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Actinic (Solar) Keratoses – Information for GPs

Background

From April 2013, NHS England took over responsibility for commissioning activity in primary care, where initial conservative treatment takes place.

NHS Scarborough and Ryedale CCG is responsible for commissioning activity in secondary care, and this policy sets out the referral criteria for the referral to secondary care for the management of Actinic (Solar) Keratoses.

Definition

  • Scaly, flat pink, red or brownish lesions, on any sun exposed skin from mid-life onwards
  • Typical areas affected are scalp in balding patients, upper pinna, temples, bridge of nose, anterior upper chest
  • Images – click here
  • Often multiple, with a dry adherent scale. They occasionally itch
  • Hyperkeratotic scale can form a cutaneous horn
  • The vast majority of actinic keratosis do not progress to squamous cell carcinoma (SCC). Evidence suggests that the annual incidence of transformation to SCC is less than 2%. This risk is higher in immuno-compromised patients
  • The majority of patients can be managed in primary care

Exclude red flag symptoms

  • Tender and/or indurated lesions are more likely to be SCCs or other significant pathology
  • Also if bleed spontaneously. Refer if querying SCC or concerns about malignant change

Management

  • See the Primary Care Treatment pathway attached to the PDF at the end of this page.
  • Fluorouracil (Efudix®) is the most cost effective treatment. Its application and use needs care and there are a number of leaflets within the treatment pathway that help to explain this to patients. Apply every night for up to 4 weeks. Wash hands thoroughly after application. Leave treated areas uncovered and wash the following morning. Patients should be advised to expect a degree of redness and discomfort during the treatment period which can occasionally be severe. If this occurs the treatment can be stopped early and inflammation would generally settle over a 6 week period at which stage the skin should be reviewed
  • AKs can regress spontaneously especially if sun exposure is reduced
  • Do a full body examination for other sun induced lesions
  • For all patients advise them to avoid sun exposure by wearing hats and clothing, use sunscreens (SPF 50+) applied from April to October and re-apply frequently on sunnier days or when outside for longer periods. Re-inforce this frequently.
  • If the patient follows this rigorously may need Vitamin D measurement or supplementation – see formulary for guidance
  • Isolated well defined lesions:
  • Consider not treating – many regress spontaneously - Cryotherapy – not on lower legs (thermal injury takes too long to heal); 10-20 second freeze, depending on thickness; can be useful for thicker or resistant lesions

Referral Criteria

  • Diagnostic doubt
  • Failure of 2 different treatments
  • Immuno-compromised patients

Information to include in referal letter:

  • Previous treatments tried and their effect
  • Photograph is desirable
  • Relevant past medical / surgical history
  • Current regular medication
  • BMI / Smoking status
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