Controversies in the management of actinic keratoses in the 21st century


Debate about the optimal management of actinic keratoses (AKs) shows no signs of abating. Opinion differs on whether they all should be treated and, if they are treated, whether intervention should be confined to the lesions themselves, directed at the area affected by field change or both. Evidence of efficacy and tolerability of recently introduced drugs has prompted clinicians  to re-evaluate management and reconsider their approach to treatment. Patient preference has always been an important determinant of treatment; now there is more choice and new treatment regimens to support greater concordance.

A group of leading dermatologists discussed how these issues will affect clinical practice at a meeting held at the Royal College of Physicians in London on 21 March 2013. The Chair, Dr Stephen Kownacki, Executive President of  the Primary Care Dermatology Society (, Dr Colin Morton  (Consultant Dermatologist, Falkirk and District Royal Infirmary), Dr Girish Gupta (Consultant Dermatologist and West of Scotland Skin Cancer Lead Clinician, NHS Lanarkshire), Dr Jonathan Bowling (Consultant Dermatologist and Honorary Senior Clinical Lecturer, Oxford University Hospitals NHS Trust) and Dr Christopher Bower (Consultant Dermatologist, Royal Devon and Exeter NHS Foundation Trust) reviewed the optimal management of AKs and the likely impact of new treatments.

What is current practice?

There are currently three guidelines for the management of AKs. The UK guideline was published in 2007,1 predating some of the treatments now available; it is now being updated. It acknowledges the differing views about whether or not to treat AKs, but makes no specific recommendation about treatment choice or the role of field-directed or lesion-specific treatment.

The European guideline, developed by the European Dermatology Forum, identifies many risk factors for progression of AKs to squamous cell carcinoma (SCC) – duration, course, localisation and extent of lesions, solitary or  multiple AKs, age, comorbidity, adherence, pre-existing skin cancer and  immunosuppression. However, it does not adopt a risk-based approach, instead recommending that all AKs are treated because of the risk that they may progress.2

The UK Primary Care Dermatology Society (PCDS) guidance, the most recently updated advice, makes the clearest distinction between a field-directed and lesion-specific approach3 and most closely reflects current UK practice. It states that treatment should be directed at the lesion and not the surrounding skin when there are few lesions or larger numbers that are widely distributed. Patients with field change should have more vigorous treatment applied to the affected area and not just the individual lesions.

None of these guidelines is directive about treatment choice, opting instead to outline the options available. As a result, clinical practice varies according to local specialist opinion, commissioning arrangements and the constraints  of drug formularies. This leaves several unresolved questions:

• Should AKs be treated?
• If treatment is indicated, should it be field-directed or lesion-specific?
• What are the challenges in prescribing a topical treatment for AK?



Commissioned and sponsored by Meda Pharmaceuticals. Meda Pharmaceuticals was involved in the outline development and medico-legal approval of this article and provided financial support for its publication.


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Meeting participants

  • Dr Stephen Kownacki, Executive President of the Primary Care Dermatology Society 
  • Dr Colin Morton, Consultant Dermatologist, Falkirk and District Royal Infirmary
  • Dr Girish Gupta, Consultant Dermatologist and West of Scotland Skin Cancer Lead Clinician, NHS Lanarkshire
  • Dr Jonathan Bowling, Consultant Dermatologist and Honorary Senior Clinical Lecturer, Oxford University Hospitals NHS Trust
  • Dr Christopher Bower, Consultant Dermatologist, Royal Devon and Exeter NHS Foundation Trust

Medical writer in attendance: Steve Chaplin