Etiology

• Chronic, cumulative sun exposure leading to hyperkeratosis (thickening of keratin layer) and atypical keratinocytes within the basal layer (Figure 1)

Figure 1. Actinic keratosis.

• Many now consider it to be squamous cell carcinoma (SCC) in-situ (Ackerman 2006)

Epidemiology

• More common in the elderly, particularly those with fair complexion and a history of chronic sun exposure
• Affects 11–26% of the United States population (Iorio 2013)
• 4% of men > 40 years old, 34% of men > 70 years old
• 9% of women > 40 years old, 18.2% of women > 70 years old
• Risk of transformation to SCC is 0.1–0.24% per year
• Rate of conversion to invasive SCC is 5–20% over 10–25 years
• (Dréno 2014) more available?

History

• Chronic sun exposure
• Age
• History of previous skin cancer
• Immunosuppression
• Transplant patients
• HIV
• Pruritus and burning of affected area

Clinical features

• Flat or elevated, scaly, erythematous, keratotic plaque
• Rarely occurs as a single lesion; most commonly there are multiple lesions over a "field"
• Found on sun-exposed areas (face, dorsum of hands, head, neck, forearms)
• Can be pigmented (Figure 2)

Figure 2. Pigmented actinic keratosis.

• Can form a keratin horn
• Sandpapery texture on palpation
• Lesion will vary in size and texture over periods of time depending on the amount of keratinization, which can flake off and reaccumulate

Testing

• Typically actinic keratosis (AK) is a clinical diagnosis and biopsy is not necessary
• Biopsy can be considered in the following situations due to increased risk of a SCC (Dréno 2014)
• Skin is thickened
• > 1 cm
• Induration
• Inflammation
• Ulceration
• Bleeding
• Rapid growth
• Pain on palpation

(Iorio 2013)

• Cumulative ultraviolet radiation
• Sun exposure
• Lack of sunscreen use
• Common in the elderly population because sunscreen was not widely available until the 1950s and its importance not fully realized until more recently
• Proximity to the equator
• Tanning beds and sunbathing
• Fair complexion
• Most commonly Fitzpatrick Type I and II; however, often seen in Type III and even Type IV
• Advanced age
• History of previous SCC and other skin carcinomas
• Immunocompromised state
• Males > females

• SCC
• Bowen's disease
• Basal cell carcinoma
• Seborrheic keratosis
• Actinic lentigines (sun spots)
• Melanoctic lentigines
• Melanoma

Topical 5% fluorouracil

• Extreme photosensitivity expected and normal
• Severe erythema and crusting expected and normal
• Scarring and poor cosmetic outcome
• Careful patient selection and counsel prior to use
• Treatment can be temporarily discontinued if significant reaction occurs
• Mild ocular irritation

Imiquimod therapy

• Similar to 5-FU but not as severe
• Improved cosmetic outcome compared to 5-FU (Krawtchenko 2007)
• Ocular irritation and keratitis

Surgical excision

• Scarring or tissue loss can result in
• Eyelid malposition
• Trichiasis
• Mechanical impairment of lacrimal drainage
• Infection is rare.
• Complications can generally be prevented by careful surgical technique.

Cryosurgery

• Hypo-and hyperpigmentation
• Scarring can occur especially if the freeze is too deep.
• Since no excision occurs, free surgical margins cannot be checked.

Risks of all techniques

• Recurrence or progression to squamous cell carcinoma
• Incomplete removal
• One of the main drawbacks of nonsurgical treatments that can limit their use in the periocular setting
• There is significant dermatology literature documenting success of nonsurgical treatment, but reports of their periocular use are relatively limited.
• Although the risk of recurrence, SCC foci, and progression to SCC is relatively low, it is the opinion of the authors that lesions involving the eyelids often necessitate more aggressive management than similar lesions found on other areas of the face and body.
• Complete excision is more easily justified because of the risk of development of destructive SCC that could result in a large defect and difficult repair.
• This sentiment is seemingly reflected in the survey done by Lagler and Freitag showing a higher rate of excision of AK by ASOPRS members.
• By the same reasoning, it could also be beneficial to use nonsurgical methods on large lesions, potentially sparing the patient a large resection of an in-situ lesion and a complicated repair.

Risk of malignant transformation

(Werner 2013)

Rate of progression to SCC is variable, but approximate lifetime risk is 10%.

• Rate of progression is dependent upon several factors
• Presence of multiple vs single actinic keratosis (AK)
• History of other NMSC
• Without history of NMSC: 0.075% per year
• With at least two NMSC: 0.53% per year
• Immunocompetence
• 40% progression in immunosuppressed transplant patients

97% of SCC arise from AK.

Squamous cell carcinoma that develops from an AK is usually very indolent, but can be invasive.

• The management of AK has changed significantly, shifting from primarily surgical to nonsurgical.
• There are increasing numbers of studies using nonsurgical methods for eyelid lesions, and these techniques will likely continue to increase in the future.

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