Dr Kash Bhatti highlights recent updates to the PCDS pathway on actinic keratosis and considerations when assessing and managing this common condition

Dr Kash Bhatti

Read the related Guidelines summary

COVID-19 considerations

With the constantly developing knowledge around COVID-19, it is difficult to find definitive evidence or guidance for treating AK in the current (April 2020) situation. High-risk lesions should be managed as they would be normally. Depending on locality, facilities may exist for teledermatology or advice and guidance, or it may be necessary to fall back on 2-week-wait clinics; bear in mind that many of these patients may be the very same ones that should be shielded from the virus.

For low-risk disease, my personal view is to suggest managing with sun protection (for those out in their gardens) and moisturisers until conditions improve. Guidance for or against the use of active topicals during the pandemic is not available yet; low-risk disease does not immediately need to be treated and can be deferred.

Of course, one should have a discussion with the patient and come to an agreed shared decision; it is unlikely, theoretically, that any risk is present, but the absence of evidence should be considered.

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Read and reflect on the PCDS pathway for the management of actinic keratoses
  • Review local care pathways against the PCDS pathway and update and adapt them as required
  • Ensure that during the COVID-19 pandemic there are local tele dermatology services to help primary care clinicians with diagnosis and to provide them with support
  • Publish locally agreed choices for topical chemotherapies in local formularies
  • Identify in referral guidelines lesions that should be referred under the 2-week-wait rules (suspected SCC) and those for more routine referral

STP=sustainability and transformation partnership; ICS=integrated care system; PCDS=Primary Care Dermatology Society; SCC=squamous cell carcinoma

References

  1. Conforti C, Beninati E, Dianzani C. Are actinic keratoses really squamous cell cancer? How do we know if they would become malignant? Clin Dermatol 2018; 36 (3): 430–432.
  2. Berker D, McGregor J, Mohd Mustapa M et al. British Association of Dermatologists’ guidelines for the care of patients with actinic keratosis 2017. Br J Dermatol 2017; 176 (1): 20–43.
  3. Gupta G, Madan V, Lear J. Squamous cell carcinoma and its precursors. In: Griffiths C, Barker J, Bleiker T et al, editors. Rook’s Textbook of Dermatology. 9th ed. Chichester: Wiley, 2016: 1–11.
  4. European Medicines Agency. EMA suspends Picato as a precaution while review of skin cancer risk continues. Press release. European Medicines Agency, 17 January 2020. Available at: www.ema.europa.eu/en/news/ema-suspends-picato-precaution-while-review-skin-cancer-risk-continues (accessed 27 April 2020).
  5. Cunliffe T, Peace J. Actinic (solar) keratosis primary care treatment pathway. Primary Care Dermatology Society, 2020. Available at: www.pcds.org.uk/ee/images/uploads/general/AK_guidelines_2020-new-web-v01.pdf
  6. Wheller L, Soyer H. Clinical features of actinic keratoses and early squamous cell carcinoma. In: Soyer H, Prow T, Jemec G, editors. Actinic keratosis. Current Problems in Dermatology vol. 46. Basel: Karger, 2015: 58–63.
  7. Zalaudek I, Piana S, Moscarella E et al. Morphologic grading and treatment of facial actinic keratosis. Clin Dermatol 2014; 32 (1): 80–87.
  8. Siegel J, Korgavkar K, Weinstock M. Current perspective on actinic keratosis: a review. Br J Dermatol 2017; 177 (2): 350–358.
  9. Fernandez Figueras M. From actinic keratosis to squamous cell carcinoma: pathophysiology revisited. J Eur Acad Dermatol Venereol 2017; 31 (S2): 5–7.
  10. Rigel D, Stein Gold L. The importance of early diagnosis and treatment of actinic keratosis. J Am Acad Dermatol 2013; 68 (1 Suppl 1): S20–S27.
  11. Ruiz E, Schmults C. Risk stratification: should all actinic keratoses in all patients be treated? Curr Derm Rep 2018; 7: 99–104.
  12. Primary Care Dermatology Society. Actinic keratosis (syn. solar keratosis). www.pcds.org.uk/clinical-guidance/actinic-keratosis-syn.-solar-keratosis (accessed 29 April 2020).