Do I need to refer a patient with a biopsy-confirmed actinic keratosis to a dermatologist for further evaluation and treatment?

Management of Biopsy-Confirmed Actinic Keratosis in Primary Care

Most patients with biopsy-confirmed actinic keratosis can be managed in primary care without dermatology referral, using topical therapies or cryosurgery. 1

When Referral is NOT Required

You can confidently manage actinic keratosis in primary care when: 1

• The lesion is a simple, uncomplicated AK confirmed by biopsy
• The patient has mild disease (few lesions)
• The lesion responds to standard first-line treatments
• The patient is not immunosuppressed

Most patients with mild AK will be seen in primary care and can manage their disease with topical therapy. 1

First-Line Treatment Options in Primary Care

You have several effective options available: 1

Topical Therapies

• 5-fluorouracil cream (various concentrations and formulations) 1
• Imiquimod cream (2 times per week for 16 weeks, with 46% complete clearance rates) 2
• Diclofenac gel 1
• Ingenol mebutate 1

Physical Therapies

• Cryosurgery (liquid nitrogen) - flexible and effective for lesion-based treatment 1
• Can be performed in primary care settings 1

When Dermatology Referral IS Required

You must refer to dermatology (via urgent 2-week cancer pathway) when: 1

• The lesion is bleeding - may indicate invasive SCC
• The lesion is painful - concerning for malignant transformation
• The lesion is thickened with substance when held between finger and thumb - suggests possible invasive SCC
• Treatment failure - AK fails to respond to standard primary care treatments
• Multiple or relapsing AKs represent a management challenge
• Patient is long-term immunosuppressed (e.g., organ transplant recipients)
• Extensive disease requiring specialized management

Critical Clinical Pitfall

The positive predictive value of clinical diagnosis of AK is only 74% in high-risk patients, with 83% of misdiagnoses being skin cancer (most commonly squamous cell carcinoma). 3 This is why the biopsy was appropriate, and now that you have histologic confirmation, you can proceed with treatment confidently.

However, if the biopsied lesion showed any concerning features beyond simple AK (such as severe dysplasia, SCC in situ, or invasive features), immediate dermatology referral is mandatory. 1

Practical Management Algorithm

1. Review the biopsy report carefully - ensure it confirms simple AK without features of SCC 1

2. Examine the patient for concerning features (bleeding, pain, thickness) 1

3. Assess disease burden - single lesion vs. multiple lesions vs. field cancerization 1

4. If uncomplicated: Initiate treatment in primary care with topical therapy or cryosurgery 1

5. Monitor response - lesions that fail to respond require further evaluation, potentially including re-biopsy or referral 1

Important Counseling Points

Actinic keratosis is a chronic disease requiring ongoing management rather than cure. 1 Patients need education about: 1

• Risk of developing additional AKs over time
• Association with increased risk of squamous cell carcinoma (approximately 10% risk over 10 years with multiple AKs) 1
• Importance of sun protection
• Self-monitoring for new or changing lesions
• When to return for evaluation (new bleeding, pain, or rapid growth)

An important benefit of treating AK is identifying lesions that don't respond to standard therapy, as these may represent a subgroup with higher malignant potential. 1, 4