Management
Treatment of AKs is very much patient centred. The PCDS offer advice stating most AKs can be diagnosed and treated in primary care. Their guidance supports teledermatology use for diagnosis and management of AKs. It acknowledges AKs are part of the spectrum of actinic damage, with an aim for management and follow up opposed to cure. The following are a list of recommendations when to refer to secondary care as advised by BAD;
- AK fails to respond to standard treatments
- Multiple or relapsing AKs that represent a management challenge
- AK occurs in the long-term immunosuppressed
- Very young patients presenting with AK – consider xeroderma pigmentosum
- There is concern an AK lesion might be an SCC - for this an USC referral should be used. Examples of stage 3 AKs, leading to suspicion of it being a SCC is when the skin lesion bleeds, feels painful and feels thickened when held between finger and thumb.
On first diagnosing AKs the location and grade should be defined to enable monitoring, and response to treatment. This can be done using drawings, body maps and photography numbering the lesions. Examination should involve reviewing for an elevated lesion (papule / nodule). Surface scale should be removed allowing for a proper assessment of the lesion, ulceration, induration, tenderness and surrounding inflammation. PCDS also state ‘Beware lesions on lips - SCC can be very subtle at this site’.
Field-based treatment can act to manage a range of actinic changes in a zone such as the forehead, scalp or central face, and may provide some benefit in reduction of onset of new lesions for which topical therapies and PDT are suitable. Field change refers to areas of skin that have multiple AKs, with a background of erythema and telangiectasia with a generalised sun damaged appearance. As such, the treatments should be applied to the whole area of field change and not just the individual lesions. The main agents include 5-fluorouracil (5-FU), imiquimod, ingenolmebutate and variants of PDT. Topical therapies are usually avoided near the mouth and eyes due to risk of severe reactions. Areas requiring field treatment are more at risk of developing SCC, especially if left untreated. Therefore more intense treatment is advised. Treatments should be applied to the whole area of field change and not just the individual lesions.
Usually, focal destructive therapies such as curettage and cautery or cryotherapy are limited to treating isolated lesions. A European AK guideline achieved consensus showing a preference for cryosurgery for isolated lesions with curettage for larger ones.
A set of treatment guidelines advised by PCDS include the following:
Initial advice for all patients where an AK has been identified;
- AK are a marker of sun damage, the patient should therefore receive a thorough skin examination to look for further lesions
- A patient information leaflet on UV protection (and vitamin D) including the need to wear a hat - up to 25% of AK will resolve if patients adhere to advice
- Provide a patient information leaflet on AK
- Using a moisturiser can aid differentiating between areas of normal and abnormal skin
- Once a patient develops AK, they are likely to develop more. The aim of any treatment is to reduce the total number of AK on the skin at any one time
- Education - inform patients which skin changes need to be reported. Transformation into an SCC can be suggested by recent growth, discomfort, ulceration and bleeding. Patients also need to report any other skin lesions they are not familiar with
- Larger numbers of actinic keratosis patients should be advised to take Nicotinamide 500 mg BD, a vitamin that has been shown to reduce the number of actinic keratoses and non-melanoma skin cancers
- Patients with smaller numbers of lesions, especially if they have a reduced life expectancy, should be given a choice or whether or not they wish to have their lesions treated.
For lesion specific treatment PCDS advise the following guideline for treating larger numbers that are widely distributed or not requiring field treatment.