ORIGINAL ARTICLE   Free access

Italian Journal of Dermatology and Venereology 2021 April;156(2):213-9

DOI: 10.23736/S2784-8671.21.06892-9

Copyright © 2021 EDIZIONI MINERVA MEDICA

language: English

Treatment-resistant actinic keratoses are characterized by distinct clinical and histological features

Lutz SCHMITZ ^{1, 2} ✉, Amrei BREHMER ^{3, 4}, Conrad FALKENBERG ⁵, Thilo GAMBICHLER ¹, Markus V. HEPPT ⁶, Theresa STEEB ⁶, Girish GUPTA ^{7, 8}, Josep MALVEHY ⁹, Thomas DIRSCHKA ^{4, 10}

¹ Department of Dermatology, Venereology and Allergology, Ruhr-University, Bochum, Germany; ² Institute of Dermatopathology, MVZ Corius DermPathBonn, Bonn, Germany; ³ Department of Dermatology, Klinikum Dortmund gGmbH, Dortmund, Germany; ⁴ Faculty of Health, University Witten-Herdecke, Witten, Germany; ⁵ Department of Dermatology, Faculty of Medicine, Heinrich-Heine-University, Düsseldorf, Germany; ⁶ Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany; ⁷ Department of Dermatology, Lauriston Building, Edinburgh, UK; ⁸ School of Medicine, University of Glasgow, Glasgow, UK; ⁹ Department of Dermatology, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University Hospital of Barcelona, University of Barcelona, Barcelona, Spain; ¹⁰ CentroDerm Clinic, Wuppertal, Germany

BACKGROUND: Actinic keratoses (AK) are generally treated to reduce the risk of progression into invasive cutaneous squamous cell carcinoma (cSCC). However, this risk of transformation is low, and rather than focusing on these lesions, current treatment studies report on complete clearance of AKs in an entire field. This study aimed to investigate treatment-resistant AKs (trAK) after field therapy compared to randomly chosen AKs prior to treatment.
METHODS: AKs were clinically assessed according to the grade of hyperkeratosis and pain on palpation, prior to treatment. TrAKs were biopsied and compared to AKs which were biopsied prior to any treatment. AKs were evaluated regarding histological severity (AKI-III), their basal growth grading (PROI-III), acantholysis, elastosis, follicular extension of atypical keratinocytes and accompanying infiltrate.
RESULTS: Two hundred eleven AKs in 171 patients were identified. TrAKs (N.=79) were significantly more painful (64.6% vs. 22.0%; P<0.0001), showing acantholysis (57.0% vs. 33.3%; P=0.0007); and with distinct basal proliferation (PROIII) (64.4% vs. 46.2%; P=0.0099) compared to the control group (N.=132). In a multivariate analysis using logistic regression, pain and PRO III graded lesions were significant independent (P<0.0001 and P=0.0179) predictors for trAKs. Focusing on individual histological features in the trAK group, AKs with grade AKIII, PROIII or follicular extension reaching the sebaceous gland were the most common findings with 51.9%, 64.6%, and 59.5% AKs demonstrating this, respectively.
CONCLUSIONS: TrAKs are often painful, showing a distinct basal proliferation (PROIII) and acantholysis. As these features are also seen in invasive cSCCs, trAKs may represent a subgroup of AKs and, for this reason, it requires further evaluations.

KEY WORDS: Keratosis, actinic; Acantholysis; Pain; Disease progression