Updated: 12/17/2019

Actinic Keratosis

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Snapshot
  • A 67-year-old man with male-patterned baldness comes to the dermatologist. He realized recently that the skin on his scalp was not smooth. He describes it as feeling rough, like “sandpaper.” While he is now retired, he was a gardener and often spent hours under the sun.
Introduction
  • Keratotic, pre-malignant lesions
  • Epidemiology
    • common in fair-skinned individuals
    • common in elderly patients
    • results from significant lifetime sun exposure 
      • keratinocyte damage
  • May lead to squamous cell carcinoma
Presentation
  • Symptoms
    • typically asymptomatic
    • occasionally tender
  • Physical exam
    • thin, adherent transparent or yellow scale that progressively increases in thickness
    • often with telangiectasias
    • can progress to cutaneous horn
      • difficult to distinguish from squamous cell carcinoma at this point
    • rough, “sand-paper” texture
      • often easier to detect by palpation rather than observation
    • frequently on sun-exposed areas
      • face, head, neck, dorsal hands, ears
Evaluation
  • Skin biopsy
    • dysplastic epidermis with keratinocyte atypia
      • hyperkeratotic cell with lower epithelial cells showing loss of polarity and hyperchromatic nuclei
      • no invasion into dermis
Differential
  • Squamous cell carcinoma
  • Actinic cheilitis
  • Lentigo maligna
Treatment
  • Annual follow-up for skin cancer monitoring
  • Lifestyle modification
    • avoid sun exposure
    • use sunscreen
  • Surgical
    • liquid nitrogen (cryotherapy) = most common treatment
    • electrodesiccation and curettage
  • Pharmacological
    • topical 5-fluorouracil
      • typically reserved for those with widespread actinic keratoses
Prognosis, Prevention, and Complications
  • Prognosis
    • typically slow-growing and persistent if untreated
  • Prevention
    • avoid sun exposure
    • use sunscreen
  • Complications
    • risk of progression to squamous cell carcinoma

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