1. Rob Sheehan-Dare Leeds Centre for Dermatology
Actinic Keratosis
Rob Sheehan-Dare
Leeds Centre for Dermatology

2. Pre-Cancerous Lesions
Actinic Keratoses
Intra-epithelial Squamous Cell Carcinoma
Lentigo maligna
Skin Cancer
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
Lymphoma

3. What are Actinic keratoses?
Epidermal dysplasia
Associated with UV exposure
Sun exposed sites
Elderly
Outdoor occupations
Warmer climates
Lighter skin types
Immunosuppression

4. What are Actinic keratoses?
Histologically
Epidermal cell disorganisation
Acanthosis
Reduced granular layer
Parakeratosis
Hyperkeratosis

6. What is risk of malignancy?
?Less than 1:1000 per year
Increased by
Immunosuppression
Increased numbers of lesions
Co-factors (radiation, exposure to tar)
Prior Squamous cell carcinoma
Some lesions resolve spontaneously
Most SCC’s are well differentiated

7. What do they look like? Clinically
Adherent scale (variable but always)
Erythema (often)
Light pigmentation (sometimes)
Merge with surrounding skin
Usually not indurated

11. Diagnostic difficulties
Cutaneous horn
Hypertrophic actinic keratoses
Inflammatory lesions
Often in immunosuppressed

12. What to treat Lesions in immunosuppressed patients
Lesions at high risk sites (e.g. lip)
Where previous history of SCC
Inflamed Actinic keratoses
Lesions in younger age group
Symptomatic lesions

13. How to treat Cryotherapy Curettage & cautery 5-fluorouracil cream
Diclofenac gel
Imiquimod cream
Photodynamic therapy

14. Cryotherapy Destruction by cold injury Cotton bud or cryospray
20-30 second freeze
Moderate pain
Immediate blistering
Heals in 10 days
Suitable for small/few lesions
Suitable where compliance poor

17. Curettage and cautery Physical removal/thermal injury
Requires local anaesthesia
Moderate pain
Eschar
Heals in 10 days
Suitable for solitary/few lesions
Suitable for cryo resistant lesions
Suitable for hyperkeratotic lesions
Suitable where histology required

18. 5-fluorouracil cream
Inhibits DNA synthesis by inactivating thymidine synthase
4 weeks treatment
Inflammatory reaction (moderate-severe)
Little pain
Interrupted treatment may be required
Suitable for multiple/extensive lesions
Suitable for compliant patients

19. Diclofenac gel Inhibits Cyclo-oxygenase (COX-2) 8 weeks treatment
Mild-moderate inflammatory reaction
No pain
Long term benefits uncertain
Suitable where intolerance to other treatment

20. Imiquimod cream Toll-like receptor 7 agonist induces apoptosis
4-8 weeks treatment
Inflammatory reaction (moderate-severe)
Little pain
Interrupted treatment may be required
Suitable for multiple/extensive lesions
Suitable for compliant patients

21. Photodynamic therapy
ALA induced protoporphyrin IX synthesis sensitizes cells to photodynamic effect
1-2 prolonged treatments
Moderate pain
Inflammatory reaction (moderate-severe)
Heals in 10 days
Suitable for multiple/extensive lesions
Suitable where compliance poor

22. Treatment summary Cryotherapy small/few lesions
5-fluorouracil larger/multiple lesions
Curettage for hyperkeratotic lesions
Solaraze for patients with poor tolerance
Imiquimod cream or PDT for resistant lesions

23. “They look benign , but keep out of the sun”