When to Biopsy Actinic Keratosis and How to Counsel Patients on Sun Damage

AK Awareness Day is recognized globally on May 24 and serves as an opportunity to raise awareness surrounding actinic keratosis (AK), non-melanoma skin cancers, sun protection, and patient education. For the second year in a row, Almirall launched its Hats On For AK initiative alongside AK Awareness Day, and this year collaborated with Biofrontera and SUN Pharma. Co-founded in 2025, the social media campaign was developed as a collaborative effort involving patients, health care professionals, advocacy organizations, and the broader public to encourage conversations about AK and preventive skin care behaviors.¹

This year, the initiative again supports the work of The Skin Cancer Foundation, which partners with the campaign to promote education surrounding sun-induced skin disease and skin cancer prevention. Almirall also announced its support at the organization’s Champions for Change Gala, which raised $930,000 to “support our lifesaving educational campaigns, community programs and research initiatives.”²

To discuss the importance of AK Awareness Day, AK detection, and the Hats on for AK campaign, Dermatology Times spoke with Deborah S. Sarnoff, MD, a board-certified dermatologist and Mohs surgeon, the director of dermatology at Cosmetique Dermatology, Laser & Plastic Surgery, LLP, clinical professor of dermatology at NYU Grossman School of Medicine, and president of the Skin Cancer Foundation.

Recognizing Actinic Keratosis: Presentation and Common Locations

Actinic keratoses are frequently more palpable than visible, presenting as rough, scaly lesions in a range of colors from pink to beige, tan, or pigmented. Common sites include the scalp (particularly in bald men), the tops and edges of the ears, the face, and the lower lip.

"I tell patients they sometimes give the skin a texture like sandpaper, or almost they feel like little Rice Krispies on the skin," Sarnoff said.

Sarnoff noted lower lip lesions warrant close attention, as tissue in this location may not appear visibly normal, prompting consideration of biopsy.

Biopsy Indications and Clinical Red Flags

Several features should prompt biopsy consideration. Tenderness, pain, active bleeding, crusting as evidence of prior bleeding, rapid growth, increased elevation, and induration or thickening on palpation are all relevant indicators.

"If you palpate, even through gloves, and you feel the skin is a little bit indurated or harder, or you feel there's a thickness to it, that's usually an indication to biopsy," Sarnoff said.

An outlier lesion within a field of actinic damage also warrants evaluation. A lesion appearing more inflamed, enlarged, or simply different from surrounding tissue can indicate a need for biopsy, even when nearby AKs appear clinically unremarkable.

Patient Counseling on Sun Damage and Prevention

Patients often fail to connect their skin changes to prior sun exposure, particularly when they no longer spend significant time outdoors. Sarnoff described using direct visual comparison between sun-exposed and chronically protected skin to illustrate the relationship.

"I'll often show them the skin on their breast or on the buttocks and show them skin that's been protected all these years with two layers of clothing versus the skin on the decolletage," she said.

AKs signal cumulative, historical sun damage, Sarnoff noted. Some may progress to squamous cell carcinoma; others indicate a vulnerable area requiring ongoing protection. For scalp-involved patients, she recommended a wide-brimmed hat with approximately 3 inches of brim for adequate coverage of both the scalp and face.

"It's really important to make patients understand what the actinic keratosis are coming from and what they might do about it going forward," Sarnoff concluded.

References

1. Almirall continues partnership for second edition of the Hats On For AK initiative. News release. Almirall. May 17, 2026. Accessed May 28, 2026. https://www.almirall.com/news-media/newsroom/almirall-continues-partnership-second-edition-hats-ak-initiative
2. Champions for Change Gala. The Skin Cancer Foundation. May 2026. Accessed May 28, 2026. https://www.skincancer.org/get-involved/gala/

Click here to watch part 2 of Sarnoff’s interview.