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Actinic Keratosis

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									Actinic Keratosis
       Rob Sheehan-Dare
  Leeds Centre for Dermatology
Pre-Cancerous Lesions
  Actinic Keratoses
  Intra-epithelial Squamous Cell Carcinoma
  Lentigo maligna


Skin Cancer
  Basal Cell Carcinoma
  Squamous Cell Carcinoma
  Melanoma
  Lymphoma
 What are Actinic keratoses?

Epidermal dysplasia
Associated with UV exposure
  Sun exposed sites
  Elderly
  Outdoor occupations
  Warmer climates
  Lighter skin types
  Immunosuppression
 What are Actinic keratoses?

Histologically
  Epidermal cell disorganisation
  Acanthosis
  Reduced granular layer
  Parakeratosis
  Hyperkeratosis
 What is risk of malignancy?

?Less than 1:1000 per year
Increased by
  Immunosuppression
  Increased numbers of lesions
  Co-factors (radiation, exposure to tar)
  Prior Squamous cell carcinoma
Some lesions resolve spontaneously
Most SCC’s are well differentiated
    What do they look like?

Clinically
  Adherent scale (variable but always)
  Erythema (often)
  Light pigmentation (sometimes)
  Merge with surrounding skin
  Usually not indurated
     Diagnostic difficulties

Cutaneous horn
Hypertrophic actinic keratoses
Inflammatory lesions
  Often in immunosuppressed
           What to treat

Lesions in immunosuppressed patients
Lesions at high risk sites (e.g. lip)
Where previous history of SCC
Inflamed Actinic keratoses
Lesions in younger age group
Symptomatic lesions
          How to treat

Cryotherapy
Curettage & cautery
5-fluorouracil cream
Diclofenac gel
Imiquimod cream
Photodynamic therapy
              Cryotherapy
 Destruction by cold injury
 Cotton bud or cryospray
 20-30 second freeze
 Moderate pain
 Immediate blistering
 Heals in 10 days

 Suitable for small/few lesions
 Suitable where compliance poor
         Curettage and cautery
   Physical removal/thermal injury
   Requires local anaesthesia
   Moderate pain
   Eschar
   Heals in 10 days

   Suitable for solitary/few lesions
   Suitable for cryo resistant lesions
   Suitable for hyperkeratotic lesions
   Suitable where histology required
        5-fluorouracil cream
 Inhibits DNA synthesis by inactivating
  thymidine synthase
 4 weeks treatment
 Inflammatory reaction (moderate-severe)
 Little pain
 Interrupted treatment may be required

 Suitable for multiple/extensive lesions
 Suitable for compliant patients
             Diclofenac gel

 Inhibits Cyclo-oxygenase (COX-2)
 8 weeks treatment
 Mild-moderate inflammatory reaction
 No pain
 Long term benefits uncertain

 Suitable where intolerance to other treatment
           Imiquimod cream

 Toll-like receptor 7 agonist induces apoptosis
 4-8 weeks treatment
 Inflammatory reaction (moderate-severe)
 Little pain
 Interrupted treatment may be required

 Suitable for multiple/extensive lesions
 Suitable for compliant patients
      Photodynamic therapy
 ALA induced protoporphyrin IX synthesis
  sensitizes cells to photodynamic effect
 1-2 prolonged treatments
 Moderate pain
 Inflammatory reaction (moderate-severe)
 Heals in 10 days

 Suitable for multiple/extensive lesions
 Suitable where compliance poor
         Treatment summary

 Cryotherapy small/few lesions
 5-fluorouracil larger/multiple lesions

 Curettage for hyperkeratotic lesions
 Solaraze for patients with poor tolerance

 Imiquimod cream or PDT for resistant lesions
“They look benign , but keep out of the sun”

								
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