Actinic Keratosis & Photodamage
Before & After
Actinic keratoses (AKs) arise in areas of sun damage and typically coincide with other signs of sun damage such as uneven pigmentation, wrinkles, and loss of skin elasticity. They are red flaky and scaly spots that may be slightly painful to the touch. While AKs are not skin cancer, they are considered to be precancerous, which means that If they are left untreated, a significant proportion may develop into skin cancer called squamous cell carcinoma. Research has shown that people with AKs have an increased risk of developing other types of skin cancer, including basal cell carcinoma and melanoma.
Guidelines published in 2015 for Canadian doctors recommend that all actinic keratoses be treated, since it is impossible to predict which ones will develop into skin cancer.
If you have several actinic keratoses (AKs) or if your skin is showing irregular or uneven patches of pigmentation it is a sign of skin damage and that puts you at a higher risk for developing skin cancer. Identifying and treating damaged skin helps you reduce that risk. It is important to remember that for every one AK or visible area of uneven pigmentation that we see, there are many more that are hiding under the surface, invisible to the naked eye. Studies have shown that for every single AK that we see, there can be anywhere between 10-1000 that we do not see. The spots serve as an early warning system, a sort of “Canary in the Coal Mine”
While there are numerous treatment options available, the optimal treatment depends on how many lesions you have, where they are, your age and overall health.
Generally if there are 5 or more Actinic Keratosis on the whole face or 3 or more in a small region (ie temple, forehead or nose) it is time to consider treating the whole field much like you would treat the whole grass rather than plucking individual weeds out.
Localized treatments (individual lesions)
- Liquid Nitrogen, Trichloroacetic Acid
- Surgical Procedures (shave, cryosurgery, excision, curettage)
Whole Field Treatments
- Laser procedures (CO2, Erbium Yag and Fraxel)
- Topical treatments (Efudex, Zyclara, Picato)
- Photodynamic therapy (PDT)
- Combination therapy
Generally, combination / pairing of therapies tends to have the greatest efficacy when compared to any one treatment. However, if caught early we may start with one treatment.
Most Frequent Combinations include:
- Laser Treatment (CO2 or Erbium YAG, Fraxel) and PDT
- Efudex shortened course and PDT
- Efudex and Dovonex
In addition to treating the damaged cells, a new and growing body of research is showing that it may also be important to regenerate the skin cells and to restore their ability to protect themselves from UV damage. In fact, recent findings have identified new concepts to treat precancerous actinic damage by
preventing the development of skin cancer. Under normal settings (assuming no genetic abnormalities), young and functional skin cells have self-protective mechanisms that repair the damage from UV / sun exposure, thereby preventing or delaying the formation of skin cancer. However, after a certain amount of exposure to UV light, this repair mechanism itself gets damaged and damaged skin cells are able to continue proliferating. Compared to sun protected skin, sun damaged skin has a higher incidence of senescence (sleeping cells) and a decreased production of a protective factor known as Insulin Growth Factor 1 (IGF-1). Fortunately, there is a way to reverse this damage.
- Carbon Dioxide (CO2) Laser
- Erbium Yag Laser
- Dermabrasion (not micro-dermabrasion)
- Micro-needling (does not fix pigmentation and doesn’t destroy Actinic Keratosis)
Numerous studies have shown that combination treatment is the best treatment. This may be done right away or over time if one type of treatment fails to generate the desired results. In addition, one must consider that certain treatments eliminate the damage already present, while other treatments may increase your skin’s ability to repair itself. Ultimately a combination of both mechanisms will lead to optimal outcomes. New options in field-directed therapy with superior efficacy, cosmesis, and convenience with much less downtime, and redness may appeal to patients, but these may not be covered by OHIP or private insurance plans. Ablative and non-ablative lasers may fulfill these advantages and have been investigated as monotherapies as well as combination therapies for treating extensive AKs.
Some of these combination therapies can increase photosensitivity (make it easier for you to burn in the sun). Be sure to be especially careful about protecting your skin from sun / UV rays during and after treatment as directed.
Skin care after-treatment including the addition of topical Vitamin C serum, Retinol and Sunscreen with an SPF >30 are recommended for optimal skin health. Please note that most over the counter Vitamin C serums have been shown to be ineffective – it is important to select ones that are properly formulated and have proven evidence of efficacy. Taken properly, these treatments reduce the risk of AKs, skin cancers, and visible signs of aging. They can also reduce the need for more extensive therapy.
After treatment, it is important to inspect your skin regularly and visit your dermatologist or family doctor (based on your severity) at recommended intervals to screen for AKs and monitor for skin cancers. It is important to know that no treatment is curative, and treatments may need to be repeated based on what is determined at your physical exam. Everyone is different and repeat treatments can vary from anywhere from 3 months to 2 years, however, the average is yearly treatment.
- Fractionated laser resurfacing corrects the inappropriate UVB response in geriatric skin. DF Spandau, DA Lewis, et al. – Journal of investigative Dermatology 2012
- Fibroblast Senescence and Squamous Cell Carcinoma: How Wounding Therapies Could Be Protective. Travers JB et al. Dermatol Surg. 2013 Jul; 39(7):967-73. Epub 2013 Feb 25
- Senescent fibroblasts drive ageing pigmentation: A potential therapeutic target for senile lentigo JE Yoon et al. Theranostics, 2018
- How wounding via lasers has potential photocarcinogenic preventative effects via dermal remodeling A Krbanjevic, et al – Current dermatology reports, 2016 – Springer
- Unravelling the insulin-like growth factor I-mediated photoprotection of the skin MJ Andrade, DR Van Lonkhuyzen, Z Upton… – Cytokine & Growth …, 2020 – Elsevier
- Protective effect of pre-and post-vitamin C treatments on UVB-irradiation-induced skin damage S Kawashima et al- Scientific reports, 2018 – nature.com
- Energy-Based Devices for Actinic Keratosis Field Therapy. Goldberg G, Cutis. 2018 May;101(5):355-360https://www.mdedge.com/dermatology/article/164878/actinic-keratosis/energy-based-devices-actinic-keratosis-field-therapy