Actinic keratosis

Mild: flat, pink patch with slight scale or rough to touch  

• Advise all patients on use of sun protection and emollients.

For lesion and field treatment for isolated or scattered AK with no suspicious features: 

• Topical Fluorouracil 5% (Efudix) cream apply BD for 3-4 weeks.  
• Actikerall (0.5% 5FU/10% salicylic acid solution) apply once daily for 6-12 weeks, useful for hyperkeratotic AKs. 
• Imiquimod cream 5% applied 3 x weekly for 4 weeks or 3.75% cream applied od for 2 weeks repeated after 2 weeks. 
• Diclofenac sodium (Solaraze) apply BD for 60-90 days. 

Counsel patient regarding side effects of chosen treatment 

Moderate: larger numbers of moderately thick keratotic red patches that are easily felt and seen 

• Advise all patients on use of sun protection and emollients. 
• Topical Fluorouracil 5% (Efudix) cream apply BD for 3-4 weeks.  
• Imiquimod cream 5% applied 3 x weekly for 4 weeks or 3.75% cream applied od for 2 weeks repeated after 2 weeks. 
• Actikerall (0.5% 5FU/10% salicylic acid solution) apply once daily for 6-12 weeks, useful for hyperkeratotic AKs 
• Tirbanibulin (Klysiri) applied once daily for 5 consecutive days. 
• Counsel patient regarding side effects of chosen treatment 
• Cryotherapy for isolated hypertrophic lesions. 
• Curettage or shave excision with histology sent for confirmation of diagnosis and to rule out early SCC. 
• Surgical excision for individual keratoses that are symptomatic or have a thick hard surface scale. 
• Photodynamic therapy [PDT] (refer to secondary care service) test

Severe: Any of the following high-risk factors: Thick AK with indurated base, growing rapidly, tender bleeding, ulcerating  

• Advise all patients on use of sun protection and emollients. 
• Rapid growth, an indurated base, ulceration (in the absence of topical therapy) could suggest SCC rather than AK. Topical treatment should only be commenced with specialist advice. 

Mild: flat, pink patch with slight scale or rough to touch  

Manage in primary care. Seek advice and guidance where there is diagnostic uncertainty.  

Many actinic keratosis can become tender/ulcerated during topical treatment but this should improve with topical steroid or cessation of treatment. Consider SCC if it does not. 

Suspect SCC if a lesion develops a thickened painful base or ulcerates. 

Moderate: larger numbers of moderately thick keratotic red patches that are easily felt and seen 

Seek advice and guidance if there is diagnostic uncertainty.  

Refer to secondary care if there is failure of response to one cycle of treatment (requires biopsy) or if multiple / relapsing AKs represent a management challenge. 

Many actinic keratoses can become tender/ulcerated during topical treatment but this should improve with topical steroid or cessation of treatment. Consider SCC if it does not. 

Suspect SCC if a lesion develops a thickened painful base or ulcerates. 

Severe: Any of the following high-risk factors: Thick AK with indurated base, growing rapidly, tender bleeding, ulcerating  

Tender, thickened, ulcerated or enlarging actinic keratoses, may be suspected SCC and should be referred on the USOC pathway. 

High risk patient factors: past history of skin cancer, extensive UV damage, immunosuppressed, very young, more than 10 AKs, high-risk site i.e. ear or lip. Advise a lower threshold for referral in this group. 

BNF -fluorouracil-with-salicylic-acid:  

BNF – fluorouracil:  

BNF – Imiquimod cream:     

BNF Solaraze:  

BAD Actinic keratosis guidelines 2017: 

PCDS Actinic keratosis guidelines:  

DermnetNZ- Actinic Keratosis: 

• Options for treatment of AKs in primary care are Efudix, Actikerall, Imiquimod and Solaraze. All treatments cause an inflammatory reaction; the efficacy is largely in proportion to the reaction. The reaction for Solaraze is less.  
• If there is significant inflammation, you can reduce treatment e.g. to once daily, or pause treatment and consider a topical steroid e.g. Eumovate. 
• Treatment for thicker lesions includes cryotherapy, curettage & cautery, surgical excision and PDT.  
• Refer routinely for AKs if failure to respond to standard treatments.  
• Refer urgently via USOC pathway for all tender, thickened, enlarging, bleeding or ulcerated AKs, particularly in high-risk sites. Studies suggest treatment of field change in high-risk patients may lessen risk of SCC. 
• If high risk patient (past history of skin cancer, extensive UV damage, immunosuppressed, very young) consider referral to secondary care. 
• Once a person develops actinic keratoses they have commenced a chronic disposition to UV-pathology and should consider sun protection and self-examination for potential skin cancers. Those with multiple AK and skin cancers may be candidates for nicotinamide prophylaxis. 

1. BAD information leaflet Actinic Keratoses:   
2. Patient.co.uk Information leaflet:  
3. BAD Patient information leaflet - 5-Fluorouracil cream:   
4. BAD patient information leaflet – Imiquimod:  
5. NHS Patient Information- Actinic Keratoses:  

Benign 

ICD11 code - EK90