THE SURGERY CENTERPLANO DERMATOLOGY

Actinic Keratosis

Actinic keratoses are rough, scaly patches caused by years of sun — precancerous lesions, not yet cancer. Not every AK progresses, but some become squamous cell carcinoma, which is why persistent lesions deserve treatment.

You may also see them called solar keratoses — the same condition under an older name. They turn up where a lifetime of sun has landed: the face, ears, scalp, neck, forearms, and the backs of the hands. You can often feel one before you can see it, as a patch of sandpaper that never quite goes away. They are among the most common conditions dermatologists diagnose and treat.

How often does one become cancer? For any single spot, the risk is low. In a study that tracked 7,784 AKs on the face and ears of 169 high-risk veterans, about 0.6 percent had progressed to squamous cell carcinoma at one year and about 2.6 percent at four years, and more than half of the spots being followed were no longer present a year later. But in that same study, roughly two-thirds of the squamous cell carcinomas that did develop arose where an AK had been diagnosed. AKs matter for two reasons: some of them progress, and all of them mark skin that has had enough sun to form skin cancer.

Treatment options for actinic keratosis fall into two groups, and the American Academy of Dermatology's guidelines support both. Spot treatment deals with AKs one at a time — most often by freezing with liquid nitrogen (cryosurgery), sometimes by scraping (curettage) when a lesion is very thick. Field treatment covers a whole sun-damaged area, the spots you can see and the damage you cannot yet: prescription creams such as 5-fluorouracil, imiquimod, or tirbanibulin, and photodynamic therapy. Laser treatment and medical-grade chemical peels are also used. Which approach fits depends on how many spots there are, where they are, what they look like, and how much of a skin reaction you are willing to go through — a decision made between you and your dermatologist.

Small, early lesions are often handled with cryotherapy in the office. Thicker or stubborn lesions may warrant removal, and high-risk lesions in sensitive locations can be treated with margin control.

A spot that turns thick, firm at its base, or tender, that grows quickly, bleeds, or opens into a sore deserves a closer look — those are the changes associated with an AK becoming squamous cell carcinoma, and a biopsy is how the question gets answered. If the answer is skin cancer, removing it with the margins checked is what this practice does every day.

A selection of the literature appears below ↓

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Stained tissue section as abstract art

When to come in

  • Rough, scaly patches on sun-exposed skin that keep coming back
  • A lesion that itches, bleeds, or has not resolved with creams
  • A history of skin cancer with new sun-damage spots
  • A spot that has become thick, firm, or tender, or is growing quickly
  • Many AKs across one area — the scalp, face, forearms, or backs of the hands
  • An AK your dermatologist wants biopsied or removed

How we treat it

Cryotherapy

Freezing of small, early lesions in the office.

Excision or Mohs for high-risk lesions

Thicker, persistent, or sensitively-located lesions may warrant surgical removal.

Field resurfacing

For skin with many AKs across a whole area, Dr. Modi performs fractional CO2 laser resurfacing and Jessner's + TCA chemical peels — described on our skin resurfacing page.

Your surgeon will walk you through what to expect — including preparation and aftercare — before anything is scheduled.

See also: How Mohs surgery works · Skin resurfacing for sun-damaged skin · Squamous cell carcinoma

Figure

Field treatments for actinic keratosis, compared head to head

A randomized trial of 624 patients, each with five or more AKs on the head. The bars show the share of patients whose treatment was still holding twelve months later, meaning at least 75% fewer AKs than when they started.

Tirbanibulin ointment 1% ointment, five-day course

Not tested in this trial

The trial’s fourth treatment, ingenol mebutate gel, is no longer on the market. The newest option, tirbanibulin, has so far been compared only with a placebo ointment, and measured a different way: in two trials of 702 patients, 44% and 54% were completely clear about two months after treatment, and among those patients AKs had returned in an estimated 47% within a year. Its numbers cannot be set on the scale above.

Data: Jansen MHE, et al. Randomized trial of four treatment approaches for actinic keratosis. New England Journal of Medicine. 2019;380:935–946. The trial was run at four Dutch hospitals and treated AKs on the head; ingenol mebutate gel, its fourth arm, scored 28.9%. Tirbanibulin data: Blauvelt A, et al. New England Journal of Medicine. 2021;384:512–520, whose authors note that trials against conventional treatments are still needed. This figure is our own drawing of the published numbers.

See the numbers as a table
Treatment success at twelve months in the Jansen 2019 trial
TreatmentPatientsSuccess at 12 months (95% CI)
5-Fluorouracil cream, 5% cream15574.7% (66.8 to 81.0)
Imiquimod cream, 5% cream15653.9% (45.4 to 61.6)
Photodynamic therapy, light treatment with methyl aminolevulinate15637.7% (30.0 to 45.3)
Ingenol mebutate 0.015% gel (no longer marketed)15728.9% (21.8 to 36.3)
Tirbanibulin 1% ointment (separate placebo-controlled trials, Blauvelt 2021)702 across two trialsNot measured on this scale: 44% and 54% completely clear at about two months; estimated 47% recurrence within a year

Spot treatment vs. field treatment for actinic keratosis

CompareSpot (lesion-directed) treatmentField-directed treatment
What it treatsIndividual AKs that can be seen and felt.A whole sun-damaged area — the visible AKs plus the surrounding damage that has not surfaced yet.
ExamplesFreezing with liquid nitrogen (cryosurgery); scraping (curettage) for a very thick lesion.Prescription creams or gels — 5-fluorouracil, imiquimod, tirbanibulin, diclofenac — photodynamic therapy, and medical-grade chemical peels.
Best suited toOne or a few isolated AKs.Many AKs in one area, AKs that can be felt but not seen, or spots that keep returning across the same skin.
What to expectDone in a single office visit. Stinging during the freeze, then crusting or a blister while it heals; the treated spot can heal lighter than the skin around it. Some AKs need more than one freeze.Creams are applied at home for anywhere from five days to a few months, depending on the medication, and the treated skin is expected to become red, irritated, and crusted before it heals. Photodynamic therapy and peels are done in the office.
What the evidence saysStrongly recommended in the AAD guidelines. In one prospective study, a single freeze cleared about two-thirds of treated AKs — more with longer freeze times.5-fluorouracil, imiquimod, and tirbanibulin are strongly recommended in the AAD guidelines; photodynamic therapy and diclofenac conditionally. In a randomized trial of four field treatments for AKs on the head, 5-fluorouracil cream was the most effective at twelve months.

Neither approach is better across the board, and the two are sometimes combined. This table describes treatment categories in general, drawn from the American Academy of Dermatology guidelines and the studies listed below — it is not a menu of what any one office offers. Your dermatologist will help you choose what fits your skin.

Common questions

Answers reflect the typical course — your surgeon will go over the specifics of your own plan.

It usually deserves treatment, but "removed" rarely means surgery. Some AKs fade on their own and some progress to squamous cell carcinoma, and research cannot yet say reliably how often, or which ones — which is why guidelines recommend treating them. Most are treated by freezing or with a prescription cream, not by cutting. The same guidelines recognize that watching is a reasonable choice in some situations, such as when treatment would be harder on the patient than the spots themselves. That is a decision to make with your dermatologist.

There is no single best treatment. The American Academy of Dermatology's guidelines strongly recommend sun protection, cryosurgery (freezing), and the creams 5-fluorouracil, imiquimod, and tirbanibulin, and conditionally recommend photodynamic therapy and diclofenac gel. In a randomized trial of 624 patients with multiple AKs on the head, 5-fluorouracil cream had the highest rate of treatment success at twelve months (success meaning at least a 75 percent reduction in AKs) — about 75 percent, compared with 54 percent for imiquimod, 38 percent for photodynamic therapy, and 29 percent for ingenol mebutate, a gel since discontinued in the United States. With 5-fluorouracil, local skin irritation is the main drawback and the most common reason people stop early. For one or a few spots, freezing in the office is quick and effective.

One or a few spots are usually frozen in the office. When there are many, dermatologists often turn to field treatment — a prescription cream or photodynamic therapy — so the whole area is treated at once; tirbanibulin ointment, a five-day course, is FDA-approved specifically for the face and scalp. Because freezing can leave a spot lighter than the skin around it, the cosmetic trade-offs are worth discussing for facial lesions. For widespread sun damage, Dr. Modi also performs field resurfacing with fractional CO2 laser and chemical peels.

With the same tools, but expect it to take more persistence. AKs on the hands and forearms are generally considered harder to treat than those on the face and scalp. In a U.S. phase 3 trial of photodynamic therapy for AKs on the arms and hands, treatment was repeated at eight weeks when lesions remained, and about a third of treated patients were completely clear at twelve weeks. Freezing, prescription creams, and photodynamic therapy are all used. A thick spot that does not respond may be biopsied or removed to make sure it is not an early squamous cell carcinoma.

Yes. Solar keratosis and actinic keratosis are two names for the same precancerous, sun-caused lesion — the American Academy of Dermatology lists both. "Actinic" and "solar" each point to the same cause, ultraviolet light, and treatment is the same whichever name is on your paperwork.

The only way to know for certain is a biopsy. The changes that published reviews associate with progression are a spot that becomes thick or firm at its base, grows quickly or past about a centimeter, bleeds, turns red and inflamed, or opens into a sore; tenderness is another. Any of those is a reason to be seen soon. If a biopsy shows squamous cell carcinoma, treatment depends on the tumor and where it is, and for high-risk or cosmetically sensitive locations Mohs surgery is the treatment of choice.

New ones are likely, because the sun damage that produced the first AKs is spread across the surrounding skin. That is why regular skin checks with your dermatologist matter — some people need one once or twice a year, and your dermatologist will tell you how often. Sun protection makes a measurable difference: in a randomized trial of 588 adults in Australia, those who applied sunscreen daily for one summer developed fewer new AKs, and saw more of their existing ones clear, than those given a cream without sunscreen.

Rarely — most AKs never need it. A thick or stubborn spot may be removed so that the whole lesion can be examined under the microscope. If that examination, or a biopsy, shows that the spot is already squamous cell carcinoma, the plan changes from treating a precancer to treating a cancer, and that is where margin-controlled surgery comes in.

Guidelines and studies behind this page

For colleagues — and patients who want the data behind the approach.

  1. Eisen DB, et al. Guidelines of care for the management of actinic keratosis. Journal of the American Academy of Dermatology. 2021;85(4):e209-e233.
  2. Eisen DB, et al. Guidelines of care for the management of actinic keratosis: Executive summary. Journal of the American Academy of Dermatology. 2021;85(4):945-955.
  3. Eisen DB, et al. Focused update: Guidelines of care for the management of actinic keratosis (tirbanibulin). Journal of the American Academy of Dermatology. 2022;87(2):373-374.e5.
  4. Blauvelt A, et al. Phase 3 trials of tirbanibulin ointment for actinic keratosis. New England Journal of Medicine. 2021;384(6):512-520.
  5. Criscione VD, et al. Actinic keratoses: natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial. Cancer. 2009;115(11):2523-2530.
  6. Werner RN, et al. The natural history of actinic keratosis: a systematic review. British Journal of Dermatology. 2013;169(3):502-518.
  7. Quaedvlieg PJF, et al. Actinic keratosis: how to differentiate the good from the bad ones? European Journal of Dermatology. 2006;16(4):335-339.
  8. Jansen MHE, et al. Randomized trial of four treatment approaches for actinic keratosis. New England Journal of Medicine. 2019;380(10):935-946.
  9. Thai KE, et al. A prospective study of the use of cryosurgery for the treatment of actinic keratoses. International Journal of Dermatology. 2004;43(9):687-692.
  10. Thompson SC, Jolley D, Marks R. Reduction of solar keratoses by regular sunscreen use. New England Journal of Medicine. 1993;329(16):1147-1151.
  11. Jiang SIB, et al. A randomized, vehicle-controlled phase 3 study of aminolevulinic acid photodynamic therapy for the treatment of actinic keratoses on the upper extremities. Dermatologic Surgery. 2019;45(7):890-897.
  12. Reinhold U, et al. Low-dose 5-fluorouracil in combination with salicylic acid for the treatment of actinic keratoses on the hands and/or forearms. Journal of the European Academy of Dermatology and Venereology. 2017;31(3):455-462.
  13. American Academy of Dermatology. Actinic keratosis: Overview (patient information).
  14. American Academy of Dermatology. Actinic keratosis: Diagnosis and treatment (patient information).
  15. American Academy of Dermatology. Actinic keratosis: Signs and symptoms (patient information).

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