Cancer Association of South Africa (CANSA)

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1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet n Actinic Keratsis Intrductin Actinic keratses (AKs) frm n skin that saks up lts f sun ver the years. An actinic keratsis (AK), is a rugh, dry, scaly patch r grwth that frms n the skin. An AK frms when the skin is badly damaged by ultravilet (UV) rays frm the sun r indr tanning. Mst peple get mre than ne AK. When ne has mre than ne AK, ne has actinic keratses, r AKs. [Picture Credit: Actinic Keratsis] Anyne wh has many AKs shuld be under a dermatlgist s care. Mst peple wh have many AKs cntinue t get new AKs fr life. AKs are cnsidered precancerus. Left untreated, AKs may turn int a type f skin cancer called squamus cell carcinma (please refer t the Fact Sheet n Squamus Cell Carcinma). AKs typically appear n sun-expsed areas such as the face, bald scalp, lips, and the back f the hands, and are ften elevated, rugh in texture, and resemble warts. Mst becme red, but sme will be tan, pink, and/r flesh-tned. If left untreated, up t ten percent f AKs develp int squamus cell carcinma (SCC), the secnd mst cmmn frm f skin cancer. In rarer instances, AKs may als turn int basal cell carcinmas, the mst cmmn frm f skin cancer (please refer t the Fact Sheet n Basal Cell Carcinma). By seeing a dermatlgist fr check-ups, the AKs can be treated befre they becme skin cancer. If skin cancer des develp, it can be caught early when treatment ften cures skin cancer. (American Academy f Dermatlgy; Skin Cancer Fundatin). Incidence f Actinic Keratsis (AK) in Suth Africa. The Natinal Cancer Registry () des nt prvide any infrmatin regarding the incidence f Actinic Keratsis (AK). Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 1

2 Basal Cell Carcinma Accrding t the Natinal Cancer Registry () the fllwing number f Basal Cell Carcinma cases was histlgically diagnsed in Suth Africa during : Grup - Males Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All males :16 25,53% Asian males 49 1:123 5,83% Black males 374 1:240 3,47% Clured males 934 1:15 22,37% White males :5 38,73% Grup - Females Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All females :35 17,96% Asian females 42 1:167 4,10% Black females 317 1:557 2,03% Clured females 680 1:30 16,77% White females :7 34,86% The frequency f histlgically diagnsed cases f Basal Cell Carcinma in Suth Africa fr were as fllws (Natinal Cancer Registry, ): Grup - Males All males Asian males Black males Clured males White males Grup - Females All females Asian females Black females Clured females White females N.B. In the event that the ttals in any f the abve tables d nt tally, this may be the result f uncertainties as t the age, race r sex f the individual. The ttals fr all males and all females, hwever, always reflect the crrect ttals. Squamus Cell Carcinma Accrding t the Natinal Cancer Registry () the fllwing number f squamus cell carcinma (SCC) cases was histlgically diagnsed in Suth Africa during : Grup - Males Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All males :39 10,93% Asian males 21 1:258 3,07% Black males 410 1:268 3,81% Clured males 371 1:41 8,89% White males :11 15,50% Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 2

3 Grup - Females Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All females :108 6,79% Asian females 21 1: ,63% Black females 342 1:575 1,58% Clured females 233 1:100 9,45% White females :27 11,90% The frequency f histlgically diagnsed cases f squamus cell carcinma (SCC) in Suth Africa fr was as fllws (Natinal Cancer Registry, ): Grup - Males All males Asian males Black males Clured males White males Grup - Females All females Asian females Black females Clured females White females N.B. In the event that the ttals in any f the abve tables d nt tally, this may be the result f uncertainties as t the age, race r sex f the individual. The ttals fr all males and all females, hwever, always reflect the crrect ttals. Causes f Actinic Keratsis (AK) Chrnic sun expsure is the cause f almst all actinic keratses. Sun damage t the skin is cumulative, s even a brief perid in the sun adds t the lifetime ttal. Cludy days are nt safe either, because percent f slar ultravilet (UV) rays can pass thrugh cluds. These harmful rays can als bunce ff sand, snw and ther reflective surfaces, giving ne extra expsure. The ultravilet radiatin given ff by the lamps in a tanning saln can be even mre dangerus than the sun. CANSA, therefre, warns against the use f tanning beds/sunbeds. Occasinally, actinic keratses may be caused by extensive expsure t X-rays r a number f industrial chemicals, e.g. arsenic, cal tar, st, pitch, creste, shale ils, and petrleum prducts, such as mineral il r mtr il. [Picture Credit: Tanning Bed] Because the ttal amunt f time spent in the sun adds up year by year, lder peple are mst likely t develp actinic keratses. Hwever, nwadays, sme individuals in their 20s are affected. Still, actinic keratses becme much mre cmmn in Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 3

4 peple ver the age f 50. Sme experts believe almst everyne ver 80 has actinic keratses. Als, individuals whse immune defences are weakened by cancer chemtherapy, Aids, rgan transplantatin r excessive UV expsure are less able t fight ff the effects f the radiatin and thus mre likely t develp actinic keratses. Peple wh have fair skin, blnde r red hair, and blue, green, r gray eyes are at the greatest risk, but darker-skinned peple can develp keratses if they expse themselves t the sun withut prtectin. Peple with certain rare cnditins that make the skin very sensitive t the sun's UV rays, such as albinism and xerderma pigmentsum (XP), are at very high risk. [Picture Credit: Albinism] Thugh nly abut 10 percent f AKs turn int cancers, there is n way t knw ahead f time which nes are precursrs f squamus cell carcinma. That is why it is frtunate that there are s many effective treatments fr eliminating actinic keratses. When an AK is suspected t be an early cancer, the physician may take tissue fr bipsy. This is dne by shaving ff the tp f the lesin with a scalpel r scraping it ff with a curette. Lcal anaesthesia may be required. Bleeding is usually stpped with a styptic agent. (Skin Cancer Fundatin; Jhns Hpkins Medicine; Cancer Research UK). Wh is at Risk fr Actinic Keratsis? Thse individuals wh develp actinic keratsis tend t be fair-skinned peple wh have spent a lt f time utdrs at wrk r at play ver the curse f many years r wh have expsed their skin t indr tanning radiatin. Their skin ften becmes wrinkled, mttled, and disclured frm sun expsure. Others at risk fr develping actinic keratsis include thse wh have their immune systems suppressed, such as rgan-transplant patients, as well as patients with psriasis treated with PUVA therapy (tpical lng-wave ultravilet light plus ral chemicals called psralens). (MedicineNet). Signs and Symptms f Actinic Keratsis (AK) The signs and symptms f an actinic keratsis include: Rugh, dry r scaly patch f skin, usually less than 2.5 centimetres in diameter Flat t slightly raised patch r bump n the tp layer f skin In sme cases, a hard, wart-like surface Clur as varied as pink, red r brwn, r flesh-clured Itching r burning in the affected area Actinic keratses (AKs) are fund primarily n areas expsed t the sun, including the face, lips, ears, back f the hands, frearms, scalp and neck. (May Clinic). Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 4

5 Diagnsis f Actinic Keratsis (AK) A General Practitiner (GP) may be able t diagnse actinic keratsis by examining the patches n a persn s skin. In sme cases, the diagnsis may need t be cnfirmed by remving a small sample f skin and examining it under a micrscpe. Actinic keratsis can ften be managed by a GP, but ne may need t see a skin specialist (dermatlgist) fr further assessment if the: GP is nt certain abut the diagnsis GP thinks ne r mre f the patches may be cancerus r at a high risk f becming cancerus patches are particularly severe r widespread patient is taking immunsuppressant drugs - fr example, fllwing an rgan transplant patches have nt respnded t treatment (NHS Chices). Tips fr Managing Actinic Keratsis (AK) An actinic keratsis (AK) frms n skin that has been badly damaged by ultravilet (UV) rays. The sun and indr tanning expse individuals t these harmful rays. If a persn has been diagnsed with AKs, dermatlgists recmmend prtecting the skin frm the sun. By prtecting the skin frm the sun, ne can help prevent new AKs frm frming. This als will help make the treatment mre effective. Dermatlgists ffer the fllwing tips t their patients wh have AKs: Avid the midday sun. D this by scheduling utdr activities fr earlier in the mrning (befre 10:00) and later in the afternn (after 15:00). Put n sunscreen every day even n cludy days and in the winter. Apply sunscreen t all skin that clthing will nt cver. 3 things that a sunscreen must ffer: SPF (sun prtectin factr) f 30 r higher UVA/UVB prtectin (label may say brad-spectrum ) Water resistance Prtect the lips. Apply a lip balm that cntains sunscreen (if available). The lip balm als shuld ffer an SPF f 30 r greater and UVA/UVB prtectin. Prtect the skin with clthing, preferably with a gd UPF value. Whenever pssible wear: A wide-brimmed hat Lng sleeves Lng pants T see hw well the clthes will prtect - hld each garment in frnt f bright light. If ne can see light thrugh the clth, harmful light frm the sun can penetrate the clth. Select anther garment. One culd als wear that garment but apply sunscreen first t the skin that the garment will cver. Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 5

6 D nt use tanning beds r ther indr tanning devices. Tanning beds and sun lamps emit UV rays that can be strnger than the rays frm the sun. This can cause new AKs. Check the skin as ften as the dermatlgist recmmends. If ne ntices a grwth n the skin that has any f the fllwing traits, cntact a dermatlgist right away: Starts t itch r bleed. Becmes nticeably thicker. Remains after treatment. Changes in size, shape, r clur. Keep all appintments with a dermatlgist. Left untreated, AKs can turn int a type f skin cancer called squamus cell carcinma (please refer t the Fact Sheet n Squamus Cell Carcinma). With early detectin and treatment, skin cancer has a high cure rate. Because AKs develp n skin that has been badly damaged by UV rays, ne als has a higher risk fr develping ther types f skin cancer, including melanma (please refer t the Fact Sheet n Melanma). Keeping ne s appintments helps t detect skin cancer early when a cure is likely. Realise that new AKs may frm. AKs frm n badly damaged skin. Sme peple will cntinue t develp new AKs fr life, even when they prtect their skin frm the sun. This des nt mean that sun prtectin and treatment are nt wrking. (American Academy f Dermatlgy). Treatment f Actinic Keratsis (AK) Early treatment f actinic keratsis is recmmended t stp the pssible prgressin t a type f skin cancer (squamus cell carcinma). Treatment may include: Almst all AKs can be eliminated if treated early, befre they becme skin cancers. Varius treatment ptins are available, which depend n the grwth s characteristics and the patient s age and health. Sme f these strategies increase sun sensitivity, s check with yur dctr, and be especially diligent abut using sun prtectin during the treatment perid. Cmmn treatments include the fllwing. This is the mst cmmnly used treatment methd when a limited number f lesins exist. Treatment can be perfrmed in the physician s ffice, and n cutting r anaesthesia is required. Liquid nitrgen, applied with a spray device r cttn-tipped applicatr, freezes the grwths. The lesins subsequently shrink and/r blister, becme crusted and fall ff. Temprary redness and swelling may ccur after treatment, and in sme patients, pigment may be lst, leaving white spts. When AKs are numerus and widespread, tpical creams, gels and slutins are especially useful by themselves r in cmbinatin with anther frm f treatment. They treat bth visible and invisible lesins with a minimal risk f scarring. One f the mst cmmnly used tpical medicatins fr AK is 5-flururacil (5- FU) cream r slutin, an FDA-apprved tpical chemtherapy rubbed gently nt the lesin areas nce r twice daily fr tw t fur weeks. It can be used n all Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 6

7 affected areas. Temprary side effects include redness, swelling, and crusting but fr many the therapeutic benefits utweigh any temprary discmfrt. 5-FU is available in a variety f frmulatins, in cncentratins ranging frm 0.5 percent t 5 percent. The treated areas usually heal within tw weeks, there is rarely scarring, and the csmetic result is gd. Imiquimd cream, als FDA-apprved, wrks in a different way: It stimulates the immune system t prduce interfern, a chemical that destrys cancerus and precancerus cells. Available in cncentratins f 5%, 3.75% and 2.5 %, it is rubbed gently n the lesin, mst ften tw r three times a week fr several weeks r mnths. The cream is generally well-tlerated, but sme individuals develp redness and ulceratins. A gel cmbining hyalurnic acid, a chemical fund naturally in the bdy, with thenn-steridal anti-inflammatry drug diclfenac may als be effective fr peple whse skin is versensitive t ther tpical treatments. The gel is applied twice a day fr tw t three mnths, thugh curses f treatment under three mnths have prven less effective. Recent research fund that a frmula f 3 percent diclfenac twice daily successfully eliminated AKs in rgan transplant patients (wh are highly susceptible t AKs and skin cancers) and als was effective at preventing invasive squamus cell carcinmas. In 2012, the FDA apprved an effective new tpical medicine called Picat (ingenl mebutate). Available in cncentratins f and 0.05 percent depending n the AK site, this gel is the first tpical therapy t treat AKs effectively with just tw r three days applicatin time three cnsecutive days fr the 0.015% cncentratin (used n the face and scalp) and tw cnsecutive days fr the mre cncentrated 0.05% gel (used n the trunk and extremities). Skin redness, flaking/scaling, crusting, and swelling are the mst cmmn side effects. Picat can cause painful reactins in the first days f treatment, but these usually begin t abate within a week f starting treatment. This prduct is nt available in Suth Africa. PDT is FDA-apprved fr the treatment f bth AK and Bwen s Disease, a superficial frm f SCC that appears as a persistent red-brwn scaly patch. PDT is especially useful fr widespread lesins n the face and scalp. A light-sensitizing agent, tpical 5 aminlevulinic acid (5-ALA) r methyl aminlevulinate (MAL), is applied t the lesins in the physician s ffice. Subsequently, thse medicated areas are activated by strng blue r red light, which selectively destrys AKs while causing minimal damage t surrunding nrmal tissue. Sme redness, pain and swelling can result. After the prcedure, patients must strictly avid sunlight fr at least 48 hurs, as UV expsure will increase activatin f the medicatin, and may cause severe sunburns. Dctrs may cmbine therapies fr a perid f time t treat AKs. Typically, treatment regimens cmbine crysurgery with PDT r a tpical agent like imiquimd, diclfenac, f 5-FU. The tpical medicatins and PDT may als be used serially every three mnths, six mnths, r year, as determined by the physician at rutine skin examinatins. This apprach may bth imprve the cure rate and reduce side effects. One t tw weeks f 5-FU fllwed by crysurgery can reduce the healing time fr 5-FU and decrease the likelihd f white spts fllwing crysurgery. When an AK is suspected t be an early cancer, the physician may take tissue fr bipsy by shaving ff a prtin f the AK with a scalpel r scraping the lesin with a curette (an instrument with a sharp ring-shaped tip). The curette may als be used t Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 7

8 scrape ff the base f the lesin. Bleeding is stpped with an electrcautery needle r by applying trichlracetic acid (TCA). Lcal anaesthesia is necessary. This methd, best knwn fr reversing the signs f phtaging, is als used t remve sme superficial actinic keratses n the face, especially when ther techniques have nt succeeded. Trichlracetic acid (TCA) and/r similar chemicals are applied directly t the skin, causing the tp skin layers t slugh ff. New skin generally regrws within a few weeks. This technique may require lcal anaesthesia and can cause temprary disclratin and irritatin. The skin s uter layer and variable amunts f deeper skin are remved using a carbn dixide r erbium YAG laser. Lasers are effective fr remving actinic cheilitis frm the lips and AKs frm the face and scalp. They give the physician gd cntrl ver the depth f tissue remved. Lasers are als used as a secndary therapy when tpical medicatins r ther techniques are unsuccessful. Hwever, lcal anaesthesia may be required. The risks f scarring and pigment lss are slightly greater than with ther techniques. (Skin Cancer Fundatin; WebMD; DermNet NZ). Medical Disclaimer This Fact Sheet is intended t prvide general infrmatin nly and, as such, shuld nt be cnsidered as a substitute fr advice, medically r therwise, cvering any specific situatin. Users shuld seek apprpriate advice befre taking r refraining frm taking any actin in reliance n any infrmatin cntained in this Fact Sheet. S far as permissible by law, the Cancer Assciatin f Suth Africa (CANSA) des nt accept any liability t any persn (r his/her dependants/estate/heirs) relating t the use f any infrmatin cntained in this Fact Sheet. Whilst CANSA has taken every precautin in cmpiling this Fact Sheet, neither it, nr any cntributr(s) t this Fact Sheet can be held respnsible fr any actin (r the lack theref) taken by any persn r rganisatin wherever they shall be based, as a result, direct r therwise, f infrmatin cntained in, r accessed thrugh, this Fact Sheet. Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 8

9 Surces and References Actinic Keratsis Albinism American Academy f Dermatlgy Cancer Research UK DermNet NZ Jhns Hpkins Medicine cancerus_cnditin_85,p01335/ May Clinic MedicineNet ratsis NHS Chices Skin Cancer Fundatin Tanning Bed WebMD Researched and Authred by Prf Michael C Herbst Cunselling; Diagnstic Radigrapher; Dip Audimetry and Nise Measurement] Nvember 2017 Page 9