline

DermNet NZ

Dermatology Times

American Academy of Dermatology

Robert Tisserand Website

Articles Cited

  1. Hashim PW, Chen T, Regel D, et al. Actinic keratosis: current therapies and insights into new treatments. J Drugs Dermatol 2019;18(5 Suppl 1):s161-166 Accessed April 21, 2021 at https://jddonline.com/articles/dermatology/S1545961619S0161X
  2. Fernandez Figueras MT. From actinic keratosis to squamous cell carcinoma: pathophysiology revisited. J Eur Acad Dermatol Venereol (JEADV) 2017;31(Suppl 2):5-7. doi:10.1111/jdv.14151
  3. Mane S, Singer J, Corin A, et al. Successful treatment of actinic keratosis with kanuka honey. Case Rep Dermatol Med 2018; 4628971. Published online 2018 May 31. doi: 10.1155/2018/4628971.

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Our comprehensive dermatology clinic is dedicated to providing you with the highest quality of care, innovative practices, helpful resources and state-of-the-art technology to prevent and treat a multitude of skin disorders. Led by Medical Director, Dathan Hamann, MD, FAAD, our passionate team looks forward to serving you with respect and compassion.

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