Actinic Keratosis

What is Actinic Keratosis?

Actinic Keratosis, also known as a solar keratosis, is a pre-cancerous form of Squamous Cell Carcinoma of the skin arising from the flat (squamous) cells in the uppermost layers of the skin known as the epidermis.

They usually present as scaly or crusted areas on the surface of the skin.

You will often see the plural, “Actinic Keratoses,” because they are often multiple and are the most common lesions treated at the Bondi Junction Skin Cancer Clinic.

Often Actinic Keratoses are so small that they can only be detected by expert examination. Patients may have many times more invisible (subclinical) lesions than those that appear on the surface.

Studies state that up to 20% can progress to become Squamous Cell Carcinoma or other skin cancers

When treated early the vast majority of Actinic Keratosis are not serious and their significance lies in their potential to transform, and in cases of heavy encrustation, to cause cosmetic impact that in severe cases can be significant.

Actinic Keratosis Risk Factors

Anyone with a history of sun exposure can develop Actinic Keratosis. However groups of people at greater risk include:

  • Fair Skin Types - people who are at highest risk have fair skin, freckles, blond or red hair, and blue, green, or grey eyes. They have a tendency to burn rather than tan
  • Prior Actinic Keratoses - People who have had prior AK diagnosis or an increased number of unusual moles
  • Prior Skin Cancer - People who have had one Actinic Keratosis are at risk for developing others, in the same area or elsewhere on the body. If you’ve had a Actinic Keratosis you have a 10 times higher risk of developing another skin cancer of any type and so routine reviews are advised on a 6 monthly basis.
  • Family History - The tendency to develop Actinic Keratosis may also be inherited. People genetic disorders like Xeroderma Pigmentosa - which causes photosensitivity
  • Older People - Actinic Keratoses is common in people over the age of 50. The number of Actinic Keratoses increases dramatically with age, with an untreated individual in their 70’s likely to have 35 times the number of Actinic Keratoses vs when they were in their 50's. Some experts believe almost everyone over 80 has Actinic Keratoses.
  • Weak Immune Systems - Patient with immunosuppression from any cause: HIV, immunosuppression after transplants etc
  • Occupational - Workers in occupations that require long hours outdoors or people who have an exposure to cytotoxics such as aniline dyes in the printing industry
  • Recreational -  People who pursue outdoor recreation activities for hours at a time

Where Are Actinic Keratosis Found?

Actinic Keratoses most often appear on the bald scalp, face, ears, lips, back of the hands and forearms, shoulders, neck or any other areas of the body frequently exposed to the sun.

They most commonly occur on the face and the back of the hands.

Another form of Actinic Keratosis, actinic cheilitis, develops on the lips and may also evolve into squamous cell carcinoma.

Actinic Keratoses are usually multiple and commonly occur in areas known as ‘fields’. The localised nature of this pre-cancerous change is known as ‘field change’ and includes visible and invisible (subclinical) Actinic Keratoses.

Why Actinic Keratosis is a Concern?

Although the vast majority of Actinic Keratoses remain benign, some studies report that up to twenty percent can progress and become Squamous Cell Carcinoma.

This percentage does not sound very large, but it is significant. With Squamous Cell Carcinomas, 40-60 percent begin as untreated Actinic Keratoses and may invade surrounding tissues or spread to other areas of the body (metastasise).  About 2 to 10 percent of these Squamous Cell Carcinomas spread which can be life-threatening.

The more Actinic Keratoses you have, the greater the chance that one or more may turn into Squamous Cell Carcinoma. In fact, some researchers regard Actinic Keratoses as an early highly localised form of Squamous Cell Carcinoma.

What Causes Actinic Keratosis?

95% of Actinic Keratosis in Australia are the result from skin damage caused by

  • Cumulative long-term sun exposure  
  • Intermittent overexposure to ultraviolet (UV) radiation from the sun (typically leading to sunburn)

Cloudy days aren’t safe, because 70-80 percent of solar ultraviolet (UV) rays can pass through clouds. These harmful rays can also bounce off sand, snow and other reflective surfaces, heightening UV exposure. This is especially the case at higher altitudes.

The ultraviolet radiation given off by the lamps in a tanning salon can be even more dangerous than the sun, so our Doctors warn against using sunbeds.

Most Actinic Keratoses occur on parts of the body exposed to the sun — especially the face, ears, neck, scalp, shoulders, and back, but many can be found in areas that are only burned or exposed occasionally - such as the abdomen or upper thighs

It is often not possible to pinpoint a precise, single cause for a specific Actinic Keratosis. Some Actinic Keratoses can also result from less common causes such as:

  • contact with arsenic,
  • exposure to ionising radiation such as X-rays (used in radiotherapy)
  • open sores that resist healing,
  • chronic inflammatory skin conditions, and
  • as complications of burns and scars.

Also, individuals whose immune defenses are weakened by cancer chemotherapy, AIDS, organ transplantation or excessive UV exposure are less able to fight off the effects of the radiation and thus more likely to develop Actinic Keratoses.

When an Actinic Keratosis is suspected to be an early Squamous Cell Carcinoma, your Doctor may take tissue for biopsy. This is done by doing a punch biopsy, or shaving off the top of the lesion with a scalpel, or scraping it off with a curette. Local anesthesia is required. Bleeding is usually stopped with a styptic agent or by placing light sutures to counter the small amount of bleeding that may ensue.

Stages of Actinic Keratosis

In the beginning, Actinic Keratoses are so small that they can only be detected by expert examination. Over time they enlarge to a size where the patient becomes aware of them by touch and feel as if you were running your finger over sandpaper. As they progress they may become large enough to be seen with the naked eye.

Most often, Actinic Keratoses develop slowly and reach a size between 2mm to 4mm. Early on, they may disappear only to reappear later.

Though less than 20 percent of Actinic Keratoses transform into Squamous Cell Carcinoma there is no way to know which will transform. Fortunately there are a number of highly effective treatments for them.

What are the Symptoms of Actinic Keratosis?

If you have Actinic Keratoses, it indicates you have chronic sun damage and could be at higher risk of any kind of skin cancer – not just Squamous Cell Carcinoma. A key factor used to identify an Actinic Keratosis is any ongoing crusting change persists beyond a few weeks in a lesion on the skin.

If you observe two or more of the signs below, you should consult the Bondi Junction Skin Cancer Clinic immediately.

  • A pigment change - as well as freckles, “age spots,” skin that is red is an indicator, but some will be light or dark tan.
  • A Sore with a crusted surface that crusts, only to heal up again. A persistent, non­–healing sore is a very common sign of early Actinic Keratosis. In rare instances, Actinic Keratoses can even bleed
  • A shiny area that itches or produces a pricking feeling or sensation of tenderness
  • A pink growth with a slightly elevated rolled edge. The growth slowly enlarges, tiny blood vessels may develop on the surface.

Actinic Keratosis Warning Signs

At the Bondi Junction Skin Cancer Clinic we use the adage ‘The faster an Actinic Keratosis grows the faster it needs to go’.

Faster changing or growing Actinic Keratosis need your attention because it may be a precursor to or actually be a Squamous Cell Carcinoma.  Any rapidly changing skin growth, should prompt an immediate visit to a Bondi Junction Skin Cancer Clinic.

Actinic Keratosis Screening

Diagnosis and management of Actinic Keratosis is best performed via a Full Body Scan. In the first incidence, this process includes

  • Digitally Mapping a patient's entire body for any suspicious skin damage or lesion
  • Followed by a detailed Dermoscopic examination by a trained skin cancer specialist
  • Recording and combining all images and skin metrics (size, shape, colour, and other attributes) into the patient record

Our expert Doctors at Bondi Junction Skin Cancer Clinic will then clearly identify and diagnose any skin disease.

Having a digital molemap or a baseline of all your skin’s moles skin for all family members with Actinic Keratosis, those with a large number of moles, or have been diagnosed with melanoma is recommended. Any changes can be more easily spotted and understood.

Actinic Keratosis Self Checks

Examine your skin regularly for scaly lesions in sun exposed areas. The rule of thumb is that roughened areas may come and go on anyone but it is advisable to show the lesions that don’t go away after 2-3 weeks to the Doctors at the Bondi Junction Skin Cancer Clinic without delay.

Many Actinic Keratoses have quite unique appearances, and growth rates can vary enormously so if you find any unique change or rapidly enlarging growths, be suspicious and see our Skin Cancer Doctors promptly.

In simple terms the quicker a lesion grows the quicker it needs to go.

Actinic Keratosis Diagnosis

This diagnostic process involves a Doctor visually examining the suspect skin lesion. Rarely it can involve taking a tissue sample for biopsy by removing a portion of the lesion with a biopsy punch or by scraping the lesion with a curette (an instrument with a sharp ring-shaped tip).

In almost all cases - Actinic Keratoses are diagnosed clinically.

Untreated Actinic Keratosis

Actinic Keratoses respond well to early treatment. If untreated the consequences could include disfigurement from the Actinic Keratoses or their treatment, and up to and including death if transformation into Squamous Cell Carcinoma occurs and this is not treated early enough.

In 2016 it is estimated that there were 560 deaths in Australia from non-melanoma skin cancers. It is not possible to identify how many of these are Actinic Keratosis as this data is not separately recorded.

Actinic Keratosis Treatment Options

Almost all Actinic Keratoses (AKs) can be eliminated if treated early, before they become skin cancers.

Various treatment options are available, and selection criteria involve the particular lesion/s growth characteristics and the patient’s age and health. Some of these strategies may increase sun sensitivity, so be sure to follow the instructions given by the Bondi Junction Skin Cancer Clinic before commencing them and be especially diligent about using sun protection during the treatment period.

Liquid Nitrogen for Actinic Keratosis

Liquid Nitrogen or Cryosurgery is the most commonly used treatment method for Actinic Keratoses.

It is only suitable when the Actinic Keratoses are both of limited number and  visible. This treatment can be performed at Bondi Junction Skin Cancer Clinic, with no cutting or anaesthesia required.

This treatment is very fast (5sec/lesion), requires no patient preparation and is suitable for multiple lesions.

Liquid Nitrogen Treatment Process - It involves a Doctor spraying Liquid Nitrogen with a spray device that freezes the lesions.

Application may vary due to distance from nozzle, spray duration, spray intensity (can be varied just like a spray nozzle on a garden hose) and spray aperture diameter (tips or various diameters can be screwed on/changed and several come with each unit).  

Liquid Nitrogen Recovery - After application

  • the lesions blister, crust up and a scab forms - 2 days
  • the scab falls off - 1-3 weeks
  • some patients experience temporary redness, swelling or itching
  • pigment may be lost, leaving white or red spots

These side-effects are less likely if the lesions are treated earlier and when the Doctor is highly experienced with this technique. Downtime from work or lifestyle depends on number of lesions treated and a patient’s chosen occupation. A patient is physically capable of normal work immediately.

Liquid Nitrogen Prognosis - Cryosurgery is non invasive, operator dependent success rate, can cause hypopigmentation, even scarring if used excessively, painful, can cause transient ‘ice-cream headache’ especially on the forehead.

Range of outcomes from no effect to good clearance of treated lesions. Higher recurrence rate than field treatments. Cannot treat subclinical lesions.

In some patients, pigment may be lost, leaving white or red spots.

Combination Therapy for Actinic Keratosis

At the Bondi Junction Skin Cancer Clinic we may recommend combination therapy to treat the Actinic Keratosis. Some combinations are:

  1. Photodynamic therapy - treats thick or crusted lesions, combined with Topical Agents. for 4-6 weeks. Benefits include reduced side effects, and increase response rates.
  2. Topical Agents - treats lesions requiring descaling, combined with Liquid Nitrogen. 3-4 weeks. Benefits include reduce skin spotting, and increase cure rates.

Topical Chemotherapy - Imiquimod for Actinic Keratosis

This is a prescription only cream and is approved for the treatment of superficial Actinic Keratosis that are not otherwise requiring surgical removal, but is not appropriate for use on thicker Actinic Keratoses.

It is used once every 2-3 days for up to 6 weeks.

Topical Chemotherapy Treatment Process - Before administering the cream, the patient should clean and moisten skin, and the treatment can then be applied by the patient or by a Registered Nurse at our Clinic

Topical Chemotherapy Treatment Recovery - Expect some pain, redness, swelling, crusting ‘like a pizza’. Recovery may take 2 weeks after  treatment ceases.

It is a non invasive treatment but can be highly unsightly and cause pain for up to 2 months.

Topical Chemotherapy Prognosis - The cure rate for most shallow Actinic Keratosis ranges from 70 to 80%

Topical Chemotherapy - 5-Fluorouracil for Actinic Keratosis

One of the most commonly used topical medications for AK is 5-fluorouracil (5-FU) cream, a  topical cytotoxic agent rubbed gently onto lesion bearing areas of skin once or twice daily for 4 to 6 weeks.

5-FU is the ‘grandaddy’ of topical agents for AK having been around for over 50 years and remains the cheapest.

Topical Chemotherapy Treatment Process - It is generally applied twice a day using a gloved finger, and notably increases the rate of sun damage (photosensitivity) so treatment is preferred during winter months or in patients who are able to stay indoors and wear extensive barrier clothing when outside for the whole of the treatment period.

Before administering the cream, the patient should clean and moisten the skin, and the treatment can then be applied by the patient or by a Registered Nurse at our Clinic

Topical Chemotherapy Treatment Recovery - Expect some pain, redness, swelling, crusting ‘like a pizza’

It is a non invasive treatment but can be highly unsightly and cause pain for up to 2 months

Topical Chemotherapy Prognosis - The cure rate for most shallow Actinic Keratosis ranges from 70 to 80%

Topical Chemotherapy - Ingenol Mebutate for Actinic Keratosis

Ingenol mebutate is the active ingredient isolated from ‘milkweed’ and offers the shortest treatment times for any of the field treatments.

It is applied for just 2 days on the body and 3 days on the face and so is the treatment of choice in patients who are in public-facing roles or paid employment.

It is the newest field treatment having been released as recently as 2013..

This treatment generates clearance rates that are very similar to 5-FU in a fraction of the time.

Topical Chemotherapy Treatment Process - Before administering the gel, the patient should clean and moisten the skin, and the treatment can be administered by the patient or by a Registered Nurse at our Clinic

The gel is applied daily for just 2 days on the body, and 3 days on the face

Topical Chemotherapy Treatment Recovery - Expect some minor pain, redness, swelling, crusting ‘like a pizza’ for the first 5-7 days. By Day 10-14 the patient has effectively healed with only mild residual redness. This redness resolves almost completely in the ensuing 2-3 months.

It is a non invasive treatment but can be highly unsightly and cause pain for 5-6 days.

Topical Chemotherapy Prognosis - The cure rate for most shallow Actinic Keratosis ranges from 70 to 80%

Topical Chemotherapy - Diclofenac for Actinic Keratosis

A gel containing the non-steroidal anti-inflammatory drug diclofenac may also be effective for people whose skin is very sensitive to other topical treatments.

The gel is applied twice a day for three months, as courses of treatment under three months have proven less effective

Topical Chemotherapy Treatment Process - Before administering the gel, the patient should clean and moisten the skin, and the treatment can be administered by the patient or by a Registered Nurse at our Clinic

The gel is applied twice daily for up to three months

Topical Chemotherapy Treatment Recovery - Expect some minor pain, redness, swelling, crusting ‘like a pizza’

This redness resolves almost completely in the ensuing 2-3 weeks.

It is a non invasive treatment but can be highly unsightly and cause minor pain and discomfort for most of the treatment period

Topical Chemotherapy Prognosis - The cure rate for most shallow Actinic Keratosis ranges from 70 to 80%

PhotoDynamic Therapy for Actinic Keratosis

Photodynamic therapy (PDT) involves the use of photochemical reactions mediated through the interaction of photosensitizing agents, light, and oxygen for the treatment of superficial Actinic Keratosis. It is especially useful for larger superficial Actinic Keratosis on the face and scalp.

Pre-cancerous cells accumulate more light absorbing cells (porphyrins) than normal cells that when exposed to certain light wavelengths potentiates a beneficial chemical reaction. It is this principle that underpins the use of PDT for such tissues.

The treatment selectively destroys Actinic Keratosis while causing minimal damage to surrounding normal tissue.

PhotoDynamic Therapy Treatment Process - Photodynamic therapy is a 2-Step Procedure.

  • The First Step: involves the application to the target growths cells with a photosensitizer in the form of a chemical agent that reacts to light such as Aminolevulinic Acid (ALA) or methyl aminolevulinate (MAL). Curettage is often needed to destroy epidermis to allow egress of sensitising cream into lesion for 1 hour under occlusion

  • The Second Step: involves the activation of the photosensitizer in the presence of oxygen with a specific wavelength of light directed toward the target tissue. The photosensitizer is preferentially absorbed by cells that are dividing (which occurs at a greater rate in Actinic Keratoses) and when the light source is directed to the affected areas of skin. This leads to activation of protoporphyrins and inflammation and destruction of the lesion.

Photodynamic therapy achieves dual selectivity with minimal damage to adjacent healthy structures.

The process is invasive, and can be very painful when light is applied and for a day post treatment, and the curettaged areas will scar.

The approach offers less scarring than surgical excision, and is suitable for larger superficial lesions than surgery, and can be used as a field treatment for areas with multiple small Actinic Keratoses. Success rates are highly operator dependent.

Common side effects are redness, pain, bleeding, and swelling.

PhotoDynamic Therapy Treatment Recovery - After treatment, patients become locally photosensitive for 48 hours where the light-sensitizing agent was applied, and must avoid both outdoor and indoor light and be careful to use sun protection

PhotoDynamic Therapy Treatment Prognosis - 70-80% cure rate. Can mask the presence of residual disease and so delay successful treatment

Recurrence rates vary considerably (from 0 to 52 percent), so the technique is not currently recommended for potentially invasive lesions.

General Prognosis After Treatment

The majority of Actinic Keratoses can be successfully treated.

Individuals with a high disease load of Actinic Keratoses can reasonably expect to develop new lesions requiring treatment in the future, especially if preventative advice goes unheeded.

Actinic Keratosis Recurrence

Doctors at the Bondi Junction Skin Cancer Clinic have seen a significant increase in the number of patients in their twenties and thirties are being treated for Actinic Keratosis over the last 17 years.

Men with Actinic Keratosis have outnumbered women with the disease, but more women are getting Actinic Keratosis than in the past.

Regular checks at the Bondi Junction Skin Cancer Clinic should be performed so that not only the site(s) previously treated, but the entire skin surface can be examined, and mapped digitally and compared to the images taken at subsequent skin checks.

Actinic Keratosis on the scalp and nose are especially troublesome, with higher rates of recurrence and with these recurrences typically taking place within the first two to three years following treatment. Should lesions recur, your Doctor might recommend a different type of treatment.

Actinic Keratosis Prevention

Anyone who has had one Actinic Keratosis has an increased chance of developing another, especially in the same skin area or nearby. That is usually because the skin has already suffered irreversible sun damage.

Thus, it is crucial to pay particular attention to any previously treated site, and any changes noted should be shown immediately to your Doctor at the Bondi Junction Skin Cancer Clinic.

Actinic Keratosis on the nose, ears, and lips are especially prone to recurrence.

Even if no suspicious signs are noticed, regularly scheduled follow-up visits including total-body skin exams are an essential part of post-treatment care every 6 months.

To prevent Actinic Keratosis make sure you follow the recommendations below:

  • Seek the shade, especially between 10am and 3pm when UV levels are most intense
  • Avoid sunburn by minimising sun exposure when the SunSmart UV Alert exceeds 3 and especially in the middle of the day in the warmer half of the year
  • Avoid tanning and never use UV tanning beds
  • Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses
  • Use Nicotinamide (Vitamin B3) 500mg twice a day unless contraindicated
  • Use a broad spectrum (UVA/UVB) sunscreen with an SPF of 30+ or higher every day. For extended outdoor activity, use a water-resistant, broad spectrum (UVA/UVB) sunscreen with an SPF of 30+ or higher
  • Apply sunscreen to your entire body 10 minutes before going outside. Reapply every two hours or immediately after swimming or excessive sweating, or towelling down
  • Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months
  • Examine your skin head-to-toe every month looking for unique changes.

If you see unique changes anywhere and of any kind, keep an eye on it and if it continues to change for more than 2-3 weeks the notify the Bondi Junction Skin Cancer Clinic without delay.

If you have Actinic Keratoses you are at increased risk of Squamous Cell Carcinoma and all other forms of skin cancer - including Melanoma.