Most people do not see an actinic keratosis first. They feel it. A small rough spot on the back of a hand, the forehead or the rim of an ear, noticed while washing or shaving, that feels rough under the fingertips. Moisturiser is applied, the patch settles, then it returns to the same place.
If a doctor has since used the word precancerous, that is alarming to hear about a patch you had barely registered. The reality is more measured than the word suggests.
In short: Actinic keratoses, also called solar keratoses, are areas of sun-damaged skin that usually appear on the face, ears, bald areas of the scalp, forearms and backs of the hands. Left untreated over many years, an individual patch carries a very small risk of turning into a squamous cell carcinoma, but the presence of several is a marker of cumulative sun damage. A patch that becomes a lump, grows quickly, turns tender, ulcerates or bleeds should be assessed promptly.
What an actinic keratosis actually is
An actinic keratosis is an area of skin damaged by ultraviolet light over many years. The British Association of Dermatologists explains the name simply: actinic and solar both mean caused by sunlight, while keratosis refers to thickened skin.
According to the British Association of Dermatologists (BAD), they occur where the body gets the most sun: the forearms, the backs of the hands, the face, the ears and any areas of scalp without hair, for example as a result of balding. They can also appear on the lips. The cause is cumulative exposure rather than any single episode, and the BAD lists sunbathing, sunbed use, outdoor work, outdoor recreation and living in a sunny climate. Actinic keratoses are not contagious.
What they look and feel like
Appearance varies, which is why they are so often mistaken for dry skin. The BAD describes these features.
- Texture before colour: a change in the feel of the skin is often noticed before any change in colour, and the patch may simply feel rough or scaly and look like dry skin.
- Colour: often pink, but they can also be skin-coloured or red.
- Size: they can grow to one or two centimetres across, and occasionally develop a thicker, lumpy layer on top.
- The skin around them: usually looks sun-damaged in its own right, meaning blotchy, freckled and wrinkled.
- Rarely alone: there are usually several in the same area of sun-exposed skin. A single isolated one is uncommon.
- Symptoms: they often cause no trouble at all, but some people find them itchy or sore.
Who tends to get them
They are more common than most patients realise. NHS Scotland’s dermatology pathway, adapted from the BAD referral guidelines, reports that limited UK studies found 19 to 24 per cent of people aged over 60 had at least one, and that they were present in 3 to 6 per cent of men aged 40 to 49. The BAD identifies the groups most affected.
- Older people, because the damage is cumulative and builds over decades.
- Fair-skinned people with blue eyes and red or blonde hair, who burn easily in the sun.
- People with albinism or xeroderma pigmentosum, who are at increased risk.
Actinic keratoses are not hereditary, though the BAD notes that some risk factors do run in families, such as a tendency to burn rather than tan, fair or red hair, blue eyes and freckles.
How likely is one to become skin cancer
The BAD’s position is that if an actinic keratosis is left untreated for many years, there is a very small risk it can progress into a squamous cell carcinoma, a form of skin cancer. For any single patch, the risk is genuinely low.
The number of patches changes the picture. NHS Scotland’s pathway states that in patients with ten or more actinic keratoses there is a 10 to 15 per cent risk of developing a squamous cell carcinoma at some stage. The BAD adds that people affected by many actinic keratoses are also at higher risk of developing other types of skin cancer than someone of the same age who has none.
One rough patch is unlikely to be the problem. Several are a measure of how much ultraviolet damage the skin has accumulated, and that is the finding worth acting on.
Changes that need prompt assessment
If a patch changes in any of the following ways, we would want it looked at without delay. The BAD advises seeking medical advice for each of them.
- Develops into a lump or a horn.
- Grows very quickly.
- Becomes tender.
- Forms an ulcer.
- Starts to bleed.
The BAD notes that these changes could indicate the early onset of skin cancer, and that early treatment is usually curative. NHS Scotland’s pathway adds that rapid growth, a hardened base or ulceration may suggest a squamous cell carcinoma rather than an actinic keratosis, and identifies the ear and the lip as higher-risk sites.
Those most at risk of these changes, according to the BAD, are people with multiple actinic keratoses and people taking immunosuppressive drugs, for example organ transplant patients.
One caveat matters if you are already using a prescribed cream. The same pathway notes that actinic keratoses commonly become tender or ulcerated during topical treatment, and that this should settle once the course ends or with a topical steroid. Soreness during a course is expected. Soreness that does not settle afterwards is worth reporting.
Telling an actinic keratosis apart from other marks
Several harmless marks are commonly confused with actinic keratosis. We cover the benign look-alikes in our article on whether a spot is a mole or something else.
| Mark | Typical look and feel | Where it appears | Colour |
|---|---|---|---|
| Actinic keratosis | Rough or scaly, often noticed by touch before it is seen | Sun-exposed sites, usually several in one area | Often pink, sometimes skin-coloured or red |
| Seborrhoeic keratosis | Looks stuck on to the skin, rough, waxy or warty surface | Anywhere, more common from middle age | Tan to dark brown or black |
| Age spot (solar lentigo) | Flat and well defined, does not fade in winter | Areas with the most cumulative sun exposure | Darker than the surrounding skin |
This table is a general guide only. It cannot diagnose any individual patch, and the features separating a benign growth from an early skin cancer are often too subtle to judge without magnified examination.
One distinction matters more than the rest. Dry skin and mild eczema improve with moisturiser and stay improved. The BAD notes that moisturisers can be used on scaly patches, but they do not treat the sun damage underneath, so the patch returns to the same spot. A rough patch that keeps coming back in one place on sun-exposed skin is worth having identified properly.
How actinic keratoses are diagnosed
In most cases the diagnosis is made by looking. The BAD states that the appearance is usually enough for a doctor who manages skin problems, whether a GP or a dermatologist, to identify it.
Where there is uncertainty, the answer comes from the laboratory rather than the eye. The BAD explains that a sample, or the whole affected area, may be removed surgically under local anaesthetic and examined under a microscope. That matters most where the concern is whether a thickened or tender patch has already become a squamous cell carcinoma.
What treatment involves
Not every actinic keratosis needs treating. The BAD notes that some go away without treatment, particularly if small and protected from the sun, and that some people choose simply to monitor their skin. Treatment depends on the number of patches, where they are, and factors that differ between people. The BAD’s options fall into a few groups.
- Prescription creams and gels, including 5-fluorouracil and imiquimod, which the BAD describes as effective but which often cause temporary redness and soreness of the treated area. Diclofenac and tirbanibulin are also licensed for this use.
- Cryotherapy, meaning freezing with liquid nitrogen. The BAD describes this as effective and notes it does not normally scar, though it can be painful and may cause the treated area to lose its natural pigment permanently.
- Surgical removal, where the area is numbed and the patch is scraped off with a curette (a sharp spoon-shaped instrument) or cut out and stitched. This leaves a scar but produces a sample that confirms the diagnosis.
- Photodynamic therapy and laser treatment, which the BAD notes are only available in certain clinics.
One point surprises people. The BAD states that while an individual actinic keratosis can be cured, they tend to recur, and their presence indicates sun damage, so the person remains at risk of developing more. Treating a patch resolves that patch, not the damage around it, which is why sun protection and self-monitoring matter as much as any single treatment.
Protecting your skin from further damage
Protecting skin from the sun reduces the number of new actinic keratoses and the risk of skin cancer. The BAD recommends the following.
- Cover up with clothing, a hat that protects the face, neck and ears, and UV protective sunglasses.
- Use shade between 11am and 3pm when it is sunny.
- Avoid sunburn, and avoid sunbeds and UV tanning cabinets. The BAD adds that a tan is itself a sign of skin damage.
- Use high protection sunscreen of at least SPF 30 with high UVA protection, applied generously 15 to 30 minutes before going outdoors and reapplied frequently, including straight after swimming or towel drying.
- Check your own skin every few months, and see a doctor if something new appears abnormal.
The BAD adds that no sunscreen offers 100 per cent protection, and that sunscreen is additional protection rather than a substitute for clothing and shade.
Why a specialist assessment is worth it
GPs play a vital role, and many actinic keratoses are managed perfectly well in primary care. The reason to see a consultant dermatologist is usually not the patch that prompted the appointment. It is the skin around it.
A consultant examines the patch in the context of your whole skin and history, can use magnified examination to see detail invisible to the naked eye, and can arrange laboratory confirmation rather than an estimate. The decisions that follow, whether to treat and how closely to follow you up, depend on the number of lesions, their sites and your risk profile rather than on one spot.
At 108 Harley Street, our Skin Clinic has provided consultant-led dermatology since 1991. We offer a one-stop service, from consultation through to minor operations, with same-day procedures in our on-site day surgery.
The bottom line
An actinic keratosis is a patch of sun damage, not a cancer, and the risk that any individual one becomes a squamous cell carcinoma is very small.
What they do tell you is how much ultraviolet damage your skin has accumulated. Several together, or any patch that becomes lumpy, tender, fast-growing, ulcerated or bleeding, is a reason to stop guessing and have your skin assessed.
If a rough patch keeps returning on your face, scalp, ears or hands, you can book an appointment with our Skin Clinic.
