AK: Stopping the Progression
Jerome R. Obed, DO, FAOCD
Broward Dermatology &Cosmetic Specialists
Objectives
• Pathophysiology of cutaneous malignancy
• Recognition of suspicious lesions
• Prognosis & long-term risks
• Treatment options
Types of Actinic keratosis
• Classic
• Hyperplastic
• Pigmented
• Lichenoid
• Atrophic
• Actinic Cheilitis
• Bowenoid
Sun Damage (Solar Elastosis)
68 y/o female with extensive sun damage, as well as a history of cutaneous malignancy
More Dermatoheliosis(37 y/o male)
More Dermatoheliosis(48 y/o female)
More Dermatoheliosis(60 y/o male)
Extensive solar elastosis
More Dermatoheliosis(89 y/o female)
26 y/o female with early malignancy
Normal Skin
Actinic keratosis
Normal v/s AK
Squamous cell carcinoma
Normal v/s SCC
Keratoacanthoma
AK: Stopping the Progression
• Non-melanoma skin cancers are the most common malignancy amongst Caucasians
• Risk factors include UV light exposure, ionizing radiation, arsenic, organic chemicals, HPV, immunosuppression, and genetics
Actinic keratosis
Described as precancerous/premalignant because the atypical keratinocyteswithin these lesions are confined to the epidermis
Actinic keratosis
• Risk of malignant transformation is 0.075-0.096% per lesion per year
– patient with 7.7 AK’s: SCC risk is 10.2% over
10 years
• These numbers are similar to those determined for intraepithelial neoplasms in other sites
– 15% of untreated cervical CIN lesions will progress if left untreated
AK: Clinical Features
• Well demarcated erythematous hyperkeratoticlesions on sun-exposed skin
• Overlying scale is white to yellow-brown
• Surrounding areas typically demonstrate overt evidence of long-standing actinic damage
• Usually asymptomatic but itching or tenderness may be present
AK: Differential Diagnosis
• SCC in situ
• Superficial BCC
• Bowenoid Papulosis
• Lentigo Maligna
• Spongiotic Dermatosis
What are we looking for? What are we missing?
Extensive sun damage with well-demarcated AK
Well-demarcated AK
Well-demarcated AK
Numerous AK
Extensive sun damage with numerous Actinic keratosis
Same patientSCC (well differentiated)
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar Elastosis + AK
Hyperplastic AK
More Hyperplastic AK’s
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar elastosis + AK
Actinic Keratosis
Solar elastosis + AK
Solar elastosis + AK
Solar elastosis with numerous AK
Solar elastosis with numerous AK
Solar Elastosis/Actinic Keratosis
SCC in-situ
SCC in-situ
SCC (well-differentiated)
SCC (microinvasive)
Forehead: Hyperplastic AK
Temple: Squamous cell carcinoma in-situ
AK + SCC
SCC
SCC x 2
Solar elastosis + SCC
Solar elastosis + SCC
AK + SCC
AK + SCC (1 of 2)
AK + SCC (2 of 2)
A: Hyperplastic AK
B: Squamous cell carcinoma (well differentiated)
SCC
SCC in-situ
SCC (well differentiated, invasive)
Actinic Cheilitis
• Premalignant condition that predisposes to intraepidermal carcinoma and invasive SCC
• Involved skin (usually lower lip) has a mottled appearance with indistinct vermilion border
• Scaling, crusting, and erosions are seen, as well as loss of elasticity, dryness, and atrophy
Actinic Cheilitis
• DDX: contact dermatitis; plasma cell cheilitis
• Recurring cycle of crusting and healing is common, while prolonged ulceration ulceration may signify malignancy
Actinic Cheilitis
Actinic Cheilitis
Therapeutic options
• Watchful waiting
• Cryotherapy
• Chemical Peels
• Laser resurfacing
• Photodynamic Therapy
• Topical immunotherapy
• Electrodessication & Curretage
• Nicotinamide??
Topical immunotherapy
• Imiquimod
– Aldara/Zyclara
• 5-Fluorouracil
– Effudex, Carac, Fluoroplex
• Ingenol mebutate
– Picato
Treatment benefits
• Halt disease progression
• Field cancerization
Treatment complications
• Pain/Discomfort
• Scarring
• Post-inflammatory pigmentary changes
Before and during treatment with topical Imiquimod
Before and during treatment with topical Imiquimod
During and following treatment with topical Imiquimod
During treatment with IngenolMebutate
During treatment with Fluorouracil
Thank you!!