Sun damage and actinic keratoses

Reducing UV exposure with shade, long sleeves, wide-brimmed hats, UV-blocking sunglasses and smart timing outdoors.

Often considered for everyone with sun damage, especially after an actinic keratosis is found, because new damage can keep adding up.

There is no real downside. People who cover up nearly all the time may want to ask a clinician about vitamin D.

Heat comfort in dark or heavy clothing. Sunscreen is still often used on skin that stays uncovered.

Protection works the day you use it. Visible changes in skin can take months to years, and old damage may not fully fade.

• Which parts of my skin are most sun-damaged?
• What clothing or hat features do you suggest for my daily life?

A lotion, cream or stick that helps block UVA and UVB light. Labels such as broad-spectrum, SPF 30 or higher, and water resistant are what dermatologists often point to.

Often considered for skin that cannot be covered by clothing, such as the face, ears, neck and hands, including on cloudy days.

Some people react to certain ingredients. Mineral (zinc or titanium) products are sometimes better tolerated by sensitive skin. Babies under 6 months are usually kept out of the sun instead.

Stinging, rash or eye irritation. Sunscreen reduces risk but does not make staying in the sun risk-free.

Protective effect is immediate. Studies suggest regular use may lower new actinic keratoses over time.

• Which type of sunscreen would suit my skin and routine?
• Is my scalp or lip area protected enough?

Vitamin A-related creams or gels, such as tretinoin, that are used to smooth fine lines, rough texture and uneven color in sun-damaged skin.

Often considered when a person's main concern is the look and feel of photoaged skin, such as fine wrinkles, roughness and dark spots.

Often avoided or discussed carefully in pregnancy and when trying to conceive. Can be too irritating for very sensitive skin or skin with eczema.

Dryness, peeling, redness and sun sensitivity, especially early on. On brown and Black skin, irritation can leave darker marks.

Improvement is usually gradual, often judged after several months. Gains are modest and tend to fade if use stops.

• Is a retinoid reasonable for my skin and goals?
• How can I limit irritation, and is this safe if I may become pregnant?

Prescription creams applied to a whole area of sun-damaged skin, so they can treat visible spots and ones not yet visible. This is called field treatment.

Often considered when there are several actinic keratoses or widespread sun damage on one area, such as the face or scalp.

Not usually used in pregnancy. Can be hard to tolerate for people who dislike strong skin reactions. Allergies to ingredients matter.

Expected redness, crusting, soreness and peeling that can look dramatic for a while. Redness can be harder to see on brown and Black skin. Flu-like feelings can happen with imiquimod. Ask when to call if reactions are severe.

A treatment course lasts weeks, and skin often takes a few more weeks to settle. Results are usually judged one to a few months later.

• Would a field treatment make sense for my pattern of spots?
• What reaction is normal, and what would mean I should call you?
• How will we check that the treated area has healed?

Two other prescription field treatments. Diclofenac is an anti-inflammatory gel. Tirbanibulin is a newer ointment that the FDA approved for actinic keratoses on the face or scalp.

Often considered when a person wants a field treatment, and these are sometimes chosen for gentler or shorter courses. Choice depends on the area, the number of spots and how much skin reaction a person can accept.

Diclofenac may be less suitable for people allergic to aspirin or similar pain medicines. Tirbanibulin is approved for the face or scalp, not other body areas. Neither is usually discussed during pregnancy without a clinician.

Redness, scaling, itching and skin soreness. Diclofenac may take longer to work and may be less effective in studies than some others.

Diclofenac courses last many weeks. Tirbanibulin courses are short. Results are usually judged weeks to months later.

• Why might one of these suit me better than a stronger cream?
• Is my area one the treatment is approved for?

A clinician applies very cold liquid nitrogen to an individual actinic keratosis so the abnormal skin blisters and peels off.

Often considered for a few distinct spots, and it is a common first-line choice in the clinic.

Less suited to many spots across a large area, or to spots that look unusual and may need a biopsy first. Can lighten brown or Black skin where it is applied.

Stinging during treatment, blistering, scabbing, and lighter or darker marks afterward. Signs of infection such as spreading redness, pus or fever.

Healing usually takes a couple of weeks. Spots that stay or return may need another visit.

• Does this spot look like it needs a biopsy first?
• Could freezing change my skin color in this area?

A light-sensitive medicine is placed on the skin, then a special light is shone on it to destroy sun-damaged cells.

Often considered for larger areas of sun damage, for people who prefer a clinic-based treatment, or when other options are not a good fit.

Less suitable for people with certain light-sensitivity conditions or allergies to ingredients. Needs strict sun avoidance after treatment.

Burning or stinging during light exposure, then redness, swelling, crusting and peeling for days. Brown and Black skin may get darker spots afterward.

Skin often heals in one to two weeks. Results are judged over a few months and some people need repeat sessions.

• How uncomfortable is PDT and how should I plan for downtime?
• Can I do PDT for my particular area?

A clinician looks closely at your skin, sometimes with a handheld magnifier, and may remove a small sample (biopsy) from a spot that looks unusual.

Often considered for a spot that is thick, bleeding, painful, growing, not responding to treatment, or hard to name by eye. People with many AKs or a transplant history are often advised to have regular full-skin checks.

Not usually avoided, but people on blood thinners, with bleeding problems or with allergies to numbing medicine should tell the clinician first.

Mild soreness and a small scar. Signs of infection or bleeding that does not stop.

Results often take days to about two weeks.

• How often should I have a full-skin check?
• Should any of my spots be sampled?

A form of vitamin B3 taken by mouth. It has been studied as a way to lower new skin cancers and actinic keratoses in people at high risk. It is not the same as niacin.

May be discussed when a person has had several skin cancers or many actinic keratoses and wants an added step beyond sun protection.

Not studied as a treatment for existing spots, and not a replacement for sun protection or skin checks. Evidence in organ transplant recipients is less clear. People with kidney or liver disease or who are pregnant should ask a clinician.

It is usually well tolerated, but quality and strength of supplements vary. Any benefit seen in studies may not last after stopping.

Studies followed people for about a year or longer. Ask your clinician how benefit would be judged.

• Is nicotinamide reasonable for my history?
• How would it fit with my other treatments and checks?