Actinic Keratosis Management in Everyday Practice

In a recent discussion with Dermatology Times, Michael O’Donoghue, MD, a practicing dermatologist with the Illinois Dermatology Institute, outlined his clinical experience and approach to the management of actinic keratosis (AK). O’Donoghue described AK as a significant and routine component of his dermatologic practice, reflecting broader epidemiologic trends in sun-exposed, aging populations.

O’Donoghue reported seeing approximately 175 patients per week, many of whom are of Northern European ancestry and a substantial proportion of whom are older than 65 years. These demographic factors are clinically relevant, as fair skin types and cumulative ultraviolet exposure are well-established risk factors for the development of AK. Within this context, he noted that AK represents a considerable share of his procedural volume. Referencing Medicare and CMS data, O’Donoghue stated that he consistently ranks in the 80th percentile for AK treatment utilization, including lesion-directed destruction (CPT 17000 series) and photodynamic therapy (PDT). This volume reflects both patient demand and the prevalence of actinic damage in his practice regions.

A central theme of the discussion was clinical decision-making at the time of patient presentation. O’Donoghue emphasized the importance of lesion number, distribution, and anatomic clustering in determining treatment strategy. For patients presenting with one or several discrete AK lesions—whether on the face, arms, or hands—he typically favors lesion-directed therapies. These approaches are commonly used when lesions are isolated and spatially separated.

However, O’Donoghue highlighted a shift in management once AKs are concentrated within a defined anatomic region. When multiple lesions are observed within a single area—such as one side of the face or forehead—and when those lesions vary in size, thickness, and palpability, he advocates for a broader treatment approach. In these cases, lesions may range from minimally palpable to clearly hyperkeratotic, suggesting differing stages of keratinocyte dysplasia within the same area.

This clinical pattern, he explained, aligns with the concept of field cancerization. Rather than viewing AKs solely as isolated lesions, field cancerization recognizes the presence of widespread subclinical damage within chronically sun-exposed skin. Under this model, treating only visible lesions may leave adjacent dysplastic keratinocytes untreated. Consequently, O’Donoghue supports field-directed therapies, such as PDT, when appropriate, to address both clinically apparent and subclinical disease.

Overall, the discussion underscores the importance of individualized AK management based on lesion burden, distribution, and underlying photodamage. O’Donoghue’s perspectives reflect a pragmatic, experience-driven approach that integrates patient demographics, disease patterns, and evolving concepts such as field cancerization to guide treatment selection in routine dermatology practice.