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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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