History

Actinic keratoses are seen almost exclusively in whites, especially those with skin phototypes I and II.^[4]The incidence increases with each decade of life, and men have a slightly increased frequency of actinic keratosis.^{[4, 21]}Actinic keratosis is correlated with long-term UV exposure, such as occurs in persons with outdoor occupations.^[4]

Patient who are immunosuppressed following organ transplantation are at markedly increased risk of developing actinic keratoses.^[29]The lesions still arise in areas of long-term exposure,^{[6, 27, 38]}and they are thought to be actinically induced.

Physical Examination

The typical patient with actinic keratoses is an elderly, fair-skinned, sun-sensitive person.^[4]The lesions arise in areas of long-term sun exposure, including the face, ears, bald scalp in men, and the dorsal forearms and hands.^{[5, 6]}Actinic keratoses begin as small rough spots that are easier felt than seen, often described as being similar to rubbing sandpaper.^[1]With time, the lesions enlarge, usually becoming red and scaly; most are only 3-10 mm, but they may enlarge to several centimeters.^{[1, 2, 3]}Note the images below.

Actinic keratosis. Courtesy of Hon Pak, MD.

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Erythematous, scaly lesions on the temple area, typical of actinic keratosis.

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Patients may develop multiple lesions within a single anatomic area, to the extent that the lesions collide and produce confluent actinic keratosis over a relatively large area. Variants may be brown (pigmented actinic keratosis), atrophic, bowenoid, lichen planus–like, or have exaggerated hyperkeratosis, producing a hornlike projection above the skin surface known as a cutaneous horn.^[7]

Complications

Lesions may progress into invasive squamous cell carcinomas. A biopsy should be performed on nodular, indurated, or unresponsive lesions.^[9]

Differential Diagnoses

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[Guideline] Eisen DB, Asgari MM, Bennett DD, Connolly SM, Dellavalle RP, Freeman EE, et al. Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol. 2021 Apr 2. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

Actinic keratosis. Courtesy of Hon Pak, MD.
Actinic keratosis during treatment with topical 5-fluorouracil. Courtesy of Hon Pak, MD.
Actinic keratosis right after treatment with topical 5-fluorouracil. Courtesy of Hon Pak, MD.
Erythematous, scaly lesions on the temple area, typical of actinic keratosis.

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Author

James M Spencer, MD Professor of Clinical Dermatology, Mount Sinai School of Medicine; Private Practice, Spencer Dermatology

James M Spencer, MD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American College of Mohs Surgery, American Medical Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, International Society for Dermatologic Surgery

Disclosure: Received grant/research funds from Genentech for independent contractor; Received grant/research funds from DUSA for independent contractor; Received honoraria from Leo Pharmicuticals for review panel membership.

Coauthor(s)

Laura Jordan, DO, MA, MS, MLS Dermatology-Focus Traditional Rotating Intern, UH Regional Hospitals

Laura Jordan, DO, MA, MS, MLS is a member of the following medical societies: American Osteopathic College of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

Kelly M Cordoro, MD Assistant Professor of Clinical Dermatology and Pediatrics, Department of Dermatology, University of California, San Francisco School of Medicine

Kelly M Cordoro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Medical Society of Virginia, Society for Pediatric Dermatology, Women's Dermatologic Society, Association of Professors of Dermatology, National Psoriasis Foundation, Dermatology Foundation

Disclosure: Nothing to disclose.

Michelle Henry, MD Fellow in Procedural Dermatology, Department of Dermatology, Lahey Clinic, Harvard Medical School

Disclosure: Nothing to disclose.

Acknowledgements

Amy Lynn Basile, DO, MPH Sun Coast Hospital/Largo Medical Center, Largo, Florida

Disclosure: Nothing to disclose.

Mary Farley, MD Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center

Disclosure: Nothing to disclose.

James Fulton Jr, MD, PhD Medical Director, Fulton Skin Institute

Disclosure: Nothing to disclose.