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Actinic Keratoses / Solar Keratoses

Actinic keratoses (= solar keratoses, AK, SK) are pre-malignant (pre-cancerous) skin lesions with the potential to develop into cancer (squamous cell carcinoma, SCC). Actinic keratoses are the result of long-term sun overexposure and sun damage. They are extremely common lesions, especially on the sun-exposed skin of fair-skinned people. More than 80% occur on the head and neck, back of the hands and forearms. Advancing age, male sex, outdoor occupation or hobbies are all risk factors.

Some consider AK to be one stage of a continuum of malignant change
starting with UV-induced DNA damage
followed by neoplastic transformation
proliferation and
invasion to SCC
metastasis and death

Not all AKs progress to SCC and
Estimates for transformation have ranged from 0.1% to 26.7%.
Perhaps a more realistic figure is 1-2%

Appearance

Usually actinic keratoses appear as small, brown, pink or whitish, scaly erythematous (red) single or multiple rough spots smaller than 1cm in diameter. They may be flesh-toned, pink or brown and typically present on sun-exposed sites. They feel rough or cause soreness, irritation, discomfort or pain or they may just pose a cosmetic nuisance.

TREATMENT of AK

Practically, it is impossible to treat all AK. Approximately 25% of AK may spontaneously disappear. But knowing which will involute is impossible, so most physicians will treat AKs.

The choice depends on the location and number of lesion, the individual and the experience of the physician with the treatment modalities.

Cryotherapy

For small individual lesions or a small number of lesions probably the treatment of first choice is cryotherapy. This is liquid nitrogen destruction of AK and is a quick and easily performed technique with cure rates up to 95-100%.

Patients tolerate cryotherapy for their solar keratoses well with few side effects

There are several methods for applying the cryogen – Open Spray gun or cotton bud

Diclofenac sodium in hyaluronan gel (Solaraze)

A good treatment for thin AK.

Needs to be applied thinly bd for 60-90 days

5-Fluorouracil (5-FU, Efudix)

see SKCIN Trustee John Holmes being treated with Efudix for his Aks. (www.bbc.co.uk/nottingham)

This is a safe and highly effective treatment for AK. 5-FU spares normal skin but can “light-up” clinically inapparent or early AK. However, treatment can be long and produce inflammation at the site of the AK resulting in prolonged redness and unsightly and sore erosions. It is available as Efudix cream and suited to the treatment of multiple AKs.

Safe and effective with cure rates up to 93%
The usual duration of initial treatment 3-4 weeks

Successful treatment can entails erythema, vesiculation, erosions, ulceration, necrosis and then re-epithelialisation

Unfortunately lower cure rate are reported when patients cannot comply or the medication is used improperly. Treatment failures as high as 60% have been reported.

Sunlight can cause pain and discomfort at the sites being treated.

Curettage and cautery

”scrape and burn”. This technique uses a curette to mechanically scrape away the AK’s atypical cells then cauterises the base and is an excellent way to treat AK. It offers high cure rates with excellent cosmetic outcomes. It is a safe and effective treatment for AK.

Curettage is effective for almost all clinical types of AK but is particularly useful for those lesions thought to be closer to invasive squamous cell carcinoma (SCC),
lesions resistant to other treatments, and after biopsy.

Disadvantage of curettage is that a local anaesthetic is required.
If the skin is burned too rigorously a scar can result.
Infection and other complications are rare

Surgical Excision

Generally surgery is unnecessary but there are exceptions. Bleeding, induration, rapid growth, or pain suggest progression to SCC or when AK are very thick or resemble cutaneous horns, hyperkeratotic AK or where invasive squamous cell carcinoma is suspected or where the diagnosis is in doubt.

Photodynamic therapy(PDT)

Topical PDT results in almost universal initial clearance. Recurrence rates at 12 months vary between 28% and 0%. Treatment of the scalp can be extremely painful. Treatment of solar keratoses with PDT appears to be as effective as 5-fluorouracil. This is available in some NHS hospitals and is time-consuming thereby limiting its use.

In extensive disease PDT can have an advantage as PDT is capable of treating multiple lesions or areas that amounting to a “field change” for example on the dorsae of the hands of scalp.

There are several new treatments that become available over the past few years including Picato, Aktikerall, Zyclara, Ameluz

Ingenol Mebutate (Picato)

This is for non-hyperkeratotic solar keratoses

Read about Picato in the Daily Mail
Visit Picato.com to understand better method of application and reaction.

There are two specific preparations depending on which site is being treated

For AK on Face or Scalp
One tube of Picato 150 mcg/g applied once daily to AK for 3 days.

For AK on trunk and limbs
One tube of Picato 500 mcg/g applied once daily to AK for 2 days

Actikerall (fluorouracul & salicylic acid)
This is for palpable and/or moderately thick hyperkeratotic solar keratoses

This is a topical solution in a 25ml bottle check Applied precisely with a brush

O.d for up to 12 weeks

Zyclara
For typical nonhyperK AK face or scalp when other options are contraindicated or less appropriate

This is a cream that comes in sachets check
The sachet contains imiquimod 3.75% cream check
Apply o.d. Before bedtime to AK or to the field for 2 treatment cycles of 2 weeks each separated by 2 weeks rest.

LSR = local skin reactions = redness, sore, crusty area is to be anticipated.

Success of treatment needs to be undertaken at 2 months after the second treatment cycle.

Remember

If a lesion does not respond to treatments for AK, then biopsy should be considered to exclude SCC
the benefits of sunscreen and modifying solar exposure are important
 
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