{"id":3675,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/actinickeratosesandbowendisease\/"},"modified":"2024-10-09T13:14:54","modified_gmt":"2024-10-09T12:14:54","slug":"actinickeratosesandbowendisease","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/dermatology\/actinickeratosesandbowendisease\/","title":{"rendered":"Actinic Keratoses and Bowen Disease"},"content":{"rendered":"\n<p><strong>Actinic (Solar) Keratoses<\/strong><\/p>\n\n\n\n<p>Actinic keratoses (AK) occur on sites of chronic sun exposure, the  dorsum of the hands, face and scalp, especially in the fair-skinned. May present as:<\/p>\n\n\n\n<figure class=\"wp-block-gallery aligncenter has-nested-images columns-default is-cropped wp-block-gallery-1 is-layout-flex wp-block-gallery-is-layout-flex\">\n<figure class=\"wp-block-image\"><img loading=\"lazy\" decoding=\"async\" width=\"641\" height=\"483\" data-id=\"1039\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-Telangectasia-02-04-20.png\" alt=\"Dermatology Actinic Keratoses Telangectasia\" class=\"wp-image-1039\" srcset=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-Telangectasia-02-04-20.png 641w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-Telangectasia-02-04-20-300x226.png 300w\" sizes=\"auto, (max-width: 641px) 100vw, 641px\" \/><figcaption class=\"wp-element-caption\"><span class=\"media-credit\">DermNet (dermnetnz.org)<\/span> face telangiectasia<\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"353\" height=\"265\" data-id=\"19019\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Hands-Telangiectasia.png\" alt=\"Hands Telangiectasia\" class=\"wp-image-19019\" srcset=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Hands-Telangiectasia.png 353w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Hands-Telangiectasia-300x225.png 300w\" sizes=\"auto, (max-width: 353px) 100vw, 353px\" \/><figcaption class=\"wp-element-caption\"><span class=\"media-credit\"><a href=\"https:\/\/dermnetnz.org\/#gsc.tab=1&#038;gsc.q=actinic%20keratoses%20hands%20telangiectasia\">DermNet<\/a><\/span> <a href=\"https:\/\/dermnetnz.org\/topics\/actinic-keratosis-affecting-the-hand-images\">Actinic keratoses affecting the hands images | DermNet (dermnetnz.org)<\/a><\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-image\"><img loading=\"lazy\" decoding=\"async\" width=\"641\" height=\"483\" data-id=\"1041\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-head-31-03-20.png\" alt=\"Dermatology Actinic Keratoses head\" class=\"wp-image-1041\" srcset=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-head-31-03-20.png 641w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-head-31-03-20-300x226.png 300w\" sizes=\"auto, (max-width: 641px) 100vw, 641px\" \/><figcaption class=\"wp-element-caption\"><span class=\"media-credit\">\u00a9 DermNet New Zealand<\/span> head telangiectasia<\/figcaption><\/figure>\n<\/figure>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"641\" height=\"483\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-feet-31-03-20.png\" alt=\"Dermatology Actinic Keratoses feet\" class=\"wp-image-1040\" style=\"width:325px;height:auto\" srcset=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-feet-31-03-20.png 641w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Dermatology-Actinic-Keratoses-feet-31-03-20-300x226.png 300w\" sizes=\"auto, (max-width: 641px) 100vw, 641px\" \/><figcaption class=\"wp-element-caption\"><span class=\"media-credit\">DermNet (dermnetnz.org)<\/span> feet telangiectasia<\/figcaption><\/figure>\n<\/div>\n\n\n<div class=\"wp-block-media-text is-stacked-on-mobile is-vertically-aligned-top\" style=\"grid-template-columns:32% auto\"><figure class=\"wp-block-media-text__media\"><img loading=\"lazy\" decoding=\"async\" width=\"642\" height=\"482\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Actinic-hyperkeratosis.png\" alt=\"Actinic hyperkeratosis\" class=\"wp-image-19094 size-full\" srcset=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Actinic-hyperkeratosis.png 642w, https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Actinic-hyperkeratosis-300x225.png 300w\" sizes=\"auto, (max-width: 642px) 100vw, 642px\" \/><\/figure><div class=\"wp-block-media-text__content\">\n<p>some Actinic Keratosis can be very Hyperkeratotic.<\/p>\n\n\n\n<p>image from <a href=\"https:\/\/dermnetnz.org\/#gsc.tab=1&amp;gsc.q=hyper%20actinic%20keratoses&amp;gsc.page=1\">Search DermNet | DermNet (dermnetnz.org)<\/a><\/p>\n<\/div><\/div>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Bowens disease (SCC in-situ): <\/strong><\/h3>\n\n\n\n<div class=\"wp-block-media-text is-stacked-on-mobile\" style=\"grid-template-columns:33% auto\"><figure class=\"wp-block-media-text__media\"><img loading=\"lazy\" decoding=\"async\" width=\"237\" height=\"178\" src=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Bowens-Disease.png\" alt=\"Bowens Disease\" class=\"wp-image-19028 size-full\" \/><\/figure><div class=\"wp-block-media-text__content\">\n<ul class=\"wp-block-list\">\n<li>Persistent, scaly non-thickened macules or patches, often asymptomatic, Variable size up to several centimetres. Common on lower legs in women.<\/li>\n\n\n\n<li>May be multiple.<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<p><strong>R.C 18-05-24<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>Actinic keratoses (AK) are common and are due to chronic UV damage, commonly occurring on photo-exposed sites in the older population. There is no cure and the aim of treatment is to control AK numbers. Not all patients with AK will require treatment and prior to any treatment initiated a risk assessment should be made. All patients should be advised to use emollients and sunscreens (SPF 30+). Patients at a higher risk of developing keratinocyte cancers may require treatment. This includes patients who are immunosuppressed, have a history of invasive keratinocyte cancers and those with extensive disease (large areas of scalp\/face).<\/p>\n\n\n\n<p>Criteria for Dermatology Referral<\/p>\n\n\n\n<p><strong>&nbsp;Actinic Keratoses\/IEC<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Diagnostic doubt<\/li>\n\n\n\n<li>Painful rapidly growing lesion (think SCC \u2013 refer urgently!)<\/li>\n\n\n\n<li>&#8220;High risk&#8221; disease\n<ul class=\"wp-block-list\">\n<li>Immunosuppressed patients<\/li>\n\n\n\n<li>Extensive disease involving large field areas (i.e. large areas of scalp\/face)<\/li>\n\n\n\n<li>Previous invasive keratinocyte cancers<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Lack of response to treatment<\/li>\n\n\n\n<li>Bowens disease around nails\/digits<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h3 class=\"wp-block-heading\">Diagnostic Tips<\/h3>\n\n\n\n<p><strong>Actinic Keratoses\/Bowens<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Actinic keratoses are pre-malignant but transformation to invasive squamous cell carcinoma (SCC) is rare. Specific treatment is not essential, particularly in&nbsp; low risk disease.<\/li>\n\n\n\n<li>Suspect SCC if a lesion develops a thickened painful base or ulcerates<\/li>\n\n\n\n<li>Solitary cutaneous horns should be removed for histopathology if they are painful and have a broader base compared to their height<\/li>\n<\/ul>\n\n\n\n<p><strong>If suspicious follow pathway for squamous cell carcinoma<\/strong><\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Management<\/h4>\n\n\n\n<p><strong>ActinicKeratoses<\/strong><\/p>\n\n\n\n<p><strong>General:<\/strong><\/p>\n\n\n\n<p>&nbsp;<strong>Sun protection advice\/emollient<\/strong>&nbsp;\u2013 this is essential as there is evidence that sunblocks can clear AKs and reduce future risks.<\/p>\n\n\n\n<p><strong>Specific management options:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Single or few scattered AK<\/strong><\/li>\n\n\n\n<li>Generally no treatment indicated except for emollients and sunblocks. In patients with &#8220;high risk&#8221; disease (see criteria above) one could use the following:\n<ul class=\"wp-block-list\">\n<li>5% 5-fluorouracil<\/li>\n\n\n\n<li>0.5% 5-fluorouracil\/salicylic acid<\/li>\n\n\n\n<li>5% imiquimod cream<\/li>\n\n\n\n<li>Cryotherapy \u2013 infrequently used<\/li>\n\n\n\n<li>Curettage and cautery through local minor surgery (only when diagnostic doubt)<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Multiple (Field) AK<\/strong><\/li>\n\n\n\n<li>5% 5-fluorouracil<\/li>\n\n\n\n<li>3.75% imiquimod cream<\/li>\n\n\n\n<li>Diclofenac gel 3%<\/li>\n\n\n\n<li>PDT \u2013 not currently available in NHS Lothian<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Long term management<\/strong><\/li>\n\n\n\n<li>Patients may present with few scattered AK or large field change. However the majority will have microscopic disease and so if treatment is indicated the preference would be to treat field change, ideally with 5% 5-fluorouracil cream as first \u2013line therapy. Patients are likely to need ongoing treatment and not just a single course due to the chronic nature of this condition. 5% 5-fluorouracil cream can be used as per licence indication but many patients are unable to tolerate the skin reaction so the frequency can be reduced to three times per week and given over a longer period of time. Most will require treatment over a three to six month period following which a re-assessment should be made. Treatment can be discontinued if there is an improvement but most patients will require re-treatment due to the chronic nature of AKs.<\/li>\n<\/ul>\n\n\n\n<p><em>See BNF for dosing<\/em><\/p>\n\n\n\n<p><strong>Bowens disease<\/strong><\/p>\n\n\n\n<p><strong>Bowens disease is common and due to chronic UV damage, commonly occurring on photo-exposed sites in the older population. There is no cure and the aim of treatment is to control lesion numbers. All patients should be advised to use emollients and sunscreens (SPF 30+).<\/strong><\/p>\n\n\n\n<p><strong>Solitary\/few lesions<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Topical 5% 5-fluorouracil cream<\/li>\n\n\n\n<li>Curettage \u2013 only where there is diagnostic doubt. Must be sent to pathology.<\/li>\n\n\n\n<li>Cryotherapy \u2013 may be suitable for small lesions if you are confident of the diagnosis.<\/li>\n<\/ul>\n\n\n\n<p><strong>Multiple lesions<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Topical 5% 5-fluorouracil cream<\/li>\n\n\n\n<li>PDT \u2013 not available in NHS Lothian<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">For Patients<\/h4>\n\n\n\n<p>PIL Actinic Keratosis<\/p>\n\n\n\n<p><a href=\"http:\/\/www.bad.org.uk\/shared\/get-file.ashx?id=66&amp;itemtype=document\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.bad.org.uk\/shared\/get-file.ashx?id=66&amp;itemtype=document<\/a><\/p>\n\n\n\n<p>PIL IEC\/Bowen&#8217;s Disease<\/p>\n\n\n\n<p><a href=\"http:\/\/www.bad.org.uk\/shared\/get-file.ashx?id=235&amp;itemtype=document\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.bad.org.uk\/shared\/get-file.ashx?id=235&amp;itemtype=document<\/a><\/p>\n\n\n\n<p>PIL 5 Fluorouracil cream<\/p>\n\n\n\n<p><a href=\"https:\/\/www.bad.org.uk\/pils\/5-fluorouracil-cream\/\" data-type=\"URL\" data-id=\"https:\/\/www.bad.org.uk\/pils\/5-fluorouracil-cream\/\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.bad.org.uk\/shared\/get-file. document fluorouracil cream (Efudix)<\/a><\/p>\n\n\n\n<h4 class=\"wp-block-heading\">For Health Professionals<\/h4>\n\n\n\n<p><a href=\"http:\/\/www.pcds.org.uk\/clinical-guidance\/actinic-keratosis-syn.-solar-keratosis\" target=\"_blank\" rel=\"noreferrer noopener\">Link to PCDS Actinic\/Solar Keratosis guidance<\/a><\/p>\n\n\n\n<p><a rel=\"noreferrer noopener\" href=\"http:\/\/www.pcds.org.uk\/clinical-guidance\/bowens-disease\" target=\"_blank\">Link to PCDS Bowen&#8217;s Disease guidance<\/a><\/p>\n\n\n\n<p><strong>Dermnet NZ:<\/strong>&nbsp;<a rel=\"noreferrer noopener\" href=\"http:\/\/www.dermnetnz.org\/\" target=\"_blank\">http:\/\/www.dermnetnz.org\/<\/a><\/p>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Actinic (Solar) Keratoses Actinic keratoses (AK) occur on sites of chronic sun exposure, the dorsum of the hands, face and scalp, especially in the fair-skinned. May present as: some Actinic Keratosis can be very Hyperkeratotic. image from Search DermNet | DermNet (dermnetnz.org) Bowens disease (SCC in-situ): R.C 18-05-24<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":3853,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[95],"class_list":["post-3675","page","type-page","status-publish","hentry","category-actinickeratosesandbowendisease"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/dermatology\/actinickeratosesandbowendisease\/\" rel=\"tag\">Actinic Keratoses and Bowen Disease<\/a>","rttpg_excerpt":"Actinic (Solar) Keratoses Actinic keratoses (AK) occur on sites of chronic sun exposure, the dorsum of the hands, face and scalp, especially in the fair-skinned. May present as: some Actinic Keratosis can be very Hyperkeratotic. image from Search DermNet | DermNet (dermnetnz.org) Bowens disease (SCC in-situ): R.C 18-05-24","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3675","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=3675"}],"version-history":[{"count":40,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3675\/revisions"}],"predecessor-version":[{"id":21161,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3675\/revisions\/21161"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3853"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=3675"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=3675"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}