Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Editorial
2006:72:5;331-333
doi: 10.4103/0378-6323.27747
PMID: 17050925

Treatment of actinic keratoses: Why, when and how?

Volker Steinkraus, Almut Boer
 Dermatologikum, Hamburg, Germany

Correspondence Address:
Volker Steinkraus
Dermatologikum, Hamburg, Stephansplatz - 5, 20354, Hamburg
Germany
How to cite this article:
Steinkraus V, Boer A. Treatment of actinic keratoses: Why, when and how?. Indian J Dermatol Venereol Leprol 2006;72:331-333
Copyright: (C)2006 Indian Journal of Dermatology, Venereology, and Leprology

For more than a century, it has been the conviction of dermatologists that actinic keratosis is a precancerous condition. Only recently, the thinking about actinic keratoses is beginning to change, those lesions now being increasingly considered as the earliest visible pattern of squamous cell carcinoma.[1],[2],[3],[4]

However, the idea that actinic keratosis is itself a squamous cell carcinoma, is not new. It was in the 1930s, that Richard L. Sutton Jr.[5],[6] wrote "They [actinic keratoses] are called precancerous lesions; they are, in fact, cancerous already, early, superficial and requiring time to manifest those characteristics of cancer with which all clinicians are familiar, but cancerous nevertheless."[5] In the last decade, A. B. Ackerman and co-workers clarified the nature of actinic keratoses through numerous articles.[7],[8],[9],[10],[11],[12] They emphasized that actinic keratosis fulfills histopathologic criteria for an early squamous cell carcinoma because (1) it is made up of epithelial cells that have crowded, large and pleomorphic nuclei, some of which are in mitosis, (2) its cells have an acidophilic cytoplasm in sections of tissue stained by hematoxylin and eosin, (3) epithelial cells show signs of faulty cornification in the form of dyskeratotic cells and parakeratosis, (4) no boundary has been established histopathologically for separating actinic keratosis, with certainty from so-called invasive squamous cell carcinoma.[7],[8],[9],[10],[11],[12]

Slowly, the concept of actinic keratosis being a squamous cell carcinoma is beginning to take hold in the brains of dermatologists, dermatopathologists and pathologists. Of course, changing concepts of diseases almost invariably have implications for the treatment of these conditions. The concept that actinic keratosis is a very early squamous cell carcinoma implies that these lesions have to be treated either by removal or by destruction and that their early treatment is preferable to "wait and see". Therefore, it is not surprising that during the last years research has been devoted to new therapeutic strategies for actinic keratoses and that new medications and procedures have been made available to dermatologists in the daily practice. What follows is a brief summary of all these options of treatment.

For most actinic keratoses, curettage or shave excision is a very effective treatment. Especially for hyperplastic types of actinic keratosis, shave excision is a valuable tool because the tissue removed can be examined by microscopy. The cosmetic result is usually good, but sometimes, shave excisions or curettings might heal with a delled or hypopigmented scar. Another treatment modality is cryotherapy, which is cheap, easy to perform and efficacious, but bearing the risk of persistent hypo- or depigmentation. Ablative laser systems such as Carbon dioxide laser or Erbium:YAG laser have replaced the curette and scalpel in some private practices of dermatology and they may also be used to remove actinic keratoses, but ablative laser systems remove tissue by destruction and no viable tissue is sampled for microscopic examination. Ablative laser systems share with curettage and shave excision a small risk of scarring and of hyper- or hypopigmentation. Topical treatment with 5-fluorouracil is a very efficient therapy with good cosmetic results, but patients always suffer from heavy inflammation and in many cases from pain in the treated skin area.[13] Combination of 5-fluorouracil with isotretinoin given orally shortens the duration of treatment considerably.[14] Diclofenac, an inhibitor of cyclo-oxygenase I and II, can be used topically for treatment of very early, i.e., flat, actinic keratoses, but it must be applied for several months.[15] The exact mechanism of action of topical diclofenac in the treatment of actinic keratoses is not known but it has been proposed that the development of actinic keratosis is linked to elevated prostaglandins.[16] It is not very effective, however, in advanced lesions as reported in a study by Fariba et al .[17] Imiquimod is an immune response modifier that activates pro-inflammatory cytokines. Administered three times a week overnight, it induces an inflammatory reaction that may cause complete resolution of actinic keratoses.[18] The treatment usually lasts for three to six weeks with severe inflammatory reaction, but cosmetic results are excellent. Photodynamic therapy with methyl-(5-amino-4-oxopentanoat) aminolevulinate cream and red light is another treatment modality that selectively destroys neoplastic keratinocytes.[19] The procedure is quite painful but it allows both, early and advanced, as well as sub-clinical lesions to be treated effectively. The inflammatory response is often heavy but heals within several days or a few weeks with very good cosmetic results.

In sum, noninvasive options for the treatment of actinic keratoses have increased notably. When in times past the question was whether actinic keratoses needed any treatment, the considerations of a dermatologist today are about which treatment to apply for a particular patient and at which time. All of the modalities currently available have advantages and disadvantages. A big plus of operative treatments such as shave or curettage is that tissue can be sampled for microscopic examination, that procedure decreasing the risk of insufficient treatment of invasive squamous cell carcinoma. All topical treatments, no matter whether 5-fluorouracil, imiquimod, diclofenac or photodynamic treatment have in common that they may be inadequate when a lesion is more invasive than suspected on clinical inspection. When lesions are numerous, however, operation may be impossible. Topical medications such as diclofenac, 5-fluorouracil, imiquimod or photodynamic treatment are a major improvement in handling these patients. Cosmetic results of all treatments are more or less comparable.

In our own practice we have developed a pragmatic approach to the treatment of actinic keratoses. Our decision regarding which treatment to use in a particular patient not only takes into account the stage of development of an individual lesion, i.e., early flat lesions or advanced elevated, markedly keratotic ones, but also the number and the site of lesions and the individual situation of the patient biologically, socially and professionally. If lesions are few, we prefer to remove them by shave excision. If lesions are many and flat, we use diclofenac in very early stages and 5-fluorouracil or photodynamic treatment in later stages. If lesions are well advanced and numerous, we perform photodynamic treatment if a patient has limited time. If a patient has no time constraints and is not bothered by several weeks of inflamed skin, we use 5-fluorouracil or imiquimod.

A caveat should be added in regard to all these options for treatment considering the increasing demand for evidence-based medicine. Even though many of the rather new topical treatments for actinic keratoses are used frequently in the practices of dermatologists every day, the evidence as to which treatment really is the best for which lesion in which patient is sparse. Comparative and comparable studies on the various topical agents currently available are needed to determine, with surety, the most effective treatment for actinic keratoses in order to develop evidence-based guidelines for dermatologists in clinic and practice.

References
1.
Tomas D, Kruslin B, Cupic H, Stanimirovic A, Bosnjak B, Lovricevic I, et al . Correlation between Bcl-2 and Bax in atrophic and hypertrophic type of actinic keratosis. J Eur Acad Dermatol Venereol 2006;20:51-7.
[Google Scholar]
2.
Cockerell CJ, Wharton JR. New histopathological classification of actinic keratosis (incipient intraepidermal squamous cell carcinoma). J Drugs Dermatol 2005;4:462-7.
[Google Scholar]
3.
Anwar J, Wrone DA, Kimyai-Asadi A, Alam M. The development of actinic keratosis into invasive squamous cell carcinoma: Evidence and evolving classification schemes. Clin Dermatol 2004;22:189-96.
[Google Scholar]
4.
Lober BA, Lober CW. Actinic keratosis is squamous cell carcinoma. South Med J 2000;93:650-5.
[Google Scholar]
5.
Sutton RL Jr. Early epidermal neoplasia: Description and interpretation-The theory of mutation in the origin of cancer. Arch Derm Syphil 1938;37:737-80.
[Google Scholar]
6.
Sutton RL Jr. Early cutaneous carcinoma. J Am Med Assoc 1935;104:433-9.
[Google Scholar]
7.
Ackerman B, Mones JM. Solar Keratosis? In : Ackerman B, Mones JM, editors. Ackermans resolving quandaries in dermatology, pathology and dermatopathology. 2nd ed. Ardor Scribiendi: New York; 2001. p. 341-50.
[Google Scholar]
8.
Javier BJ, Ackerman AB. Solar keratosis with 'Darier-like features' is 'pseudoglandular' squamous-cell carcinoma. Dermatopathol Pract Concept 2000;6:114-21.
[Google Scholar]
9.
Heaphy MR Jr, Ackerman AB. The nature of solar keratosis: A critical review in historical perspective. J Am Acad Dermatol 2000;43:138-50.
[Google Scholar]
10.
Brand D, Ackerman AB. Squamous-cell carcinoma, not basal-cell carcinoma, is the most common cancer in humans. J Am Acad Dermatol 2000;42:523-6.
[Google Scholar]
11.
Jones EC, Ackerman AB. About the matter of solar keratosis. Dermatopathol Pract Concept 1999;5:303-11.
[Google Scholar]
12.
Ng P, Ackerman AB. The major types of squamous-cell carcinoma. Dermatopathol Pract Concept 1999;5:252.
[Google Scholar]
13.
Goette DK. Topical chemotherapy with 5-fluorouracil. A review. J Am Acad Dermatol 1981;4:633-49.
[Google Scholar]
14.
Sander CA, Pfeiffer C, Kligman AM, Plewig G. Chemotherapy for disseminated actinic keratoses with 5-fluorouracil and isotretinoin. J Am Acad Dermatol 1997;36:236-8.
[Google Scholar]
15.
Wolf JE Jr, Taylor JR, Tschen E, Kang S. Topical 3.0% diclofenac in 2.5% hyaluronan gel in the treatment of actinic keratoses. Int J Dermatol 2001;40:709-13.
[Google Scholar]
16.
Rivers JK. Topical 3% diclofenac in 2.5% hyaluronan gel for the treatment of actinic keratoses. Skin Therapy Lett 2004;9:1-3.
[Google Scholar]
17.
Fariba I, Ali A, Hossein SA, Atefeh S, Behbahan AZ, Afshin S. Efficacy of 3% diclofenac gel for treatment of actinic keratoses. Indian J Dermatol Venerol Leprol 2006;72:346-9.
[Google Scholar]
18.
Schon M, Bong AB, Drewnick C, Herz J, Geilen CC, Reifenberger J, et al . Tumor-selective Induction of apoptosis and the small-molecule immune response modifier imiquimod. J Natl Canc Inst 2003;95:1138-49.
[Google Scholar]
19.
Kalka K, Merk H Mukhtar H. Photodynamic therapy in dermatology. J Am Acad Dermatol 2000;42:389-413.
[Google Scholar]

Fulltext Views
414

PDF downloads
219
Show Sections