GPAtlas🧭 When to suspect
Suspect an actinic keratosis (AK) – also called a solar keratosis – in an older, fair-skinned patient with persistent rough, scaly or crusty patches on chronically sun-exposed skin, typically the scalp, face, ears, lips, forearms and backs of the hands.
Actinic keratoses (AKs) are a marker of cumulative ultraviolet (UV) damage:
• they are uncommon under the age of 45
• they become more frequent with age, and are more common in men
• NICE estimates that over 23% of people aged 60 and over in the UK have at least one AK.
The clinical significance of an AK is its potential – usually small – to progress to cutaneous squamous cell carcinoma (SCC). The risk of any single lesion transforming is low and uncertain, but it rises with:
• the number of lesions – as a useful rule of thumb, a patient with ten AKs carries roughly a 14% risk of developing an SCC within five years
• increasing age
• immunosuppression
Many lesions also regress spontaneously, so the aim of treatment is usually to reduce the overall lesion burden rather than to achieve a "cure".
In practice, you need to:
• distinguish discrete (lesion-directed) disease from field change (field-directed) disease
• never miss an SCC hiding within an AK
Severity is often described using the Olsen grade:
| Olsen grade | Clinical appearance | Typical implication |
|---|---|---|
| Grade 1 | • Slightly palpable – often better felt than seen • Flat, pink, fine scale |
Thin disease – lesion-directed or milder field treatment |
| Grade 2 | • Moderately thick • Easily felt and seen • Rough, raised scale |
Lesion- or field-directed topical treatment |
| Grade 3 | • Very thick or hyperkeratotic • Obvious, warty or horn-like |
• Keratolytic-containing or physical treatment • Exclude SCC if indurated |
Field change refers to multiple AKs on a background of erythema, telangiectasia and mottled sun damage; these areas carry a higher SCC risk and are treated across the whole field, not lesion by lesion.
Source: British Association of Dermatologists · DermNet
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