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Actinic keratosis — Clinical Guidelines

Overview

Actinic keratosis (AK) are precancerous skin lesions resulting from chronic sun exposure, often found on sun-exposed areas and associated with an increased risk of squamous cell carcinoma 1 3 7 14.

Diagnosis

Clinical appearance of scaly, erythematous, often hyperkeratotic papules 3.

Biopsy for histopathological confirmation if clinical diagnosis is uncertain 3 24.

Grading systems often based on severity and extent of lesions 18 20.

Management

First-line treatments:

- Cryotherapy 3 13 22. - Topical agents: - Imiquimod 5% cream 22. - Tirbanibulin 1% ointment 4. - Photodynamic therapy (PDT): - ALA-PDT with daylight or laser light 1 2 5. - Blue light PDT with vitamin D pretreatment showing promise 5.

Adjunctive treatments:

- Microdermabrasion preceding ALA application to reduce incubation time 23.

Special Populations

Pregnancy: Limited data; avoid systemic treatments; topical therapies may be considered with caution 3.

Pediatrics: Rarely seen; management similar to adults but with caution due to skin sensitivity 3.

Elderly: Increased prevalence; consider comorbidities and treatment tolerability 11 16.

Comorbidities: Tailor treatment based on patient's overall health; avoid systemic risks 16.

Key Recommendations

Use cryotherapy or topical treatments like imiquimod or tirbanibulin as first-line options for AK management (Evidence: Strong 3 4 22).

Consider photodynamic therapy (PDT) for extensive or recurrent AK, optimizing light fractionation for efficacy (Evidence: Moderate 2).

Implement patient-specific treatment choices considering comorbidities and patient preference (Evidence: Expert opinion 8 16).

Utilize teledermatology for improved access and diagnosis in underserved populations (Evidence: Moderate 6 17).

Evaluate and standardize AK quantification methods to improve clinical trial outcomes and patient care (Evidence: Weak 18 20).

References

1 Gracia-Cazaña T, Gilaberte Y. [Translated article] Home Self-Applied Daylight Photodynamic Therapy: Current Map in Spain and Management Proposals. Actas dermo-sifiliograficas 2025. link 2 Alonso-Mtz de Salinas L, Garcia-Mouronte E, Naharro-Rodriguez J, Perez-Gonzalez LA, Fernández-Guarino M. Optimization of Photodynamic Therapy in Dermatology: The Role of Light Fractionation. International journal of molecular sciences 2025. link 3 Kandolf L, Peris K, Malvehy J, Mosterd K, Heppt MV, Fargnoli MC et al.. European consensus-based interdisciplinary guideline for diagnosis, treatment and prevention of actinic keratoses, epithelial UV-induced dysplasia and field cancerization on behalf of European Association of Dermato-Oncology, European Dermatology Forum, European Academy of Dermatology and Venereology and Union of Medical Specialists (Union Européenne des Médecins Spécialistes). Journal of the European Academy of Dermatology and Venereology : JEADV 2024. link 4 Pellacani G, Schlesinger T, Bhatia N, Berman B, Lebwohl M, Cohen JL et al.. Efficacy and safety of tirbanibulin 1% ointment in actinic keratoses: Data from two phase-III trials and the real-life clinical practice presented at the European Academy of Dermatology and Venereology Congress 2022. Journal of the European Academy of Dermatology and Venereology : JEADV 2024. link 5 Bullock TA, Negrey J, Hu B, Warren CB, Hasan T, Maytin EV. Significant improvement of facial actinic keratoses after blue light photodynamic therapy with oral vitamin D pretreatment: An interventional cohort-controlled trial. Journal of the American Academy of Dermatology 2022. link 6 Sola-Ortigosa J, Muñoz-Santos C, Masat-Ticó T, Isidro-Ortega J, Guilabert A. The Role of Teledermatology and Teledermoscopy in the Diagnosis of Actinic Keratosis and Field Cancerization. The Journal of investigative dermatology 2020. link 7 Yaldiz M. Prevalence of actinic keratosis in patients attending the dermatology outpatient clinic. Medicine 2019. link 8 Noels EC, Lugtenberg M, van Egmond S, Droger SM, Buis PAJ, Nijsten T et al.. Insight into the management of actinic keratosis: a qualitative interview study among general practitioners and dermatologists. The British journal of dermatology 2019. link 9 Zheng Z, Zhang LL, Shi L, Zhang YF, Wang B, Wu QQ et al.. What is the most relevent factor causing pain during ALA-PDT? A multi-center, open clinical pain score research trial of actinic keratosis, acne and condylomata acuminata. Photodiagnosis and photodynamic therapy 2019. link 10 Diepgen TL, Kresken J, Krutmann J, Merk HF, Senger E, Surber C et al.. Commentary on the "Evidence- and Consensus-Based (S3) Guidelines for the Treatment of Actinic Keratosis" Published by the International League of Dermatological Societies in Cooperation with the European Dermatology Forum. Skin pharmacology and physiology 2018. link 11 Yeung H, Baranowski ML, Swerlick RA, Chen SC, Hemingway J, Hughes DR et al.. Use and Cost of Actinic Keratosis Destruction in the Medicare Part B Fee-for-Service Population, 2007 to 2015. JAMA dermatology 2018. link 12 Fargnoli MC, Altomare G, Benati E, Borgia F, Broganelli P, Carbone A et al.. Prevalence and risk factors of actinic keratosis in patients attending Italian dermatology clinics. European journal of dermatology : EJD 2017. link 13 Schaefer D. Survey of Patient Satisfaction With Ingenol Mebutate Gel Treatment for Actinic Keratosis From a Community Dermatology Practice. Skinmed 2016. link 14 Ferrándiz C, Plazas MJ, Sabaté M, Palomino R. Prevalence of actinic keratosis among dermatology outpatients in Spain. Actas dermo-sifiliograficas 2016. link 15 Kirby JS, Delikat A, Leslie D, Miller JJ. Bundled Payment Models for Actinic Keratosis Management. JAMA dermatology 2016. link 16 Erlendsson AM, Egekvist H, Lorentzen HF, Philipsen PA, Stausbøl-Grøn B, Stender IM et al.. Actinic keratosis: a cross-sectional study of disease characteristics and treatment patterns in Danish dermatology clinics. International journal of dermatology 2016. link 17 Janda M. Teledermatology: its use in the detection and management of actinic keratosis. Current problems in dermatology 2015. link 18 Lee KC, Lew R, Weinstock MA. Improvement in precision of counting actinic keratoses. The British journal of dermatology 2014. link 19 Peris K, Neri L, Calzavara Pinton P, Catricalà C, Pellacani G, Pimpinelli N et al.. Physicians' opinions and clinical practice patterns for actinic keratosis management in Italy. Giornale italiano di dermatologia e venereologia : organo ufficiale, Societa italiana di dermatologia e sifilografia 2014. link 20 Chen SC, Hill ND, Veledar E, Swetter SM, Weinstock MA. Reliability of quantification measures of actinic keratosis. The British journal of dermatology 2013. link 21 Lagler CN, Freitag SK. Management of periocular actinic keratosis: a review of practice patterns among ophthalmic plastic surgeons. Ophthalmic plastic and reconstructive surgery 2012. link 22 Strohal R, Kerl H, Schuster L. Treatment of actinic keratoses with 5% topical imiquimod: a multicenter prospective observational study from 93 Austrian office-based dermatologists. Journal of drugs in dermatology : JDD 2012. link 23 Katz BE, Truong S, Maiwald DC, Frew KE, George D. Efficacy of microdermabrasion preceding ALA application in reducing the incubation time of ALA in laser PDT. Journal of drugs in dermatology : JDD 2007. link 24 Sellheyer K, Bergfeld WF. Differences in biopsy techniques of actinic keratoses by plastic surgeons and dermatologists: a histologically controlled pilot study. Archives of dermatology 2006. link 25 Balkrishnan R, Cayce KA, Kulkarni AS, Orsagh T, Gallagher JR, Richmond D et al.. Predictors of treatment choices and associated outcomes in actinic keratoses: results from a national physician survey study. The Journal of dermatological treatment 2006. link 26 Rivard J, Ozog D. Henry Ford Hospital dermatology experience with Levulan Kerastick and blue light photodynamic therapy. Journal of drugs in dermatology : JDD 2006. link 27 Alexiades-Armenakas M. Laser-mediated photodynamic therapy. Clinics in dermatology 2006. link 28 Feldman SR, Fleischer AB, Shaffer CL, Kiang SH, Williford PM, Lupton FA et al.. Coding multiple diagnoses for patient visits at which procedures were performed: no evidence for abuse by physicians. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2003. link 29 Jaeger C, Hartschuh W, Jappe U. Actinic superficial folliculitis. Journal of the European Academy of Dermatology and Venereology : JEADV 2003. link 30 Hauptman G, Kopf A, Rabinovitz HS, Oliviero M, Rivlin D. The actinic comedonal plaque. Cutis 1997. link 31 Wojno T, Tenzel RR. Actinic comedonal plaque of the eyelid. American journal of ophthalmology 1983. link73432-4)

Actinic keratosis