1. health and fitness
2. disease
3. cancer

Frequently Asked Questions in Dermatology:
► Author
Adam Natsheh, MD, BSc (Pharm), FRCPC
► Learning Objectives
File # 1015-2013-738-I-P
To obtain your credits, please visit
www.cmesolutions.ca/cme-programs
and complete the post-test for this program.
Your unique access code is: AK2013
After reviewing this newsletter, pharmacists should be able to:
• Define actinic keratosis and its prevalence in Canada
• Explain the link between actinic keratosis and non-melanoma skin cancers
• Identify patients at risk of actinic keratosis and the signs/symptoms of lesions
• Describe current treatment options for actinic keratosis
• Educate and counsel patients about actinic keratosis, treatments, and prevention
► Introduction
The purpose of this newsletter is to provide Canadian pharmacists with the knowledge and tools to better help
them identify and counsel patients with actinic keratosis or who are at high risk of actinic keratosis.
The content of this newsletter is based on a recent continuing education needs assessment.1 Pharmacists from across
Canada indicated an interest in the following topics related to the treatment of actinic keratosis:
• Clinical signs of actinic keratosis
• Risk factors for/causes of actinic keratosis
• Identifying patients at risk of actinic keratosis
• The link between actinic keratosis and skin cancer
• Pre-cancerous skin lesions versus non-melanoma skin cancer
• Safety and efficacy of topical medications for actinic keratosis
• Treatment of subclinical (non-visible, non-palpable) actinic keratosis lesions
• Counselling patients on proper application of topical preparations
• When to recommend to your patient to stop treatment and contact his/her physician
Terminology used in this newsletter2
Actinic elastosis:
Degeneration of collagen fibres caused by exposure to UV radiation resulting in a degenerative
change in elastic tissue.
Dysplasia:
Abnormal tissues development.
Epidermis:
The superficial epithelial portion of the skin.
In situ:
In position, not extending beyond the focus or level of origin.
Keratin:
Collective name for a group of proteins that form the intermediate filaments in epithelial cells. Antibodies to keratin proteins are widely used for histologic typing of tumours, and are especially useful for distinguishing carcinomas from melanomas, sarcomas, and lymphomas.
Keratinocyte:
A cell of the living epidermis that produces keratin.
Lentigines
(plural of lentigo):
Benign, acquired brown macules resembling a freckle except that the border is usually regular.
Senile or solar lentigines are variably pigmented benign macules occurring on exposed skin
of older white people (also known as liver spots).
Melanocyte:
A pigment-producing cell in the basal layer of the epidermis.
Suppuration:
The formation of pus.
Telangiectasia:
A dilated, superficial blood vessel.
To review the anatomy of the skin, you may wish to refer to Medscape Reference at http://emedicine.medscape.com/article/1294744.
To learn more about the pathophysiology of actinic keratosis, you may wish to refer to Medscape Reference at: http://emedicine.medscape.com/article/1099775.
The Canadian Council on Continuing Education in Pharmacy has accredited this program
for 1.5 CEUs. CCCEP File # 1015-2013-738-I-P
Disclosure Statement: This program has been supported in part by an educational grant from LEO Pharma Inc.
1
► Test Your Knowledge of Actinic Keratosis
1. True or false: Actinic keratosis is a type of pre-cancerous skin lesion.
a. True
b. False
2. True or false: Actinic keratosis is a risk factor for squamous cell carcinoma.
a. True
b. False
3. True or false: Actinic keratosis lesions may progress to melanoma.
a. True
b. False
4. Which of the following is not a sign or symptom of actinic keratosis?
a. Lesions are less than 1 cm in diameter
b. Lesions are generally found on sun-exposed areas of the body
c. Lesions are dark brown or black
d. Lesions may be rough and/or scaly to the touch
5. True or false: Actinic keratosis is a field disease.
a. True
b. False
6. True or false: a. True
b. False
Actinic keratosis lesions may be non-visible and/or non-palpable.
7. Which of the following is not a risk factor for the development of actinic keratosis lesions?
a. Fair skin
b. Excessive/habitual alcohol consumption
c. Older age (50+ years)
d. Immunosuppression
8. True or false: Men and women are at equal risk of developing actinic keratosis lesions.
a. True
b. False
9. Which of the following topical medications is not indicated in Canada for the treatment of actinic keratosis?
a. Tretinoin cream 0.025%
b. Ingenol mebutate 0.015%
c. 5-fluorouracil
d. Imiquimod 3.75%
10. True or false: a. True
b. False
2
Topical medications for the treatment of actinic keratosis lesions should be applied only within the margins of the lesions.
► What is actinic keratosis (AK)?
Actinic keratoses are pre-cancerous skin lesions that develop in response to prolonged exposure to sun/ultraviolet
(UV) radiation.3,4 Chronic UV exposure results in a series of potential sequential mutations that, in turn, result in
keratinocyte dysplasia.5
Actinic keratosis is considered a field disease because most lesions appear in a field of UV-damaged skin and the
histopathology of AK is found in the skin surrounding lesions.6,7 While many AK lesions are visible and/or palpable,
this field of cancerisation can be partially or completely non-visible.7 Non-palpable, non-visible AK lesions occur
approximately 10 times more often than clinical AK lesions in sun-damaged skin.8
► What is the prevalence of AK?
Since the 1960s, the incidence of AK has increased an average of 3% to 8%,9-11 and it is becoming more prevalent
in people younger than age 40 years.11 The increased prevalence of AK has been linked not only to increased
longevity and an increase in the popularity of outdoor activities, but also to clothing styles that expose skin and a
culture that promotes tanning.9
► Estimated Prevalence of AK: Canada 2012
► Projected Prevalence of AK: Canada 2013/2036
► What are the differences between AK and
non-melanoma and melanoma skin cancers?
Actinic keratoses are pre-cancerous
skin lesions. Non-melanoma skin cancer
(NMSC) is the most common type of
cancer, and includes both squamous cell
carcinoma (SCC) and basal cell carcinoma
(BCC). 12 Those with a history of nonmelanoma skin cancer are at increased
risk for malignant melanoma and other
types of cancer, including colon, lung, and
breast cancers.13
Squamous cell carcinoma is a locally
invasive malignant tumour that arises from
keratinocytes in the superficial layers of
the epidermis.14,15 Keratinocyte damage
is a response to repeated exposure to
UV radiation.14 Although typically locally
invasive, SCC has the potential to
metastasize to other organs of the body.14
Basal cell carcinoma is a slow-growing,
locally invasive malignant epidermal skin
tumour derived from the basal layer of the
epidermis.16 Like SCC, cell changes are
a response to cumulative exposure to UV
radiation; however, metastasis is rare.14
Calculated for Canadian population based on M Augustin, et al. Br J Dermatol. 2011;165:865-73, as applied to Statistics
Canada data: http://www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.pdf.
3
► By 2031, it is estimated that there will be 201,302 cases of NMSC in Canada, including approximately 157,711
cases of BCC and 43,591 cases of SCC.17
While melanoma accounts for only a small percentage of skin cancers, it is responsible for the largest number
of skin cancer-related deaths. It is a malignancy of melanocytes, which are the cells that produce pigment in the
skin. The pathogenesis of melanoma is poorly understood, but is likely a result of progressive genetic mutations
associated with cumulative UV radiation, and may be associated with a high number of nevi (moles).18-20
► Estimated Prevalence of NMSC: Canada 201117
Actinic keratosis. ©DermNet NZ
Squamous cell carcinoma in situ (Bowen’s disease).
©
Danderm; www.danderm-pdv.is.kkh.dk
Basal cell carcinoma.
Danderm; www.danderm-pdv.is.kkh.dk
©
► Is there a link between AK and non-melanoma skin cancer or melanoma?
Actinic keratosis lesions can progress to SCC and less often to BCC; they do not progress to melanoma.3,21-23
Actinic keratosis lesions and SCC are frequently adjacent to each other, as they share the same genetic alterations
and morphology; this link is confirmed through histological and immunohistochemical tests.24,25 Actinic keratosis
lesions that progress may be identified as hypertrophic AK, SCC in situ (Bowen’s disease), and/or invasive SCC.3,21
The natural course of AK is unpredictable, with 60% to 80% of SCCs arising from or near an AK lesion.3,21-23,25 For
that reason, all AK lesions should be treated.3,21,23 AK lesions that regress may recur, from 32% within one year to
92% within five years.3,21
4
► What are the risk factors for AK?
More than 80% of all AK lesions are found on sun-exposed areas of the body, such as the scalp, face, ears, lower
lip, neck, upper chest, upper back, forearms, and dorsa of hands.26
General risk factors for AK include intense or cumulative exposure to UV radiation, use of tanning beds, prior
history of AKs or other skin cancer, and clinical signs of photodamage (solar/senile lentigines, facial telangiectasia,
or actinic elastosis of the neck).9,10,24,25 Immunosuppression, whether due to the use of immunosuppressive drugs
or to conditions such as chronic lymphocytic leukemia or human immunodeficiency virus, is also linked to AK.24
Individual susceptibility factors for AK include male gender, older age (50 years and older), red or blond hair, lightcoloured eyes, and a fair skin complexion that never tans/always burns or tans with difficulty/usually burns.26,27
It should be noted that there is an increasing incidence of non-melanoma and melanoma skin cancers among
people with medium skin complexions (e.g., Asian and Hispanic populations) who sometimes burn but tan more
easily than those with fair complexions.28-30
There are some differences in risk factors for AK than for SCC, BCC, and melanoma. They all share risk factors
such as cumulative sun exposure, history of pre-cancerous or cancerous lesions, a fair complexion, older age,
and immunosuppression.14,31-33 Other risk factors include:14,31-35
• Childhood sunburn and/or excessive childhood sun exposure (BCC, melanoma)
• Old burn scars (SCC)
• Smoking (AK, SCC)
• Gamma radiation exposure (cancer therapy, psoriasis treatment, past acne treatment) (SCC and BCC)
• Increased number of common or atypical/dysplastic nevi (moles) (melanoma)
• Family history of melanoma (melanoma)
• Human papillomavirus infection
► How is AK diagnosed?
Visible or detectable AK lesions are reddish to reddish-brown, rough, scaling patches, pinhead-sized to 4 to
5 mm in diameter.5,14 They may also appear as a white scale over a pink macule or papule.14 Often, they can be
felt more easily than seen, with a feeling similar to rubbing sandpaper.14,36,37 Actinic keratosis lesions are generally
asymptomatic, although they may be itchy.14,37
There is no single distribution pattern to AK lesions; a solitary lesion may be seen, or several may be clustered or
disseminated.14 It is important to note that non-visible, non-palpable lesions occur up to 10 times more often
than visible lesions, particularly in sun-damaged skin.6 When one AK lesion is seen, one can assume that other
non-visible lesions exist.24 This is an important factor in the treatment of AK.
Solitary actinic keratosis lesion. ©DermNet NZ
Multiple actinic keratosis lesions. ©DermNet NZ
5
► What are the treatment options for AK lesions?
There are currently three approaches to
treatment of AK lesions:
Currently available field-directed, topical therapies include:
• 5-fluorouracil (5-FU)38
• Imiquimod 3.75% for the face and balding scalp39
• Imiquimod 5% for the face and balding scalp40
• Ingenol mebutate 0.015% for the face and scalp41
• Ingenol mebutate 0.05% for the trunk and extremities41
• Aminolevulinic acid42 with photodynamic therapy (PDT)
• Methyl aminolevulinate43 with PDT
1. Topical, field-directed therapy
2. Lesion-directed treatment
3. Combination/sequential therapy
► Indications, dosing, and duration of topical AK treatments
Treatment
AK indications
Dosing
Duration of treatment
5-fluorouracil (5-FU)38
Pre-malignant keratoses
Twice daily
2 to 4 weeks
Imiquimod 3.75%39
Multiple clinically typical visible
or palpable actinic keratoses
on face and balding scalp
Up to 2 packets once daily
6 weeks: 2 treatment cycles
of 2 weeks, separated by a
2-week no-treatment period
Imiquimod 5%40
Clinically typical,
non-hyperkeratotic,
non-hypertrophic actinic
keratoses on face and balding
scalp
Non-hyperkeratotic, nonhypertrophic actinic keratosis
lesions on face and scalp
Non-hyperkeratotic,
non-hypertrophic actinic
keratosis lesions on trunk and
extremities
Single and multiple
non-hyperkeratotic actinic
keratoses of face and scalp
Thin or non-hyperkeratotic
and non-pigmented actinic
keratosis on face and scalp
Twice weekly
16 weeks
Once daily
3 consecutive days
Once daily
2 consecutive days
Applied day before light
treatment
1 to 2 treatment cycles
May be retreated 8+ weeks
after initial treatment
1 to 2 treatment cycles
May be retreated 3+ months
after initial treatment
Ingenol mebutate
0.015%41
Ingenol mebutate
0.05%41
Aminolevulinic
acid42 with PDT
Methyl
aminolevulinate43 with
PDT
Applied a few hours before
light treatment by a qualified
healthcare professional
► Efficacy of topical AK treatments*
Follow-up
period
Patients with
sustained
clearance, %
Follow-up
period
48–58%44-46
4 weeks
54%47
12 months
36%39
8 weeks
41%48
12 months
Imiquimod 5%40
45%
8 weeks
43%
12-18 months
Ingenol mebutate
0.015%49
42%
57 days
46%
12 months
Ingenol mebutate
0.05%49
34%
57 days
50%
12 months
47–82%50-52
1–3 months
40%50
12 months
Treatment
5-FU
Imiquimod 3.75%
PDT
Complete
clearance,
% patients
*Between-study comparisons are not intended due to differences in patient demographics and other study parameters.
6
Lesion-directed treatments include physically destructive methods (cryosurgery, laser ablation) and surgical
removal (shave excision, curettage, electrodessication).53 In combination/sequential therapy, cryosurgery is
used to treat visible AK lesions and topical treatment is used to treat underlying field cancerisation, e.g., topical
5-fluorouracil followed by cryosurgery54 or cryosurgery followed by 3.75% imiquimod.55
The ultimate goal of treatment in AK is to clear the entire actinically damaged field, which can only be confirmed
through reflectance confocal microscopy. This test, unfortunately, is not generally available in Canada. Treating
both visible and non-visible lesions may help to reduce recurrence rates and prevent progression to invasive SCC
or SCC in situ. For these reasons, the therapeutic algorithm for actinic keratosis has changed in recent years;
topical treatments are now preferred versus lesion-directed therapies.5
► What is the expected response to treatments for AK lesions?
Temporary local skin reactions (LSRs), such as erythema or blistering, are normal, common, and expected
responses to the use of topical medications for treatment of AK. Local skin reactions may develop as early as day
one after initiating treatment, and may resolve or persist to varying degrees throughout treatment. Reactions can
include:38-43
• Erythema (redness)
• Flaking/scaling
• Crusting
• Swelling
• Vesiculation/pustulation
• Erosion/ulceration
► Potential LSRs of topical AK treatments*
Treatment
Local skin reactions
5-FU38,56
• Erythema, erosion, crusting, ulceration
• Significant erythema, burning, erosion, crusting, and/or ulceration can occur during treatment and may require treatment interruption
• Erythema, flaking/scaling/dryness, scabbing/crusting
• Intense local skin reactions including erythema, scabbing/crusting, and erosion/
ulceration can occur after a few applications, and may require treatment interruption
• Erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation
• Typically occur within 1 day of treatment initiation and peak in intensity up to 1 week following completion of treatment
o Usually resolve within 2 weeks on face and scalp and within 4 weeks on trunk
and extremities
• Erythema, edema, crusting
Imiquimod 3.75%, 5%39,40
Ingenol mebutate
0.015%, 0.05%41
Aminolevulinic acid42 or
methyl aminolevulinate43
*Between-study comparisons are not intended due to differences in patient demographics and other study parameters.
This LSR comprises erythema, vesiculation, and mild swelling.
This LSR comprises more pronounced swelling and erythema.
7
► Non-LSR adverse events of topical treatments for AK*
Treatment
Adverse events
5-FU38,56
• Application site pain, pruritus, burning, dermatitis, soreness, tenderness, hyperpigmentation, scarring
• Insomnia, stomatitis, suppuration, scaling, swelling, irritability, medicinal taste, photosensitivity, and lacrimation
• Laboratory abnormalities (leukocytosis, thrombocytopenia, toxic granulation, eosinophilia)
Imiquimod 3.75%, 5%39,40
• Target site pain, tenderness, bleeding, itching, stinging, burning, tingling, irritation, photosensitivity
• Flu-like symptoms, including malaise, fever, nausea, myalgias, and chills
• Exacerbation of inflammatory skin conditions
Ingenol mebutate
0.015%, 0.05%41
• Administration site pruritus, irritation, pain, infection
• Periorbital pain
• Headache
• Eyelid edema
Aminolevulinic acid42
for use with PDT
• Stinging and burning during light therapy
• Application site itching, photosensitivity
Methyl aminolevulinate43
for use with PDT
• Stinging and burning during light therapy
• Application site itching, photosensitivity
• Headache
*Between-study comparisons are not intended due to differences in patient demographics and other study parameters.
► How should I counsel people about the proper use of topical medications prescribed
for AK?
While there are patient instructions specific to each of the topical AK medications, there are a few general
counselling tips that are common to 5-FU, imiquimod, and ingenol mebutate:38-41
• Use treatment on the appropriate body areas as directed by your doctor
• Wash hands before and after applying treatment
• Use care if applying the medication near the eyes, nostrils, or mouth
• Some local skin reactions may become visible and/or cause discomfort
Note that 5-FU is indicated for use on AK lesions only. Imiquimod and ingenol mebutate are field treatments that
can be used on the skin surrounding an AK lesion, up to 25 cm2.
Note also that aminolevulinic acid and methyl aminolevulinate should only be applied by a qualified healthcare
professional.
8
► Treatment-specific counselling tips for topical AK medications
Treatment
Patient information
5-FU38,56
• Before applying medication, wash the area to be treated with soap and water and dry carefully
• Apply a thin layer of medication to the affected area
• Apply with cotton-tipped applicator or suitable glove
• Do not cover the treated area with a bandage or other type of dressing
• If the area being treated becomes painful with continued use, stop treatment for 1 to 3 days; applying an over-the-counter steroid may help to alleviate swelling and soreness
• During treatment and for 1 to 2 months after treatment has ended, stay out of direct sunlight, especially between the hours of 10 a.m. and 3 p.m., and do not use tanning
beds/booths or sunlamps
o Wear protective clothing, including a hat and sunglasses
o Apply a sun block product that has a skin protection factor (SPF) of at least 15
o If you have a severe reaction from the sun, consult your doctor
• Do not store in the bathroom, near the kitchen sink, or in other damp places; heat or moisture may cause the medication to break down
Imiquimod 3.75%, 5%39,40
If using packets of medication:
• Do not use more than 2 packets for each application
• Partially used packets of medication should be discarded and not reused
If using cream pump:
• Before using the pump for the first time only, remove the cap and prime the pump until the product appears – discard this portion of the product
• Do not use more than two full pump actuations for each daily application
General instructions:
• Apply medication before bedtime
• Apply a thin layer of medication only to the affected area(s) to be treated, no larger than 25 cm2
• Rub the cream in all the way to the affected area(s)
• Avoid the cream in or around your eyes, lips, and nostrils; if the cream accidentally gets
in your mouth, eyes, and nostrils, rinse well with water right away
• Do not cover the treated area
• Avoid washing or getting the treated area wet for 8 hours
• After the treatment period, wash the treated area with mild soap and water
• If you have a severe local skin reaction, wash off the medication with mild soap and water; consult your doctor before restarting treatment
• If skin breaks down, if sores develop during the first week of treatment, or if you have any skin reactions that affect your daily activities or do not go away, stop treatment immediately
and contact your doctor
• Non-visible lesions may become visible during treatment
• During treatment, avoid exposure to sunlight, a sunlamp, or a tanning bed, and wear protective clothing and hat if you go outside during daylight
• Contact your doctor if you develop flu-like systemic signs and symptoms, including malaise (generalized feeling of discomfort, illness, or lack of well-being), fever, nausea, myalgias (muscle aches/pains), and chills
• Store between 15°C and 25°C
Ingenol mebutate 0.015%,
0.05%41
• Apply gel gently with the fingertip to the treatment field area (up to 25 cm2) as defined by your doctor
• Allow to dry for 15 minutes
• Avoid washing or touching the treated skin for 6 hours
• Avoid applying immediately after taking a shower or less than 2 hours before bedtime
• Do not cover the treated area with a bandage or other type of dressing
• If a local skin reaction does not improve, contact your doctor
• Put medication in a refrigerator (at 2°C to 8°C) as soon as possible after picking it up from the pharmacy
• Always store medication in a refrigerator (2°C to 8°C)
• These treatments should only be applied by a qualified healthcare professional
Aminolevulinic acid42
or methyl aminolevulinate43
9
► How can I counsel people with AK about steps they can take to prevent future AK lesions?
Counsel people with AK to practice sun safety, particularly between the hours of 11 a.m. and 4 p.m. Sun safety
includes wearing protective clothing, including a broad-brimmed hat, staying in the shade, and using a broadspectrum sunscreen with SPF of 30 or higher. People with AK should also avoid using artificial UV-light tanning
beds.6,57,58
In addition to sun protection, encourage people with AK to perform skin self-examinations on a regular basis, to
look for changes in the skin, including lesions that bleed, enlarge quickly, or heal poorly. Lesions of concern can
be reported to the physician at the next appointment.59
► Summary
• Actinic keratosis is a pre-cancerous skin lesion that develops in response to prolonged exposure to sun/UV radiation
• While many AK lesions are visible and palpable, non-palpable, non-visible AK lesions occur approximately
10 times more often than clinical AK lesions in sun-damaged skin
• Actinic keratosis is becoming increasingly prevalent due to increased life expectancy, increased popularity
of outdoor activities, and the popularity of tanning
• Actinic keratosis lesions can progress to SCC; which lesions will progress to SCC is unpredictable
• Most AK lesions are found on sun-exposed areas of the body
• Risk factors for AK include intense or cumulative exposure to UV (including tanning beds), male gender, older age, red or blond hair, light-coloured eyes, and a fair skin complexion
• Visible AK lesions are reddish to reddish-brown, rough, scaling patches, pinhead-sized to 4 to 5 mm in diameter, and are generally asymptomatic
• There are three approaches to treatment of AK lesions: topical, field-directed therapy; lesion-directed treatment; and combination/sequential therapy
• Common side effects of topical treatments include erythema, burning, crusting, scaling, and photosensitivity
o These are expected responses to treatment and will resolve or persist at varying times depending on
the treatment
• People with AK should be counselled to practice sun safety and avoid using artificial UV-light tanning beds
10
► Re-test Your Knowledge of Actinic Keratosis
1. True or false: Actinic keratosis is a type of pre-cancerous skin lesion.
a. True
b. False
2. True or false: Actinic keratosis is a risk factor for squamous cell carcinoma.
a. True
b. False
3. True or false: Actinic keratosis lesions may progress to melanoma.
a. True
b. False
4. Which of the following is not a sign or symptom of actinic keratosis?
a. Lesions are less than 1 cm in diameter
b. Lesions are generally found on sun-exposed areas of the body
c. Lesions are dark brown or black
d. Lesions may be rough and/or scaly to the touch
5. True or false: Actinic keratosis is a field disease.
a. True
b. False
6. True or false: a. True
b. False
Actinic keratosis lesions may be non-visible and/or non-palpable.
7. Which of the following is not a risk factor for the development of actinic keratosis lesions?
a. Fair skin
b. Excessive/habitual alcohol consumption
c. Older age (50+ years)
d. Immunosuppression
8. True or false: Men and women are at equal risk of developing actinic keratosis lesions.
a. True
b. False
9. Which of the following topical medications is not indicated in Canada for the treatment of actinic keratosis?
a. Tretinoin cream 0.025%
b. Ingenol mebutate 0.015%
c. 5-fluorouracil
d. Imiquimod 3.75%
10. True or false: Topical medications for the treatment of actinic keratosis lesions should be applied only within the margins of the lesions.
a. True
b. False
11
► Accreditation Criteria
This program is accredited as an Independent Study Program for 1.5 CEUs. To complete this course adequately and obtain your credits,
please go to www.cmesolutions.ca/cme-programs and follow the steps below to complete the online post-test and obtain your
certificate.
(1) Select the program: Frequently Asked Questions in Dermatology: Actinic Keratosis
(2) Create an account by completing the form on the right hand side of the page
(3) Enter your email address at Step 1 to login
(4) At Step 2, enter your access code: AK2013
(5) At this point, you will be asked to enter your name and license # for accreditation reporting purposes
(6) Complete the online test and print/download your Statement of Attendance for your files and evaluation form to provide your feedback
Should you encounter any problems and/or have questions about this program, please contact the program provider,
CME Solutions Canada, at 1-877-685-1888. Contact person: Hope Woodham
References: 1. LEO Pharma Inc. Data on file. February 2013. 2. Stedman’s Medical Dictionary. 28th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006. 3. Criscione VD, Weinstock MA, Naylor MF, et al; Department
of Veteran Affairs Topical Tretinoin Chemoprevention Trial Group. Actinic keratoses: Natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial. Cancer.
2009;115(11):2523-30. 4. Lober BA, Lober CW. Actinic keratosis is squamous cell carcinoma. South Med J. 2000;93:650-5. 5. Ulrich M, Krueger-Corcoran D, Roewert-Huber J, et al. Reflectance confocal microscopy for
noninvasive monitoring of therapy and detection of subclinical actinic keratoses. Dermatology. 2010;220(1):15-24. 6. Berman B, Amini S, Valins W, et al. Pharmacotherapy of actinic keratosis. Expert Opin Pharmacother.
2009;10(18):3015-31. 7. Vatve M, Ortonne JP, Birch-Machin MA, et al. Management of field change in actinic keratosis. Br J Dermatol. 2007;157(Suppl 2):21-4. 8. Braakhuis BJ, Tabor MP, Kummer JA, et al. A genetic
explanation of Slaughter’s concept of field cancerization: evidence and clinical implications. Cancer Res. 2003;63(8):1727-30. 9. Hemminki K, Zhang H, Czene K. Time trends and familial risks in squamous cell carcinoma
of the skin. Arch Dermatol. 2003;139:885-9. 10. Diepgen TL, Mahler V. The epidemiology of skin cancer. Br J Dermatol. 2002;146(suppl 61):1-6. 11. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal
cell and squamous cell carcinomas in a population younger than 40 years. JAMA. 2005;294:681-90. 12. Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United
States, 2006. Arch Dermatol. 2010;146(3):283-7. 13. Chen J, Ruczinski I, Jorgenson TJ. Nonmelanoma skin cancer and risk for subsequent malignancy. J Natl Cancer Inst. 2008;100:1215-22. 14. Stulberg DL, Crandell
B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician. 2004;70(8):1481-8. 15. Motley RJ, Preston PW, Lawrence CM. Multi-professional guidelines for the management
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