Journal of Clinical and Aesthetic Dermatology

Psoriasis and Cutaneous Supplement 2016

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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S 2 2 S U P P L E M E N T T O T H E J O U R N A L O F C L I N I C A L A N D A E S T H E T I C D E R M AT O L O G Y [ S E P T E M B E R 2 0 1 6 • V O L U M E 9 • N U M B E R 9 ] burden of NMSC is likely to increase with the "graying" of industrialized populations. 141 In fact, hospitalizations for skin melanomas generally exceed those for NMSC up to around age 50, when hospitalizations for NMSC increase sharply and by age 80 far exceed those for melanoma. 141 AKs are predictors of SCC, which is a prominent type of cancer in Caucasians. The disease continuum may be described as sun damage to the skin, early-stage AK, full AK, and then SCC. 1 42 The classical pathway involves AK I transforming to AK II, then AK III, and finally to invasive SCC. However, a new differentiated pathway is now being described in which an AK I transforms directly into an invasive SCC without the intervening AK II and AK III forms. The European Prevention Initiative for Dermatological Malignancies (EPIDERM) was founded to raise awareness about cutaneous oncology and to capture data important to its diagnosis and treatment. There are currently EPIDERM groups active in Scotland, Spain, the Netherlands, Germany, Italy, Malta, Poland, Finland, and Greece. In an evaluation of how dermatologists in these countries treat skin cancer, the majority in all nations favored surgical over nonsurgical approaches. 143 The relative differences were highest in Germany (88% surgical vs. 22% nonsurgical) and lowest in Greece (65% surgical vs. 35% nonsurgical). In order to better understand the different subgroups of AK and differentiate treatment strategies, the International League of Dermatological Societies (ILDS) issued their international guidelines for the treatment of AK. 144 Its diagnosis paradigm requires the clinician to evaluate both patients with actual AK and those at high risk for AK development, such as immunosuppressed patients. High-risk patients should be specifically managed to monitor for the onset of AK. Those with active AK should be grouped into those who have solitary lesions or those with multiple lesions, defined as a high number of lesions concentrated in a compact area or patients with a history of multiple lesions. In this latter group, lesion- and field-directed treatment is recommended, either with imiquimod 3.75% or 5%, diclofenac 3% gel, ingenol mebutate, resiquimod, PDT-ALA, or 5- fluorouracil. For patients with solitary lesions, a lesion- directed treatment should be commenced using a topical agent on the lesion and surrounding field; treatment choices include diclofenac 3% gel, imiquimod, PDT-ALA, or 5-fluorouracil. In some patients, cryotherapy may be appropriate to remove a specific lesion and should be followed by topical treatment. Regardless of the type of AK and the treatment selected, all patients with AK should be educated about the importance of sun protection. 144 Field therapy for AK is improving, in that efficacy is better, recurrence rates are low, there are fewer side effects, cosmesis has been improved, application times are shorter, and it has a good safety profile. AK field therapy can be considered cost effective, an increasingly important consideration for today's cost-conscious healthcare system. Since AK can be a precursor of more serious forms of potentially lethal cancers, it is important to not only recognize and treat AK appropriately, but to understand its natural history. The disease process begins with a cell with a genetic mutation, leading to hyperplasia or the build-up of abnormal cells. Hyperplasia then becomes dysplasia and finally in situ cancer, which tends to be invasive and may be aggressive. Gene expression patterns support the notion that AK is a precursor lesion to SCC as the two types of lesions are closely related genetically. 145 In a survey of 427 physicians, 70 percent of respondents believed that AK should be treated with a topical field treatment. 146 Compliance can be a major challenge in AK field treatment, and AK therapy should be considered from the patient's vantage point, namely that lengthy courses of treatment can be burdensome and inconvenient and local skin reactions can limit treatment. Thus, physicians should find topical AK field therapy that is effective, but of short duration and results in rapid clearance with good tolerability. More than 90 percent of physicians surveyed believed that shorter treatment durations for topical AK therapy would improve adherence and persistence. 146 Treating AK means deciding on a strategy based on whether the treatment should address single lesions or the field. Cryotherapy is a good option for treating single, well-defined, hyperkeratotic lesions. Field therapy with a topical agent is an appropriate treatment option for subclinical lesions not treated by cryotherapy. 147 Indeed, an important consideration for topical AK field treatment is the fact that it treats not only visible lesions, but also the expanded patches at the subclinical and cellular level. Although rare, disseminated actinic porokeratosis (DSAP) is also the subject of a paradigm shift in terms of treatment. Previously, these lesions were not well understood or diagnosed by physicians and even dermatologists did not know the optimal course of treatment. DSAP lesions are characterized by an irregular fiber-like ring (coronoid lamella) around them which produces a visible, palpable ridge. The interior of the lesion may be smooth or rough and is often discolored. Many patients find the lesions itchy and irritating, but at times they produce no symptoms. Lesions are typically small, but may grow to a diameter of 10mm. DSAP may develop in the presence of certain immune deficiencies (HIV infection, diabetes mellitus, cirrhosis, acute pancreatitis, Crohn's disease, and others) or it may be an inherited condition. It is more common in women than men, although it occurs in both sexes. Focal clonal expansion of atypical keratinocytes gives rise to the unusual shape of the cornoid lamella. Phenotypic variants indicate a simultaneous expression of closely linked genes, the loci of which can be mapped to chromosomes 12q, 15q, and 18q with various mutations identified in the SSH1

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