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Actinic keratosis

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Updated 2023 DeCOG/DKG/DDG guidelines for the diagnosis and management of actinic keratosis.

Background

Overview

Definition
Actinic keratosis is a common precancerous skin condition arising from chronic exposure to UV radiation, typically from the sun.
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Pathophysiology
The pathophysiology involves the proliferation of transformed neoplastic keratinocytes in the epidermis due to cumulative UV radiation exposure. UV radiation induces multiple molecular signaling events at the cellular level, leading to inflammation, immunosuppression, failure of apoptosis, and aberrant differentiation. These actions cumulatively result in DNA mutations and, ultimately, carcinogenesis.
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Epidemiology
The prevalence of actinic keratoses in the US in individuals aged > 30 years ranges from 11.5% to 26%, which increases with age.
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Disease course
Clinically, it presents as small, rough, scaly patche or lesion on sun-exposed areas of the skin, such as the face, scalp, back of the hands, and forearms. These lesions may be pigmented or non-pigmented and can be associated with other dermoscopic features like red pseudonetwork, targetoid-like appearance, and rosette sign.
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Prognosis and risk of recurrence
The prognosis of actinic keratosis is variable. Three possibilities exist for actinic keratosis without treatment: spontaneous remission, which can be common; remaining stable, without further progression; or transformation to invasive SCC, which may metastasize.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of actinic keratosis are prepared by our editorial team based on guidelines from the German Society of Dermatology (DDG/DKG/DeCOG 2023) and the American Academy of Dermatology (AAD 2021)....
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Diagnostic investigations

Diagnostic imaging: as per DDG/DeCOG/DKG 2023 guidelines, Consider obtaining dermatoscopy, confocal laser microscopy, and optical coherence tomography for the diagnosis of actinic keratosis when findings are clinically unclear.
E
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Diagnostic procedures

Biopsy
As per DDG/DeCOG/DKG 2023 guidelines:
Do not obtain histologic assessment in patients with typical clinical findings of actinic keratosis.
D
Obtain a tissue sample in case of resistance to treatment and clinically unclear findings.
E
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Medical management

Topical agents: as per DDG/DeCOG/DKG 2023 guidelines, Offer concurrent or sequential combinations of distinct field- or lesion-targeted treatments for actinic keratosis.
B
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  • Combination therapy

Nonpharmacologic interventions

Chemical peeling: as per DDG/DeCOG/DKG 2023 guidelines, Consider offering chemoexfoliation by chemical peelings for single or multiple actinic keratoses and field cancerization.
C
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  • UV protection

Therapeutic procedures

Photodynamic therapy: as per DDG/DeCOG/DKG 2023 guidelines, Offer photodynamic therapy using natural or simulated daylight with 5-ALA or its methyl ester for single or multiple actinic keratoses and field cancerization.
B
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Surgical interventions

Cryosurgery
As per AAD 2021 guidelines:
Perform cryosurgery for the management of actinic keratosis.
E
Consider performing cryosurgery over CO2 laser ablation for the management of actinic keratosis.
C
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Specific circumstances

Patients with actinic cheilitis, etiology: as per DDG/DeCOG/DKG 2023 guidelines, Recognize that actinic cheilitis is etiologically and morphologically the counterpart of actinic keratosis of the keratinizing squamous epithelium of the skin at the red part of the lips.
E
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  • Patients with actinic cheilitis (biopsy)

  • Patients with actinic cheilitis (indication for treatment)

  • Patients with actinic cheilitis (chemical peeling)

  • Patients with actinic cheilitis (topical agents)

  • Patients with actinic cheilitis (photodynamic therapy)

  • Patients with actinic cheilitis (laser therapy)

  • Patients with actinic cheilitis (surgical management)