Actinic keratosis: a clinical and epidemiological revision

Efficacy and safety of 0.5% colchicine cream versus 5% 5-fluorouracil cream in the treatment of cutaneous field cancerization: a randomized clinical trial

BACKGROUND

5-Fluorouracil (5-FU) is a first-line drug to treat cutaneous field cancerization (CFC). There are few clinical trials with topical colchicine (COL).

OBJECTIVE

To evaluate the effectiveness of 0.5% COL cream versus 5% 5-FU cream in the treatment of CFC.

METHOD

This was a randomized, open, self-controlled clinical trial. Forty-five patients (90 forearms), with three to ten actinic keratoses (AK) on each forearm, used 0.5% COL cream 2×/day for seven days on one forearm, and 5% 5-FU cream 2× /day, for 21 days, on the other forearm. The dosages were defined based on previous clinical trials for each drug. Adverse effects were evaluated after 14 days and outcomes after 90 days of inclusion. The primary outcome was complete AK clearance and the secondary outcomes were: partial clearance (≥50%), reduction in AK count, assessment of the Forearm Photoaging Scale (FPS), AK Severity Score (AKSS), and adverse effects.

RESULTS

After 90 days, there was complete clearance of AK in 37% (95% CI 24%-49%) and partial clearance in 85% (95% CI 76%-93%) of the forearms treated with 5-FU,versus 17% (95% CI 7%-27%) and 78% (95% CI 66%-88%) for COL (p > 0.07). There was a percentage reduction of 75% in the AK count of the forearms treated with 5-FU (95% CI 66%-83%) and 64% in those treated with COL (95% CI 55%-72%). Regarding FPS and AKSS, there was improvement in both groups, with no difference regarding FPS (p = 0.654), and 5-FU superiority for AKSS (p = 0.012).

STUDY LIMITATIONS

Single-center study.

CONCLUSIONS

5-FU and COL are effective for treating CFC, with neither showing superiority regarding the reduction in AK counts.

Advancements in elucidating the pathogenesis of actinic keratosis: present state and future prospects

Solar keratosis, also known as actinic keratosis (AK), is becoming increasingly prevalent. It is a benign tumor that develops in the epidermis. Individuals with AK typically exhibit irregular, red, scaly bumps or patches as a result of prolonged exposure to UV rays. These growths primarily appear on sun-exposed areas of the skin such as the face, scalp, and hands. Presently, dermatologists are actively studying AK due to its rising incidence rate in the United States. However, the underlying causes of AK remain poorly understood. Previous research has indicated that the onset of AK involves various mechanisms including UV ray-induced inflammation, oxidative stress, complex mutagenesis, resulting immunosuppression, inhibited apoptosis, dysregulated cell cycle, altered cell proliferation, tissue remodeling, and human papillomavirus (HPV) infection. AK can develop in three ways: spontaneous regression, persistence, or progression into invasive cutaneous squamous cell carcinoma (cSCC). Multiple risk factors and diverse signaling pathways collectively contribute to its complex pathogenesis. To mitigate the risk of cancerous changes associated with long-term UV radiation exposure, prompt identification, management, and prevention of AK are crucial. The objective of this review is to elucidate the primary mechanisms underlying AK malignancy and identify potential treatment targets for dermatologists in clinical settings.

Shedding new light on actinic keratoses and squamous cell carcinoma in situ

ABSTRACT

Cutaneous squamous cell carcinoma can arise from various premalignant lesions such as actinic keratosis, Bowen disease, and premalignant genital squamous cell lesions. Identification and treatment can prevent malignant transformation and death. This article describes the causes, epidemiology, and characteristics of suspicious premalignant squamous cell lesions so that clinicians can identify these lesions and refer patients for specialist treatment as appropriate.

Association between calcium channel blockers and the severity of actinic keratosis on face and scalp: a cross-sectional study

BACKGROUND

Actinic keratosis (AK) is a skin condition associated with age, sun exposure, and immunosuppression. Certain drugs, such as photosensitizing medications and calcium channel blockers (CCBs), have been linked to AK. This study explores the impact of individual, behavioral, and exposure factors on the severity of AKs on the face and scalp.

METHODS

A multicenter cross-sectional study was conducted on immunocompetent individuals with at least one AK on their face or scalp and assessed demographic factors, sun exposure and protection, history of skin cancer, and medication use within the last 6 months. The primary outcome was the Actinic Keratosis Area and Severity Index (AKASI) score, and a hierarchical generalized linear model was used to evaluate the variation in AKASI scores, adjusting for gender, age, and skin phototype.

RESULTS

Two hundred seventy subjects between 39 and 92 years were evaluated. The majority had phototype I or II (77%), male gender (51%), personal history of skin cancer (55%), and low adherence to sunscreen use (29%). The use of photosensitizing medications was reported by 61%. Through multivariate analysis, older age (βSE  = 0.14; P < 0.01), lighter skin phototype (βSE  = 0.15; P = 0.01), history of skin cancer (βSE  = 0.12; P < 0.01), sunburning (βSE  = 0.12; P < 0.01), and use of CCBs (βSE  = 0.11; P = 0.02) were identified as independent risk factors for AK severity. Photosensitizing drugs were not identified as risk factors.

CONCLUSION

Older age, lower skin phototype classifications, and a personal history of skin cancer were confirmed as severity risk factors for AK, while the use of CCBs was associated with more severe AK.

Smartphone-based dual radiometric fluorescence and white-light imager for quantification of protoporphyrin IX in skin

Significance

The quantification of protoporphyrin IX (PpIX) in skin can be used to study photodynamic therapy (PDT) treatments, understand porphyrin mechanisms, and enhance preoperative mapping of non-melanoma skin cancers.

Aim

We aim to develop a smartphone-based imager for performing simultaneous radiometric fluorescence (FL) and white light (WL) imaging to study the baseline levels, accumulation, and photobleaching of PpIX in skin.

Approach

A smartphone-based dual FL and WL imager (sDUO) is introduced alongside new radiometric calibration methods for providing SI-units of measurements in both pre-clinical and clinical settings. These radiometric measurements and corresponding PpIX concentration estimations are applied to clinical measurements to understand mechanistic differences between PDT treatments, accumulation differences between normal tissue and actinic keratosis lesions, and the correlation of photosensitizer concentrations to treatment outcomes.

Results

The sDUO alongside the developed methods provided radiometric FL measurements (nW / cm 2 ) with a demonstrated sub nanomolar PpIX sensitivity in 1% intralipid phantoms. Patients undergoing PDT treatment of actinic keratosis (AK) lesions were imaged, capturing the increase and subsequent decrease in FL associated with the incubation and irradiation timepoints of lamp-based PDT. Furthermore, the clinical measurements showed mechanistic differences in new daylight-based treatment modalities alongside the selective accumulation of PpIX within AK lesions. The use of the radiometric calibration enabled the reporting of detected PpIX FL in units of nW / cm 2 with the use of liquid phantom measurements allowing for the estimation of in-vivo molar concentrations of skin PpIX.

Conclusions

The phantom, pre-clinical, and clinical measurements demonstrated the capability of the sDUO to provide quantitative measurements of PpIX FL. The results demonstrate the use of the sDUO for the quantification of PpIX accumulation and photobleaching in a clinical setting, with implications for improving the diagnosis and treatment of various skin conditions.

A novel combination of isovanillin, curcumin, and harmine (GZ17-6.02) enhances cell death and alters signaling in actinic keratoses cells when compared to individual components and two-component combinations

Actinic keratosis is a pre-malignant skin disease caused by excessive exposure to ultraviolet light. The present studies further defined the biology of a novel combination of isovanillin, curcumin, and harmine in actinic keratosis cells in vitro . An oral formulation (GZ17-6.02) and topical preparation (GZ21T) comprised of the same fixed, stoichiometric ratio have been developed. Together, the three active ingredients killed actinic keratosis cells more effectively than any of its component parts as either individual agents or when combined in pairs. The three active ingredients caused greater levels of DNA damage than any of its component parts as either individual agents or when combined in pairs. As a single agent, compared to isolated components, GZ17-6.02/GZ21T caused significantly greater activation of PKR-like endoplasmic reticulum kinase, the AMP-dependent protein kinase, and ULK1 and significantly reduced the activities of mTORC1, AKT, and YAP. Knockdown of the autophagy-regulatory proteins ULK1, Beclin1, or ATG5 significantly reduced the lethality of GZ17-6.02/GZ21T alone. Expression of an activated mammalian target of rapamycin mutant suppressed autophagosome formation and autophagic flux and reduced tumor cell killing. Blockade of both autophagy and death receptor signaling abolished drug-induced actinic keratosis cell death. Our data demonstrate that the unique combination of isovanillin, curcumin, and harmine represents a novel therapeutic with the potential to treat actinic keratosis in a manner different from the individual components or pairs of the components.

Factors for risk stratification of patients with actinic keratosis using integrated analysis of clinicopathological features and gene expression patterns

BACKGROUND

Actinic keratosis (AK) is considered as precursor lesion of invasive squamous cell carcinoma. Molecular studies on AK are limited because of too small size of the biopsy specimen to obtain enough DNA or RNA.

METHODS

Twenty biopsy cases of AK, followed by second same-sited biopsies, were included. Ten cases were diagnosed with total regression (regression group), while the other 10 were diagnosed with invasive carcinoma (progression group) in the follow-up biopsies. Using digital spatial profiling (DSP) technology, whole-gene expression analysis defined by specific regions of interest was performed for all 20 cases. After the clinicopathological features were assessed, separate and integrated analyses of these features and gene expression patterns were performed using machine-learning technology. All analyses were performed on both lesion keratinocytes (KT) and infiltrated stromal lymphocytes (LC).

RESULTS

Among the 18,667 genes assessed, 33 and 72 differentially expressed genes (DEGs) between the regression and progression groups were found in KT and LC respectively. The primary genes distinguishing the two groups were KRT10 for KT and CARD18 for LC. Clinicopathological features were weaker in risk stratification of AK progression than the gene expression patterns. Pathways associated with various cancers were upregulated in the progression group of KT, whereas the nucleotide-binding oligomerization domain (NOD)-like receptor signalling pathway was upregulated in the progression of LC.

CONCLUSION

Gene expression patterns were effective for risk stratification of AK progression, and their distinguishing power was higher than that of clinicopathological features.

Cannabinoid Compounds as a Pharmacotherapeutic Option for the Treatment of Non-Cancer Skin Diseases

The endocannabinoid system has been shown to be involved in various skin functions, such as melanogenesis and the maintenance of redox balance in skin cells exposed to UV radiation, as well as barrier functions, sebaceous gland activity, wound healing and the skin's immune response. In addition to the potential use of cannabinoids in the treatment and prevention of skin cancer, cannabinoid compounds and derivatives are of interest as potential systemic and topical applications for the treatment of various inflammatory, fibrotic and pruritic skin conditions. In this context, cannabinoid compounds have been successfully tested as a therapeutic option for the treatment of androgenetic alopecia, atopic and seborrhoeic dermatitis, dermatomyositis, asteatotic and atopic eczema, uraemic pruritis, scalp psoriasis, systemic sclerosis and venous leg ulcers. This review provides an insight into the current literature on cannabinoid compounds as potential medicines for the treatment of skin diseases.

Actinic Keratoses (AK): An Exploratory Questionnaire-Based Study of Patients’ Illness Perceptions

Simple Summary

We recorded 208 patients receiving treatment for AK and conducted a cross-sectional questionnaire-based study, which aimed to investigate patients’ perceptions of their illness. Our main objective was the detection not only of the illness perception of AK patients, but also of its influence on their perception of treatment and the correlation with patients’ demographic characteristics and history, as well as the readiness to use sunscreen. The rising incidence of AK and its socioeconomic burden place the illness perception of AK patients among the most important barriers to overcome for the effective management of the disease. To the best of our knowledge, this is one of the first studies to attempt to unveil the illness perceptions of AK patients and their correlation with patients’ demographics and sunscreen use and the influence on AK treatment. We strongly support reinforcing the awareness of AK and the role of dermatologists is crucial for this direction.

Abstract

Background: Decreased illness perception among actinic keratoses (AK) patients is a major barrier to the effective management of AK. Objective: We aimed to investigate patients’ illness and treatment perceptions, their correlation to demographics and AK/skin cancer history, and secondarily the influence of these perspectives on treatment and sunscreen use. Materials and Methods: Participants completed questionnaires based on the Brief Illness Perception Questionnaire and statistical analysis was performed. Results: In total, 208 AK patients were enrolled. A large proportion were poorly aware of the disease (41.4%), with less than half (43%) being familiar with AK. Patients were aware of the chronic nature of the disease and its correlation to sunlight regardless of demographic characteristics. The level of education played a role in disease awareness (p = 0.006), and treatment plan perception (p = 0.002). The increase in sunscreen protection after AK diagnosis was higher in women (p = 0.009) and younger patients (p = 0.044). Patients’ concerns regarding treatment were mainly related to the duration (30%) and effectivity (25%). Dermatologists’ statements highlighting that AK are precancerous lesions (86.2%) influenced patients’ willingness for treatment. Conclusion: Improved awareness of AK is necessary to increase treatment seeking and compliance, regarding both treatment and sunscreen use. Dermatologists’ statements may have critical influence on patients’ decisions to receive treatment for AK.

Actinic keratosis (review of literature)

Actinic keratosis is an important medical and social problem, the correct diagnosis and treatment of which will help to avoid the development of invasive forms of cutaneous squamous cell carcinoma. With the further development of the early diagnosis of cancer, including skin cancer, the increase in human life expectancy, and the popularization of travel to exotic countries, the number of cases of actinic keratosis among the population will continue to grow. In this regard, it is important to discuss the causes and pathogenesis of the disease, the varied clinical picture of the disease, methods of non-invasive diagnostics, as well as methods of treatment, of which there are a great many in the treatment of actinic keratosis today. However, each of the methods has both advantages and disadvantages, and in the global trend towards a personalized approach to treatment, it is important to choose from the standpoint of evidence-based medicine the most suitable for each individual patient. Moreover, after treatment of actinic keratosis, relapses often occur, which are the result of insufficient diagnosis and the development of incorrect treatment tactics. The review article provides the clinical picture of actinic keratosis, diagnostic and therapeutic methods, and their comparison with each other in terms of efficacy and safety

Short-Term Follow-Up of a Randomized Controlled Trial of 0.5% and 5% 5-Fluorouracil After Microneedling for Treatment of Facial Actinic Keratoses

INTRODUCTION

Topical 5-fluorouracil (5-FU) is used to treat actinic keratosis, although side effects limit treatment. Microneedling might be a tool for reducing treatment duration.

OBJECTIVE

To evaluate microneedling to promote 5-FU delivery at different concentrations (0.5% and 5%) for actinic keratoses (AKs) treatment.

METHODS

Forty-four patients with facial AKs subjected to 1.0 mm microneedling on 1 side of the face were randomized into 5% 5-FU or 0.5% 5-FU groups. Evaluations of efficacy and safety were conducted on days 21 and 111.

RESULTS

Forty-four patients aged 47 to 85 years were enrolled. Complete clearance of AKs was similar within groups for the side of the face treated with microneedling and 5-FU and the side treated with 5-FU alone in both the 5% and 0.5% 5-FU groups. Microneedling and 5% 5-FU was superior to microneedling and 0.5% 5-FU to reduce AKs (p = .025). Microneedling and 5% 5-FU resulted in fewer adverse effects than 5% 5-FU alone (p = .011).

CONCLUSION

Topical 5% and 0.5% 5-FU delivery for 3 days after microneedling was effective for treating facial AKs and equivalent to 5% and 0.5% 5-FU alone for 15 days after 3 months of follow-up. Microneedling may potentiate 5-FU treatment, reducing treatment time without losing efficacy.

Exposome and Skin. Part 2. The Influential Role of the Exposome, Beyond UVR, in Actinic Keratosis, Bowen's Disease and Squamous Cell Carcinoma: A Proposal

Actinic keratosis (AK) is the main risk factor for the development of cutaneous invasive squamous cell carcinoma (SCC). It represents the first sign of severe chronic ultraviolet radiation exposure, which has a clear significant effect. Nevertheless, the skin is exposed to many other exposome factors which should be thoroughly considered. Our aim was to assess the impact of exposome factors other than ultraviolet radiation (UVR) on the etiopathology of AK and Bowen's disease (BD) and progression of AK to SCC and to design tailored prevention strategies. We performed an exhaustive literature search in September 2021 through PubMed on the impact of exposome factors other than UVR on AK, BD and SCC. We conducted several parallel searches combining terms of the following topics: AK, BD, SCC and microbiome, hormones, nutrition, alcohol, tobacco, viral infections, chemical contaminants and air pollution. Notably, skin microbiome studies have shown how Staphylococcus aureus infections are associated with AK and AK-to-SCC progression by the production of chronic inflammation. Nutritional studies have demonstrated how a caloric restriction in fat intake, oral nicotinamide and moderate consumption of wine significantly reduce the number of premalignant keratoses and SCC. Regarding lifestyle factors, both alcohol and smoking are associated with the development of SCC in a dose-dependent manner. Relevant environmental factors are viral infections and chemical contaminants. Human papillomavirus infections induce deregulation of cellular proliferation and are associated with AK, BD and SCC. In addition to outdoor jobs, occupations such as industrial processing and farming also increase the risk of developing keratoses and SCC. The exposome of AK will undoubtedly help the understanding of its etiopathology and possible progression to SCC and will serve as a basis to design tailored prevention strategies.

Risk factors for actinic keratoses: A systematic review and meta-analysis

Objective

To integrate evidence and assess the risk factors associated with actinic keratosis (AK).

Methods

Unrestricted searches were conducted on five electronic databases, with an end-date parameter of September 2021. We summarized the study characteristics and pooled the results from individual studies by using a random-effects model. The risk of bias was estimated using the Cochrane Risk of Bias Tool, and the quality of evidence was estimated according to the Newcastle-Ottawa Scale.

Results

Sixteen studies were included in final analysis, and we assessed the AK risk among a variety of risk factors. Overall, the male sex (odds ratio (OR): 2.51; 95% confidence interval (CI): 1.94-3.25; P < 0.01), age >45 years (OR = 7.65, 95% CI: 2.95-19.86; P < 0.01), light Fitzpatrick skin phototype (OR = 2.32, 95% CI: 1.74-3.10; P < 0.01), light hair color (OR = 2.17, 95% CI: 1.40-3.36; P < 0.01), light eye color (OR = 1.67, 95% CI: 1.03-2.70; P = 0.04), freckles on face/arms (OR = 1.88, 95% CI: 1.37-2.58; P < 0.01), suffered positive history of other types of non-melanoma skin cancer (OR = 4.46, 95% CI: 2.71-7.33; P < 0.01), sunburns in childhood (OR = 2.33, 95% CI: 1.47-3.70; P < 0.01) and adulthood (OR = 1.50, 95% CI: 1.12-2.00; P < 0.01), severe sunburn (OR = 1.94, 95% CI: 1.62-2.31; P < 0.01), and chronic occupational and/or recreational sun exposure (OR = 3.22, 95% CI: 2.16-4.81; P < 0.01) increased the risk of AK. Moreover, sunscreen use (OR = 0.51, 95% CI: 0.34-0.77; P < 0.01) and history of atopy reduced the risk of AK. Sensitivity analysis yielded consistent results. The included studies showed a high risk of bias.

Conclusion

We confirm several well-known AK risk factors and their quantitative data, and summarized the uncommon risk factors and protective factors. Our results may inform on the design and implementation of AK screening and educational programs.

RANDOMIZED CONTROLLED TRIAL FOR EVALUATION OF EFFICACY AND PAIN DURING PHOTODYNAMIC THERAPY FOR ACTINIC KERATOSIS OF FACE AND SCALP COMPARING TWO IRRADIATION PROTOCOLS

BACKGROUND

Pain is a frequent adverse event during photodynamic therapy, which can limit treatment acceptance. This study aimed to evaluate the efficacy and pain during photodynamic therapy with two irradiation protocols in patients with actinic keratosis on the face and scalp.

METHODS

In this intra-patient randomized controlled trial, participants were randomly allocated to receive photodynamic therapy with methyl aminolevulinate and red light on the right or left side with protocol 1 (irradiation device in contact with the skin) and protocol 2 (device 3 cm away from the skin). There was a 15-day interval between the protocols. The primary outcome was the frequency of mean intensity of moderate or severe pain during photodynamic therapy. Secondary outcomes were actinic keratosis clearance rate, protoporphyrin IX consumption, participant preference, skin appearance, and adverse events.

RESULTS

Forty-one participants were included, yielding 47 and 50 randomized sites for protocols 1 and 2. There was no difference in the frequency of moderate and severe pain, with a relative risk of 1.09 (95% CI 0.70-1.70), p>0.05. An actinic keratosis count reduction >60% was observed in both protocols (p<0.01), with no difference between them. There was no difference in protoporphyrin IX consumption. Most treated sites were of good to excellent quality. There was a greater patient preference for protocol 2 (p<0.01).

CONCLUSIONS

The pain intensity was similar between the protocols, and the protocols were equally effective for actinic keratosis clearance, protoporphyrin IX consumption, and improvement in the quality of the treated areas. Both protocols can be considered safe.

Guidelines of care for the management of actinic keratosis

BACKGROUND

Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma.

OBJECTIVE

This analysis examined the literature related to the management of AK to provide evidence-based recommendations for treatment. Grading, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs are also discussed.

METHODS

A multidisciplinary Work Group conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus.

RESULTS

Analysis of the evidence resulted in 18 recommendations.

LIMITATIONS

This analysis is based on the best available evidence at the time it was conducted. The pragmatic decision to limit the literature review to English language randomized trials may have excluded data published in other languages or limited identification of relevant long-term follow-up data.

CONCLUSIONS

Strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are made for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Origins and Evolution of Photocarcinogenesis Action Spectra, Including Germicidal UVC†

Germicidal ultraviolet radiation (GUV) provides a means of dramatically reducing airborne spread of microorganisms in residential and workspace environments. Regarding design and use of GUV, both efficacy and safety data have accumulated over several decades, with a substantial increase of attention during the current COVID-19 pandemic. Considerations for skin and eye safety previously resulted in guidance on exposures in institutional and workplace settings. This report details the evolution of limits for skin exposures, with particular attention to the risk of skin neoplasia.

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.

The Mast Cell-SCF-CB1 Interaction Is a Key Player in Seborrheic Keratosis

Mast cell (MC) is an important player in the development of skin diseases, including atopic dermatitis, psoriasis, and urticaria. It is reported that MC infiltration and activation are observed around various types of tumors and speculated that MCs play key roles in their pathogenesis. As MCs in human seborrheic keratosis (SK) have not been well investigated, here we focused on the MCs in SK. The number of c-Kit and tryptase-positive MCs was significantly increased around the SK compared with the marginal lesion. Degranulated MCs were also increased around the tumors. Furthermore, MC growth factor, stem cell factor (SCF), expression within the SK was significantly upregulated compared with the marginal lesion. Interestingly, one of the cognitive regulators of SCF expression, cannabinoid receptor type 1 (CB1) immunoreactivity was downregulated within the SK. Our results suggest that MCs play important roles in the pathogenesis of SK and that SCF can be also deeply involved in the development of SKs. Our current results highlight the CB1-SCF-MC interaction as a novel mechanism of SK development and this also will be utilized for developing a novel treatment.

Awareness, knowledge, and attitude toward nonmelanoma skin cancer and actinic keratosis among the general population of western Saudi Arabia

Background:

This study evaluated the levels of awareness, knowledge, and attitude, including sun-protection habits, toward basal cell carcinoma and actinic keratosis among the Saudi population.

Materials and Methods:

A cross-sectional study was conducted among the general population of Jeddah, Saudi Arabia using a 12-item survey concerning the knowledge and awareness of basal cell carcinoma and actinic keratosis, as well as associated preventive measures. A Chi-square test was used to determine associations among variables.

Results:

The majority of participants were unaware of basal cell carcinoma and actinic keratosis (80.7%), while 8.6% were aware of both, and 9.8% and 1% were aware of only basal cell carcinoma or actinic keratosis, respectively. The majority of participants who were educated up to high school level had no knowledge of either condition (96%, P < 0.0001). Among participants with high levels of awareness of basal cell carcinoma and actinic keratosis, medical practitioners were identified as the main source of information (72.5%, P < 0.0001, and 70.6%, P < 0.0001, respectively). The majority of participants whose knowledge of the relationship between sun exposure and skin cancer was insufficient also lacked sufficient awareness of either basal cell carcinoma or actinic keratosis (92.6%, P < 0.0001). The majority of participants (62.8%) declared using sunscreen “rarely”.

Conclusion:

This study showed a low level of knowledge about the risks associated with sun exposure and suitable protection methods, with only a small fraction of participants declaring a regular use of sunscreen. Public education campaigns are required to increase the awareness of cancer risks and protection methods among the Saudi population.

Épidémiologie des kératoses actiniques

Actinic keratosis is a premalignant skin lesion resulting from proliferation of atypical epidermal keratinocytes. Actinic keratoses are very frequent and their prevalence is increasing. Risk factors for actinic keratosis include intrinsic and environmental factors, particularly exposure to ultraviolet radiation and advanced age. The main factor is the exposition to ultraviolet radiation. Better sun protection decreases the risk of actinic keratosis and also the risk of progression to squamous cell carcinoma, even though not all actinic keratoses progress to invasive squamous cell carcinoma. A diagnosis of actinic keratosis should encourage patients to do an annual dermatological screening of skin cancers. Given the economic cost of actinic keratoses, a global approach of health authorities could be interesting for their management. © 2019 Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Kératoses actiniques : comprendre et traiter réalisé avec le soutien institutionnel de Galderma International.

Contribution to characterization of skin field cancerization activity: morphometric, chromatin texture, proliferation, and apoptosis aspects

Background

A skin field cancerization is a cutaneous area with subclinical changes resultant from chronic sun exposure, with a higher predisposition to development of pre-neoplastic and neoplastic lesions. So far, there are no well-defined objective parameters that can indicate their degree of activity.

Objectives

To describe and compare morphometric aspects and expression of factors related to apoptosis and cell proliferation in actinic keratosis (AK), in both photoexposed and photoprotected epidermis.

Methods

A cross-sectional study of patients with actinic keratosis in the forearms, biopsied at two points: the actinic keratosis and the axillary region. The biopsies of the actinic keratosis, perilesional area, and axilla were evaluated through keratinocyte intraepithelial neoplasia (KIN), and immunohistochemistry of p53, survivin, and Ki67. Nuclear morphometry of basal layer cells was performed through digital image analysis: entropy, area, perimeter, Ra, fractal dimension, circularity, color intensity, and largest diameter.

Results

There were 13 patients included and 38 actinic keratosis biopsied. In morphometry, 1039 nuclei were analyzed, of which 228 represented axillary skin, 396 demonstrated actinic keratosis, and 415 represented the perilesional area to the actinic keratosis. There was a significant difference (p < 0.05) in all variables tested for the topographies evaluated. A significant correlation was identified between nucellar morphometric elements, KIN, proliferation markers, and apoptosis. Joint patterns of p53, Ki67, and KIN discriminated the topographies sampled.

Study limitations

This was a cross-sectional study with a small number of patients.

Conclusions

There are patterns of proliferation, resistance to apoptosis, and different cellular morphometrics between photoprotected skin and photoexposed skin. The joint expression of p53, Ki67, and KIN can characterize skin field cancerization activity.

Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects

Actinic keratoses are dysplastic proliferations of keratinocytes with potential for malignant transformation. Clinically, actinic keratoses present as macules, papules, or hyperkeratotic plaques with an erythematous background that occur on photoexposed areas. At initial stages, they may be better identified by palpation rather than by visual inspection. They may also be pigmented and show variable degrees of infiltration; when multiple they then constitute the so-called field cancerization. Their prevalence ranges from 11% to 60% in Caucasian individuals above 40 years. Ultraviolet radiation is the main factor involved in pathogenesis, but individual factors also play a role in the predisposing to lesions appearance. Diagnosis of lesions is based on clinical and dermoscopic examination, but in some situations histopathological analysis may be necessary. The risk of transformation into squamous cell carcinoma is the major concern regarding actinic keratoses. Therapeutic modalities for actinic keratoses include topical medications, and ablative and surgical methods; the best treatment option should always be individualized according to the patient.

Treatment of actinic keratoses and cancerization field of the face and scalp with 0.015% ingenol mebutate gel in Brazilian individuals: safety, tolerability and patients' perspectives

BACKGROUND

Actinic keratosis (AK) represents a risk of progression to squamous cell carcinoma. Ingenol mebutate gel is a novel therapeutic option for field-directed treatment.

OBJECTIVES

To evaluate the safety, tolerability and patients' perspectives, related to the therapeutic success of managing AKs on the face and scalp with ingenol mebutate gel in Brazilian individuals.

METHODS

This was an observational, retrospective and descriptive study of 68 areas of actinic keratosis on the face and scalp treated with Ingenol mebutate gel involving a total of 37 patients. The drug was applied for three consecutive days on an area of of 25 cm2 and documentation was performed on baseline and days 4, 8, 15, 60 and 180. On day 4, the composite local skin reaction score was calculated. At the end, a questionnaire was applied to evaluate patients' perspectives about the treatment.

RESULTS

Adherence was 100%, no serious adverse events were recorded and the mean composite local skin reaction score (standard deviation) was 8.61±4.22. The treatment was considered optimum by 75.68% of the patients.

STUDY LIMITATIONS

Calculation of composite local skin reaction score performed only on the fourth day.

CONCLUSIONS

Treatment with ingenol mebutate gel was considered safe and tolerable in Brazilian subjects. Patients had a maximum adherence rate and a great improvement in self-esteem. The results of this research reproduce the findings of the literature.

Sun exposure, skin lesions and vitamin D production: evaluation in a population of fishermen

BACKGROUND

Exposure to UVR provides benefits related to vitamin D synthesis, but also causes harms, since UVB is considered a complete carcinogen. There is no definition of the level of sun exposure and the proportion of exposed body required for proper synthesis of vitamin D in the skin without causing it damage.

OBJECTIVES

This study aims to analyze the sun exposure index, vitamin D levels and clinical changes in the skin caused by constant sun exposure in the fishermen population.

METHODS

It is a cross-sectional, observational and analytical study. The sample consisted of fishermen and was calculated in 174 individuals. The questionnaire was applied, the dermatological examination was carried out and the examinations of calcidiol, parathyroid hormone, calcium and phosphorus were requested. Data were expressed as percentages. The comparative analysis was done through the Chi-square test, and the correlations were established through the Pearson's linear coefficient. Results: We observed that there was vitamin D deficiency in a small part of the cases (11.46%), and the frequency of diagnosis of skin cancer was 2.7% of the cases surveyed.

STUDY LIMITATIONS

The difficulty in categorizing the sun exposure index.

CONCLUSION

The fact that fishermen expose themselves to the sun chronically and have been exposed to the sun for more than 15 years, between 21 and 28 hours a week, and without photoprotection, were indicative factors for protection against vitamin D deficiency. Chronic exposure to sun and high vitamin levels D may be indicative of protection of this population against skin cancer.

The impact of airborne pollution on skin

Indoor and outdoor airborne pollutants modify our environment and represent a growing threat to human health worldwide. Airborne pollution effects on respiratory and cardiac health and diseases have been well established, but its impact on skin remains poorly described. Nonetheless, the skin is one of the main targets of pollutants, which reach the superficial and deeper skin layers by transcutaneous and systemic routes. In this review, we report the outcomes of basic and clinical research studies monitoring pollutant levels in human tissues including the skin and hair. We present a current understanding of the biochemical and biophysical effects of pollutants on skin metabolism, inflammatory processes and oxidative stress, with a focus on polyaromatic hydrocarbons and ground-level ozone that are widespread outdoor pollutants whose effects are mostly studied. We reviewed the literature to report the clinical effects of pollutants on skin health and skin ageing and their impact on some chronic inflammatory skin diseases. We also discuss the potential interactions of airborne pollutants with either ultraviolet radiation or human skin microbiota and their specific impact on skin health.

Profile of dermatological consultations in Brazil (2018)

BACKGROUND

Dermatological diseases are among the primary causes of the demand for basic health care. Studies on the frequency of dermatoses are important for the proper management of health planning.

OBJECTIVES

To evaluate the nosological and behavioral profiles of dermatological consultations in Brazil.

METHODS

The Brazilian Society of Dermatology invited all of its members to complete an online form on patients who sought consultations from March 21-26, 2018. The form contained questions about patient demographics, consultation type according to the patient's funding, the municipality of the consultation, diagnosis, treatments and procedures. Diagnostic and therapeutic decisions were compared between subgroups.

RESULTS

Data from 9629 visits were recorded. The most frequent causes for consultation were acne (8.0%), photoaging (7.7%), nonmelanoma skin cancer (5.4%), and actinic keratosis (4.7%). The identified diseases had distinct patterns with regard to gender, skin color, geographic region, type of funding for the consultation, and age group. Concerning the medical conducts, photoprotection was indicated in 44% of consultations, surgical diagnostic procedures were performed in 7.3%, surgical therapeutic procedures were conducted in 19.2%, and cosmetic procedures were performed in 7.1%.

STUDY LIMITATIONS

Nonrandomized survey, with a sample period of one week.

CONCLUSION

This research allowed us to identify the epidemiological profiles of the demands of outpatients for dermatologists in various contexts. The results also highlight the importance of aesthetic demands in privately funded consultations and the significance of diseases such as acne, nonmelanoma skin cancer, leprosy, and psoriasis to public health.

Daylight photodynamic therapy in 25 patients with actinic keratosis and evaluation of efficacy by confocal microscopy

BACKGROUND

Daylight photodynamic therapy (PDT) has been reported as having similar efficacy to conventional photodynamic therapy in actinic keratosis treatment.

METHODS

25 patients with actinic keratosis of the scalp and/or face were submitted to a daylight photodynamic therapy session. Adverse reactions were evaluated after one week and efficacy after 3 months. Confocal Microscopy was performed in 6 patients, before and one week after the treatment. Our aim was to compare our results with others studies and analyse the changes occurring in the epidermis and upper dermis with confocal microscopy.

RESULTS

76% of the patients were male. The mean age was 74.2 years. In 51.7% of patients the treatment site was the scalp. Mean cure rate at 3 months was 74%. Aesthetic results were excellent in all patients and only one patient reported mild pain during the 2 h exposure. Confocal Microscopy showed a normalization of the honeycomb pattern in all of the patients.

CONCLUSIONS

This therapy has similar results to conventional photodynamic therapy and stands out for less discomfort, fewer adverse effects and better cost-effectiveness. Using confocal microscopy it's possible to in vivo demonstrate the efficacy of this method, with normalization of the honeycomb pattern in the epidermis following succcessful PDT.

A randomized, open, controlled trial of tretinoin 0.05% cream vs. low-dose oral isotretinoin for the treatment of field cancerization

BACKGROUND

Sun exposure may lead to actinic keratoses (AKs), field cancerization, and skin cancer. Effective treatment of AKs and field cancerization is important. Oral and topical retinoids can be used for this purpose. To compare clinical, histological, and immunohistochemical effects of oral and topical retinoid for AKs and field cancerization on face and upper limbs of immunocompetent patients, as well as the impact on quality of life, safety, and tolerability.

METHODS

This study compared 10 mg/day oral isotretinoin (ISO) to 0.05% tretinoin cream (TRE) every other night, associated with sunscreen (SPF 60). Patients of both genders, aged 50-75 years, underwent cryotherapy with liquid nitrogen for AKs at baseline and after 120 days when they were randomized into two groups, TRE (n = 31) and ISO (n = 30), for 6 months. Outcome measures were: number of AKs, histological (thickness of stratum corneum and epithelium) and immunohistochemical parameters (p53, Bcl-2 and Bax), dermatology life quality index (DLQI), and adverse events.

RESULTS

Both treatments reduced the number of AKs (around 28%), the thickness of stratum corneum, and expression of p53 and Bax. By contrast, the epithelium thickness and Bcl-2 expression increased. There was no difference in the outcomes between TRE and ISO. Both treatments improved quality of life and were well tolerated with minimal side effects.

CONCLUSIONS

Retinoids are effective and safe for field cancerization. Classical treatments for field cancerization (imiquimod and ingenol mebutate) are used for a short period; retinoids may be a good choice to intercalate with them and can be used continuously.

Klotho Protein Protects Human Keratinocytes from UVB-Induced Damage Possibly by Reducing Expression and Nuclear Translocation of NF-κB

Background

UV-related skin disease such as actinic keratosis is a major concern in public health. In view of the cell injury induced by UVB, Klotho protein it is an ideal therapy to eliminate UVB-induced cell damages and the associated signaling pathways.

Material/Methods

To gain insights into the potential role of Klotho and the underlying molecular mechanism, we constructed a Klotho-overexpress HaCaT cell line and assessed the protection against UVB insults. The effects of exposure to UVB radiation on the human keratinocyte HaCaT cells, including cell growth, apoptosis, and changes of selected biomarkers, were measured by CCK-8, flow cytometry, Quantitative real-time PCR, and Western blot analysis.

Results

We found that enhanced NF-κB activity was accompanied by decreased expression of the anti-aging protein Klotho upon UVB stimulation, which was further confirmed with in vivo experiments. Overexpression of Klotho was able to considerably alleviate the UVB-induced damages to cells and reversed the UVB-caused biomarker changes to a great extent, which was comparable to the effects of administration of NF-κB inhibitor PDTC, suggesting the inhibition of nuclear translocation and DNA-binding activity of NF-κB. Furthermore, Klotho overexpression was proved to decrease the nuclear expression of NF-κB as much as the treatment with PDTC, which provides support for the direct regulation of NF-κB by Klotho.

Conclusions

Collectively, our work provides new insight into the potential role of Klotho in the context of UVB-induced injuries in human keratinocytes, as well as providing the basis for future study of new therapies against UV-related skin disease.

Current developments in pharmacotherapy for actinic keratosis

INTRODUCTION

Actinic keratosis (AK) is a superficial squamous cell carcinoma (SCC) where chronic sun exposure playing central role in its pathogenesis. UVB causes direct damage to DNA, producing pyrimidine dimers, and suppressing the protective role of p53. The stepwise progression of AK, with increased expression of anti-apoptotic Bcl-2, favors progression to SCC. Moreover, the dermal response characterized by inflammation and mediated by prostaglandins is a critical component of tumorigenesis that promotes tumor growth, tissue invasion, angiogenesis and metastasis. Other risk factors are represented by age, gender, phototype and drugs.

AREAS COVERED

In this review, the authors document the recent developments of different therapies used to treat AK and provide their perspectives on current and future treatment strategies.

EXPERT OPINION

The usefulness of long-term treatment with piroxicam and sun filters or diclofenac targeting the inflammation phases of skin tumorigenesis favors AK's healing and provides greater control of the cancerization field. Nonsteroidal anti-inflammatory drugs can be safely used in patients who use photosensitizing drugs and, therefore, are more at risk of developing skin tumors. Immunomodulatory therapies, which require shorter treatment, are characterized by more common local side effects, and need more attention by the dermatologist in the concern of patient education, resulting essential to improve adherence and outcomes.

Ingenol mebutate in the treatment of actinic keratoses: clearance rate and adverse effects

BACKGROUND

Actinic keratoses are benign intraepithelial skin neoplasms that develop in photoexposed areas and can progress to invasive carcinoma. They are seen frequently in dermatological practice, occurring in 5.1% of consultations. Ingenol mebutate (IM) was recently approved in Brazil as a topical therapy for field cancerization in actinic keratosis.

OBJECTIVE

To evaluate the clearance rate and adverse events in the treatment of actinic keratoses with ingenol mebutate.

METHODS

A longitudinal, prospective, non-randomized, interventional, open, single-center study was conducted. Patients with actinic keratoses applied ingenol mebutate on a 25cm2 area of the face and/or scalp for three consecutive days (0.015%) or on the forearm for two days (0.05%).

RESULTS

27 patients completed the protocol, of whom 13 on the face and/or scalp and 14 on the forearm. Complete clearance occurred in 53.8% in the first group and 42.8% in the second. Partial response was observed in 15.4% and 35.7%, respectively. The most common side effects were erythema, edema, desquamation, pruritus, and local erosion.

STUDY LIMITATIONS

The study had a small sample and was not randomized, double-blind, placebo-controlled, or vehicle-controlled.

CONCLUSION

Ingenol mebutate is well-tolerated for the treatment of actinic keratosis, with good patient adherence thanks to the short treatment period.

Successful Treatment of Actinic Keratosis with Kanuka Honey

Actinic keratoses form as rough, scaly plaques on sun-exposed areas; they can be an important step in premalignant progression to squamous cell cancer of the skin. Currently, pharmacological treatments consist of topical immunomodulatory agents with poor side effect profiles. Use of honey has been common in both ancient and modern medicine, where it is now a key therapy in the management of wound healing. In vitro studies show the New Zealand native Kanuka honey to have immunomodulatory and antimitotic effects, with recent evidence suggesting efficacy of topical application in a variety of dermatological contexts, including rosacea and psoriasis. Here, we present a case report of a 66-year-old gentleman with an actinic keratosis on his hand, which had been present for years. Regular application of Kanuka honey over three months resulted in remission immediately following the treatment period with no signs of recurrence at nine months.

Treatment of Grade II and III Actinic Keratosis Lesions with a Film-Forming Medical Device Containing Sunscreen/Piroxicam 0.8% and a Retinoic Acid/Glycolic Gel: A Pilot Trial

Introduction

Lesion and field-targeted treatments of actinic keratosis (AK) are commonly indicated for grade I and II type lesions. Grade III lesions are in general more difficult to treat. A film-forming medical device containing piroxicam 0.8% and sunscreen (SPF 50+) (PS) has been shown to be effective in the treatment of grade I and II AK lesions. Topical and oral retinoids have been utilized in AK and non-melanoma skin cancers. Topical glycolic acid promotes keratolysis and stimulates collagen synthesis for repair and skin rejuvenation and could be useful in AK treatment strategies. A gel containing retinoid acid (0.02%) and glycolic acid (4%) (RC) is commercially available. The objective of the study was to evaluate the efficacy and local tolerability of a combined treatment approach with PS and RC in subjects with multiple grade II and III AK lesions.

Methods

Twenty-two subjects (16 males and 6 females; mean age 68 years) with more than five AK lesions were enrolled after obtaining their informed consent in a 3-month trial. PS cream was applied twice daily every day and RC gel was applied twice daily for 2 consecutive days every week. The primary endpoint was the evolution of the AK mean number from baseline to the end of the trial. Secondary endpoints were the thickness of the target lesion (expressed in mm³) and the erythema score (hemoglobin content), evaluated using a standardized computer-based image acquisition analysis system (Anthera 3D).

Results

At baseline, the mean (SD) lesion number was 7.7 (3) for grade II and 1.4 (1) for grade III AK. At the end of the study, a significant (P = 0.001) reduction was observed for both grade II (− 81%; from 7.7 to 1.5) and grade III (− 22%) lesions. Six grade III lesions out of 31 (20%), presented at baseline, completely disappeared at month 3. For grade III lesions, a significant mean thickness reduction of 51% was observed at month 3. The erythema score (all lesions) was reduced by 70%. Four patients out of 22 (18%) were completely free of AK lesions at month 3. No severe side effects were reported.

Conclusion

In this exploratory trial, a combined treatment with a cream containing piroxicam and sunscreen and a retinoic/glycolic gel was associated with a substantial reduction of both grade II and III AK lesions with good local tolerability.

Funding

Cantabria Labs Difa Cooper.

P21 Immunoexpression in Actinic Keratosis and Cutaneous Carcinomas

Actinic keratosis is a precancerous lesion of the skin with variable rates of transformation into non-melanocytic carcinomas. The present study aims to analyze p21 expression in actinic keratosis and cutaneous squamous carcinomas. P21 expression analysis revealed a positive reaction in 63 (71.4%) of the investigated cases. The immunostaining analysis revealed positivity in 82.1% of the studied actinic keratosis cases and in 43.9% of the investigated carcinomas. High scores of immunoreactions were identified only for the well-differentiated and for the carcinomas in initial stages. Association of p21 expression with pre-invasive or well-differentiated invasive lesions in early stages of tumor progression suggests that p21 may be an early event in squamous carcinogenesis.

Transfersomes as versatile and flexible nano-vesicular carriers in skin cancer therapy: the state of the art

Introduction: The skin acts as a barrier and prevents transcutaneous delivery of therapeutic agents. Transfersomes are novel vesicular systems that are several times more elastic than other vesicular systems. These are composed of edge activator, phospholipids, ethanol, and sodium cholate and are applied in a non-occlusive manner. Areas covered: This article covers information such as merits/demerits of transfersomes, regulatory aspects of materials used in preparation, different methods of preparation, mechanism of action, review of clinical investigations performed, marketed preparations available, research reports, and patent reports related to transfersomes. Expert opinion: Research over the past few years has provided a better understanding of transfersomal permeation of therapeutic agents across stratum corneum barrier. Transfersomes provides an essential feature of their application to variety of compositions in order to optimize the permeability of a range of therapeutic molecules. This is evidenced by the fact that there are several Transfersome products being processed in advanced clinical trials. It is noteworthy that a number of Transfersome products for dermal and transdermal delivery will gain a global market success in near future.

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.

Efficacy of ingenol mebutate gel for actinic keratosis in patients treated by thiazide diuretics

Actinic keratosis (AK) is considered as superficial squamous cell carcinoma. Chronic sun exposure plays a central role in its pathogenesis. In particular, ultraviolet B radiation causes direct damage to the DNA, producing pyrimidine dimers that suppress the protective role of p53. Other risk factors include advanced age, male sex, and fair skin type. Even some drugs used for treating blood hypertension, such as thiazide diuretics, can increase the risk of developing AK. Their photosensitizing action seems to be connected with reactive oxygen species production. We report our experience with ten patients affected by multiple AK, in therapy with thiazide diuretics, treated by ingenol mebutate gel. AK was clinically and dermoscopically evaluated at baseline and after 30 days from the beginning of the treatment. Moreover, patients were screened for vitamin D₃ values and reported a general hypovitaminosis status. To our knowledge, we report for the first time the efficacy of ingenol mebutate gel in this group of patients, particularly at risk of developing AK.

PDT and emerging therapies for Actinic Keratosis-A resource letter

Aktinic Keratosis is common and if left untreated may develop into life threatening squamous cell carcinoma. Therefore early intervention is the standard of care. While many treatments are available PDT continues to move to the for - front for this indication (Brito et al., 2016 [31]). Topical PS is commercially available that are able to reliably ablate these lesions. Innovative protocols including sunlight, large volume LED arrays and maneuvers to improve treatment parameters and cosmesis continue to make this a worldwide treatment of choice for AK.