Precancerous Lesion Treatment (Actinic Keratoses)
Actinic keratoses — AKs — are the skin’s ledger of accumulated sun damage. They’re rough, scaly, sometimes slightly raised patches that develop most commonly on sun-exposed areas: the face, scalp (especially in men with thinning hair), ears, neck, forearms, and backs of the hands. Some are clearly visible; others are more easily felt than seen — a persistent sandpapery texture that doesn’t resolve the way dry skin from low humidity would.
They are not cancer. But a meaningful percentage will progress to squamous cell carcinoma if left alone. More practically: once you develop them, you tend to keep developing them. Sun damage doesn’t reverse, and new lesions continue to form on chronically exposed skin. The goal of treatment isn’t just to address what’s there now — it’s to manage an ongoing process.
Diagnosis
Most actinic keratoses are diagnosed clinically — the appearance and texture are characteristic enough that biopsy isn’t routinely required. When a lesion looks thicker, more indurated, or has features suggesting it may have already progressed to early squamous cell carcinoma, a biopsy provides clarity. During a full-body skin exam, we inventory the AKs systematically, note their location and character, and factor that into treatment planning. Patients with widespread sun damage across multiple areas benefit from a different approach than someone with one or two isolated lesions.
Treatment options
Cryotherapy with liquid nitrogen is the most straightforward approach for individual, well-defined lesions. It’s quick, effective, and can be done during a routine visit without any preparation. The treated area blisters, scabs, and heals over one to two weeks. It’s the right tool when lesions are discrete and manageable in number.
Topical prescription medications — fluorouracil (Efudex), imiquimod (Aldara), and ingenol mebutate among others — are better suited for patients with numerous or diffuse lesions across a field of sun-damaged skin. These agents treat both visible AKs and the subclinical lesions that exist in the same damaged tissue but aren’t yet visible. They require consistent application over several weeks and cause a significant inflammatory reaction — redness, crusting, sometimes significant discomfort — that reflects the treatment working. Patients need to be prepared for what the treatment course looks like before starting.
Photodynamic therapy (PDT) with Blu-U light and Levulan or Ameluz is one of the most effective options for patients with widespread AKs across larger surface areas. It combines high clearance rates with cosmetic improvement of the surrounding sun-damaged skin. See the Blu-U Light Therapy page for a full description of what the treatment involves.
Prevention going forward
Treatment addresses what’s currently present; it doesn’t prevent new lesions from forming on skin that’s already been extensively damaged. Consistent broad-spectrum sunscreen, protective clothing, sun avoidance during peak hours, and regular follow-up exams are the tools for managing the ongoing process. We give specific recommendations based on what we see and what a patient’s history looks like.
Frequently asked questions
How do I know if I have actinic keratoses?
The most reliable way is to have a dermatologist examine your skin. The telltale sign many patients notice themselves is a rough, slightly elevated patch on sun-exposed skin that doesn’t smooth out with moisturizer. It may be mildly itchy or tender when pressed. If you’ve spent significant time outdoors in Florida and notice anything like this, it’s worth having it evaluated.
If they’re not cancer, do I really need to treat them?
For most patients, treatment is recommended because the risk of individual progression is real and the presence of many lesions multiplies that risk. Leaving them untreated in elderly patients or those with limited treatment tolerance is a reasonable decision in some contexts. We discuss the specifics with each patient rather than applying a blanket recommendation.
Will the treatment be painful?
Cryotherapy causes a brief stinging sensation. Topical treatments cause a prolonged inflammatory reaction that patients often describe as looking much worse than it feels, though it can be uncomfortable. PDT involves a burning sensation during light exposure. We prepare patients thoroughly for each approach so there are no surprises.
Do they come back after treatment?
On chronically sun-damaged skin, new lesions will continue to form regardless of treatment. Treatment clears what’s there now; regular follow-up and sun protection manage what develops going forward. This isn’t a failure of treatment — it’s the nature of the underlying sun damage.