Actinic Keratosis: Symptoms, Cancer Risk, and Treatment

What is actinic keratosis?

Actinic keratosis (AK) refers to rough or scaly lesions that develop on skin exposed to ultraviolet (UV) radiation for many years. They most commonly appear on sun-exposed areas such as the face, hairless scalp, ears, backs of the hands, and forearms.

Actinic keratosis is not an invasive skin cancer, but a precancerous lesion associated with the development of cutaneous squamous cell carcinoma (cSCC).

Because we cannot reliably predict which actinic keratosis will progress, the current European guidelines generally recommend treatment.

Briefly, what you need to know

It is associated with long-term UV damage.

It usually feels rough and gritty to the touch, like sandpaper.

There may be a single lesion or multiple lesions over a large area.

Not all actinic keratoses turn into cancer.

However, we cannot predict with certainty which one will progress to cSCC.

A single lesion and widespread sun damage are not treated in the same way.

New actinic keratoses may develop after treatment.

What does actinic keratosis look like?

Generally:

pink, red or brownish,

scaly or crusty,

hard and rough,

sometimes very thin and hard to see

It is a lesion.

In fact, some actinic keratoses can be felt with the fingers before they are visible to the naked eye.

The Turkish Dermatology Association also describes the typical appearance as rough, textured pink, red, or brown spots that appear in sun-exposed areas. (Turkish Dermatology Association)

Where is it found?

Especially those who are chronically sun exposed:

face · forehead · nose · ears · hairless scalp · backs of hands · forearms

It is frequently seen in regions such as these.

Actinic damage developing in the lower lip is called actinic cheilitis and requires further evaluation.

What causes actinic keratosis?

The primary cause is cumulative UV damage.

The risk specifically:

in people with fair skin,

people who have worked under intense sunlight for many years,

in old age,

In people with thinning or hair loss,

immunosuppressed patients

increases.

Therefore, actinic keratosis is not just a single lesion, but sometimes one of the visible signs of UV damage the skin has sustained over the years.

Is actinic keratosis cancer?

It is not yet invasive cSCC.

However, there is a biological link between actinic keratosis and squamous cell carcinoma, and some AKs can progress to invasive cSCC over time.

Not all actinic keratoses turn into cancer; however, since we cannot predict with certainty which lesion will progress, monitoring and appropriate treatment are important.

The 2024 European consensus also considers the Council of Europe (CoE) as potential predecessors to the cSCC.

Which changes are more noteworthy?

In an AK Party:

rapid growth,

noticeable thickening,

hardening,

tenderness or pain,

bleeding,

ulceration

If it develops, reassessment for the possibility of invasive cSCC is important.

In these types of lesions, instead of simply classifying it as "actinic keratosis" and performing destructive treatment, a biopsy may be necessary.

European guidelines recommend biopsy for clinically or dermoscopically suspicious lesions, or lesions that are resistant to treatment.

How is the diagnosis made?

Most actinic keratoses can be identified during a dermatological examination.

Dermoscopy can be helpful in differential diagnosis.

However:

If there is suspicion of SCC,

if the appearance is atypical,

if the lesion persists despite treatment

A biopsy may be required for histopathological evaluation.

“What is "field cancerization"?

Sun damage may not be found only in a single actinic keratosis that we see with the naked eye.

For example, on the scalp of a person who has lost their hair:

5 visible AK

However, UV-induced cellular changes can also be found in the surrounding large area of skin.

This type of cancerization is called field cancerization.

Therefore, we plan the treatment with two different logic:

Lesion-focused therapy: Treats single or a small number of acute coronary arteries (ACAs).

Area therapy: Targets the sun-damaged area, including both visible and less obvious lesions.

The 2024 European guidelines specifically recommend field therapy for patients with multiple ectasia.

How is actinic keratosis treated?

Treatment:

to the number of lesions,

thickness,

to the region where it is located,

the presence of area cancerization,

patient characteristics

It is selected according to...

Cryotherapy

For single or a small number of suitable lesions, cryotherapy with liquid nitrogen is a frequently used method.

It can be implemented quickly; however, freezing a large area containing numerous combat zones individually is not always the best strategy.

The AAD (American Academy of Dermatology) lists cryosurgery among the treatments that receive strong recommendations for AK (Acute Acute Retinitis Pigmentation).

Topical area treatments

In cases of multiple lesions or areas of cancerous transformation:

5-fluorouracil (5-FU)

imiquimod

tirbanibulin

diclofenac in selected cases

Topical treatments such as these can be used.

The application times, levels of inflammation, and evidence of these medications vary; therefore, the same cream is not prescribed to everyone.

The AAD strongly recommends 5-FU and imiquimod; tirbanibulin also received a strong recommendation in a subsequent focused update. (American Academy of Dermatology)

Photodynamic therapy (PDT)

It is a particularly important option in cases of numerous AK (Acute Retinal Familial Dissection) and field cancerizations.

A photosensitizing agent is applied, and then activated with appropriate light to target abnormal cells.

The European guidelines recommend PDT in conjunction with topical area treatments as a treatment option for multiple lesions.

Curettage and other destructive methods

In selected thick/hyperkeratotic lesions:

curettage,

electrosurgery,

ablation

Such methods may have a place.

Lasers can also be used in appropriately selected cases; the AAD considers laser ablation among the lesion-focused options. (American Academy of Dermatology)

The basic safety rule is this:

We do not destroy a lesion suspected of having SCC with laser, plasma, or other energy device, ignoring the need for histopathological evaluation.

First the diagnosis, then the treatment.

Why does it reappear after treatment?

Because even if the treated lesion disappears, the UV damage that has accumulated over the years will not be eliminated.

Development of new actinic keratoses in the same area:

“"The treatment was unsuccessful."”

That may not mean anything.

Therefore, in some patients, the long term:

sun protection + skin check + repeated area treatments as needed

It may be necessary. European consensus supports this approach, especially in high-risk patients.

Does sun protection really make a difference?

Yes.

UV protection is not merely a cosmetic component of EC management, but an integral part of the treatment and prevention strategy.

The AAD (American Academy of Dermatology) strongly recommends UV protection.

But we won't just explain sun protection by saying "apply sunscreen (SPF)":

shade + clothing + hat + appropriate sunscreen + avoidance of tanning beds

They should be considered together.

Frequently Asked Questions

Is actinic keratosis cancer? It is not invasive skin cancer; however, it is a precancerous lesion associated with the development of cSCC.

Do all actinic keratoses turn into cancer? No. However, because we cannot reliably predict which lesion will progress, treatment is generally recommended.

Can actinic keratosis resolve spontaneously? Some lesions may regress; however, they can recur, and simply waiting for this to happen is not the general approach due to the potential for progression to cSCC. (American Academy of Dermatology)

Are single sunburn lesions treated the same as multiple sunburn lesions? No. Lesion-focused treatments may be more meaningful for single lesions, while area treatments may be more meaningful for widespread sun damage.

Can actinic keratosis be treated with laser? Laser ablation can be used in selected lesions. However, if SCC is suspected, histopathological evaluation is required first. (American Academy of Dermatology)