Clinical Recognition of Actinic Keratoses in a High-Risk Population

Recalcitrant Cutaneous Warts in a Family with Inherited ICOS Deficiency

Recalcitrant warts, caused by human papillomaviruses (HPVs), can be a cutaneous manifestation of inborn error of immunity. This study investigated the clinical manifestations, immunodeficiency, single-gene susceptibility, and HPV repertoire in a consanguineous family with severe sinopulmonary infections and recalcitrant warts. Clinical and immunologic evaluations, including FACS and lymphocyte transformation test, provided evidence for immunodeficiency. Combined whole-exome sequencing and genome-wide homozygosity mapping were utilized to disclose candidate sequence variants. Whole-transcriptome sequencing was used to concomitantly investigate the HPV genotypes and the consequences of detected sequence variants in the host. The proband, a male aged 41 years, was found to be homozygous for the c.6delG, p.Lys2Asnfs∗17 variant in ICOS, encoding the inducible T-cell costimulator. This variant was located inside the 5 megabase of runs of homozygosity on 2q33.2. RNA sequencing confirmed the deleteriousness of the ICOS variant in three skin biopsies revealing significant downregulation of ICOS and its ligand, ICOSLG. Reads unaligned to the human genome were applied to 926 different viruses, and α-HPV57, β-HPV107, β-HPV14, and β-HPV17 were detected. Collectively, we describe a previously unrecognized inborn error of T-cell immunity to HPVs, indicating that autosomal recessive ICOS deficiency can underlie recalcitrant warts, emphasizing the immunologic underpinnings of recalcitrant warts at the nexus of human and viral genomic variation.

Combined versus conventional photodynamic therapy with 5-aminolaevulinic acid nanoemulsion (BF-200 ALA) for actinic keratosis: A randomized, single-blind, prospective study

BACKGROUND

Photodynamic therapy (PDT) has become one of the most effective therapies for the treatment of actinic keratosis, allowing the removal of more than one lesion in a single session. However, the pain sustained by the patient during treatment and local skin reactions can limit its use.

OBJECTIVES

To determine the efficacy and safety of combined PDT (daylight PDT followed by conventional PDT) vs conventional PDT 12 weeks after treatment.

METHODS

The study was performed as a randomized, single-center, non-inferiority clinical trial with two parallel groups. A total of 51 patients with grade I and II AKs on the scalp or face were randomized. Twenty-five patients received one session of combined PDT (combPDT), and 26 patients received one session of conventional PDT (cPDT). The primary endpoint was the reduction of AKs, 12 weeks after treatment. The secondary endpoint was the reduction in pain and local skin reaction.

RESULTS

The reduction rate of grade I and II AKs was similar in combPDT and cPDT, showing no statistically significant differences between both groups, 76.67% vs 86.63% [P = .094] and 80.48% vs 83.08% [P = .679], respectively. However, pain was significantly lower in the combPDT group (2.56 vs 5, P < .01), as were local skin reactions.

CONCLUSIONS

CombPDT has proven to be as effective as cPDT for the treatment of grade I and II AKs located on the scalp and face. Furthermore, combPDT has been shown to be considerably more tolerable than cPDT, causing only mild local skin reactions.

Hippo Signaling Pathway as a New Potential Target in Non-Melanoma Skin Cancers: A Narrative Review

Non-melanoma skin cancers (NMSCs), including basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC), are the most frequently diagnosed cancers in humans, however, their exact pathogenesis is not fully understood. In recent years, it has been hypothesized that the recently discovered Hippo pathway could play a detrimental role in cutaneous carcinogenesis, but no direct connections have been made. The Hippo pathway and its effector, YAP, are responsible for tissue growth by accelerating cell proliferation, however, YAP upregulation and overexpression have also been reported in numerous types of tumors. There is also evidence that disrupted YAP/Hippo signaling is responsible for cancer growth, invasion, and metastasis. In this short review, we will explore whether the Hippo pathway is an important regulator of skin carcinogenesis and if it could be a promising target for future therapies.

The burden of cutaneous disease in solid organ transplant recipients of color

Organ transplant recipients (OTRs) are at increased risk of cutaneous malignancy. Skin disorders in OTRs of color (OTRoC) have rarely been systematically assessed. We aimed to ascertain the burden of skin disease encountered in OTRoC by prospectively collecting data from OTRs attending 2 posttransplant skin surveillance clinics: 1 in London, UK and 1 in Philadelphia, USA. Retrospective review of all dermatological diagnoses was performed. Data from 1766 OTRs were analyzed: 1024 (58%) white, 376 (21%) black, 261 (15%) Asian, 57 (3%) Middle Eastern/Mediterranean (ME/M), and 48 (2.7%) Hispanic; and 1128 (64%) male. Viral infections affected 45.1% of OTRs, and were more common in white and ME/M patients (P < .001). Fungal infections affected 28.1% and were more common in ME/M patients (P < .001). Inflammatory skin disease affected 24.5%, and was most common in black patients (P < .001). In addition, 26.4% of patients developed skin cancer. There was an increased risk of skin cancer in white vs nonwhite OTRs (HR 4.4, 95% CI 3.5-5.7, P < .001): keratinocyte cancers were more common in white OTRs (P < .001) and Kaposi sarcoma was more common in black OTRs (P < .001). These data support the need for programs that promote targeted dermatology surveillance for all OTRs, regardless of race/ethnicity or country of origin.

A review of actinic keratosis, skin field cancerisation and the efficacy of topical therapies

While a wide range of treatments exist for actinic keratosis and skin field cancerisation, the long‐term benefits of the most common topical therapies are poorly defined. This report reviews the efficacy of the most commonly used topical therapies to treat regional or field lesions. Limited clinical and histopathological data are available on clearance rates at 12 months post‐treatment for the most commonly used agents, with varied outcome measures making any comparison difficult. In general, total field clearance rates at 12 months are suboptimal for the most commonly employed agents. Given the increasing incidence of actinic keratosis and skin field cancerisation due to an ageing population, further research into the efficacy of therapies is critical to guide treatment choice.

Evaluation of diagnostic criteria of actinic keratosis through reflectance confocal microscopy

BACKGROUND

The diagnosis of actinic keratosis (AK) is based on clinical evaluation and confirmed by histopathological analysis (HA). The challenge is to establish the correct diagnosis with a minimally invasive assessment. The aim of this study is to validate the analysis of AK by reflectance confocal microscopy (RCM), a cellular resolution, noninvasive imaging method and to determine the relevant parameters for diagnosis, compared to HA, by calculating the sensitivity (S), specificity (E), positive predictive value (PPV), and negative predictive value (NPV) of each criterion.

MATERIALS AND METHODS

Through clinical examination, 25 AKs were selected for dermoscopy and RCM evaluation followed by shaving excision for HA. Statistical analysis was done by hypothesis tests (McNemar for binary and Wilcoxon for continuous variables).

RESULTS

There was no significant difference between RCM and HA for 5 of the 6 parameters analyzed. The criteria that were statistically relevant were as follows: parakeratosis (p-value 0.449690; S 90%; PPV 78.26%), hyperkeratosis (p-value 0.248213; S 87.5%; E 100%; PPV 100%; NPV 25%), dyskeratosis (p-value 0.617075; S 85.71%; E 75%; PPV 94.74%; NPV 50%), spinous layer keratinocyte atypia classified as mild, moderate or severe (P-value 0.145032) and inflammation in epidermis (P-value 1.000000; S 75%; E 20%; PPV 78.95%; NPV 16.67%). RCM could not adequately measure inflammation in dermis (P-value 0.013328), despite good sensitivity (68%) and PPV (100%).

CONCLUSION

RCM proved to be an effective method for the diagnosis of AK, contributing to the selection of the most appropriate treatment option.

Skin cancer risk and shade: comparing the risk of foresters with other outdoor workers

BACKGROUND

Keratinocyte carcinoma (KC) is an increasingly important public health problem with an especially high prevalence in outdoor workers. In contrast to other occupations, foresters spend most of their outdoor time under the shade of trees.

OBJECTIVES

We aimed to compare the unique sun exposure patterns and sun protection behaviour of foresters with those of other outdoor workers and their relation to the KC risk.

METHODS

In July 2018, a cross-sectional study was conducted at an international forestry fair using a questionnaire about health awareness and skin cancer screening by dermatologists to assess the prevalence of KC.

RESULTS

A total of 591 participants (78.7% male; mean age 46.8 ± 16.2 years) including 193 foresters were enrolled. Of all foresters, 72% experienced sunburns (solar erythema) within the past year and 50% of them experienced the worst sunburn during work. Foresters were most likely to often/always wear protective clothes (29.0%) but were least likely to often/always avoid midday sun (23.8%) and stay in the shade (31.1%). Having an outdoor profession or spending hours outside for leisure was negatively associated with sun protection. Skin examination revealed an overall KC prevalence of 16.7%, with 16.5% of foresters being affected.

CONCLUSION

Despite being protected by trees, the risk of KC for foresters is comparable to that of other professional groups. Shade alone may not provide sufficient protection. Additional sun protection measures are necessary.

Current therapies for actinic keratosis

Actinic keratosis (AK) is a very common skin disease caused by chronic sun damage, which in 75% of cases arises on chronically sun-exposed areas, such as face, scalp, neck, hands, and forearms. AKs must be considered an early squamous cell carcinoma (SCC) for their probable progression into invasive SCC. For this reason, all AK should be treated, and clinical follow-up is recommended. The aims of treatment are: (i) to clinically eradicate evident and subclinical lesions, (ii) to prevent their evolution into SCC, and (iii) to reduce the number of relapses. Among available treatments, it is possible to distinguish lesion-directed therapies and field-directed therapies. Lesion-directed treatments include: (i) cryotherapy; (ii) laser therapy; (iii) surgery; and (iv) curettage. Whereas, field-directed treatments are: (i) 5-fluorouracil (5-FU); (ii) diclofenac 3% gel; (iii) chemical peeling; (iv) imiquimod; and (v) photodynamic therapy (PDT). Prevention plays an important role in the treatment of AKs, and it is based on the continuous use of sunscreen and protective clothing. This review shows different types of available treatments and describes the characteristics and benefits of each medication, underlining the best choice.

Dynamic thermal imaging on actinic keratosis patients: A preliminary study

BACKGROUND

Diagnosis of actinic keratosis (AK) based only on clinical findings can be misleading, and histopathological diagnosis results in scars. Dynamic thermal imaging is a potential non-invasive tool for the diagnosis of AK. This imaging technique quantifies the infrared (IR) radiation emitted by a subject after exposure to external thermal stimuli, such as heat or cold.

METHODS

Twenty-six histopathologically confirmed AK patients participated in the study. We compared the dynamic thermal images of AK lesions and normal skin (control sites). Temperature changes were plotted as a thermal response graph. After fitting exponential curves to the thermal response graph, the curve was converted to a logarithmic form.

RESULTS

Comparison of the early thermal response graphs of lesions and control sites showed faster thermal recovery of AK lesions. There was a significant difference in the gradient component of the calculated logarithmic equation between the AK lesions and control sites (P < 0.001).

CONCLUSION

Dynamic thermal imaging can be used as an auxiliary diagnostic tool for AK.

Different outdoor professions have different risks - a cross-sectional study comparing non-melanoma skin cancer risk among farmers, gardeners and mountain guides

BACKGROUND

One of the main risk factors for non-melanoma skin cancer (NMSC), the most common cancer worldwide, is solar ultraviolet radiation (UVR). This has led to the recognition of NMSC as occupational disease for outdoor workers in several countries. However, outdoor professions are a very heterogeneous group with diverse daily activities and associated UVR exposure.

OBJECTIVE

To compare the prevalence of NMSC and associated risk behaviour in different outdoor professions.

METHODS

Cross-sectional study among outdoor workers (farmers, gardeners, mountain guides) and indoor workers (office employees) as control group using a paper-based questionnaire on UVR exposure and protective behaviour followed by a skin examination by a dermatologist.

RESULTS

A total of 563 participants (46.9% women, 46.9 ± 13.8 years) consisting of 348 outdoor workers (38.8% farmer, 35.3% gardener, 25.9% mountain guides) and 215 indoor workers were included in the study between March and September 2017. NMSC incl. actinic keratosis was diagnosed in 33.3% of mountain guides, 27.4% of farmers, 19.5% of gardeners and in 5.6% of indoor workers. Significant differences were seen between the outdoor professions with mountain guides at highest risk compared to farmers (OR = 2.6, 95% CI = 1.2-5.7). Substantial differences between the professions were also seen in skin cancer screening attendance rates (indoor worker 61.4%, mountain guides 57.8%, farmers 31.9%, gardeners 27.6%), daily UVR exposure during work and protective behaviour such as sunscreen use during work.

CONCLUSION

Different outdoor professions have significant different risks for NMSC and show different risk behaviour. Tailoring prevention efforts to different professions based on their individual needs could be the key to lower the global burden of (occupational) NMSC.

Can the lesions induced with actinic keratosis become an enigma for dermatologists? Results of an open perspective study

Different face skin diseases (basal cell carcinoma, actinic keratosis, rosacea, solar elastosis, etc.) could clinically manifest itself as erythematic patches, pimples or plagues. It is very hard to make the clinical exclusion in some cases of these diseases since their characters can partially overlap or certain lesion can mimic another one especially in the cases of skin areas affected with sun. Therefore, the histopathological analysis remains the “golden standard” of the dermatological diagnosis at skin diseases. Our study has shown that certified dermatologists detect actinic keratosis (AK) of face/head skin of I/II levels very well. Verdicts of dermatologists and pathomorfologists are congruent on account of diagnosis in 90,7% cases. Diseases clinically excluded as AK revealed as malignant neoplasms (basal cell carcinoma) in less than 1% of case lesions.

Precancerous Skin Lesions

Certain clinically and histologically recognizable skin lesions with a degree of risk of progression to squamous cell carcinoma have been traditionally grouped as precancerous skin conditions but now tend to be classified as in situ carcinomas. This consensus statement discusses various aspects of these lesions: their evaluation by means of clinical and histopathologic features, the initial evaluation of the patient, the identification of risk factors for progression, and the diagnostic and treatment strategies available today.

Current perspective on actinic keratosis: a review

Actinic keratoses (AKs) are common, with prevalence in the U.S.A. estimated at almost 40 million in 2004 and annual costs of > $1 billion (U.S.D.). However, there is no universally accepted definition of AK and thus it is difficult to identify reliably. AKs are lesions of epidermal keratinocytic dysplasia that result from chronic sun exposure and have the ability to progress to invasive squamous cell carcinoma (SCC), but clinicians disagree about whether AKs are premalignant lesions, superficial SCCin situ or epiphenomena of chronically sun-damaged skin. Yearly AK to SCC progression rates of 0·6% were reported in an elderly population with multiple prior keratinocyte carcinomas (KCs); and rates of spontaneous AK regression have been reported to be > 50%, but regressed lesions often reappear. As AKs have both cosmetic consequences and potential for malignant transformation, there are multiple reasons for treatment. There is no current agreement on the most efficacious treatment, but 5-fluorouracil has been shown to both prevent and treat AKs, and imiquimod and photodynamic therapy may have the best cosmetic outcomes. AKs may be treated to improve appearance and relieve symptoms, but the keratinocytic dysplasia that gives rise to malignancy, and sometimes appears as an AK, may be what actually threatens patient health. Thus, treatments should aim to decrease the risk of KC or facilitate KC diagnosis by reducing the potential for misidentification created when a KC appears in a field of AKs. Improved agreement among clinicians on AK definition may improve management.

IRF4, MC1R and TYR genes are risk factors for actinic keratosis independent of skin color

Actinic keratosis (AK) is a pre-malignant skin disease, highly prevalent in elderly Europeans. This study investigates genetic susceptibility to AK with a genome-wide association study (GWAS). A full body skin examination was performed in 3194 elderly individuals from the Rotterdam Study (RS) of exclusive north-western European origin (aged 51-99 years, 45% male). Physicians graded the number of AK into four severity levels: none (76%), 1-3 (14%), 4-9 (6%) and ≥10 (5%), and skin color was quantified using a spectrophotometer on sun-unexposed skin. A GWAS for AK severity was conducted, where promising signals at IRF4 and MC1R (P < 4.2 × 10(-7)) were successfully replicated in an additional cohort of 623 RS individuals (IRF4, rs12203592, Pcombined = 6.5 × 10(-13) and MC1R, rs139810560, Pcombined = 4.1 × 10(-9)). Further, in an analysis of ten additional well-known human pigmentation genes, TYR also showed significant association with AK (rs1393350, P = 5.3 × 10(-4)) after correction for multiple testing. Interestingly, the strength and significance of above-mentioned associations retained largely the same level after skin color adjustment. Overall, our data strongly suggest that IRF4, MC1R and TYR genes likely have pleiotropic effects, a combination of pigmentation and oncogenic functions, resulting in an increased risk of AK.

Prevalence of actinic keratosis among dermatology outpatients in Austria

BACKGROUND

Actinic keratoses (AKs) are common precursors of squamous cell carcinomas (SCCs) of the skin making them an important public health issue with information on their prevalence widely lacking.

OBJECTIVES

To define the prevalence of AK in dermatology outpatients in Austria and to identify more accurately the target population for AK screening, treatment and prevention.

METHODS

Each of the 48 randomly selected Austrian office-based dermatologists simultaneously screened 100 consecutive patients (aged ≥ 30 years) for the presence of AK.

RESULTS

In total, 4449 evaluable patients showed an overall AK prevalence of 31·0%, which was higher in men (39·2%) than in women (24·3%) and increased with age in both sexes. AK distribution among sun-exposed body sites and extent of disease varied with sex and region.

CONCLUSIONS

In Austria, AKs are common among dermatology outpatients, who have access to professional education and treatment. Investigations regarding the efficacy of routine AK screening in dermatology outpatients for the prevention of invasive SCC is warranted.

A prospective randomized exploratory study comparing the efficacy of once-daily topical 0.5% 5-fluorouracil in combination with 10.0% salicylic acid (5-FU/SA) vs. cryosurgery for the treatment of hyperkeratotic actinic keratosis

BACKGROUND

Actinic keratoses (AKs) are clinically significant and require therapy. Efficacy of low-dose (0.5%) 5-fluorouracil with 10% salicylic acid (5-FU/SA) has been shown in randomized comparative trials of hyperkeratotic lesions of various grades.

OBJECTIVES

To evaluate the efficacy, tolerability and safety of low-dose 5-FU/SA topical solution vs. cryosurgery in patients with moderate/severe (grade II/III) hyperkeratotic AKs (NCT01358851).

METHODS

In an exploratory, open, randomized study, patients with histologically confirmed moderate/severe hyperkeratotic AKs on the face/forehead or bald scalp received 6 weeks of once-daily topical 0.5% 5-FU/SA, or up to two cryosurgery treatments (3 weeks apart). Histological outcomes were determined from punch biopsies. Clinical, cosmetic and tolerability outcomes were also assessed.

RESULTS

Sixty-six patients received treatment (33 per arm). The baseline total number of lesions was 266 (8.1/patient) in the 0.5% 5-FU/SA and 263 (8.0/patient) in the cryosurgery group. Most (74.5%) lesions were grade II (grade III, 25.5%). Mean change in lesion count from baseline to Day 98 was -5.2 and -5.7 lesions per patient for 0.5% 5-FU/SA and cryotherapy groups respectively. Histological AK clearance rates on Day 98 were 62.1% and 41.9% respectively. At 6-month posttreatment follow-up, recurrence of cleared lesions (no clinically visible lesions in treatment area) occurred in 39.4% of 0.5% 5-FU/SA and 84.8% of cryosurgery patients. Drug-related adverse events (AEs), including local skin reactions considered 'severe' by the investigator, were reported in 24.2% of 0.5% 5-FU/SA and 6.1% of cryosurgery patients. All drug-related AEs were skin reactions.

CONCLUSIONS

Although the study was not powered to explore statistical differences in clinical efficacy between treatments, a short (6-week) schedule of topical treatment with 0.5% 5-FU/SA achieved greater histological clearance and lower recurrence of grade II/III hyperkeratotic AKs than cryosurgery. AE incidence across both treatment groups was relatively low and AEs were generally mild or moderate. Clinical trials.gov identifier: NCT01358851.

Clinical and pathological study of 328 cases of actinic keratosis in eastern chinese patients

BACKGROUND

Actinic keratosis (AK) is prevalent and has been widely studied in fair-skinned populations. However, this is not the case in eastern countries. AK in Asians has not been so thoroughly investigated.

OBJECTIVES

To analyse the clinical and pathological features of a relatively large number of cases of AK diagnosed in older Chinese patients.

METHODS

Case histories of 328 patients with pathologically diagnosed AK were analysed retrospectively. Their demographic, clinical, pathological and treatment data were collected for analysis of associated factors.

RESULTS

Lesions were usually distributed on the face, especially the cheeks and temples. The most frequent pathological type was hypertrophic. Only 34% of the cases had been diagnosed correctly as AK before biopsy; many were mistaken for seborrhoeic keratosis.

CONCLUSIONS

Most patients were elderly females and there was a higher incidence of lesions on the face, and a lower incidence on the extremities and trunk; this finding contrasts with previous investigations in fair-skinned people.

Prevalence of actinic keratosis and its risk factors in the general population: the Rotterdam Study

Limited data are available on the prevalence and risk factors of actinic keratoses (AKs). Within the Rotterdam Study, full-body skin examinations were performed among participants aged 45 years or older to estimate the age- and sex-standardized prevalence of AK and its associated risk factors. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for associations between risk factors and the presence of 1-3, 4-9, and ≥ 10 AKs. Of the 2,061 inspected cohort members (mean age 72 years), 21% had 1-3, 9% had 4-9, and 8% had ≥ 10 AKs. AK prevalence was 49% (95% CI: 46-52%) for men and 28% (26-31%) for women. Male gender, older age, light pigmentation status, severe baldness, skin wrinkling, and high tendency for sunburn were significantly associated with extensive actinic damage (≥ 10 AKs) in the multivariate analyses. Especially bald males were at an increased risk of severe actinic skin damage (adjusted OR=7.0 (3.8-13.1)). The prevalence of AK is very high, especially among elderly bald males. The prevention and management of AK is a true challenge for patients, physicians, and health-care policymakers.

Actinic keratosis: a clinical and epidemiological revision

Actinic keratoses are benign intraepithelial skin neoplasms constituted by atypical proliferation of keratinocytes that may evolve to squamous cell carcinoma. They develop in photoexposed skin areas; they are induced mainly by ultraviolet radiation and are considered cutaneous markers of chronic exposure to sunlight. They develop mainly in adults and older, fair skinned individuals, and are the fourth most common cause of dermatologic consultation in Brazil. Damage to the apoptosis pathway in photoexposed epithelium favors cellular proliferation and the permanence of the lesions. In this revision, the authors assemble the main epidemiological data regarding this disease and suggest that strategies to identify risky phenotypes, early diagnosis, adequate treatment, clinical follow-up, stimulus to skin self examination, photoeducation and photoprotection should be promoted with the aim of avoiding the progression to malignancy and also the prevention and the diagnose of concomitant neoplasms also induced by ultraviolet radiation.

The importance of early diagnosis and treatment of actinic keratosis

Chronic, long-term sun exposure results in genetic changes in epidermal keratinocytes and the development of various skin lesions ranging from actinic keratosis (AK) to skin cancer. AK lesions may first appear as rough, scaly spots on sun-exposed skin, and, although most individual AK lesions do not become invasive cancers, the majority of invasive squamous cell carcinomas originate from AK. Genetic analysis demonstrates that ultraviolet radiation-induced mutations and changes in gene expression are present in squamous cell carcinoma, AK, and clinically normal-appearing perilesional sun-exposed skin, which supports the progressive nature of keratinocyte transformation. The presence of certain clinical features, such as large size, ulceration, or bleeding, suggests an increased risk of disease progression. The risk is also increased by evidence of extensive solar damage, advanced age, and immunosuppression. Early diagnosis and consideration for treatment are indicated to clear actinically damaged sites and diminish the risk of invasive squamous cell carcinoma.

Fluorescence detection and diagnosis of non-melanoma skin cancer at an early stage

BACKGROUND

The occurrence of non-melanoma skin cancer (NMSC), including actinic keratosis (AK) is increasing all over the world. The detection and diagnosis of NMSC is not optimal in clinical practice. Complementary methods for detection and accurate demarcation of NMSC at an early stage are needed in order to limit the damage caused by tumours.

OBJECTIVE

The purpose of the present study was to use a large area skin fluorescence detection system to detect early NMSCs (clinical visible as well as non-visible lesions) in the face, neck, chest, back and hands of patients treated with UV and outdoor workers.

METHODS

Fluorescence detection with a purpose-made digital camera and software (Dyaderm combined with 5-aminolevulinic acid (5-ALA) encapsulated in liposomes.

RESULTS

In 93 consecutively referred patients positive skin fluorescence was detected in 61 patients. After histological examination the positive fluorescence appeared to be correlated to benign lesions in 28 patients (sebaceous gland hyperplasia in 22 patients) and to (pre-) malignant lesions in 33 patients (actinic keratosis in 29, BCC in 3 and SCC in 1 patient). False negative fluorescence was found in only one lesion. In five patients the FD technique used in this study appeared to be more sensitive for the identification of (pre-) malignant lesions than the clinical examination. This is in contrast with FD techniques used in previous studies.

CONCLUSION

Diagnostic skin fluorescence using liposomal encapsulated 5-ALA and a specialised computerised detection and visualisation system offers the possibility for detection of NMSC at an early, pre-clinical stage. The technique is well suited to examine large areas of skin. It also identifies areas of most interest for performing confirmatory skin biopsies, as well as pre-operative assessment of boundaries of skin malignancies, and finally, the technique is applicable in the control and follow-up of skin cancer treatment.

Actinic keratoses: non-invasive diagnosis for field cancerisation

BACKGROUND

Actinic keratoses (AKs) are among the most common cutaneous malignancies and have previously been classified as in situ squamous cell carcinoma (SCC) with reported progression rates of up to 20% over 10 years. Since current scientific evidence suggests the presence of multilocular preneoplastic changes in the areas surrounding the affected skin sites, the detection of subclinical AKs remain an ongoing and challenging effort in the clinical and diagnostic management of these lesions. In vivo reflectance confocal microscopy (RCM) has been used for evaluation of the morphological features of non-melanoma skin cancer (NMSC) and RCM evaluation parameters for the diagnosis of AKs have been reported.

OBJECTIVES

The objective of this study was to evaluate the RCM-morphology of clinically diagnosed AKs in our study population and to correlate the findings with routine histopathology.

PATIENTS/METHODS

Forty four Caucasians (SPT I-III) with a minimum of one actinic keratosis (AK) lesion were included in this study. Evaluation consisted of clinical examination, RCM and routine histology. Reflectance confocal microscopy evaluation parameters included parakeratosis, architectural disarray and keratinocyte pleomorphism.

RESULTS

A total of 44 AKs were included in the final analysis. Following blinded evaluation by two independent investigators, 97.7% of all skin samples were identified as AK using RCM. 2.3% were incorrectly identified as normal skin by RCM, while routine histology showed features consistent with AK.

CONCLUSIONS

Reflectance confocal microscopy may be a feasible alternative in the diagnosis of AK and may aid in the differentiation against normal skin, as well as in the detection of subclinical disease.

Solar keratosis: epidemiology, pathogenesis, presentation and treatment

Solar keratosis is a common problem encountered by dermatologists, particularly in Australia. Solar keratosis is most commonly found on sun-exposed areas such as the scalp, face and forearms. UV radiation is thought to be the major aetiological factor, with age, immunosuppression and human papillomavirus being important contributing factors. Solar keratosis usually presents as a discrete, variably erythematous and irregular lesion with a scaly surface. Although the exact rate of malignant transformation to squamous cell carcinoma is unknown, the majority of squamous cell carcinomas appear to arise from within solar keratosis. For this reason, solar keratosis is commonly treated and, consequently, an increasing number of therapeutic options is now available. Traditional therapies, such as liquid nitrogen cryotherapy, are still popular, but newer choices, such as photodynamic therapy and imiquimod cream, are now providing further options with similar efficacy and superior adverse effect profiles, albeit at a higher cost.

A clinical comparison and long-term follow-up of topical 5-fluorouracil versus laser resurfacing in the treatment of widespread actinic keratoses

BACKGROUND AND OBJECTIVES

Many treatment modalities exist for actinic keratoses (AK). Topical 5-fluorouracil (5-FU) has been one of the standard treatments. Laser resurfacing is a more recent treatment option. In the literature prospective randomized studies comparing these treatments are lacking.

STUDY DESIGN/PATIENTS AND METHODS

Prospective randomized study to compare topical 5-FU with Er:YAG laser resurfacing. Fifty-five patients with multiple AK on the scalp and or the face were included. Clinical and histopathological evaluation took place at 3, 6, and 12 months after treatment.

RESULTS

At 3, 6, and 12 months after treatment, there were significantly less recurrences in the laser group compared to the group of patients treated with 5-FU. Side effects did occur more frequently in the laser group, especially erythema and hypopigmentation.

CONCLUSIONS

Compared to treatment with topical 5-FU, Er:YAG laser resurfacing is more effective regarding recurrence rates. Although significantly more side effects occur, laser resurfacing is a useful therapeutic option especially in patients with widespread AK.

Actinic Keratoses and the Incidence of Occult Squamous Cell Carcinoma: A Clinical?Histopathologic Correlation

BACKGROUND

The ability to clinically diagnose actinic keratoses (AKs) lesions has been taken for granted for some time. The importance of the malignant potential of these lesions is well known. However, a recent Phase IV, multicenter study assessing the long-term benefit of aminolevulinic acid-based photodynamic therapy provided a unique opportunity to prospectively examine the clinical histopathologic correlation of AKs.

OBJECTIVE

The objective was to characterize the histopathology of clinically diagnosed AK lesions in the study population.

METHODS

Punch biopsies of 220 clinically diagnosed untreated AKs were performed at baseline plus 51 lesions unresponsive to treatment (total, 271).

RESULTS

Clinical diagnosis and histopathologic findings agreed in 91% (246/271) of the lesions biopsied. The balance of the biopsied lesions were: (1) benign changes 4% (11/271) and (2) occult cutaneous malignancy in 5% (14/271) of the cases, 12 squamous cell carcinomas and 2 basal cell carcinomas.

CONCLUSIONS

In this study, about 1 in 25 clinically diagnosed AK lesions identified by board-certified dermatologist investigator(s) were occult early-stage squamous cell carcinomas on histologic assessment, a fact surmised by the medical community that until now had not been well quantified. These findings should be considered when clinicians decide how to treat and manage AK patients.

Frequency and cost of actinic keratosis treatment

BACKGROUND

Actinic keratosis (AK) is a common lesion with its highest incidence in the aged population. Although treatment strategies for AK have continued to develop, the cost of such treatments has not been recently investigated.

PURPOSE

The purpose of this article is to determine the frequency of visits for AK, the methods used to treat AK, and the cost of the treatments used annually.

METHODS

Data from the Medicare Current Beneficiary Survey and National Ambulatory Medical Care Survey were used to determine the frequency of office visits for AK and the frequency of destructive procedures and topical treatment of AK. Medicare reimbursement rates were used to estimate the cost of the procedures performed. Costs of medications were based on published wholesale costs.

RESULTS

There are an estimated 5.2 million AK visits annually, 60% of which are made by the Medicare population. A total of Dollars 920 million was spent on the treatment of AK annually, 6% being spent on topical therapy, 43% on office visits, and 51% on destructive procedures.

CONCLUSIONS

Even though new topical therapies are evolving for the treatment of AK, destructive procedures remain the standard of care when considering frequency of use, efficacy, and cost control.

Imiquimod for Actinic Keratosis: Systematic Review and Meta-Analysis

Benefit and harm associated with treating actinic keratosis (AK) with the immune response modifier imiquimod was assessed using published randomized-controlled trials. Five randomized double-blind trials lasted 12-16 weeks and treated 1,293 patients. Complete clearance occurred in 50% of patients treated with imiquimod, compared to 5% treated with vehicle, and the number needed to treat (NNT) for one patient to have their keratosis completely cleared after 12-16 weeks was 2.2 (95% confidence interval 2.0-2.5). For partial (>/=75%) clearance the NNT was 1.8 (1.7-2.0). The proportion of patients with any adverse event, any local adverse event, or any treatment-related adverse event was substantially higher with imiquimod than with vehicle, and numbers needed to harm for one additional adverse event with imiquimod over 12-16 weeks ranged from 3.2 to 5.9. Particular local adverse events with imiquimod included erythema (27%), scabbing or crusting (21%), flaking (9%), erosion (6%), edema (4%), and weeping (3%). Imiquimod 5% cream was effective in the treatment of AK, preventing potential development of squamous cell carcinoma. Future investigation might be aimed at elucidating optimal dosing to minimize adverse events without detriment to efficacy, and evaluating long-term recurrence.