Talk:Actinic keratosis

Wiki Education Foundation-supported course assignment
This article was the subject of a Wiki Education Foundation-supported course assignment, between 19 November 2018 and 14 December 2018. Further details are available on the course page. Student editor(s): Doxy cycling. Peer reviewers: Cec206.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 13:21, 16 January 2022 (UTC)

Treatment
I have been advised by my doctor to use Solaraze Stuart Ward UK (talk) 21:06, 21 June 2014 (UTC)
 * http://www.solaraze.com/pdsol_web_default.shtml
 * http://skincancer.about.com/od/treatmentoptions/a/diclofenac.htm

infection/spread
I think AK is not supposed to be infectious, or even self-infectious. The article should say so, one way or the other. But there still needs to be an explanation for why AKs would be clustered, for example on the forehead, yet absent from the ears, which should have had similar sun exposure? And the article needs photos, esp of what treatment with Imiquimod (Aldara) looks like! 69.87.194.177 20:01, 13 June 2006 (UTC)

I am guessing that AK is not infectious, that only if it turns into SCC can it then potentially metastasize. But it does seem like each individual area of AK traces back to just a single cell that mutates and then spreads in that area. -69.87.193.168 02:07, 6 March 2007 (UTC)

simplistic
This article is much too superficial and simplistic. No detailed discussion of the mutations involved. No details about the layers of skin involved, or cross-section diagrams, or clear links to such. We need this kind of material and more, but in words we can understand: "In both histologic and molecular parameters, AKs share features with squamous cell carcinoma. AK is an epidermal lesion characterized by aggregates of atypical, pleomorphic keratinocytes at the basal layer that may extend upwards to involve the granular and cornified layers. The epidermis itself shows an abnormal architecture, with acanthosis, parakeratosis, and dyskeratoses. Cellular atypia is present, and the keratinocytes vary in size and shape. Mitotic figures are present." -69.87.193.168 02:07, 6 March 2007 (UTC)

Incidence??
The statistics in the Incidence section make no sense. If half the population has A.K., then one small group could not possibly have 250 times the incidence. And then it says that this definitively "leads to cancer", whereas elsewhere it says 20% chance. Doc Adams (talk) 00:21, 21 January 2011 (UTC)

The comment about how prevalent the condition is requires a reference. Thimotei (talk) 22:24, 3 September 2013 (UTC)

Cost per spritz, CPT code 17000

 * www.bozemanskinclinic.com/skin-conditions/actinickeratoses.php
 * "Chemical face peels, mini dermabrasion, and superficial laser will temporarily seem to make keratoses go away. But they grow back in a few weeks to months. The reason for this is that the precancerous cells come from a reservoir in the basal layer. Peeling agents do not get that deep. If they do, they cause unacceptable scars. Liquid nitrogen tends not to damage the basement membrane."


 * emedicine.medscape.com/article/1125851-overview
 * "After the development of the vacuum flask to store subzero liquid elements, such as nitrogen, oxygen, and hydrogen, the use of cryotherapy dramatically increased. By the 1940s, liquid nitrogen became more readily available, and the most common method of application was by means of a cotton applicator. In 1961, Cooper and Lee introduced a closed-system apparatus to spray liquid nitrogen. In the late 1960s, metal probes became available. By 1990, 87% of dermatologists used cryotherapy in their practice."


 * www.princetoncryo.com/cryosurgery-and-dermatology.html
 * "Liquid nitrogen cryosurgery with a cryogun is the coldest (-196º C), most effective, and most versatile cryosurgical technique available. Using liquid nitrogen equipment like a cryogun is much colder and therefore more effective than applying LN2 with a swab (-20º C), nitrous oxide (-75º C), and disposable cold sprays (-55º C to -70º C). Also, Brymill has a MUCH lower cost to use on an ongoing basis than disposable cold sprays because it is not necessary to repeatedly buy $150-$200 disposable cans, each of which only can treat approximately 25-65 lesions."


 * www.ncbi.nlm.nih.gov/pubmed/21738958
 * "Cryopeeling for treatment of photodamage and actinic keratosis: liquid nitrogen versus portable system.
 * The aim of this study was to compare two cryopeeling methods (liquid nitrogen- LN and portable system - PS) and demonstrate their efficiency in the treatment of actinic keratoses, patient tolerance, researcher and patient preference and aesthetic results.
 * In the treatment of actinic keratoses, LN obtained 74% efficiency and PS, 62% (p = 0.019).... Treatment with LN obtained some degree of improvement in 62.5% of the cases, while treatment with PS obtained some degree of improvement in 52% of the cases (p> 0.05). Discussion: Treatment with the PS showed better tolerance, but was less efficient than LN..."

Although liquid nitrogen is the proper traditional method of skin lesion cryosurgery, other similar technologies are now common. The generic term for this alternative approach seems to be PORTABLE. The typical cost seems to be about US $5 per lesion treated, for the freezing materials:


 * www.docsavings.com/mm5/merchant.mvc?Screen=CTGY&Store_Code=D&Category_Code=Cry&gclid=CJDpxeeb_bUCFVKf4AodOxQAwA
 * "Verruca-Freeze is a simple, safe, and effective alternative to liquid nitrogen. It is cleared to treat 21 benign skin lesions including common warts, plantar warts, genital warts, skin tags, age spots, and many more!"
 * SMC35	 Verrucafreeze Mini Replacement Canister: 30-35 freezes, $185.00
 * VFC65	 Verrucafreeze Replacement Canister: 60-70 freezes, $260.00
 * VFL	 Verrucafreeze 236ml Canister (100 freezes), $305.00


 * www.portlanddermclinic.com/billing-faqs.html
 * "Q Freezing of Actinic Keratosis:  The doctor sprayed me for half a second - why is it so expensive?"
 * "A The treatment of Actinic Keratosis involves spraying liquid nitrogen on the lesions. The cost starts at $145 and increases according to the number of lesions treated.  Our fees are in line with other dermatologists in our area who provide the same service."


 * ICD-9-CM Code: 702.0	Actinic keratosis
 * "The correct code is found in the ICD-9-CM index under the main term “keratosis” and the subterm “actinic” which references code 702.0."
 * Diagnosis: ICD-9 code 702.0 (Other dermatoses; actinic keratosis) describes AK.

17000 Destruct premalg lesion 2.38rvus $81.01 17003 Destruct premalg les 2-14 0.21rvus $7.15 17004 Destroy premal lesions 15/> 5.05rvus $171.89
 * www.ama-assn.org/resources/doc/rbrvs/2012-rbrvs-congress-patch.pdf 2012 Relative Value Units

The standard Medicare insurance cost is about $81 to treat the first skin lesion, CPT code 17000; $7 per additional lesion, CPT code 17003; $172 bulk cost for 15 or more lesions, CPT code 17004.-96.233.19.238 (talk) 14:36, 15 March 2013 (UTC)

Images
The image at the top of this page is not a good example of actinic keratosis, and in my view pretty atypical. I'm adding this here because I will be looking around for a better image, but if someone else finds it first please feel free to add it. -- CFCF  (talk · contribs · email) 09:31, 2 July 2014 (UTC)

WikiProject Elective Peer-Review
Very thorough and informative article! Intro has very accessible language and is easy to follow. Overall organization is formatted in a logical manner.

For "Cause" section I would make a small edit to change the title to "Causes" since multiple causes are listed.Yst22 (talk) 20:06, 19 November 2014 (UTC)

Also under "Cause" section I would recommend redistributing the information listed in the "Cause" intro paragraph to it respective sub-heading as some of the information is repeated.Yst22 (talk) 20:06, 19 November 2014 (UTC)

Lastly I would suggest combining "Cause" and "Epidemiology" section, or at lease having them next to each other since they both discuss risk factors although the mention different ones.

Educational WikiProject Work Plan
Over the next 4 weeks, I (a medical student pursuing a career in dermatology) will be editing this article in attempt to improve its clarity, accessibility, and informative nature. After initially reading the article, I believe there are both general and more specific steps I can make in efforts for improvement. Initially, I intend to start by reviewing all resources for appropriateness. As someone engaged in the field of dermatology, I know there are several "staple" resources that should probably be included in the discussion of any dermatologic topic, due to their well-accepted nature as authorities in the field. These include textbooks by Bolognia and Andrews, as well as Elston's dermatopathology textbook. At first glance, I see that Bolognia has been cited, but Andrews and Elston have not been included. Moreover, the article contains an alert that it relies too heavily on primary sources such as recent studies on treatment efficacy, so I intend to consult various textbooks and other secondary sources such as the American Academy of Dermatology guidelines. I also intend to assess the title headings throughout the article. I believe there may be some room for improvement particularly in the "Causes" section, as it seems misleading to list baldness as a cause, whereas it might be reasonable to call baldness a risk factor for actinic keratoses. It also makes more logical sense to include epidemiology toward the beginning of the article so patients and interested parties can gain a feel for the article's relevance to them. Along with this, I want to be sure that the proper information is under the proper headings. For instance, the treatments section contains a good amount of research, but there is also a separate section on research. It might be reasonable to move some of this information to a different section or remove the "research" section altogether. I also want to do a thorough read-through for any grammatical errors, as I have already found a punctuation error where a period is missing. Medical jargon is used throughout as well, with dermatology terms such as "hyperkeratotic" and "papule" throughout, not always provided with an explanation. As this article is intended for someone without medical training, I will assess whether all of the included terminology needs to be present.

Specifically, I see several individual areas that could be improved. The initial summary needs some clarification and simplification; particularly, at least 3 paragraphs mention the nature of AKs as rough spots caused by sun exposure, which makes it repetitive and difficult to read. Moreover, it might contain misleading or at least incomplete information, as it states that "PDT is recommended for multiple AK lesions and field cancerization," when I am not sure this is the case in the US. I have worked with clinicians whose typical practice involves pursuing 5-FU (Efudex) for field treatment, not photodynamic therapy (PDT). While PDT is certainly a therapy option, it is not the definitive choice as it is portrayed here. It looks like the guidelines cited for this statement also came from a European source, so it could be important to add an American perspective as well. I also think it is important to stress patient choice and side effects of individual treatments, since the physician approach usually includes obtaining patient preference before deciding on a treatment. Elaborating on the differential diagnosis section might be informative as well. I want to fix several other smaller things, including citations in the middle of sentences, sentences where citations are missing, and potential inaccuracies like mentioning shave and curettage as "often used" without a supporting citation. I have engaged in discussing the treatment plan for actinic keratoses with patients many times, and I have never once heard this treatment mentioned as a viable option.

This article has lots of great information and is a good start, and I hope to make it even better through my edits. I look forward to engaging in a dialogue and helping to improve the public's knowledge through this article! --Doxy cycling (talk) 20:32, 19 November 2018 (UTC)

I'm going to start with the readability of the intro paragraph. Feel free to provide input to my changes.Doxy cycling (talk) 22:05, 25 November 2018 (UTC)

Since my reviewer had the same thoughts as I did regarding the placement of the Epidemiology section, I am going to move it below the introductory paragraph to help with flow of the article. Doxy cycling (talk) 21:15, 13 December 2018 (UTC)

Peer review- WikiProject medicine MUSC
'''Is the article clear and understandable? Is everything in the article relevant to the article topic? Is there anything that distracted you? Would it be understandable to a non-medical person?''' - Overall I think that this page is very helpful. The information included is relevant to the topic and does not include an unnecessary amount of accessory information that strays from the main pathology. The only suggestion that I have for improving clarity is to rearrange the order of sections to help with the flow of reading. It makes more sense to describe the epidemiology first, followed by causes, risk factors, then presenting signs and symptoms. Research at the conclusion of the page is in the perfect spot. There are some areas that have medical jargon included, but may be unavoidable in certain sections. While there are many complicated concepts included on this page, adequate simplification/clarification was provided for the most part. See below some suggestions for each section that I noted as I was reviewing the article.

'''Is the article neutral and balanced? Are there any claims that appear heavily biased toward a particular position? Is the supporting evidence from unbiased sources? Are there viewpoints that are overrepresented, or underrepresented?''' - After reviewing the talk page and work plan, I think the writer did a good job of removing primary sources, while still dedicating a section to research. A goal of the writers was to remove novel/unapproved therapies from the management section. The medical management with various topical agents was well organized and easy to read for a non-medical reader and provided hyperlinks for more difficult concepts. From a public health communication standpoint, I think that the “prevention” section is especially important for this pathology. It seems straightforward to medical professionals that limiting sun exposure is at the basis of prevention. However, for the purpose of giving adequate information about prevention to the lay person, there may need to be some expansion of information, especially more defined times of day at which the sun/UV exposure is strongest, and how to appropriately use sunscreen to prevent sun damage/burn. See suggestions below

'''Is the article supported by reliable evidence? Is each fact referenced with an appropriate, reliable reference? Are the citations from publicly available sources? Does the article paraphrase or plagiarize? Is the cited evidence current? ''' - All information is cited appropriately. There are few sentences that need citations, but I referenced them as I came across them in each section. The only other issue I found was that some words that were highlighted as hyperlinks do not actually link to another wiki page. These links are highlighted in red and may need to be addressed or removed.

Specific feedback and suggestions for each section:

Lead section: I really love how the introductory summary gives the relevance of this particular pathology as a pre-cancerous lesion. By stating this upfront, non-medical readers are quickly engaged on the importance of further evaluation and management to prevent progression to SCC. In the second paragraph, there is some redundancy of repeating that there is a relationship between sun damage and risk of this lesion. In the third paragraph, it may be helpful to add field cancerization to the final sentence: "Photodynamic therapy (PDT) is one option the treatment of numerous AK lesions in a region of the skin, termed field cancerization.”

Signs and symptoms: I appreciate that you explained exactly what “background of sundamaged skin” looks like. This was mentioned in lead, and was hoping that it would be described further. By hyperlinking “keratinocytes” you made it easier for the reader to simply hover over the word to clarify what type of cell it is. In the second paragraph, it may be helpful to add a final sentence like: “This phenomenon is referred to as field cancerization.” Clinical variants: I like how you included a picture of hyperkeratotic lesion. Maybe could hyperlink “macule”, “solar lentigo”, “lentigo maligna” if those pages exist. Including the concerning features is very helpful for readers to determine if further evaluation by a medical professional is warranted.

Causes: I would replace “commensalic” with another adjective. I suggest including some of the content within the first paragraph under the “Ultraviolet radiation” sub-heading to help flow and organization of content. Once all information related to UV exposure has been explained, new paragraph for HPV, then finally new paragraph for other oncogenes and tumor markers and how they are implicated in the pathology of this disease

Other risk factors: A citation is needed for immunosuppression. I like that you included genetic diseases that increase risk for AKs, but did not include too much information that may make the section too bulky- hyperlinks available if the readers want to know more information and can find it elsewhere. It may be helpful to explain under “balding” that lack of hair coverage increases the proportion of sun-exposed scalp skin in people that are regularly in the sun without adequate coverage i.e. sunscreen or hats.

Diagnosis: I like that you included a differential dx section at the end of the first paragraph so that the reader can easily read about similar conditions if they wish. The term “epidermolytic” may need clarification. Polarized dermoscopy section includes a lot of medical jargon but I don’t know if this is avoidable in this particular section. Not super relevant to a non-medical reader but important to include for clinicians.

Prevention: This is a very important area for the non-medical reader. Including clarification of what hours of the day specifically relate to when the sun is the strongest might be helpful. Likewise, it may be helpful to include what SPF is most protective and the frequency of application for the most effective prevention of sunburn. Finally including a hyperlink for HPV vaccination options would be helpful. This heading may make more sense to the come after management/prognosis. That order makes more sense to me personally, but may not be necessary?

Management: I like that you explained that each case is individualized and that patient preference is important in the decision-making process of this pathology. I really liked that you included common side effects of each medication. This is important for the reader who is specifically researching particular modalities and that each medication does not come without risk. You could potentially hyperlink “arachidonic pathway” or briefly describe what it is… It could be helpful to define “cryotherapy” at the very beginning of this sub-section for non-medical readers. Grammatical correction: “as (instead of is) indicated” under “photodynamic therapy”. Finally, including the contraindications to chemical peels is very useful.

Prognosis: Are the outcomes/clinical course described in the first paragraph a natural progression without treatment? May need to clarify.

Epidemiology: This section might be more helpful at the beginning of the page. I would suggest moving this heading to the very top, before “signs and symptoms”. May be helpful to explain that more sun-exposed geographic areas directly relates to proximity to the equator, etc. For example, in the United States, southeastern states, Southern California, Florida are closer to the equator, and therefore the frequency of higher UV exposure is increased

Research: I like that you included this section at the end. I know that you mentioned in your work plan that you wanted to limit the amount of primary sources and wanted to delineate novel therapies/research from currently accepted practices for this disease.

See also: no suggestions — Preceding unsigned comment added by 75.143.241.5 (talk) 16:15, 10 December 2018 (UTC)

Cec206 (talk) 17:37, 10 December 2018 (UTC)

Thank you for the great thoughts! I agree that most of your suggestions would help with understanding/clarity of the article, so I will make some changes based on your recommendations. Doxy cycling (talk) 21:48, 13 December 2018 (UTC)

Specifically, after receiving peer feedback, I elaborated on the prevention section to include more specific recommendations from the AAD on sunscreen and sun avoidance. I also moved the epidemiology and risk factors sections earlier in the article to improve flow and updated links that were not functioning, and I included a link to the arachidonic acid article as recommended. I did my best to eliminate medical jargon, but I found that the histopathology section was thorough and comprehensive as it stood in order to provide information to people with a higher level of knowledge about actinic keratosis and dermatology. Doxy cycling (talk) 03:45, 14 December 2018 (UTC)

Queen's University Student Editing Initiative
Hello, we are a group of medical students from Queen's University. We are working to improve this article over the next month and will be positing our planned changes on this talk page. We look forward to working with the existing Wikipedia medical editing community to improve this article and share evidence. We welcome feedback and suggestions as we learn to edit. Thank you. Julia.dhk (talk) 20:16, 11 November 2019 (UTC)

Introductory paragraph, after first sentence

I propose adding the following sentence to the introductory paragraph after the first sentence.

“The term actinic keratosis can be literally understood as a disorder (-osis) of overgrown horny (kerat-) skin cells (more commonly known as keratinocytes) that is induced by exposure to light rays (actin-).”

Adding this statement would provide important information about the etymological origins of the term and would help to link the origins of the words to the etiology of the disorder.
 * Thanks for sharing this. Please include your citation (added with the citation tool that we practiced in classJenOttawa (talk) 16:55, 22 November 2019 (UTC)

Introductory section (fourth paragraph of article)

I propose editing the following sentence: “ [AK] Diagnosis is suspected clinically on physical exam by a physician or other health care provider, but can be confirmed by looking at cells from the lesion under a microscope in a biopsy procedure.”

Currently, this statement is misleading and does not clearly distinguish between cytology (the study of cells) and histology. It also suggests that clinical examination alone is not enough to diagnose AK and that biopsy is required. This is incorrect. I propose the following sentence change: "If clinical examination findings are not typical of AK and there is suspicion of progression to squamous cell carcinoma (SCC), tissue is examined through a skin biopsy. This proposed change 1) emphasizes the use of histology (i.e. investigation of tissue architecture) in skin biopsies and 2) provides a more accurate context as to when a skin biopsy may be used for diagnosis.
 * Thanks for sharing this. Please add your citation with the citation tool that we practiced in class. I just did it for you BMJ reference, but please make sure that you can do this before we edit on the 25th. I can help in class on MondayJenOttawa (talk) 16:55, 22 November 2019 (UTC)

Other risk factors (sub-heading under causes)

“Immunosuppression: People who take immunosuppressive drugs, such as organ transplant patients, or patients with AIDS or undergoing chemotherapy are at increased risk for developing AKs.[32][medical citation needed]” The point on immunosuppression requires a medical citation. I plan to use Fitzpatrick’s Dermatology as a medical citation to support this statement and add on to it by adding the following: “Immunosuppression: People who take immunosuppressive drugs, such as organ transplant patients, or patients with AIDS or undergoing chemotherapy are at increased risk for developing AKs, meaning they tend to develop more AKs, and begin developing them earlier in life.[32] The proposed change adds a much needed medical citation and expands on how immunosuppression affects the timing and number of AKs that a patient may expect.
 * Thanks for sharing this. Are you adding a citation to remove the citation needed tag?JenOttawa (talk) 16:55, 22 November 2019 (UTC)

Diagnosis section

I propose a change to the following sentence in the diagnosis section “Actinic keratosis and squamous cell carcinoma (SCC) can present similarly on physical exam, and many scientists argue that they are in fact simply different changes of the same condition.” I would like to avoid non-concrete words such as “simply” and “changes” and clarify the relationship between AK and SCC.

This sentence can be changed to “Actinic keratosis may progress to invasive squamous cell carcinoma (SCC) but both diseases can present similarly upon physical exam and can be difficult to distinguish. A histological examination of a biopsy can be performed to exclude SCC with certainty in the differential diagnosis.”
 * Thanks for sharing this. Please add your citation with the citation tool that we practiced in class.JenOttawa (talk) 16:55, 22 November 2019 (UTC)

Diagnosis section, specifically under biopsy:

I propose adding the following sentences to the section on diagnosis of AK, specifically in the subheading that discusses biopsy: It is important to note that shave and punch biopsies are not the only diagnostic method of choice, as an excisiona biopsy may be recommended for the diagnosis of AK in certain circumstances. Excisiona biopsy refers to the complete removal of the affected area, and may be used for thicker lesions or when certain lesions need to be distinguished from invasive skin cancer through histological examination, allowing for both goals of diagnosis and treatment at the same time.
 * Thanks for sharing this. I feel that it is not necessary to include "it is important to note". Rather just say "Shave and punch biopsies are not the only..."JenOttawa (talk) 16:55, 22 November 2019 (UTC)

Medication section, specifically under Fluorouracil Cream:

I propose adding the following sentence to the section on medication, specifically in the subheading pertaining to topical Fluorouracil (5-FU) cream: "While topical 5-FU is a widely used and low-cost treatment for AKs, it can cause substantial side-effects, specifically: soreness, crusting, redness and local swelling [1]. These can be minimized by reducing the frequency of application or taking breaks between uses." Julia.dhk (talk • contribs) 03:26, 19 November 2019 (UTC) '''::Thank you for all your work to suggest article improvements. These look great but it is hard to tell without the references. Do you mind adding in your references to this talk page so we can see them? You can use the citation tool that we practiced in class on the 11th and paste in the PMID. Note: If you are using a textbook please include page #s of where you found the information. Thank you again!JenOttawa (talk) 13:34, 19 November 2019 (UTC)'''