Actinic keratoses (AK) presents as rough scaly patches on chronically ultraviolet-exposed skin, which can progress to keratinocyte carcinoma.

A study examined the literature on the management of AK to provide evidence-based recommendations for treatment, along with discussing Grading, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs.

The recommendations provided by the multidisciplinary Work Group were as follows- 

UV protection- 

• The use of UV protection is recommended for patients with AK, including sun avoidance, sun-protective clothing, and broad-spectrum sunscreen.

Topical agents-

• Field treatment with 5-fluorouracil is recommended for patients with AKs
• Field treatment with imiquimod is recommended for patients with AKs
• The use of diclofenac is conditionally recommended for patients with AKs, Because NSAIDs have cardiovascular and gastrointestinal side effects with other oral and topical medications in the class.

Cryosurgery 

• The use of cryosurgery is recommended for patients with AKs
• Treatment with cryosurgery over CO2 laser ablation is conditionally recommended for patients with AKs

Photodynamic therapy 

• ALA-red light PDT is conditionally recommended for patients with AKs
• 1 to 4-hour 5-ALA incubation time to enhance complete clearance with red light PDT is conditionally recommended for patients with AKs
• ALA-daylight PDT as less painful than but equally effective as ALA-red light PDT is conditionally recommended for patients with AKs
• Treatment with ALA-red light PDT over trichloroacetic acid peel is conditionally recommended for patients with AKs
• ALA-blue light PDT is conditionally recommended for patients with AKs
• Pretreatment with alpha hydroxy acid solution prior to ALA-blue light PDT is a conditional against-recommendation for patients with AKs
• Treatment with ALA-red light PDT over cryosurgery alone is conditionally recommended for patients with AKs

Combination therapy 

• The combined use of 5-FU and cryosurgery over cryosurgery alone is conditionally recommended for patients with AKs
• The combined use of imiquimod and cryosurgery over cryosurgery alone is conditionally recommended for patients with AKs
• The use of diclofenac in addition to cryosurgery compared to cryosurgery alone is a conditional against-recommendation for patients with AKs
• The use of topical adapalene in addition to cryosurgery compared to cryosurgery alone is a conditional against-recommendation for patients with AKs
• The addition of imiquimod following ALA-blue light PDT is a conditional against-recommendation for patients with AKs

Thus the committee made strong recommendations for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery, conditional recommendations for using photodynamic therapy and diclofenac for the treatment of AK, individually as well as a part of combination therapy regimens.

Source: JAAD, 2021;85(4): E209-E233. DOI:https://doi.org/10.1016/j.jaad.2021.02.082