Actinic keratoses (AKs), or solar keratoses, are common pre‑cancerous lesions resulting from cumulative ultraviolet (UV) exposure. Particularly among older adults, these scaly, often asymptomatic patches are frequent—but potentially serious—findings in primary care.
Why early treatment matters
- Risk of progression to squamous cell carcinoma (SCC): Although each individual AK carries a low annual risk of malignant transformation (typically < 1%), cohort data indicate that around 60% of SCCs arise from pre‑existing Aks. With multiple lesions—for example ≥10—patients face a significantly higher cumulative risk (estimated ~14% over five years) Primary Care Dermatology Society.
- Field cancerization: Sun‑damaged skin often harbours subclinical dysplasia across a field; targeting only visible AKs may miss latent lesions that can evolve. Early field‑directed treatment reduces total lesion burden and lowers future risk
- Prevention and cosmetically sensitive outcomes: Treating AKs early preserves skin integrity and patient quality of life, reducing symptoms such as stinging, bleeding, or crusting, and improving cosmetic appearance
Guidance for UK primary care
In the UK, actinic keratoses are routinely managed in primary care unless red‐flag features or diagnostic uncertainty suggest SCC. The Primary Care Dermatology Society (PCDS) and NHS local protocols empower general practitioners to assess, treat, and monitor AKs safely. Guidance highlights:
- Diagnose clinically (dermoscopy can support but is not essential).
- Use lesion‑specific treatments (e.g. cryotherapy for discrete AKs) or field‑directed therapies (e.g. topical 5‑fluorouracil, imiquimod, daylight photodynamic therapy) depending on lesion count, location, patient tolerance and preference.
- Counsel patients on sun protection, skin self‑examination, and danger signs: E = Elevated, F = Firm, G = Growth of lesions persisting >4 weeks particularly with pain, ulceration or bleeding.
- Offer structured follow‑up and safety‑netting, especially in older adults with multiple lesions or immunosuppression.
Primary care challenges and opportunities
Recent qualitative studies with GPs highlight variability in familiarity with field treatments like 5‑FU and photodynamic therapy; many still default to cryotherapy for a few lesions without exploring alternatives with patients. Uptake of guidelines improves with education and experiential support—both clinical and practical.
Action steps for clinicians
- Screen proactively: In older patients, particularly fair‑skinned, inquire about sun‑damage and look for early AKs even if asymptomatic.
- Educate patients on sun avoidance, SPF ≥30 sunscreen, protective clothing, and vitamin D supplementation if necessary to support adherence.
- Select appropriate treatment:
- Cryotherapy for isolated lesions;
- Topical therapies (5‑FU, imiquimod, diclofenac gel, photodynamic therapy) for multiple or field lesions.
Explain expected inflammatory responses, the importance of treatment adherence, and strategies to manage side effects.
- Safety‑net clearly: Advise patients to return if a lesion is growing, bleeding, firm or persistent. Refer urgent via 2WW pathway if features suggest possible SCC.
Why early intervention makes a difference
🌟 Cancer prevention impact: Reducing AK counts through early, consistent treatment lowers SCC risk across time and lesions.
🌟 Healthcare efficiency: Managing uncomplicated AKs within primary care conserves specialist resources and reduces referral delays.
🌟 Patient experience: Younger older-adult patients value aesthetic outcomes and early resolution of symptoms before progression or complications.
Want to improve your AK management skills?
Enrol in the “Dermatological Conditions in the Older Adult” course. This UK‑tailored programme equips primary care providers with up‑to‑date knowledge in diagnosing, treating, and preventing dermatological issues among older adults—including actinic keratosis. It offers practical case-based learning, best‑practice guidance on topical versus procedural treatment, safety‑netting strategies, and patient education tools. Early treatment matters—and this course can help make a difference.
👉 Learn more or book your place here: Dermatological Conditions in the Older Adult (PDUK Course 432)
With an informed, proactive approach in primary care, we can significantly reduce skin cancer risk, enhance patient care, and manage actinic keratoses effectively where it matters most—early.
References
Dirschka, T., Gupta, G., Micali, G., Stockfleth, E., Del Marmol, V., Basset‐Seguin, N., 2021. A European consensus-based interdisciplinary guideline for the treatment of actinic keratosis – update – short version. Journal of the European Academy of Dermatology and Venereology, 35(1), pp.42–50. [Online] Available at: https://doi.org/10.1111/jdv.19897 [Accessed 5 Aug. 2025].
Kassianos, A.P., Ntouva, A., Greenfield, S.M., Usher-Smith, J.A. and Walter, F.M., 2023. Managing actinic keratosis in primary care: a qualitative exploration of general practitioners’ experiences and perceptions. BMC Primary Care, 24(1), p.45. [Online] Available at: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-023-02202-6 [Accessed 5 Aug. 2025].
