Management of actinic keratosis in primary care continued

Indications for referral

• The majority of AKs should be managed in primary care (as set out in the NICE guidance) but the following should be referred to a specialist:
  • if the lesion is suspicious of an SCC refer to secondary care under the 2 week rule. The following could suggest transformation from an AK into an SCC:
    • recent growth/tenderness/inflammation
    • a nodular lesion
    • bleeding/ulceration and lesions on lips
  • diagnostic uncertainty
  • patients with more widepread/severe actinic damage
  • immunosuppressed patients, in particular post-transplant
  • very young patients presenting with AK—consider xeroderma pigmentosum
• Remember AKs are an indication of significant sun damage putting the patient at higher risk and thus a full examination of the skin is recommended to exclude other skin cancers

Primary care treatment pathway

• Many patients will only need a diagnosis and explanation with advice regarding sun exposure limitation and sunscreens; use of emollients for symptomatic relief, and warning of what to look out for if lesions change
• All topical treatments cause inflammation, which indicates their desired action against abnormal cells. If severe, the treatments should be stopped until the reaction subsides and then restarted, perhaps at a reduced frequency:
  • patients should be warned to expect this effect of the treatment rather than to regard it as an unwanted side-effect. Written advice is essential and nurse support is beneficial to help patients through the inflammatory phase
• Complete clearance of lesions can be delayed several weeks beyond completion of topical therapies
• For more symptomatic lesions, specific treatment may be indicated as in the AK pathway below
• None of the topical treatments apart from 0.5% fluorouracil/10% salicylic acid have a licence for non-facial sun exposed areas, e.g. backs of hands, but there is no clinical reason why they should not be used on these sites
• Note that the treatments are divided into lesion-specific or field treatments. Except for isolated or limited lesions, aim to treat the ‘field’ of actinic change since there will be subclinical lesions in the same area and these will be revealed by the topical treatments used. Often sequential treatments may be used for more hypertrophic lesions as well as the surrounding, less prominent, field change
• Two therapies, 3.75% imiquimod (for non-hyperkeratotic, non-hypertrophic, visible, or palpable AK of the full face, or balding scalp in immunocompetent adults) and ingenol mebutate (for non-hyperkeratotic, non-hypertrophic AK in adults) have recently been approved for AK treatment, especially for field treatments:
  • experience of these treatments in the UK is limited at present, but both may offer additional benefits which will find their place among our therapeutic options
• Leaflets regarding UV exposure and skin cancer awareness, and recommended regimens for treatment can be downloaded from the PCDS website at www.pcds.org.uk

Management of actinic keratosis in primary care continued

full guidelines available from…
2nd Floor, Titan Court, 3 Bishop Square, Hatfield, UK, AL10 9NA (Tel – )
www.pcds.org.uk

Primary Care Dermatology Society. Actinic (Solar) Keratosis primary care treatment pathway. September 2012

First included: Jun 13.