Checked: 16-05-2025 by
Rob Adams Next Review: 16-05-2027
Overview
Given the very large numbers of patients who have actinic keratoses (AK) it is important that the majority should be managed in the community, and preferably by GPs otherwise consultant and GPwER clinics will become overburdened, and patients with more serious skin problems will wait longer to be seen by a specialist. This approach is supported by local clinicians.
Local clinicians recommend following clinical guidelines by the Primary Care Dermatology Society (PCDS): Actinic keratosis clinical guidance (1).
Who to Refer
Uncomplicated actinic keratoses can normally be diagnosed and managed in primary care.
If advice or confirmation of diagnosis is required then consider using Dermatology Advice & Guidance initially (can be converted to a referral if box is ticked in eRS).
Consider referral if there are red flags or failure to respond to treatment in primary care.
It is important to give patients advice about sun exposure and sun protection to prevent further skin damage.
Safety-netting
Ensure that patients are advised to return if lesions do not improve following treatment in primary care or if they reccur again in future due to the small risk of malignant transformation in AKs. Giving a patient information leaflet (PCDS) can help to reinforce this advice.
Although the risk of an AK transforming into a squamous cell carcinoma (SCC) is very low, this risk increases over time and with larger numbers of lesions. The presence of ten AK is associated with a 14% risk of developing an SCC within five years (1).
Please also consider the Red Flag section below to assess for possible SCC or higher risk patients.
Red Flags
The following features could suggest transformation from an AK into an SCC:
If a lesion is suspicious of an SCC, please refer via the Skin - USC (2WW) pathway.
Other criteria for referral to a Dermatologist :-
Patients with actinic damage who are at much higher risk of developing an SCC:
- Immunosuppressed patients, in particular those post-transplant.
- Very young patients presenting with Actinic keratosis – consider xeroderma pigmentosum.
Referral
If referral is indicated and SCC/malignancy is not suspected then patients can be referred via eRS to:
- Dermatology advice and guidance (tick box allowing conversion to referral if required)
- Dermatology (secondary care) or,
- Community Dermatology Service
Please attach photos including dermoscopy images if possible.
Funding Policy
Referral to secondary care for assessment and treatment of actinic keratosis is no longer subject to the Benign Skin Lesions Policy. but the policy does state the following:
- For lesions where there is diagnostic uncertainty - please use dermatology advice and guidance service initially.
- Pre-malignant lesions (e.g. Actinic keratosis, Bowens disease) should usually be managed in primary care with support of advice and guidance if necessary. Referral should only be made following advice or treatment failure.
Resources
Information for Health Care Professionals
Patient Information
BNSSG Formulary
Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.
