Epidemiology, natural history, and diagnosis of actinic keratosis
- R Steven Padilla, MD
R Steven Padilla, MD
- Professor of Dermatology & Pathology
- The University of New Mexico School of Medicine
Actinic keratosis (AK, also known as solar keratosis) is a cutaneous lesion that results from the proliferation of atypical epidermal keratinocytes. AKs represent early lesions on a continuum with squamous cell carcinoma (SCC) and occasionally progress to SCC.
AKs often present as erythematous and scaly macules or papules; lesions are most commonly detected in adults with fair skin. Chronic sun exposure is a major risk factor for the development of these lesions, which accounts for the usual detection of AKs in frequently sun-exposed areas (eg, balding scalp, face, lateral neck, and distal upper or lower extremities).
The epidemiology, clinical features, natural history, and diagnosis of AK will be discussed here. The management of AK and SCC is reviewed elsewhere. (See "Treatment of actinic keratosis" and "Epidemiology and risk factors for cutaneous squamous cell carcinoma" and "Clinical features and diagnosis of cutaneous squamous cell carcinoma (SCC)" and "Treatment and prognosis of cutaneous squamous cell carcinoma".)
EPIDEMIOLOGY AND RISK FACTORS
In the United States, AKs are among the most common reasons for visits to dermatologists [1-4]. It is estimated that between 1990 and 1999, 14 percent of dermatology visits in the United States were related to AKs .
Individuals with fair skin are most likely to develop AKs, and many of the data on the epidemiology and risk factors for AK are derived from studies in Australia, northern Europe, and the United States. Factors such as the extent of exposure to ultraviolet light and certain phenotypic features have been associated with risk for developing these lesions.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Salasche SJ. Epidemiology of actinic keratoses and squamous cell carcinoma. J Am Acad Dermatol 2000; 42:4.
- Feldman SR, Fleischer AB Jr, McConnell RC. Most common dermatologic problems identified by internists, 1990-1994. Arch Intern Med 1998; 158:726.
- Gupta AK, Cooper EA, Feldman SR, Fleischer AB Jr. A survey of office visits for actinic keratosis as reported by NAMCS, 1990-1999. National Ambulatory Medical Care Survey. Cutis 2002; 70:8.
- Warino L, Tusa M, Camacho F, et al. Frequency and cost of actinic keratosis treatment. Dermatol Surg 2006; 32:1045.
- Leffell DJ. The scientific basis of skin cancer. J Am Acad Dermatol 2000; 42:18.
- Taguchi M, Watanabe S, Yashima K, et al. Aberrations of the tumor suppressor p53 gene and p53 protein in solar keratosis in human skin. J Invest Dermatol 1994; 103:500.
- Nelson MA, Einspahr JG, Alberts DS, et al. Analysis of the p53 gene in human precancerous actinic keratosis lesions and squamous cell cancers. Cancer Lett 1994; 85:23.
- Hensen P, Müller ML, Haschemi R, et al. Predisposing factors of actinic keratosis in a North-West German population. Eur J Dermatol 2009; 19:345.
- Green A, Beardmore G, Hart V, et al. Skin cancer in a Queensland population. J Am Acad Dermatol 1988; 19:1045.
- Frost CA, Green AC, Williams GM. The prevalence and determinants of solar keratoses at a subtropical latitude (Queensland, Australia). Br J Dermatol 1998; 139:1033.
- Trakatelli M, Barkitzi K, Apap C, et al. Skin cancer risk in outdoor workers: a European multicenter case-control study. J Eur Acad Dermatol Venereol 2016; 30 Suppl 3:5.
- Engel A, Johnson ML, Haynes SG. Health effects of sunlight exposure in the United States. Results from the first National Health and Nutrition Examination Survey, 1971-1974. Arch Dermatol 1988; 124:72.
- Thompson SC, Jolley D, Marks R. Reduction of solar keratoses by regular sunscreen use. N Engl J Med 1993; 329:1147.
- Ulrich C, Jürgensen JS, Degen A, et al. Prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: a 24 months, prospective, case-control study. Br J Dermatol 2009; 161 Suppl 3:78.
- McBride P, Neale R, Pandeya N, Green A. Sun-related factors, betapapillomavirus, and actinic keratoses: a prospective study. Arch Dermatol 2007; 143:862.
- Goldberg LH, Mamelak AJ. Review ofactinic keratosis. Part I: etiology, epidemiology and clinical presentation. J Drugs Dermatol 2010; 9:1125.
- Flohil SC, van der Leest RJ, Dowlatshahi EA, et al. Prevalence of actinic keratosis and its risk factors in the general population: the Rotterdam Study. J Invest Dermatol 2013; 133:1971.
- Memon AA, Tomenson JA, Bothwell J, Friedmann PS. Prevalence of solar damage and actinic keratosis in a Merseyside population. Br J Dermatol 2000; 142:1154.
- Marks R, Foley P, Goodman G, et al. Spontaneous remission of solar keratoses: the case for conservative management. Br J Dermatol 1986; 115:649.
- Zagula-Mally ZW, Rosenberg EW, Kashgarian M. Frequency of skin cancer and solar keratoses in a rural southern county as determined by population sampling. Cancer 1974; 34:345.
- Frost CA, Green AC. Epidemiology of solar keratoses. Br J Dermatol 1994; 131:455.
- Marks R, Jolley D, Lectsas S, Foley P. The role of childhood exposure to sunlight in the development of solar keratoses and non-melanocytic skin cancer. Med J Aust 1990; 152:62.
- Pfister H, Fuchs PG, Majewski S, et al. High prevalence of epidermodysplasia verruciformis-associated human papillomavirus DNA in actinic keratoses of the immunocompetent population. Arch Dermatol Res 2003; 295:273.
- Astori G, Lavergne D, Benton C, et al. Human papillomaviruses are commonly found in normal skin of immunocompetent hosts. J Invest Dermatol 1998; 110:752.
- Forslund O, Ly H, Reid C, Higgins G. A broad spectrum of human papillomavirus types is present in the skin of Australian patients with non-melanoma skin cancers and solar keratosis. Br J Dermatol 2003; 149:64.
- Weissenborn SJ, Nindl I, Purdie K, et al. Human papillomavirus-DNA loads in actinic keratoses exceed those in non-melanoma skin cancers. J Invest Dermatol 2005; 125:93.
- Forslund O, Lindelöf B, Hradil E, et al. High prevalence of cutaneous human papillomavirus DNA on the top of skin tumors but not in "Stripped" biopsies from the same tumors. J Invest Dermatol 2004; 123:388.
- Keller B, Braathen LR, Marti HP, Hunger RE. Skin cancers in renal transplant recipients: a description of the renal transplant cohort in Bern. Swiss Med Wkly 2010; 140:w13036.
- Boyle J, MacKie RM, Briggs JD, et al. Cancer, warts, and sunshine in renal transplant patients. A case-control study. Lancet 1984; 1:702.
- Chen QP, Aw DC. Epidemiology of skin diseases in renal transplant recipients in a tertiary hospital. Ann Acad Med Singapore 2010; 39:904.
- Duncan KO, Geisse JK, Leffell DJ. Epithelial precancerous lesions. In: Fitzpatrick's Dermatology in General Medicine, 7th ed, Wolff K, Goldsmith LA, Katz SI, et al. (Eds), McGraw-Hill, New York 2008. Vol 1, p.1007.
- Jadotte YT, Schwartz RA. Solar cheilosis: an ominous precursor: part I. Diagnostic insights. J Am Acad Dermatol 2012; 66:173.
- Padilla RS, Sebastian S, Jiang Z, et al. Gene expression patterns of normal human skin, actinic keratosis, and squamous cell carcinoma: a spectrum of disease progression. Arch Dermatol 2010; 146:288.
- Marks R, Rennie G, Selwood TS. Malignant transformation of solar keratoses to squamous cell carcinoma. Lancet 1988; 1:795.
- Criscione VD, Weinstock MA, Naylor MF, et al. Actinic keratoses: Natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial. Cancer 2009; 115:2523.
- Quaedvlieg PJ, Tirsi E, Thissen MR, Krekels GA. Actinic keratosis: how to differentiate the good from the bad ones? Eur J Dermatol 2006; 16:335.
- Fuchs A, Marmur E. The kinetics of skin cancer: progression of actinic keratosis to squamous cell carcinoma. Dermatol Surg 2007; 33:1099.
- Harvey I, Frankel S, Marks R, et al. Non-melanoma skin cancer and solar keratoses. I. Methods and descriptive results of the South Wales Skin Cancer Study. Br J Cancer 1996; 74:1302.
- Werner RN, Sammain A, Erdmann R, et al. The natural history of actinic keratosis: a systematic review. Br J Dermatol 2013; 169:502.
- Green A, Battistutta D. Incidence and determinants of skin cancer in a high-risk Australian population. Int J Cancer 1990; 46:356.
- Marks R, Rennie G, Selwood T. The relationship of basal cell carcinomas and squamous cell carcinomas to solar keratoses. Arch Dermatol 1988; 124:1039.
- Kwa RE, Campana K, Moy RL. Biology of cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992; 26:1.
- Akay BN, Kocyigit P, Heper AO, Erdem C. Dermatoscopy of flat pigmented facial lesions: diagnostic challenge between pigmented actinic keratosis and lentigo maligna. Br J Dermatol 2010; 163:1212.
- Cockerell CJ. Histopathology of incipient intraepidermal squamous cell carcinoma ("actinic keratosis"). J Am Acad Dermatol 2000; 42:11.
- Carag HR, Prieto VG, Yballe LS, Shea CR. Utility of step sections: demonstration of additional pathological findings in biopsy samples initially diagnosed as actinic keratosis. Arch Dermatol 2000; 136:471.
- Peris K, Micantonio T, Piccolo D, Fargnoli MC. Dermoscopic features of actinic keratosis. J Dtsch Dermatol Ges 2007; 5:970.
- EPIDEMIOLOGY AND RISK FACTORS
- Ultraviolet radiation
- - Extent of sun exposure
- - History of sunburn
- - Impact of sun protection
- Gender, age, and geographic location
- - Genetic disorders
- - Human papillomavirus
- - Immunosuppression
- CLINICAL FEATURES
- CLINICAL COURSE
- Progression to skin cancer
- Spontaneous resolution
- Risk for skin cancer in other sites
- Differential diagnosis
- - Technique
- - Pathology
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS