Actinic Keratoses - Leeds Pathway

1.  Background Information / Important Principles

Quick info:
Important Principles:

  • The majority of actinic keratoses (solar keratoses) can be managed in primary care
  • Not all need treatment and the risk of malignant change is very low
  • There are safe effective topical agents that can be prescribed according to the extent of the lesions and the ability of the patient to comply with the treatment regime
  • Cryotherapy should be reserved for isolated lesions where the clinician is confident that the lesion is an actinic keratosis.

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2.  Information Resource for Patients and Carers

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Patient Information Leaflets:
British Association of Dermatologists Patient Information Leaflets:
Actinic (Solar) Keratoses

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3.  Development and Updates to this Pathway

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Developed September 2014

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4.  Training and Further Resources

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Additional Resources:
British Association of Dermatologists
Primary Care Dermatology Society - Actinic Keratoses
Derm Net NZ: The Dermatology Resource

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5.  Patient Presents with Actinic Keratoses

Quick info:
Actinic Keratoses (AK) also known as Solar Keratoses, are usually multiple flat pink/red lesions with a dry adherent scale.
The vast majority of solar keratoses DO NOT progress to squamous cell carcinoma. Evidence suggests that the annual incident of transformation from actinic keratoses to SCC is less than 0.1%. This risk is higher in immunocompromised patients.

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6.  Red Flag / Lesion Suspicious of SCC

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Recent growth, pain/tenderness, bleeding or ulceration are suggestive of transformation into an Squamous Cell Carcinoma (SCC)

Lesions suspicious of SCC should be urgently referred using the 2WW proforma:

  • Growing non-healing lesions with a significant induration on palpation (commonly on face, scalp, back of hand) – with documented expansion over a period of 1 - 2 months.
  • Pain, tenderness, bleeding or ulceration

Patients who are therapeutically immunosuppressed after an organ transplant have a high incidence of skin cancers mainly squamous cell carcinoma. These tumours can be unusually aggressive and metastasize. It is therefore strongly recommended that transplant patients who develop new or growing cutaneous lesions should be referred under the two week standard Referral Form

Referral Information:
The new telephone number for this service is
(0113) 206 5141

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7.  Identification of Actinic Keratoses

Quick info:
Lesions are normally asymptomatic
Recent growth, pain / tenderness, bleeding or ulceration are suggestive of transformation into an SCC
There is often a background of significant sun-damaged skin with pigment irregularity, telangiectasia, erythema and solar elastosis (a yellow papularity of the skin)
Distribution - this reflects the intensity of sun-exposure with the greatest number of lesions occurring on the head, neck, forearms and hands

Morphology (See photos below)

  • Pink/red lesions
  • Lesions usually take on a similar appearance
  • Seldom exceed more than 1cm in diameter
  • Rough surface scale - usually white, although in patients with skin type I AK are more easily felt than seen
  • Often termed as flat, but some lesions can have significant amounts of scale

Photos (provided by Primary Care Dermatology Society - PCDS)
Figure 1 Actinic Keratosis - The features of a classical AK - a flat lesion with white, rough surface scale
Figure 2 Actinic Keratosis on nose
Figure 3 Actinic Keratosis. Evidence of surrounding UV-damaged skin with marked telangiectetic change.
Figure 4 Actinic Keratoses - dermascopic appearance. Lesions are said to have a strawberry-like appearance. The arrow denotes one of the many 'pips'. These findings will only be evident in lesions with little scale, or where the scale has been lifted off.
Figure 5 Pigmented actinic keratosis lateral and inferior to the left eye. The lesion had a very rough surface scale.
Figure 6 Actinic keratoses with field change. Field change refers to areas of skin that have multiple AK associated with a background of erythema, telangiectasia and other changes seen in UV-damaged skin.
Figure 7 Actinic Keratosis with a lot of surface scale (hyperkeratotic) Such lesions should have their surface scale removed to make sure there is no firm papule / nodule underneath that would suggest an SCC
Figure 8 A hyperkeratotic actinic keratosis. This patient had a number of AK. One of the lesions was hyperkeratotic (red arrow) - it is important to remove the scale of there is any uncertainty about the diagnosis
Figure 9 Same patient as figure 8 - scale removed. No lump, induration or ulceration to suggest an SCC
Figure 10 Well-differentiated SCC. The clues to the diagnosis were recent growth, tenderness and the development of a small nodule under the keratin.
Figure 11 Well-differentiated SCC

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8.  Treatment

Quick info:
General Measures - appropriate for all patients

  • Actinic Keratoses are a marker of sun damage and so be vigilant and enquire about other potentially more serious sun-related skin tumours
  • Emollients - it can sometimes be difficult to differentiate between early AK and dry scaly areas of normal skin. The use of an emollient two to three times a day can be helpful in differentiating between areas of normal and abnormal skin. See LHP Emollient guidance
  • Sunscreen and sun avoidance to be recommended.
  • With emollients and sunscreen some early lesions may regress so a period of watchful waiting may be appropriate.
  • Patient expectation - once patients start to develop AK they will almost certainly develop more. The aim of any treatment is to reduce the total number of AK on the skin at any one time
  • Education: inform patients which skin changes need to be reported. Transformation into an SCC can be suggested by recent growth, discomfort, ulceration / bleeding. Patients also need to report any other skin lesions they are not familiar with.

Observation
Not all patients need treating (e.g. patients with smaller numbers of lesions). As mentioned above, with emollients and sunscreen some early lesions may regress so a period of watchful waiting may be appropriate

Treatment
Follow PCDS Treatment Guidelines

Tips for successful treatment
Ensure patient understands how to apply treatment and whether to individual lesions or to an area.
Diclofenac Sodium 3% gel (Solaraze)
Twice daily for 3 months - Patients should be advised they must commit to the 90 days. Solaraze can cause dryness and irritation but generally much less than other topical treatments. Discuss irritation and inflammation with the patient as this will increase the likelihood of completing the course of treatment.
Gel formulation - apply thinly and no more than 8g per day used.

Imiquimod ( Aldara 5% cream or Zyclara 3.75% cream )
Marked inflammation occurs prior to resolution and the patient must be warned to expect this - it is a sign that the treatment is working. Flu-like illness is recognised as a side effect and may require change of treatment.
There are different strengths of cream with different treatment regimens (see BNF.) Sachets can be used multiple times after opening if kept in the fridge.

Cryotherapy - to be used only if confident the lesion is an AK
Light freezing for 5-10 seconds for few / scattered individual lesions and those who are unlikely to comply with topical treatment.

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9. Criteria for Referral

Quick info:
It is not necessary to refer all patients with actinic keratoses.

Criteria for referral to Community Dermatology services:

  • Confirmation of diagnosis of probable actinic keratoses
  • Advice on treatment for patients with more widespread / severe actinic damage (Grade 3 Wide Field - please refer to PCDS Treatment Guidelines document)

Criteria for referral to Secondary care:

  • Patients on immunosuppressant treatment
  • Suspected Skin Cancer – if concerned ensure 2ww referral is made
  • Patients < 40 years

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