Management of Actinic Keratoses

Introduction

Actinic keratosis is a chronic condition requiring ongoing management, with patient education and sun protection being essential, as recommended by the British Journal of Dermatology guidelines 1

Topical therapies, such as 5-FU, diclofenac, and imiquimod, are effective for managing actinic keratosis, with varying complete clearance rates:
Cryotherapy and photodynamic therapy (PDT) are also effective treatment options, with complete clearance rates:

The British Journal of Dermatology recommends applying 5% fluorouracil cream twice daily for 3-4 weeks 1
For arms with a "sandpaper" texture, consider pretreatment with 5% salicylic acid ointment 1
For the back of hands, pretreatment with salicylic acid 5% ointment improves outcomes 1
When using 5% fluorouracil cream below the knee, use with caution due to poor healing concerns and consider alternative treatments like diclofenac or PDT 1
5-FU 0.5% in 10% salicylic acid should be applied daily for 6-12 weeks or until clearance 1

Patient education about expected side effects is crucial to prevent premature treatment abandonment, as recommended by the British Journal of Dermatology 1
Regular use of SPF 17+ sunscreen decreases the incidence of new actinic keratosis lesions 3
Patients should perform regular self-examinations, checking for new or changing lesions monthly, and learn self-diagnosis, although they should always corroborate their assessment with a healthcare professional before initiating treatment, as recommended by the British Journal of Dermatology 1
Patients should document lesion locations, keep a simple body map to track lesions, and watch for warning signs requiring immediate medical attention, such as bleeding lesions, painful lesions, or thickened lesions with substance when held between finger and thumb, according to the British Journal of Dermatology guidelines 1

For actinic keratosis on the face and scalp, 5-FU is highly effective 1
For arms with a "sandpaper" texture, an extended course of topical therapy may be required, and pretreatment with salicylic acid 5% ointment should be considered 1
For lesions located on the face, scalp, or ears, cryosurgery, 5-fluorouracil (5-FU), and imiquimod are all effective treatment options, according to the British Journal of Dermatology guidelines 1
For periocular lesions, cryosurgery with a contact probe is recommended, avoiding topical treatments, as suggested by the British Journal of Dermatology guidelines 1
For lesions on the ears, more aggressive treatment should be considered due to the higher risk of squamous cell carcinoma (SCC) progression, as recommended by the British Journal of Dermatology guidelines 1
For lesions located below the knee, diclofenac or photodynamic therapy (PDT) should be considered due to poor healing concerns, according to the British Journal of Dermatology guidelines 3, 1

For Grade 1 (mild) lesions, all treatments are effective, and consideration should be given to emollient and sunscreen alone 1
For Grade 2 (moderate) lesions, 5-FU, imiquimod, or PDT are recommended 1
For Grade 3 (severe) lesions, cryotherapy with longer freeze times or curettage is recommended 1

Common side effects of treatment include erythema, burning, crusting, and soreness, and can be managed by reducing application frequency, taking short treatment breaks, applying emollients, and using weak topical steroids for excessive inflammation, with local skin irritation occurring in more than 90% of patients 2, 1
The following side effects have been summarized in the table below:

Evaluate response 8-12 weeks after treatment completion, and schedule regular skin examinations every 6-12 months to monitor for new or persistent lesions 1
Any lesions that fail to respond require biopsy to rule out squamous cell carcinoma, and elderly patients may require closer monitoring for adverse effects 1
Regular follow-up and consistent sun protection are essential to prevent new lesions, as emphasized by the American Academy of Dermatology and British Association of Dermatologists 2, 3, 1