Understanding Actinic Keratosis

Medical Author: Nili N. Alai, MD, FAAD
Medical Editor: William C. Shiel Jr., MD, FACP, FACR

What are actinic keratoses?

Actinic keratoses (AKs) are small, red, rough, scaly, flat spots that feel like dry skin patches. They often occur on sun-exposed areas, such as the nose, ears, face, chest, forearms, and back of the hands. Other common names include AK, AKs, solar keratosis, precancers, and pre-skin cancers.

At what age do AKs develop?

Experts agree that AKs are most common in older adults and seniors. AKs are extremely rare in children or adolescents.

What are my chances of my precancers becoming skin cancers?

Anywhere from 5%-10% of AKs can potentially go on to become skin cancers. It is not possible to tell which ones will do this. Some AKs will never develop into anything else. Some AKs go away without treatment.

Do actinic keratoses ever turn into melanoma (a deadly form of skin cancer)?

No. While AKs may give rise to skin cancers like squamous cell carcinomas, they do not turn into melanomas. Nevertheless, it is important to keep in mind that people with AKs may be more prone to melanomas simply by having more sun damage.

How do I prevent developing more precancers?

Helpful measures include sun protection with hats, clothing, sunscreen, and sun avoidance, particularly during the peak hours of 10 a.m. to 4 p.m. Additional long-term maintenance options include nightly applications of retinoid creams, such as tretinoin (Retin-A) or tazarotene (Tazorac). Some studies also have shown a benefit from using green tea creams to decrease the number of AKs.

How do I know that my AK is not cancerous?

Any non-healing or recurring AK in the same spot may need a small skin biopsy to make sure it has not turned into skin cancer. Sometimes, your physician will treat the AKs and recheck them in three to four weeks. Any non-healing spots may then be suspect for possible cancer.

Is there a blood test, skin text, or X-ray to diagnose AKs?

Most AKs are diagnosed by a physician during a skin exam. There are no blood tests or special X-rays for this.

What about "UV" cameras that show sun damage?

UV cameras using special black-and-white images depicting the amount of sun damage may be helpful in some cases to demonstrate sun damage. UV cameras do not necessarily diagnose AKs or skin cancer.

Why do I have more AKs on my left side?

Overall, many people have more AKs on their left face, or driving window side, because of possible increased sun exposure while driving.

I am an avid golfer and have noticed AKs only on my right hand. Why is my left hand better?

Commonly, golfers wear a glove on their nondominant hand. The golfing glove's physical barrier gives protection from the sun's rays on the covered hand. It is common to see an asymmetric pattern of AKs primarily on the uncovered hand in golfers. It would be a great idea to consider getting matching gloves to protect both hands!

How often should I be seen and treated for AKs?

Usually, every four to six months is a very appropriate interval for treatment of AKs. AKs are like weeds in your garden. Just like your garden, your skin also needs periodic maintenance to keep the weeds away. Left unmaintained, these weeds or AKs can grow out of control, requiring extensive "de-weeding" on your next visit.

I am very good about sun protection now and use an SPF 45 sunscreen with zinc and titanium daily. Why do I still keep getting new AKs every time I see my dermatologist?

AKs are generally a result of past sun exposure, not necessarily from current sun exposure habits. It is well known that much of sun damage occurs before age 18. Therefore, there is frequently a long lag in the appearance of AKs. The sun protection you are practicing today will help to protect your skin in 10 to 30 years.

What is the best way to treat actinic keratoses?

It depends on how many and where the AKs are. If you have just one to five AKs, then freezing them with liquid nitrogen is an excellent, quick and simple way to treat them. Also, if you have very thick AKs called hypertrophic actinic keratosis (HAK), then freezing is also a great choice. If you have more than 10 to 15 AKs scattered on your face, chest, or forearms, then a "blanket" or "field" type therapy may be better. This is because field treatments treat the AKs you see as well as the AKs you don't currently see or feel. Overall, combination treatments using one or two types of therapies are best. For example, a good program may be to freeze the individual thick AKs with liquid nitrogen, allow them to heal for two to three weeks, and then treat the entire area with a field treatment like fluorouracil (Efudex) or photodynamic therapy.

What are available field or blanket treatments for AKs?

Current options include photodynamic therapy (PDT),  Efudex 5% cream, fluorouracil (Carac 0.5% cream), imiquimod (Aldara cream), and medium-deep chemical peels. Overall, multiple treatments may be required, and it is difficult to get rid of every precancer in one treatment. Efudex and Aldara may cause three to six weeks of marked redness, skin irritation, and sun sensitivity. Photodynamic therapy requires 36 to 48 hours of absolute sun avoidance after treatment and a few days of a mild sunburn reaction.

Have any famous people used Efudex?

Former President George H. W. Bush used Efudex for his facial AKs and was photographed with a red, irritated face. Efudex has really been the gold-standard (top of the line) treatment for more than 20 years. Many people don't want treatment with creams like Efudex and Aldara because of the potential prolonged downtime and skin irritation.

What is a good AK treatment for sensitive skin? I break out with almost all kinds of creams. Which field treatment can I use for my AKs?

Photodynamic therapy may be a good option for sensitive skin because it is an in-office treatment with a simple liquid application and light exposure.


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I have a very red face and some family members have asked if I have rosacea. Is it possible that my rosacea is causing AKs?

Patients with fair skin, Irish or Scottish ancestry, and light-colored eyes are overall more prone to rosacea (red, flushed cheeks with pink bumps) as well as to AKs. Rosacea does not cause AKs. Both conditions can be worsened by continuous sun exposure and sun damage. Photodynamic therapy with intense pulse light (IPL) may be a great "two for one" package in your case because the combination treatment can effectively treat actinic keratosis, rosacea, and broken blood vessels (telangiectasia).

What general skin care tips do you give patients?

The sun is not your friend! Our main prevention measures are aimed at sun avoidance and sun protection. These include:

  • Use zinc sunscreens with SPF 30.

  • Use wide-brimmed hats (6 inches).

  • Use physical sun barriers, such as clothing and sunglasses.

  • Avoid the peak sun hours of 10 a.m. to 4 p.m.

  • Seek shade and stay indoors.

Some of the doctor's favorite actinic keratosis treatments include:

  • Photodynamic therapy (PDT)

  • Efudex 5% cream twice a day for four weeks to the entire area

  • Aldara cream once a day or every other day for four to 12 weeks

  • Retin-A or Tazorac cream nightly or every other night

  • Chemical peel using trichloroacetic acid (TCA 20%-35%)

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