Actinic Keratoses and Bowen’s Disease

Presentation

Actinic (Solar) Keratoses

Actinic keratoses (AK) occur on sites of chronic sun exposure, the dorsum of the hands, face and scalp, especially in the fair-skinned. May present as:

 

Telangiectasia

 

Multiple irregular areas of adherent keratin

 

Cutaneous horn

 

Fine hyperkeratosis with erythema and telangectasia

 Actinic keratosis can often occur on the scalp of fair skinned patients

some Actinic keratosis can be very hyperkeratotic

 

Bowens disease (SCC in-situ)

Persistent, scaly non-thickened macules or patches, often asymptomatic, Variable size up to several centimetres. Common on lower legs in women.

May be multiple.

Management

Actinic  Keratoses

General: Sun protection advice/emollient

 

Specific management options

 

Single or few scattered AK

Cryotherapy

Diclofenac gel 3%  (Solaraze)

5-fluorouracil (Efudix)

5-fluorouracil/salicylic acid (Actikerall)

5% imiquimod (Aldara)

 

 

Multiple (Field) AK

Diclofenac gel 3%  (Solaraze)

5-fluorouracil (Efudix)

5% imiquimod (Aldara)

PDT

 

See BNF for dosing

 

Refer to http://www.pcds.org.uk/ for treatment algorithm

Bowens disease

  • Topical 5-fluorouracil cream (Efudix)
  • Superficial skin surgery – curettage/electrosurgery
  • Cryotherapy – may be suitable for small lesions
Referral

Criteria for Dermatology Referral

 Actinic Keratoses

  • If suspect SCC refer urgently
  • Diagnostic doubt
  • Painful rapidly growing lesion
  • Immunosuppressed patients
  • Lack of response to treatment

Bowen’s Disease

  • If suspect SCC refer urgently
  • Diagnostic doubt
  • Treatment failures
  • Extensive disease
  • Immunosuppressed patients
  • Referral for consideration of Photodynamic therapy
Diagnostic Tips

Actinic Keratoses/Bowens

  • Solitary cutaneous horns should be removed for histopathology
  • Actinic keratoses are pre-malignant but transformation to in-situ or invasive squamous cell carcinoma (SCC) is rare. Specific treatment is not essential, particularly in mild disease.
  • Suspect SCC if a lesion develops a thickened painful base or ulcerates

If suspicious follow pathway for  squamous cell carcinoma

Patient Information