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. AKs are a marker of cumulative ultraviolet (UV) damage: they are uncommon under the age of 45, 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, increasing age and immunosuppression. As a useful rule of thumb, a patient with ten AKs carries roughly a 14% risk of developing an SCC within five years. Many lesions also regress spontaneously, so the aim of treatment is usually to reduce the overall lesion burden rather than to achieve a "cure".
The key skill in primary care is twofold: distinguish discrete (lesion-directed) disease from field change (field-directed) disease, and 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 / 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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