Medical & Surgical Dermatology

Actinic Keratoses

Water's Edge Dermatology was requested to particpate in the filming of a nation-wide Public TV  special about Actinic Keratoses.  Along side Water's Edge Dermatology, you will hear from Daniel Siegel MD, President of the American Acadeny of Dermatology and Joseph Jorizzo, MD, founding Chair of Dermatology and Wake Forrest University and a consultant with Water's Edge Dermatology. 

Click here to watch the video and learn more about actinic keratoses.

What are Actinic Keratoses?

Actinic keratoses (AKs) are dry, scaly, rough-textured patches or lesions that form on the outermost layer of the skin after years of exposure to ultraviolet (UV) light, such as sunlight. These lesions typically range in color from skin-toned to reddish brown and in size from that of a pinhead to larger than a quarter.

Occasionally, a lesion grows to resemble an animal horn and is called a “cutaneous horn.”

It is important that anyone with AKs be under a dermatologist’s care. AKs are considered the earliest stage in the development of skin cancer and have the potential to progress to squamous cell carcinoma, a type of skin cancer that can be fatal. Anyone who develops AKs has extensive sun-damaged skin. This makes one more susceptible to other forms of skin cancer, including melanoma. Melanoma is considered the most lethal form of skin cancer because it can rapidly spread to the lymph system and internal organs.


 

Why the Term “Actinic Keratoses”

The two words “actinic” and “keratoses” precisely describe what has happened to the skin. “Actinic” (ak-‘ti-nik) comes from the Greek word for ray, “aktis,” and indicates that radiant energy has produced chemical changes. The word “keratoses” (ker-ah-TOE-sees) means the skin has become hard and callous. Therefore, AKs are areas of calloused skin caused by chemical changes brought about by exposure to radiant energy, such as sunlight. The lesions may also be called “solar keratoses.”

When such a lesion occurs on the lip, dermatologists call the condition “actinic cheilitis” (key-LITE-iss).   “Cheilitis” means inflammation of the lips. Actinic cheilitis is characterized by a diffuse scaling on the lower lip that cracks and dries. Sometimes the lip has a whitish discoloration on the thickened lip.

Causes

Years of sun exposure cause AKs to develop. All AKs, including actinic cheilitis, develop in the skin cells called the “keratinocytes,” which are the tough-walled cells that make up 90% of the epidermis, the outermost layer of skin, and give the skin its texture. Years of sun exposure cause these cells to change in size, shape, and the way they are organized. Cellular damage can even extend to the dermis, the layer of skin beneath the epidermis.
 

Who Gets Actinic Keratoses?

Individuals with fair skin, a history of cumulative sun exposure, or a weak immune system are at greatest risk for developing AKs. These lesions develop on areas of the body that have received years of sun exposure, such as the face, ears, lip, scalp, neck, forearms, and back of the hands. AKs usually appear after age 40 because they take years to develop. However, even teens can have AKs when they live in areas that receive high-intensity sunlight year round, such as Florida and Southern California.

Research shows that p53, a mutant protein found in sun-damaged cells in the body, is present in more than 90% of people who have AKs and squamous cell carcinomas.

More Americans Developing AKs

Millions of Americans have AKs, and the number continues to grow. In fact, AKs are so common today that treatment for these lesions ranks as one of the most frequent reasons people consult a dermatologist.
A survey conducted by the American Academy of Dermatology (AAD) confirmed what dermatologists have long suspected: The public’s behavior regarding sun protection has not improved significantly over the last two decades. Findings indicate that people are spending more time outdoors, not adequately protecting themselves from the sun, and still believe the appearance of a tan is healthy. The survey also found that younger people tend not to use sunscreen on a regular basis and are more likely to visit a tanning salon today than in the past.

Prevention and Early Detection Key

To prevent AKs and skin cancer, the AAD recommends adopting a comprehensive sun protection program that includes:

  • Avoid deliberate tanning. Ultraviolet light from the sun and tanning beds causes skin cancer and wrinkling. If you want to look like you’ve been in the sun, consider using a sunless self-tanning product. When using a self-tanning product, you should continue to use sunscreen.
  • Get vitamin D safely through a healthy diet that includes vitamin supplements. Don’t seek the sun.
  • Generously apply sunscreen to all exposed skin. Before going outdoors, generously apply a sunscreen that has a Sun Protection Factor (SPF) of at least 30 and is broad-spectrum — protects against both ultraviolet (UVA) and ultraviolet B (UVB) rays. While outdoors, re-apply the sunscreen approximately every two hours, even on cloudy days, and after swimming or perspiring.
  • Cover up when you must be in the sun. Wear long sleeves, pants, a wide-brimmed hat, and sunglasses that protect against both UVA and UVB rays.
  • Use extra caution near water, snow, and sand. These reflect the damaging rays of the sun, which can increase your chance of sunburn.

 

When caught in the early stages, AKs and all types of skin cancer are treatable and in most cases, curable. The key to early detection is frequent skin examinations. Performing regular self-examinations and being screened by a dermatologist as needed can help detect AKs and skin cancer in the earliest and most treatable stages.

If you find a suspicious skin lesion, be sure to see a Water's Edge Dermatology practitioner for diagnosis — even if the lesion seems to appear and then disappear for weeks or months and reappear. Water's Edge Dermatology practitioners receive extensive medical training in skin conditions and have the experience necessary to diagnose various skin lesions. An accurate diagnosis is the first step to successful treatment.
Self-treating by picking off the lesions is not effective treatment; the lesions grow back. Since AKs have the potential to progress to squamous cell carcinoma, a sometimes fatal type of skin cancer, AKs should be treated.

What Actinic Keratoses are Not

While the terminology that dermatologists use can seem confusing, the precise terms allow dermatologists to clearly differentiate skin conditions and prescribe appropriate treatment. Described below are some skin conditions that patients may confuse with AKs.  The following conditions are not AKs:

  • Actinic porokeratosis: Similar in appearance to AKs, this is an uncommon, usually inherited, skin condition characterized by sun sensitivity that causes reddish brown scaly spots to develop, primarily on the arms and legs. The lesions appear after years of sun damage to the skin, so they are typically seen in middle-aged and older individuals. The lesions tend to grow or itch after sun exposure and are fairly resistant to treatment.
  • Seborrheic dermatitis: This is a red, scaly rash that itches. Seborrhea is excessive oiliness of the skin, especially on the scalp and face, without redness or scaling. If seborrhea progresses to seborrheic dermatitis, redness and scaling appear.
  • Seborrheic keratoses: Also called “benign keratoses,” these non-cancerous growths have a waxy, pasted-on look and develop on the outer layer of skin. Lesions range in size from a fraction of an inch in diameter to larger than a half dollar. AKs are flatter, redder, and rougher to the touch than seborrheic keratoses

 

What Do AKs Look Like?

Actinic keratoses (AKs) are found on areas of the body that have received long-term exposure to sunlight, such as the face, ears, lip, scalp, neck, forearms, and back of the hands.

Appearance

While AKs share common characteristics, such as being dry, scaly, and rough textured, not all AKs look alike. Some are skin-colored and may be easier to feel than see. These lesions often feel much like sandpaper. Others can appear as red bumps; scattered, thick red scaly patches or lesions; or crusted lesions varying in color from red to brown to yellowish black.

When an AK undergoes rapid upward growth, it becomes a “cutaneous horn,” so named because it resembles the horn of an animal. The size of a cutaneous horn may range from that of a pinhead to a pencil eraser, and the shape may be straight or curved. Sometimes skin cancer hides below a cutaneous horn.

If an AK forms on the lip, it is called “actinic cheilitis” and appears as a diffuse, scaling lesion on the lower lip that dries and cracks.

The skin around an AK tends to show evidence of sun damage, such as wrinkles and furrows (deep wrinkles). The size of an AK ranges from a pinhead to larger than a quarter. 


AKs Common on the Hands

actinic kerotosis AK
A fair-skinned elderly patient with numerous crusted papules on the backs
of both hands and other chronically sun-exposed parts of the body.

AKs Frequently Appear on Face and Ears



actinic kerotosis AK
This retired construction worker developed these slightly tender papules and crusts on his ears over an eight to 10-year period.

(Photos used - National Library of Dermatologic Teaching Slides)

Be sure to see a Water's Edge Dermatology practitioner if you notice a lesion that looks like any of the above or a lesion that begins to thicken, bleed, itch, or grow.

Treatment

Actinic keratoses (AKs) are so common today that treatment for these lesions ranks as one of the most frequent reasons that people consult a dermatologist.

Often patients want these lesions removed for cosmetic purposes since AKs tend to occur in highly visible places, such as the hands, arms, face, and neck. Whether or not cosmetic concerns are a motivating factor, it is extremely important to consult a dermatologist or dermatologic surgeon when an actinic keratosis (AK) lesion is suspected. Left untreated, AKs have the potential to progress to squamous cell carcinoma, a form of skin cancer that can be life threatening.

Diagnosis

AKs have unique physical characteristics that allow a Water's Edge Dermatology practitioner to visually identify these lesions. However, if an AK is especially large or thick, the lesion may be surgically removed for microscopic examination (biopsy) to determine if squamous cell carcinoma is present.

When an AK is diagnosed, your Water's Edge Dermatology practitioner considers a number of factors before choosing the most appropriate treatment method. Factors include:
  • Size, number, location, and stage of the lesions
  • Age, health, and medical history
  • Occupation
  • Cosmetic expectations and treatment preferences
  • Patient compliance (i.e., willingness to self-treat as needed for several weeks)
  • History of previous treatment

How AKs are Treated

There are several treatment options for AKs, including cryosurgery (freezing), surgical excision, curettage (scraping) with or without electrosurgery (heat generated by an electric current) and topical (applied to the skin) medications. Lasers, chemical peels, dermabrasion, and photodynamic therapy may also be used.

Patients who have multiple AKs may not have all lesions treated at the same time, and in some cases, the dermatologist or dermatologic surgeon will use more than one treatment option.

For information about specific treatments used to treat AKs, see Treatment Options further down.

What to Expect After Treatment

Practice Sun Safety.
Sun safety practices are a medical necessity in order to prevent new AKs and squamous cell carcinoma from developing. After treatment, patients routinely receive guidelines for practicing sun safety.

Sun safety practices include:
  • Avoid excessive exposure to sunlight. Stay out of direct sun exposure during peak (10a.m. — 4p.m.) sunlight hours.
  • Use a broad-spectrum sunscreen with a SPF of 30 or higher. Broad-spectrum sunscreen provides protection from both the UVA and UVB rays of the sun. Apply broad-spectrum sunscreen at least
  • 15 to 30 minutes before going outdoors, even on cloudy days.
  • Reapply sunscreen approximately every two hours. When outdoors and even on cloudy days, be sure to reapply sunscreen approximately every two hours.
  • Wear protective clothing. When outdoors during daylight, wear a wide-brimmed hat, sunglasses that block 100% of the UV rays and tightly knit clothing that covers arms and legs.

Topical Retinoids

In addition to sun-protection practices, topical (applied to the skin) retinoids (vitamin A derivatives) may be prescribed. Topical retinoids are not suitable for every patient, but may be prescribed in some cases to help prevent new AKs from developing.

Re-examination.

Your Water's Edge Dermatology practitioner regularly re-examines patients treated for AKs. Frequency depends on the extent of the AKs, sun-damaged skin, and the treatment method. Re-examination may be as frequent as every 8 to 12 weeks or require only 1 to 2 visits per year. It is extremely important to keep these re-examination appointments because when enough sun damage occurs to cause AKs, the possibility of developing more AKs or even skin cancer greatly increases.

Re-treatment.

Re-treatment is sometimes necessary as new AKs can develop and occasionally AKs recur. Whenever a lesion is spotted, be sure to consult a dermatologist or dermatologic surgeon because left untreated, AKs have the potential to progress to squamous cell carcinoma.

Prevention

Actinic keratoses (AKs) develop in skin that has been exposed to the ultraviolet (UV) light of the sun for years. Therefore, the best defense against AKs is to practice sun protection. Sun-protection practices can prevent:

 

  • AKs from developing
  • New AKs from forming
  • AKs from recurring (AKs sometimes return after treatment)

Ideally, sun protection should begin early in life because overexposure to UV radiation increases one’s risk of developing AKs. What many people do not realize is that sun protection can be beneficial at any age, even when signs of sun damage, such as AKs, have already appeared. Sun protection can prevent further damage. Research also shows that the skin’s recuperative powers can repair some of the damage when protected from ultraviolet (UV) light. 

Water's Edge Dermatology recommends that everyone protect their skin by following these sun-protection practices:

Avoid deliberate tanning. Ultraviolet light from the sun and tanning beds causes skin cancer and wrinkling. If you want to look like you’ve been in the sun, consider using a sunless self-tanning product. When using a self-tanning product, you should continue to use sunscreen.

Get vitamin D safely through a healthy diet that includes vitamin supplements. Don’t seek the sun.

Generously apply sunscreen to all exposed skin. Before going outdoors, generously apply a sunscreen that has a Sun Protection Factor (SPF) of at least 30 and is broad-spectrum - protects against both ultraviolet (UVA) and ultraviolet B (UVB) rays. While outdoors, re-apply the sunscreen approximately every two hours, even on cloudy days, and after swimming or perspiring.

Dermatologists agree that most people do not apply enough sunscreen to help protect against harmful ultraviolet (UV) radiation.  One ounce, enough to fill a shot glass, is considered the amount needed to cover the exposed areas of the body properly.  So when applying sunscreen, remember to apply it liberally.  Here are a few more tips:


Don't forget your ears, neck, and hands.  Many AKs develop in these areas.  Protect your lips, another high-risk area, with lip balm that offers sun protection with an SPF of 30 or higher.

Sunscreen should be applied to dry skin 15-30 minutes before going outdoors, and reapplied approximately every two hours.

Sunscreen should not be used to prolong sun exposure - only to avoid sunburn.  Some UV light gets through sunscreen.

Sunscreen does not make sunbathing safe.


Cover up when you must be in the sun.

Wear long sleeves, pants, a wide-brimmed hat, and sunglasses that protect against both UVA and UVB rays.  Here’s why:


Clothing protects your skin from the sun’s harmful rays

. The tighter the weave, the more sun protection provided. In fact, clothing plays such an important role in sun protection that clothing designed specifically to protect against the sun, as well as laundry additives created to boost clothing’s protective function, are available. Your Water's Edge Dermatology practitioner can provide you with more information about these products.
 

A wide-brimmed hat shades your face and neck from the sun’s rays. Wide-brimmed means the brim circles the entire hat and shades the face and neck.

Use extra caution near water, snow, and sand. These reflect the damaging rays of the sun, which can increase your chance of sunburn.

More Good Reasons to Practice Sun Protection

Aside from AKs, the sun’s UV rays also cause:

 

  • Premature aging: Signs of premature aging include wrinkles, mottled skin, and loss of skin’s firmness.

 

  • Immunosuppression (weakening of the body’s ability to protect itself from cancer and other diseases)
  • Cataracts and macular degeneration: Macular degeneration, for which there is no cure, is the leading cause of blindness in people aged 65 and older.

 

What Increases Your Risk?


If you have fair skin and have spent years in the sun, a red scaly patch or cluster of red bumps on your skin could be actinic keratoses. Individuals who have a weakened immune system also have an increased risk.
Use the checklist to gauge your risk factors.

Sun Exposure: Intense

Have you had periods of intense exposure to the sun (spend a lot of time
outdoors in the summer or live in an area that receives high-intensity sun year round)?
 

Fair Skin

Do you have pale white to creamy white skin? Fairer, less-pigmented skin increases the risk of developing AKs.
 

Color of Hair and Eyes

Do you have blond or red hair? Do you have blue, hazel, or green eyes?
 

Sun Sensitivity

Do you have a tendency to freckle or burn when exposed to sunlight?
 

Age

Are you 40 years of age or older? The likelihood of developing AKs increases with age, and lesions usually appear after age 40. However, people who live in geographic areas with year-round high-intensity sunlight, such as Florida or Southern California, may develop AKs earlier.  While uncommon, AKs have been diagnosed in teenagers. Earlier occurrence may be linked to use of tanning beds and sun lamps.
 

Immunosuppression (weak immune system)

Many factors can weaken your immune system, including  long-term exposure to sunlight, chemotherapy, taking medication to prevent organ rejection, and AIDS. Anything that suppresses your immune system greatly increases your risk.
 

Xeroderma Pigmentosum

This is a very rare condition characterized by an abnormality in the cells ability to repair DNA damage. Anyone with this condition should be seen regularly by your Water's Edge Dermatology practitioner.

If sun exposure is one of your risk factors, there is good news. It’s never too late to begin protecting your skin from the sun - even if you have AKs. Research shows that the skin’s recuperative powers can repair some of the damage when fully protected from ultraviolet (UV) light. Sun protection also can prevent further damage.
 
Anyone with an increased risk for developing AKs also should be examined by your Water's Edge Dermatology practitioner regularly. Additionally, the American Academy of Dermatology recommends that everyone, regardless of risk factors, perform regular skin self-examinations and see a dermatologist for a screening.

When to See a Dermatologist

Any new, changing, or worrisome skin lesion - including suspected or diagnosed actinic keratoses (AKs) - should be examined by a dermatologist. Dermatologists are specialists in the treatment of skin, hair, and nails. To become a dermatologist, a medical-school graduate must complete at least four years of postgraduate residency training. This training and experience gives a dermatologist the knowledge and experience needed to specialize in the diagnosis and treatment of conditions that affect the skin, hair, and nails.

Diagnosis

Several studies have reported that dermatologists correctly diagnose significantly more skin lesions, including melanoma and basal cell carcinoma (two types of skin cancer), than do non-dermatologists. Early diagnosis and treatment are crucial when a patient has AKs. Left untreated, AKs have the potential to progress to squamous cell carcinoma, a type of skin cancer that can be deadly. Dermatologists’ training also makes them more comfortable in determining whether or not an AK lesion should be biopsied.

Treatment

In-depth knowledge of the skin, skin types, various treatment options for skin conditions, and the outcome of these treatments make dermatologists uniquely qualified to treat dermatologic conditions, including AKs. New treatment options and knowledge about dermatology continue to advance this medical specialty. As new therapies and knowledge emerge, dermatologists are typically the first to learn about these - including the most effective use of new therapies.

Follow-up Care

Patients with multiple AKs require life-long treatment and counseling. Data generated from analysis of more than 700 million office visits to physicians in a given year show that dermatologists are most likely to provide effective AK and skin cancer prevention counseling. Skin cancer prevention counseling is of importance to patients with AKs since AKs have the potential to progress to squamous cell carcinoma, a type of skin cancer than can be deadly.

References:
Cassileth BR, et al. How well do physicians recognize melanoma and other problem lesions? J Amer Acad Dermatol. 1986 Apr;14(4):555-60.
Feldman SR, et al. Skin examinations and skin cancer prevention counseling by U.S. physicians: a long way to go. J Am Acad Dermatol. 2000 Aug;43(2 Pt 1):234-7

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