Differential Diagnosis

12 ■ Basal cell carcinoma: nodule with telangiectatic surface or ulcerated lesion with a pearly translucent border

■ Discoid lupus erythematosus: discoid patches with adherent thick scales and follicular plugging, atrophic scarring

■ Keratoacantoma: bud-shaped or dome-shaped nodule with a central horn-filled crater, skin colored or slightly reddish, rapid growth and possible spontaneous involution

■ Seborrhoeic keratosis: uneven, verrucous surface, soft and friable consistency; present also on non-sun-exposed areas

■ Solar lentigo: circumscribed pigmented macule, no surface scaling

■ Verrucous naevi: present at birth or developed during childhood

■ Warty diskeratoma: elevated papule with a keratotic umbilicated center, occasionally found on non-sun-exposed skin

Treatment of AK is motivated by its potential for progression to invasive squamous cell carcinoma and its cosmetic liability and/or discomfort.

■ Cryotherapy with liquid nitrogen:

no anesthesia is necessary; there is mild to moderate discomfort; multiple sessions may be necessary; and scarring may occur (Fig. 12.5a, b) [1].

■ Electrosurgery: electrodesiccation, electrocoagulation; local anesthesia is necessary; there is frequent scarring and moderate discomfort

■ Dermabrasion: local anesthesia is necessary; frequent scarring and moderate discomfort occur

■ CO2 laser Erbium:YAG laser: no anesthesia is necessary [2]

■ Chemotherapy with topical 5%

5-fluorouracil cream applied once or twice a day for 3-6 weeks: patients complain about great discomfort [3]

■ Topical diclofenac gel applied once a day for at least 6 weeks: patients complain about discomfort [4]

■ Topical tretinoin: only partially effective even after 1 year of daily application [5]

■ Imiquimod 5% cream: an effective treatment for AK used three times per week for 16 weeks (Fig. 12.6) [6]

■ Superficial medium chemical peel: 25-30% trichloracetic acid (Fig. 12.7a, b)

■ Medium depth chemical peels: 35% trichloracetic acid, 50-70% pyruvic acid [7]

■ Photodynamic therapy with 20%

6-aminolevulinic acid (ALA) or methyl aminolevulinate: expensive; has the best cosmetic results with no risk of scarring; early lesions not yet clinically perceptible are also treated [8,9]

■ Surgery: an option only when the AK is a firm horny papule with the possibility of invading the deeper layers

Fig. 12.5a, b. Actinic keratosis treated with cryotherapy and 25% TCA peeling

Actinic keratosis treated with imiquimod 5% cream. Clinical presentation after 15 days of treatment: vesicles on an erythematous base

Actinic keratosis treated with imiquimod 5% cream. Clinical presentation after 15 days of treatment: vesicles on an erythematous base

Imiquimod CreamTca Chemical Peel
Fig. 12.7a, b. Actinic keratosis of the hands before and after six peelings with 25% TCA

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