Skin Cancer

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Overview

Actinic keratosis (AK) is the most common precancerous lesion of the skin. These lesions appear as red, blotchy patches, commonly found on the face and head. They occur much more frequently in older individuals with fair skin, blue eyes, and a history of freckling. As they are directly related to cumulative sun exposure, over 50% of fair-skinned people living in sunny climates develop these lesions. Consequently, reducing sun exposure throughout one's lifetime, particularly in childhood, can dramatically reduce the risk for actinic keratosis.

The term "precancer" implies that these lesions could develop into skin cancer. This is true of actinic keratosis. Progression to actual skin cancer does not occur in most cases of AK. In actinic keratosis, early malignant cells are detected, and because they have not extended through the entire epidermis, they are fairly easy to treat.

Causes

Actinic keratoses are directly related to the amount of sun exposure one has had over a lifetime. The cumulative cell damage caused by sun exposure eventually causes mutations in the skin cell DNA, thus causing precancerous or cancerous lesions. Because fair-skinned people sunburn easily, they are at risk for AK.

Individuals that have received organ transplants and others with compromised immune systems have a much greater risk for developing AK. Certain genetic disorders result in increased sun sensitivity or decreased ability to repair cell damage. These individuals have a greater propensity for developing premalignancies and malignancies of the skin.

Signs and Symptoms

Actinic keratosis is seen primarily on the face, ears, scalp, chest, and hands, although they can occur anywhere there has been excessive exposure to the sun.

The lesions are usually pink or skin colored and typically have a dry, overlying scale. Occasionally, the scale can be quite thick and appear as a hornlike projection. They are very rough and are often better detected by touch than by sight. Some lesions can become tender or sensitive. They tend to lose their top scaly layer and may appear to be healing; however, the scaly portion usually reforms.

Actinic keratosis on the lower lip presents as diffuse chapping that does not resolve, despite liberal use of petroleum jelly or lip balms.

When a lesion appears to be thickening into deeper layers of the skin, or when an ulcer develops, the possibility of malignant changes exists.

Diagnosis

Actinic keratosis is most often diagnosed clinically and treated accordingly. When the possibility of cancer exists, a skin biopsy is obtained. The specimen is examined under a microscope to evaluate the damaged cells. If the cancerous cells fill the entire content of the epidermis, or if they extend beyond it, squamous cell carcinoma may be diagnosed.

Treatment

The most common treatment for AK is cryosurgery. A very cold substance, liquid nitrogen, is applied locally to the lesion. A scab or blister forms, which eventually falls off, leaving the area smooth. In dark-skinned individuals, care must be taken as this procedure can result in a white scar.

Another common treatment is the application of topical 5-fluorouracil (5-FU). This cream is applied twice daily to affected areas until any precancerous lesion "lights up" and becomes red and crusted. At that point the treatment is stopped and healing is allowed to occur. After the redness resolves, the skin becomes very smooth. 5-FU is useful for treating large areas with diffuse damage and on the temples, forehead, and arms.

Topical retinoids (Retin A®, Avita™) have been somewhat effective at treating and preventing AK as well. Once an area has been effectively treated, tretinoin cream or gel is recommended for daily use to reduce the need for further treatment and to counteract the effects of sun damage.

Curettage and electrodesiccation, a "scrape and burn" technique, is sometimes used, particularly for a single, thick, or hornlike lesion.

Prevention
Most sun damage is incurred from childhood through young adulthood. So minimizing exposure during those years is important. Using sunscreen every day and wearing hats are simple methods of protection. It is never too late to begin taking preventive measures. Studies have shown that while people can continue to get AKs even after strictly avoiding exposure to the sun, the number of lesions is dramatically reduced, especially when preventive measures are taken.

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