Update: Actinic Keratoses | Guidelines aim to standardize, advance actinic keratoses treatments

Maui, Hawaii - Dermatologists and other medical specialists around the world who treat patients with actinic keratoses (AKs or solar keratoses) will soon be able to refer to new evidence-based (S3) guidelines for management.  

The idea to develop evidence-based global treatment guidelines for AKs originated over two years ago in a discussion between Eggert Stockfleth, M.D., Ph.D., and George Martin, M.D. The project was undertaken by the Guideline Subcommittee of the European Dermatology Forum in collaboration with the International League of Dermatological Societies, and is now nearing completion.

Dr. Stockfleth, professor of dermatology, Charité University Medical Center, Berlin, chaired the guideline subcommittee. He reviewed the motivation, goals, and methodology used for developing the guidelines at MauiDerm 2014.

“This is the first global guideline for the treatment of AKs, and the recommendations in the guidelines are based on evidence, not eminence,” Dr. Stockfleth says.

“By undertaking a systematic assessment of the efficacy and safety of available treatment options, the guidelines aim to ensure selection of appropriate treatment for specific clinical situations, thus improving quality of care and reducing the percentage of patients with AKs progressing to invasive squamous cell carcinoma (SCC),” he says.

Evidence-based assessment

The guidelines subcommittee was comprised of an international panel that included 15 dermatologists, three dermatopathologists, and one patient representative. An evidence-based assessment of the literature was undertaken. The literature review took advantage of the work recently completed by Gupta et al in their 2012 Cochrane Database Systematic Review of interventions for AKs, but also updated the latter research to identify subsequently published data.

The evidence was critically appraised for quality, the level of evidence for individual modalities was graded, and these assessments were taken into account in a consensus process for generating recommendations on the use of the various interventions for treatment of solitary lesions, multiple lesions (>5 AKs and field cancerization), and high risk AKs (e.g., immunosuppressed and/or high risk location).

Based on a variety of factors, the therapeutic recommendations are also given a strength weighting using the five-point GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: 1. strong recommendation for use (“we recommend”), 2. weak recommendation for use (“we suggest”), 3. no recommendation (“we cannot make a recommendation with respect to”), 4. weak recommendation against (“we suggest not to”), 5. strong recommendation against (“we recommend not to”).

The draft guidelines have already undergone internal review and have been sent out for consideration by external experts whose input will be used to craft the final document. To enable clinical decisions and optimize patient care, the guidelines will feature a flowchart of pathways for management of patients in specific clinical situations. The flowchart will depict the roles of specialists and general practitioners and treatments that may be offered by each category of providers. As highlighted in the flowchart, sun protection is recommended as part of the management for all patients.

Dr. Stockfleth explains that interest in developing global AK treatment guidelines derives from recognition that AK is the most common neoplastic skin lesion in the world and has the potential for progression to invasive SCC.

“AKs are part of a biologic continuum that begins with photodamaged skin followed by progression to subclinical AKs, clinical AKs, and SCC. Not all AKs will develop into invasive cancer, but we know they represent an early stage and that patients who present with multiple AKs in an area of field cancerization are at increased risk for developing all ultraviolet light-related skin tumors,” Dr. Stockfleth says.

Understanding AKs

Despite this knowledge, conceptions of AK vary internationally and are the basis for different perceptions about the importance of treatment.

“Development of international guidelines for the treatment of AK may further advance and standardize the perception of AKs,” Dr. Stockfleth says.

In addition, there have been growing concerns about the adverse events and cosmetic outcomes associated with various treatments for AKs.

“An increase in the amount of available evidence pertaining to the different treatment options enabled a comparison of efficacy and safety,” he says.

Considering the existence of varying conceptions about AKs, one of the goals of the AK management guidelines was to establish a more widely accepted definition for the lesion. In addition, it is hoped that the document will raise awareness among other physicians who see patients with AKs about the necessity of treatment. Dr. Stockfleth says that in some countries where there is a relatively small dermatology workforce, management of patients with AKs more likely falls under the purview of general practitioners.

“In Germany, for example, there are 4,000 dermatologists available to serve a population of 80 million people, whereas there are 62 million people living in England and only about 350 dermatologists. In England, there is a need for general practitioners who have a special interest in dermatology,” he says.

“We need to educate the general practitioners, and the guidelines can be a tool to make appropriate AK treatment further known to the medical community.”

The final guidelines on management of AK will be available online at www.euroderm.org.