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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Actinic Keratoses: What You Must Know About Prevention, Diagnosis, And Treatment


GOAL
To provide dermatologists, nurse practitioners, and physician assistants with up-to-date information on the treatment and management of patients with actinic keratoses.

TARGET AUDIENCE
This activity is designed for dermatologists, nurse practitioners, and physician assistants active in dermatology care. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:

  • Identify the clinical challenges associated with the care of patients with actinic keratoses (AK).
  • Discuss the pathogenesis, the identification process, and differential diagnoses when diagnosing AK.
  • Describe currently used therapies in the treatment of AK.
  • Analyze the prognosis for the different stages and the efficacy of treatment options.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.
Release date: September 15, 2006. Expiration date: September 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Dermik Laboratories (Sanofi-Aventis).

PROGRAM DIRECTOR

Nanette J. Liégeois, MD, PhD
President and CEO
Meridian Skin Care, Ltd
Assistant Professor
Department of Dermatology
Director of Dermatological Surgery
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Liégeois reports having no significant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Murad Alam, MD
Assistant Professor
Department of Dermatology
Northwestern University
Chicago, Illinois
Dr Alam reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Victor A. Neel, MD, PhD
Director, Dermatologic Surgery
Massachusetts General Hospital
Dermatology Specialist
Dermatology Associates
Boston, Massachusetts
Dr Neel reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Perry Robins, MD
Editor-in-Chief
Journal of Drugs in Dermatology
Chief, Mohs' Micrographic Surgery Unit
Professor of Dermatology
New York University Medical Center
New York, New York
Dr Robins reports serving as a consultant for and on the speakersÕ bureau of Dermik Laboratories.

Sheri L. Rolewski, MSN, CRNP, BC
Family Nurse Practitioner
University of Pittsburgh Physicians
Department of Dermatology
Cosmetic Surgery & Skin Health Center
Sewickley, Pennsylvania
Ms Rolewski reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Notice: The audience is advised that an article in this CME activity contains reference(s) to unlabeled or unapproved uses of drugs or devices.

Ms Rolewskialdara for nodular basal cell carcinoma and actinic keratosis to the chest (right sub- clavicular); tretinoin for chemoprevention of actinic keratoses.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Actinic Keratoses: What You Must Know About Prevention, Diagnosis, and Treatment
Nanette J. Liégeois, MD, PhD*

Since the 1960s, the incidence of nonmelanoma skin cancer (NMSC) has been increasing 4% to 8% annually to the point that NMSC now constitutes more than 33% of all US cancer cases.1 Actinic keratosis (AK) is now considered the earliest clinically recognizable manifestation of squamous cell carcinoma (SCC) of the skin,1,2 1 of the 2 main types of NMSC. A growing need exists for primary care providers with the basic clinical skills required to recognize all of the stages and presentations of SCC, in addition to its precursors, and with knowledge of the treatment options for various stages of skin cancer that are necessary to recommend appropriate definitive treatments and refer patients to specialists appropriately. Although the need for primary care providers to be knowledgeable about skin cancer is increasing, studies have shown alarming gaps in the education of US medical students in skin cancer examination.3

For example, in a study of 7 institutions representative of US medical schools in general, nearly 25% of all medical students surveyed had never even observed a skin cancer examination, and 43% had never examined a patient for skin cancer.3 This lack of training in skin cancer examination may explain why few primary care providers routinely examine their patients for skin cancer,4 even though most patients with skin lesions visit non-dermatologists.3 Moreover, this lack of training was documented in 2006 even though, 10 years earlier, the American Academy of Dermatology (AAD) and the Centers for Disease Control and Prevention (CDC) recommended that all medical school graduates learn to do a skilled skin cancer examination in adults.3

In addition to the AAD and the CDC, medical educators themselves have identified several key skills and clinical pearls related to skin cancer that every medical student should know upon graduation.4 For example, along with being able to recognize the signs of skin cancer, healthcare providers should understand the causal relation between ultraviolet (UV) radiation exposure and skin cancer.4 They should be able to identify on sight patients at high risk for skin cancer4 because of fair skin that tans poorly, freckles, or does not tan.5,6 Healthcare providers should be well-versed in motivating patients to examine their own skin for possible AKs or invasive skin cancers and in educating patients about sun protection and avoidance.4 In particular, when educating patients, they should stress the importance of applying sunscreen regularly, which has been shown in a large, randomized study to substantially reduce a person's future chance of having an AK.7 They should know additional risk factors for skin cancer besides sun exposure, such as positive family history of any type of skin cancer, multiple nevi,4 advanced age, immunosuppression, and exposure to carcinogens, such as arsenic, coal tar (contained in some dandruff shampoos and skin ointments), and nonionizing radiation.8 Knowledge of when to perform a biopsy of a pigmented lesion also is key.4

This issue of Johns Hopkins Advanced Studies in Medicine has been designed to inculcate primary care providers, including nurse practitioners and physician assistants, with these and other key messages about AK. In addition, following the recommendation of one medical student surveyed about dermatology education—"If you don't constantly revisit the subject, then it's so easy to forget"4—this monograph is also designed to reinforce and supplement dermatologists' knowledge about the pathogenesis, recognition, and management of AK.

The monograph begins with a comprehensive review of the prevalence, pathogenesis, recognition, diagnosis, and prevention of AK. After stressing the nature of AK as the earliest clinically recognizable manifestation of SCC of the skin, the review notes the increasing incidence of SCC and the high prevalence of AK in older patients, particularly those with high cumulative exposure to UV radiation. After a brief review of this and other risk factors for AK, the review discusses the pathogenesis of AK and places particular focus on the role of UV-related mutations of the p53 tumor-suppressor gene. The risk of the progression of AK into invasive SCC is then quantified. Next, the review focuses on the typical clinical appearance of AK and variations on it, the indications for and use of biopsy, the histopathologic features and variants of AK, and the main differential diagnoses for AK. The review concludes with key recommendations for AK prevention, a brief list of management options, and the prognosis of patients with early-stage versus late-stage AK.

The monograph continues with a clinician interview containing the practical recommendations of 2 experts in AK and its management, Perry Robins, MD, and Victor A. Neel, MD, PhD. The interview includes valuable tips on tailoring treatment to each patient, delivering cryotherapy effectively, minimizing the pain of photodynamic therapy (PDT), increasing patient compliance with topical medications, and when to do a biopsy. The interview ends with their insights on emerging therapies that hold promise for the treatment and prevention of AK.

The insights in the clinician interview are supplemented by those contained in case studies from both of these high-profile dermatologists on the use of 5-fluorouracil cream or PDT for treating patients with diffuse AK. The monograph concludes with a fascinating case study by nurse practitioner Sheri L. Rolewski, MSN, CRNP, BC, on the use of the immune-based therapy imiquimod and the chemopreventive agent tretinoin for treating and preventing recurrent AK in a double—organ-transplant recipient.

References

1. Lober BA, Lober CW. Actinic keratosis is squamous cell carcinoma. South Med J. 2000;93:650-655.
2. Cockerell CJ, Wharton JR. New histopathological classification of actinic keratosis (incipient intraepidermal squamous cell carcinoma). J Drugs Dermatol. 2005;4:462-467.
3. Moore MM, Geller AC, Zhang Z, et al. Skin cancer examination teaching in US medical education. Arch Dermatol. 2006;142:439-444.
4. Brandling-Bennett HA, Capaldi LA, Gilchrest BA, Geller AC. Improving skin cancer prevention and detection education in US medical schools. Arch Dermatol. 2006;142:524-526.
5. Fulton J. Actinic keratosis. Available at: http://www.emedicine.com/derm/topic9.htm. Accessed June 23, 2006.
6. Salasche SJ. Epidemiology of actinic keratoses and squamous cell carcinoma. J Am Acad Dermatol. 2000;42:S4-S7.
7. Thompson SC, Jolley D, Marks R. Reduction of solar keratoses by regular sunscreen use. N Engl J Med. 1993;329:1147-1151.
8. Barnaby JW, Styles AR, Cockerell CJ. Actinic keratoses. Differential diagnosis and treatment. Drugs Aging. 1997;11:186-205.

*President and CEO, Meridian Skin Care, Ltd, Assistant Professor, Department of Dermatology, Director of Dermatological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Nanette J. Liégeois, MD, PhD,  Assistant Professor, Department of Dermatology, Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 North Caroline Street #6064, Baltimore, MD 21287. E-mail: Nliegeo1@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.