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Health condition · Clinically reviewed

Actinic keratosis, the pre-cancer of sun-damaged skin.

Rough, scaly patches on decades-sunned skin. Treatable early, but a real precursor to squamous cell carcinoma if ignored.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, BAD and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance including field treatments, photodynamic therapy and superficial radiotherapy.

Key facts

Actinic keratosis at a glance.

The essentials in plain English - what it is, who gets it and why treatment matters.

  • What it is

    Actinic keratosis (solar keratosis) is a pre-cancerous patch of UV-damaged epidermis - rough, scaly, keratotic lesions on chronically sun-exposed skin.

  • Who gets it

    Fair-skinned adults (Fitzpatrick I to II), typically over 50, and anyone with heavy lifetime sun exposure - farmers, sailors and outdoor workers.

  • Where it appears

    Face, scalp (bald men), ears, dorsal hands and forearms - the areas that catch decades of sunlight.

  • Why it matters

    Around 1 to 10% of individual lesions progress to squamous cell carcinoma each year on a cumulative basis - so treatment and surveillance matter.

  • Transplant risk

    Organ transplant recipients on long-term immunosuppression develop AKs earlier, in greater numbers, with a much higher risk of SCC.

  • Best prevention

    Daily broad-spectrum SPF 50, hats and long sleeves - sun protection reduces both new AKs and progression to skin cancer.

Why this guide matters

A pre-cancer worth treating early.

Actinic keratosis is common, easily missed and the most treatable stage of skin cancer risk. Three principles guide the plan below.

  • Prevention is the strongest lever

    Daily broad-spectrum SPF 50 and physical protection reduce both new AKs and progression to squamous cell carcinoma.

  • Field disease needs field treatment

    Multiple lesions in one area point to widespread UV damage - creams, PDT or radiotherapy treat the whole cancerised zone.

  • Immunosuppression changes the rules

    Transplant patients and those on long-term immunosuppression need earlier, more aggressive management and closer follow-up.

How the diagnosis is made

From first scaly patch to a clear plan.

The steps a UK GP or dermatologist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Skin history and risk profile

    Fair skin, cumulative sun exposure, outdoor work, previous skin cancers, and any immunosuppression - all shape the plan.

  2. 02

    Assessing

    Full skin examination

    A structured look at face, scalp, ears, neck, dorsal hands and forearms - counting lesions and mapping affected fields.

  3. 03

    Assessing

    Clinical grading

    Grade I (better felt than seen), grade II (visible and rough) or grade III (thick, hyperkeratotic) - guides treatment intensity.

  4. 04

    Confirming

    Dermatoscopy

    A dermatoscope shows a strawberry pattern - erythematous background with white keratin around follicles - and helps distinguish AK from early SCC.

  5. 05

    Confirming

    Biopsy for suspicious features

    Induration, ulceration, tenderness, bleeding or rapid growth mean biopsy to exclude invasive squamous cell carcinoma.

  6. 06

    Planning

    Field vs lesion decision

    Isolated lesions are treated individually; multiple lesions in one area point to field treatment across the whole cancerised zone.

  7. 07

    Planning

    Surveillance plan

    Everyone with AK needs a follow-up schedule and a written sun-protection plan - transplant patients need closer review.

Typical timeline: first review to a full treatment plan in one or two visits.

Symptoms

What actinic keratosis looks like.

A spectrum from barely visible sandpaper patches to thick keratotic build-up - and the features that mean it is time to biopsy.

  • Rough, scaly patches

    Sandpaper-like macules or papules - often felt before they are clearly seen, particularly on the face and scalp.

  • Erythematous background

    Pink or red base with adherent yellow-brown scale - the classic AK appearance on sun-damaged skin.

  • Hyperkeratotic lesions

    Thicker, warty or horn-like build-up on top - grade III disease that may need more aggressive treatment.

  • Field cancerisation

    Multiple lesions across a whole area of chronically damaged skin - the entire field needs treating, not just visible spots.

  • Cheilitis (lips)

    Actinic cheilitis on the lower lip - persistent dryness, scaling and blurring of the vermilion border. High SCC risk.

  • Bald scalp lesions

    Common in men with androgenetic alopecia - the unprotected scalp accumulates decades of UV damage.

  • Dorsal hand lesions

    Backs of hands and forearms - scaly patches on skin already showing wrinkling, freckling and telangiectasia.

  • Red flag - possible SCC

    Rapid growth, pain, induration, ulceration or bleeding means biopsy without delay to rule out invasive squamous cell carcinoma.

Treatment

How actinic keratosis is treated in the UK.

Prevention first, then cryotherapy for single lesions, field treatments for multiple, and PDT or superficial radiotherapy for extensive disease.

  • Sun protection and prevention

    The single most important step - daily broad-spectrum SPF 50, hats, long sleeves and shade. Reduces new lesions and progression.

  • Cryotherapy

    Liquid nitrogen for discrete individual lesions - fast, effective in clinic, but leaves a small pale scar and does not treat the surrounding field.

  • Curettage and biopsy

    For hyperkeratotic or diagnostically uncertain lesions - removes and provides tissue to exclude SCC.

  • 5-fluorouracil (Efudix)

    A field treatment - once or twice daily for three to four weeks. Expect brisk redness, crusting and inflammation, then healing.

  • Imiquimod (Aldara or Zyclara)

    A field treatment - immune-modulating cream at 3.75% or 5% strength. Effective for larger areas of the face and scalp.

  • Tirbanibulin (Klisyri)

    A newer once-daily cream applied for five days - shorter, better tolerated field treatment for face and scalp AK.

  • Photodynamic therapy (PDT)

    MAL or ALA activated by red light - excellent cosmetic results for larger fields, often preferred on the face.

  • Superficial radiotherapy (SRT)

    For extensive fields, or in frail elderly patients where creams and PDT are impractical - a specialist option in dermatology or oncology.

A note on withdrawn treatments

Ingenol mebutate (Picato) was withdrawn from the UK and European markets in 2020 following an EMA safety review linking it to a higher risk of skin cancers. It is no longer prescribed. Current options include tirbanibulin (Klisyri) as a short-course field treatment.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or dermatologist knows your skin and history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Actinic keratosis - management pathway and topical therapy guidance.

  • British Association of Dermatologists (BAD). Guidelines for the management of actinic keratoses.

  • European Dermatology Forum. Evidence-based guideline for the treatment of actinic keratosis.

  • MHRA. Ingenol mebutate (Picato) - withdrawn from the UK market in 2020 following EMA safety review.

Red flags

When actinic keratosis needs urgent attention.

Most AK is manageable in primary care with cryotherapy or a field cream. These are the situations that need a lower threshold for biopsy or referral.

  • Rapid growth or induration

    A lesion that thickens, grows or becomes firm within weeks needs urgent biopsy to exclude squamous cell carcinoma.

  • Ulceration or bleeding

    Persistent ulcers or spontaneous bleeding on sun-damaged skin should be assumed to be SCC until proven otherwise.

  • Tenderness or pain

    AKs are usually asymptomatic - pain or tenderness at a lesion is a warning sign for invasive disease.

  • Actinic cheilitis

    Chronic sun-damaged lower lip carries a higher risk of aggressive SCC - refer early for field therapy or vermilionectomy.

  • Transplant recipients

    Organ transplant patients on long-term immunosuppression need aggressive management, close surveillance and often nicotinamide plus acitretin.

  • Immunosuppression - other

    Long-term biologics, chemotherapy or HIV lower immune surveillance and accelerate AK to SCC progression.

  • Large or numerous lesions

    Extensive field disease often needs specialist input - PDT, superficial radiotherapy or systemic prevention with retinoids.

  • Failure of first-line treatment

    Persistence or rapid recurrence after cryotherapy or a field cream warrants dermatology review and biopsy.

  • Lesion on ear, lip or scalp

    These high-risk sites have poorer outcomes if SCC develops - a lower threshold for biopsy and specialist referral.

Living with it

A chronic condition, with a clear plan.

Four things that make the biggest difference year to year - sun protection, self-checks, sticking with treatment and a proper follow-up schedule.

A quiet reminder

Small habits, kept up for decades, matter most.

Daily SPF and a wide-brimmed hat are worth more than any single course of cream. Prevention runs in the background of every plan.

  1. 01 Prevention

    Sun protection every day

    Broad-spectrum SPF 50, a wide-brimmed hat and long sleeves - year round, not just on holidays. This is the single biggest lever.

  2. 02 Vigilance

    Learn your skin

    Check face, scalp, ears, hands and forearms monthly. New, changing or bleeding lesions warrant an early GP or dermatology review.

  3. 03 Adherence

    Finish the course

    Field treatments look worse before they look better - stopping early leaves untreated damage. Push through the redness with support.

  4. 04 Follow up

    Keep a review schedule

    AK is a chronic, relapsing condition - regular follow-up catches new lesions early and prevents progression to skin cancer.

Frequently asked

Everything we get asked about actinic keratosis.

Quick answers on cryotherapy, field creams, PDT, superficial radiotherapy and immunosuppressed patients.

  • What is actinic keratosis?

    Actinic keratosis, also called solar keratosis, is a pre-cancerous patch of UV-damaged epidermis. It appears as rough, scaly, red or brown patches on chronically sun-exposed skin - typically the face, scalp, ears, dorsal hands and forearms.

  • Is actinic keratosis skin cancer?

    Not yet - it is a pre-cancerous change. Around 1 to 10% of individual AK lesions progress to squamous cell carcinoma each year on a cumulative basis, which is why treatment and long-term surveillance matter.

  • How is actinic keratosis treated?

    Individual lesions are usually treated with cryotherapy (liquid nitrogen). Multiple lesions in one area need field treatment - 5-fluorouracil (Efudix), imiquimod, tirbanibulin (Klisyri), or photodynamic therapy. Superficial radiotherapy is an option for extensive or difficult fields.

  • When should I have a biopsy?

    A biopsy is needed if a lesion is indurated, ulcerated, tender, bleeding, growing rapidly or failing to respond to treatment. These features raise concern for invasive squamous cell carcinoma.

  • Why do transplant patients need extra care?

    Long-term immunosuppression after organ transplant sharply raises the risk of AK and SCC. Management is more aggressive - regular dermatology review, early field treatment, oral nicotinamide 500 mg twice daily, and often acitretin as chemoprevention.

  • Can I prevent actinic keratosis?

    Yes - daily broad-spectrum SPF 50 sunscreen, wide-brimmed hats, long sleeves and shade all reduce new AKs and slow progression of existing ones. Sun protection remains the single most effective step at every stage.

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