Advances and Considerations in the Management of Actinic Keratosis: An Expert Consensus Panel Report

August 2021 | Volume 20 | Issue 8 | Original Article | 888 | Copyright © August 2021


Published online July 30, 2021

James Del Rosso DO (Panel Chair)a, April W. Armstrong MD MPHb, Brian Berman MD PhDc, Neal Bhatia MDd, Clay Cockerell MD MBAe, Gary Goldenberg MDf, Joslyn Kirby MD MS MEdg, Mark Lebwohl MDh, Linda Stein Gold MDi, Justin W. Marson MDj, Darrell S. Rigel MD MSk

aResearch Director/Clinical Dermatology, JDR Dermatology Research/Thomas Dermatology, Las Vegas, NV
bDepartment of Dermatology, Keck School of Medicine University of Southern California, Los Angeles, CA
cDepartment of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
dDirector of Clinical Dermatology, Therapeutics Clinical Research, San Diego, CA
eDepartment of Dermatopathology, University of Texas Southwestern Medical Center, Dallas, TX
fGoldenberg Dermatology; Icahn School of Medicine at Mount Sinai, Department of Dermatology, New York, NY
gDepartment of Dermatology, Penn State Milton S Hershey Medical Center, Hershey, PA
hDepartment of Dermatology, Icahn School of Medicine, Mount Sinai, New York, NY
iDepartment of Dermatology, Henry Ford Medical Center, Detroit, MI
jNational Society for Cutaneous Medicine, New York, NY
kDepartment of Dermatology, NYU Grossman School of Medicine, New York, NY

Abstract
Background: Actinic Keratosis (AK) is a potentially pre-malignant tumor with a poorly defined risk of progression to invasive squamous cell carcinoma (SCC). Because of the typical need for recurrent cycles of AK treatment, outcomes can be limited by both therapeutic efficacy and patient adherence.
Objective: To synthesize the available and most current literature into overarching principles to provide guidance on the management of AKs, improving patient experiences and treatment outcomes.
Methods: A systematic review querying epidemiology, natural history, prognosis, management of AKs as well as the mechanism of action of and adherence to current AK therapy was conducted. After reviewing the literature, an expert consensus panel consisting of 10 expert dermatologists and dermatopathologists used a modified Delphi process to develop statements regarding the pathogenesis and management of AKs. Final statements were only adopted with a supermajority vote (≥7/10).
Results: The panel developed 7 consensus statements regarding AKs pathogenesis and management.
Conclusion: The poorly defined risk for AK progression into invasive SCC without universally accepted clinical-histopathological factors highlights the importance of long-term efficacious treatment. To effectively counsel and treat patients with actinic keratoses, dermatologists must understand how newer therapeutic approaches with mechanisms of action that have more rapid onset of action, shorter treatment courses, and less intense local skin reaction (LSRs) may promote adherence and improve long-term outcomes.

J Drugs Dermatol. 2021;20(8):888-893. doi:10.36849/JDD.6078

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INTRODUCTION

Actinic keratoses(AK) are a proliferation of atypical keratinocytes that present as hyperkeratotic, erythematous papules or occasionally plaques on a background of chronic actinic damage.1 AKs may progress to invasive squamous cell carcinoma(SCC).1-5 Several risk factors may predispose to developing AKs: lighter skin phenotypes(Fitzpatrick I-II), advanced age, increased cumulative exposure to UV radiation,6-8 occupational health exposures(eg, to excessive quantities of hydrocarbons)9, and immunosuppression.10 AKs are found on sun-exposed areas that are often not covered by clothing.11

AKs are one of the most prevalent cutaneous conditions treated by dermatologists with over 35 million cases treated in 2015,12 accounting for ≥14% of all dermatology visits13 and costing approximately $3.1B annual healthcare expenditures.12 Unfortunately, there are not universally accepted clinical or histopathological risk factors to determine which AKs may invasively progress. This is especially concerning as not all AKs are appreciable during every examination.11,15

Several key approaches to managing AKs include using proactive photoprotection, lesion-directed, and/or field-directed