A growing aging population and incidence of actinic keratosis (AK) and cutaneous field carcinogenesis demand further updates on the long-term efficacy of current therapies and new investigational agents to guide the treatment choice.

The phase II/III clinical trials show promising results from new topical agents. AK treatment must eradicate as many clinical and subclinical lesions as possible, achieve a prolonged clinical remission, provide a good cosmetic result and control progression to invasive squamous cell carcinoma (SCC).

Several features can affect the choice of AK treatment. When deciding on a specific therapeutic approach, it is crucial to consider various factors, including treatment duration, cosmetic outcome, patient compliance, local adverse reactions, treatment expense and risk factors for recurrence. 

The first recommendation is on clear physician-patient communication, starting with an explanation of the chronic nature of AK, clarifying that only a small percentage of AK may evolve into invasive SCC, thus proposing the treatment of any AK regardless of clinical grading. The ideal AK treatment should clear clinical as well as subclinical lesions across the whole field cancer, and patient adherence is crucial in their management. Since elderly individuals with chronic diseases and multiple morbidities often display AK, interventions to increase medication adherence are important.

Advising the use of soothing and moisturizing agents in combination with therapies will help to prevent or treat mild local skin reactions. In cases of severe local reactions, advise treatment discontinuation. Photographic documentation is recommended at baseline and during treatment to document both clinical benefits and local adverse events.

In patients with limited life expectancy or whose treatment morbidity outweighs the potential benefits, the treating physician may consider a "wait and see" strategy.

Finally, new treatment options are directed toward personalized treatment, considering the characteristics of both patients and lesions and the genetic basis and individual risk of developing an invasive cutaneous SCC. Other factors, such as a close correlation between human papillomavirus infection and the development of AK and ongoing research aimed at identifying high-risk AK, may lead to additional treatment options.

Source: Del Regno L, Catapano S, Di Stefani A, et al. A Review of Existing Therapies for Actinic Keratosis: Current Status and Future Directions. Am J Clin Dermatol. 2022;23(3):339-52.