Actas Dermo-Sifiliográficas (English Edition) Actas Dermo-Sifiliográficas (English Edition)
Actas Dermosifiliogr 2018;109:83-6 - Vol. 109 Num.1 DOI: 10.1016/j.adengl.2017.05.023
Case and Research Letter
Prevalence of Actinic Keratosis in Different Regions of Spain: The EPIQA Study
Prevalencia de la queratosis actínica en diferentes regiones españolas: estudio EPIQA
C. Ferrándiz-Pulidoa, M. Lera-Imbuluzquetab, C. Ferrándizc,, , M.J. Plazas-Fernandezb,1, on behalf to EPIQA Study Group
a Servicio de Dermatología, Hospital Universitario Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
b Área de Investigación Aplicada, GOC Networking, Barcelona, Spain
c Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
Dear Editor:

Actinic keratoses (AKs) are common cutaneous lesions that develop as a result of ultraviolet (UV) radiation damage.1 Risk factors associated with AKs include advanced age, male gender, high degree of sun and/or artificial UV exposure, and fair skin.2 Epidemiological studies within Europe are limited and have provided highly variable estimates of AK point prevalence (1–38%).2–6 Cumulative sun exposure, demographic AK risk factors, and lifestyle characteristics have likely contributed to the wide-ranging estimate of European AK prevalence.7,8

Comprehensive studies that measure nationwide AK prevalence within Europe would provide essential information that would aid the development of pragmatic AK management guidelines. The aim of the EPIQA study was to assess the prevalence of AKs among dermatology outpatient clinics in Spain.9 In this analysis, we report the secondary objective of describing dermatology outpatient clinic AK prevalence within four regions of Spain with different climate conditions.

The EPIQA study was an observational, cross-sectional, multicentre study that included patients attending general dermatology outpatient clinics in Spain.9 In order to represent the entire country, clinics were selected and divided into four geographical regions based on climatic conditions and lifestyle: Northern (Galicia, Asturias,Navarra and Aragón), Central (Castilla-León, Madrid, and Castilla-La-Mancha), Mediterranean (Cataluña, Comunidad Valenciana and Murcia) and Southern (Extremadura and Andalucía) regions. Whole-body examinations were performed by certified dermatologists who visually confirmed AKs. Medical history, profession, and sun/UV exposure habits were collected via standardised interviews. Statistical analysis have been previously described.9

A total of 3877 patients were included with characteristics shown in Table 1. Overall, age and sex were similar between regions. Age distributions were also similar between regions, with ages 45–50 representing 11.9% and >80 years old representing 14.0% of the population. Actinic keratosis being the reason for the dermatology consultation varied from 15.9% to 23.3%. Most patients reported low occupational but moderate recreational sun exposure.

Table 1.

Sociodemographic data.

  North (n=808)  Centre (n=847)  Mediterranean (n=1616)  South (n=606) 
Age (years), mean (SD)
  65.4 (12.3)  64.8 (12.4)  67.2 (12.0)  65.6 (12.0) 
Age (groups), n (%)
45–50  102 (12.6)  121 (14.3)  169 (10.5)  71 (11.7) 
51–60  212 (26.2)  232 (27.4)  339 (21.0)  153 (25.2) 
61–70  225 (27.9)  192 (22.7)  434 (26.9)  166 (27.4) 
71–80  156 (19.3)  198 (23.4)  431 (26.7)  135 (22.3) 
>80  113 (14.0)  104 (12.3)  243 (15.0)  81 (13.4) 
Sex, n (%)
Male  346 (42.8)  351 (41.4)  757 (46.8)  267 (44.1) 
Female  462 (57.2)  496 (58.6)  859 (53.2)  339 (55.9) 
Reason for consultation, n (%)
Actinic Keratosis  133 (16.5)  135 (15.9)  377 (23.3)  103 (17.0) 
Other  675 (83.5)  712 (84.1)  1239 (76.7)  503 (83.0) 
Occupational sun exposurea, n (%)
Low  141 (17.5)  475 (56.1)  1035 (64.0)  355 (58.6) 
Moderate  417 (51.6)  176 (20.8)  255 (15.8)  92 (15.2) 
High  250 (30.9)  196 (23.1)  326 (20.2)  159 (26.2) 
Recreational sun exposureb, n (%)
Low  141 (17.5)  179 (21.1)  274 (17.0)  123 (20.3) 
Moderate  417 (51.6)  487 (57.5)  876 (54.2)  356 (58.7) 
High  250 (30.9)  181 (21.4)  466 (28.8)  127 (21.0) 
Occupations with high sun exposurec, n (%)
Elementary occupations  233 (28.8)  313 (37.0)  453 (28.0)  198 (32.7) 
Service and sales  92 (11.4)  126 (14.9)  238 (14.7)  81 (13.4) 
Skilled agricultural, forestry and fishery  116 (14.4)  94 (11.1)  157 (9.7)  101 (16.7) 
Accountants, clerks and office  88 (10.9)  117 (13.8)  178 (11.0)  75 (12.4) 
Construction, craft and related trades  63 (7.8)  76 (9.0)  243 (15.0)  49 (8.1) 
a

Low: none; moderate: under 2h outside; high: all day outside.

b

Low: none; moderate: irregular outdoor activity participation; high: regular participation in outdoor activities all year round.

c

Occupations listed which include ≥10% total sample population.

In the study population, 1110 presented with AKs (28.6%, 95% CI: 27.2, 30.1). AK point prevalence (95% CI) differed significantly between regions, with 31.4% (29.1, 33.7) in the Mediterranean, 28.1% (24.5, 31.7) in the South, 27.5% (24.4, 30.6) in the North and 24.9% (22.0, 27.8) in the Central region (p=0.006). The most significant difference in prevalence was observed between Central and Mediterranean regions (p<0.05). Communities with the highest AK point prevalence were located in the Northern (Aragón, 39.6%), Mediterranean (Cataluña, 40.1%), and Southern (Extremadura, 36.6%) regions. Point prevalence was highest in men aged ≥51 years old (p<0.001) (Fig. 1).

Figure 1.
(0.33MB).

Prevalence of AKs according to age and sex.

A comparison of patients diagnosed with AK found a significant difference between regional skin phototypes and no difference between regional history of non-melanoma skin cancer (Table 2). In all regions, the most prevalent phototypes were types II and III, which cumulatively accounted for 80–90% of all AK patients. A significantly higher proportion of AK patients in all regions reported that AKs were the reason for consultation, compared to other reasons (p=0.006). Significant regional differences were observed when related to occupational (p<0.001), but not to recreational (p=0.267), sun exposure (Table 2).

Table 2.

Lifestyle and clinical characteristics of AK patients.

  North (n=222)  Centre (n=211)  Mediterranean (n=507)  South (n=170)  p-Value 
Skin phototype, n (%)
Type I  12 (5.4)  2 (0.9)*  16 (3.2)  10 (5.9)*  <0.001 
Type II  94 (42.3)  103 (48.8)  219 (43.2)  91 (53.5)   
Type III  81 (36.4)*  87 (41.2)  250 (49.3)*  66 (38.8)   
Type IV  35 (15.8)*  19 (9.0)*  22 (4.3)  3 (1.8)*   
NMSC history, n (%)
  74 (33.3)  57 (27.0)  173 (34.1)  51 (30.0)  0.271 
Reason for consultation, n (%)
Actinic Keratosis  130 (58.6)??  134 (63.5)  355 (70.0)??  101 (59.4)  0.006 
Other  92 (41.4)  77 (36.5)  152 (30.0)  69 (40.6)   
Occupational sun exposure, n (%)
Low  97 (43.7)  68 (32.2)*  269 (53.1)*  70 (41.2)*  <0.001 
Moderate  45 (20.3)  49 (23.2)  80 (15.8)  31 (18.2)   
High  80 (36.0)  94 (44.5)*  158 (31.2)*  69 (40.6)   
Recreational sun exposure, n (%)
Low  35 (15.8)  34 (16.1)  60 (11.8)  28 (16.5)  0.267 
Moderate  107 (48.2)  109 (51.7)  250 (49.3)  91 (53.5)   
High  80 (36.0)  68 (32.2)  197 (38.9)  51 (30.0)   
Number of lesions, n (%)
55 (24.8)  51 (24.2)  131 (25.8)  32 (18.8)  0.688 
2–4  70 (31.5)  76 (36.0)  164 (32.3)  66 (38.8)   
5–10  62 (27.9)  54 (25.6)  137 (27.0)  46 (27.1)   
11–15  13 (5.9)  13 (6.2)  41 (8.1)  13 (7.6)   
16–20  11 (5.0)  8 (3.8)  13 (2.6)  8 (4.7)   
21–25  4 (1.8)  5 (2.4)  7 (1.4)  5 (2.9)   
26–30  4 (1.8)  3 (1.4)  8 (1.6)  0 (0.0)   
>30  3 (1.4)  1 (0.5)  6 (1.2)  0 (0.0)   
*

p<0.001.

??

p<0.05. Chi-squared test used to calculate p-values. NMSC: non-melanoma skin cancer.

The distribution of anatomical areas with AK lesions was similar between regions and, in general, significantly more frequently reported on the face for women and the scalp and ears for men (Supplementary Table 1). A comparison of the number of lesions by location showed no regional differences (Supplementary Table 2).

Overall, there were observed regional differences in skin phototype, the reason for consultation, and occupational sun exposure. While skin phototype and occupational sun exposure were anticipated to differ due to regional demographic and employment variability, significant differences in the percentage of patients seeking a consultation for AK suggests differing regional attitudes towards seeking healthcare services or healthcare availability. Furthermore, as 30–42% of patients with AKs ignored these lesions, it is clear that AK remains an underdiagnosed condition within Spain.

In agreement with previous results, lesion location was consistent between regions; more frequent on the scalp and ears for men, and the face for women.10 Furthermore, despite regional variation in AK risk factor frequency, no significant differences in the number of lesions were observed.

Some limitations of this study include the unequal recruitment from each autonomous community that may have imbalanced regional comparisons and the restriction of the study population to patients visiting dermatology clinics. However, to the best of our knowledge, this is the first study that has investigated regional variation of AK prevalence within a single European country.

In summary, significant regional differences in AK prevalence have been observed in Spain; predominantly related to sex and age. Regional differences in skin phototype and occupational sun exposure do not appear to influence lesion location or severity. It is striking that despite regional differences, a high proportion of patients in Spain did not seek advice regarding their AKs. These findings highlight that regional variation in AK prevalence exists and are of value to national AK screening and management initiatives.

Conflict of interest

C. Ferrándiz-Pulido received speakers’ honoraria and/or consultation fees from Almirall, Leo Pharma and Isdin. C. Ferrándiz received speakers’ honoraria and/or consultation fees from Almirall, Leo Pharma and Spherium Biomed. M.J. Plazas was an employee of Almirall at the time of the study. All other authors have no conflicts of interest to declare.

Acknowledgements

We would like to thank to all the investigators of the EPIQA study group (in alphabetical order): Albares Tendero MP, Alcántara Reifs CM, Alfaro Rubio A, Alonso San Pablo MT, Bassas Freixas P, Blanco Barrios S, Blanes Martínez MM, Botella Estrada R, Brufau Redondo C, Castellanos González M, Curto Barredo L, De La Corte Sánchez IS, De La Cueva Dobao P, Del Prado Sanz ME, Eiris Salvado N, El-Khalili Murjan BA, Escutia Muñoz B, Fernández López E, Ferrándiz Foraster C, Ferrándiz-Pulido L, Ferrándiz-Pulido C, Figueroa Silva O, Fuente González MJ, Galiano Mejías S, García Acebes CR, García Martínez FJ, García Rodiño S, García-Melgares Linares ML, García-Patos V, Gilaberte Calzada Y, Gómez Bernal SM, Gómez López A, Gómez Sanchez ME, Gonzalez De Arriba M, Heras Mendaza F, Hernández-Gil Bordallo A, Hernández-Gil Sánchez J, Hilari Carbonell H, Hueso Gabriel L, Lera Imbuluzqueta JM, López Aventín D, Marín Corbalán N, Martorell Calatayud A, Mateo Suárez S, Navarro Mira M, Ojeda Vila, T Pérez Caballero JA, Pérez García LJ, Pujol R, Ramírez Andreo A, Ramón Sapena R, Redondo Bellón P, Rodríguez Martín AM, Román Curto C, Romo Melgar A, Roncero Riesco M, Ruiz De Casas A, Ruiz Martínez MD, Salas García T, Salido Vallejo R, Sánchez Aguilar MD, Santos Duran JC, Segurado Rodríguez MA, Soria Martínez C, Valdés Pineda FJ, Vargas Díez E, Vázques Veigas HA, Vázquez Osorio I, Vizán de Uña MC, Yuste Chaves M.

The authors would also like to thank Xavier Cortes Gil for assistance in developing this article. Writing support was provided by Jonathan Mackinnon, PhD from TFS Develop with financial support provided by Almirall S.A. The study was sponsored and financially supported by Almirall S.A.

Appendix A
Supplementary data

The following are the supplementary data to this article:

mmc1.pdf

References
1
R. Rossi,M. Mori,T. Lotti
Actinic keratosis
Int J Dermatol, 46 (2007), pp. 895-904 http://dx.doi.org/10.1111/j.1365-4632.2007.03166.x
2
I. Schaefer,M. Augustin,C. Spehr,M. Reusch,T. Kornek
Prevalence and risk factors of actinic keratoses in Germany—analysis of multisource data
J Eur Acad Dermatol Venereol, 28 (2014), pp. 309-313 http://dx.doi.org/10.1111/jdv.12102
3
L. Naldi,L. Chatenoud,R. Piccitto,P. Colombo,E.B. Placchesi,C. La Vecchia
Prevalence of actinic keratoses and associated factors in a representative sample of the Italian adult population: results from the Prevalence of Actinic Keratoses Italian Study, 2003–2004
Arch Dermatol, 142 (2006), pp. 722-726 http://dx.doi.org/10.1001/archderm.142.6.722
4
J. Eder,K. Prillinger,A. Korn,A. Geroldinger,F. Trautinger
Prevalence of actinic keratosis among dermatology outpatients in Austria
Br J Dermatol, (2014),
5
S.C. Flohil,R.J.T. van der Leest,E.A. Dowlatshahi,A. Hofman,E. de Vries,T. Nijsten
Prevalence of actinic keratosis and its risk factors in the general population: the Rotterdam Study
J Invest Dermatol, 133 (2013), pp. 1971-1978 http://dx.doi.org/10.1038/jid.2013.134
6
A.A. Memon,J.A. Tomenson,J. Bothwell,P.S. Friedmann
Prevalence of solar damage and actinic keratosis in a Merseyside population
Br J Dermatol, 142 (2000), pp. 1154-1159
7
C. Costa,M. Scalvenzi,F. Ayala,G. Fabbrocini,G. Monfrecola
How to treat actinic keratosis? An update
J Dermatol Case Rep, 9 (2015), pp. 29-35 http://dx.doi.org/10.3315/jdcr.2015.1199
8
P. Chetty,F. Choi,T. Mitchell
Primary care review of actinic keratosis and its therapeutic options: a global perspective
Dermatol Ther, 5 (2015), pp. 19-35
9
C. Ferrándiz,M.J. Plazas,M. Sabaté,R. Palomino,EPIQA Study Group
Prevalence of actinic keratosis among dermatology outpatients in Spain
Actas Dermosifiliogr, (2016),
10
P.H. Youl,M. Janda,J.F. Aitken,C.B. Del Mar,D.C. Whiteman,P.D. Baade
Body-site distribution of skin cancer, pre-malignant and common benign pigmented lesions excised in general practice

M.J. Plazas was employed at the Medical Department Spain, Almirall at the time the study was conducted.

Corresponding author. (C. Ferrándiz 40879cfp@comb.cat)
Copyright © 2017. Elsevier España, S.L.U. and AEDV
Actas Dermosifiliogr 2018;109:83-6 - Vol. 109 Num.1 DOI: 10.1016/j.adengl.2017.05.023