We conducted an organized review of the literature to identify available evidence regarding AK management using the Medline/PubMed international database. Searches employed filters and Medical Subject Headings (MeSH) combined with open search terms and Boolean connectors “OR” and “AND.” Additionally, a structured manual search of gray literature was performed on the websites of leading scientific societies such as the Spanish Academy of Dermatology and Venereology (AEDV), the Spanish Society of Primary Care Physicians (SEMERGEN), and the European Association of Dermato-Oncology, among others. Articles published in English or Spanish within the last 10 years (2014–2024) were included. Exclusion criteria were commentaries, letters to the editor, editorials, book chapters, and publications unrelated to AK.

A total of 6 experts in AK management (3 in dermatology and 3 in primary care) formed the scientific committee and focus group. With the support of a moderator, the group reviewed the collected evidence to develop the questionnaire used in the Delphi consultation. The focus group also formulated the final list of recommendations based on the consensus statements.

Spanish and European clinical practice guidelines emphasize the need to perform histopathological analyses when diagnosing lesions suspected of progressing to cutaneous squamous cell carcinoma (cSCC).19,20 This recommendation is particularly relevant in cases of actinic cheilitis, which has a malignant transformation rate between 10% and 30% and accounts for 95% of cSCCs arising on the lips.21 The panelists reached consensus on these aspects, including the management of actinic cheilitis—an aspect not addressed in the latest Spanish adaptation of the European clinical practice guidelines on the management of AK.19

In addition, the panelists recommended collecting sociodemographic information and the patient's health history. This aligns with findings from the Rotterdam Study, in which male sex, age older than 70 years, fair skin phototype, a prior history of skin cancer, and residence in regions with high sun exposure were identified as significant risk factors for AK.5

Consistent with these risk factors, it is essential to consider associated symptoms and their clinical implications. A prospective study demonstrated that manifestations such as pruritus, pain, bleeding, or changes in lesion size occur in 20–50% of patients with cSCC.11 In this context, panelists recommend assessing these signs and symptoms using the “5R+R” methodology proposed by Domínguez-Cruz et al., which facilitates a simple and systematic approach to diagnosing AK and detecting potential progression to cSCC.22 Similarly, to identify the presence of field cancerization, the panelists advise evaluating the number of lesions and the adjacent photodamaged skin, which is consistent with a previous consensus that highlighted the ambiguity surrounding the definition of field cancerization in the literature and advocated for the use of anatomical indicators as evaluation criteria.23

Complementing these considerations, diagnostic support tools play a crucial role. In line with the conclusions of the above-mentioned consensus (Figueras Nart et al.), the panelists recommend the use of dermoscopy in primary care, as it facilitates distinguishing AK from other conditions such as superficial basal cell carcinoma.19 Combining dermoscopy with appropriate training optimizes clinical diagnosis and helps determine the need for early referral to dermatology.24,25 However, widespread dermoscopy use still faces limitations, such as insufficient equipment availability.26

The use of telemedicine tools has expanded exponentially, especially in dermatology, due to the increasing number of consultations and advances in digital imaging.27 Teledermoscopy is widely recommended because it significantly improves diagnostic accuracy (92.4% with teledermoscopy vs 62.4% without it in primary care; p<0.001),28 thereby accelerating diagnostic pathways.29 Experts recommend providing all relevant information to ensure appropriate patient referral—particularly in teleconsultations—such as including a dermoscopic image in addition to a clinical photograph and the patient's health history.29,30

Panelists recommend that the patient's health record should include a clinical photograph, a dermoscopic photograph, previous treatments, and risk factors.2,30 This recommendation aligns with prior dermatology guidelines and National Health Service (UK) documents.16,31 The authors support this suggestion given existing evidence of a lack of standardized referral criteria for AK patients from primary care to dermatology.26,29,32 In line with these guidelines, panelists advise referral especially for patients with risk factors such as xeroderma pigmentosum, a history of extensive sun damage, or lesions in anatomically complex areas (periocular region, lips)16,31–33—regions that not only have higher malignant potential but also pose therapeutic challenges.16,31,33

Because AK is considered a carcinoma in situ with the potential to progress to cSCC, previous guidelines recommend treating all AKs, including early or incipient lesions.14,19 In this regard, guidelines state that treatment of choice should be based on factors such as lesion extent and severity,19,31 recommending cryotherapy for isolated lesions, especially in patients with <6 lesions or unresponsive to topical therapies.15 A systematic review reported AK clearance rates >70% within 1–12 months after cryotherapy, with increased efficacy when combined with 0.5% 5-fluorouracil (5-FU), resulting in a mean improvement of 13.3%.18 Additionally, a clinical trial showed that cryotherapy followed by imiquimod significantly reduced lesion numbers vs control (78 vs. 116).34 For these reasons, both combinations were recommended by the panelists.

Curettage is not only effective for treating isolated grade 3 lesions but also enables histopathologic sampling.35 However, panelists discouraged its use for extensive involvement, as it is a painful procedure requiring local anesthesia15,36 and because clinical trial evidence is limited.

Regarding topical therapies, panelists recommended 5-FU for both isolated lesions (0.5% with 10% salicylic acid) and for field cancerization (4%). A meta-analysis showed lesion reductions up to 80.1% at 3 months and 67.4% at 6 months, although efficacy is strongly influenced by treatment adherence, which may be affected by adverse effects such as pruritus and burning sensation.37 Notably, combining 0.5% 5-FU with 10% salicylic acid improves penetration and enhances therapeutic action.38

Imiquimod, at both 3.75% and 5%, was recommended for field cancerization regardless of severity. Reviews agree that formulation and frequency should be tailored to each patient.15 The 5% formulation has demonstrated lesion clearance rates of up to 85%,37 whereas the 3.75% formulation shows similar efficacy with fewer adverse events.39

Regarding diclofenac sodium, panelists recommended its use for grade 1–2 lesions, both isolated and in field cancerization, highlighting that combining it with hyaluronic acid enhances drug penetration.40 However, its use was discouraged for grade 3 lesions due to its lower efficacy (36% lesion reduction) vs cryotherapy (72.3%) and 5-FU (80.1%).18 For tirbanibulin, clinical trials have demonstrated that 1% formulations achieve complete clearance in approximately half of patients with mild to moderate involvement and have a favorable safety profile.41 Accordingly, panelists recommended its use for grade 1–2 lesions, both isolated and in field cancerization.

Consistent with a recent narrative review,42 panelists recommended photodynamic therapy (PDT) for patients with field cancerization. While daylight-PDT has been described as less painful,43 a recent meta-analysis found that although efficacy is similar to conventional PDT for isolated grade 1–2 lesions (RR, 0.97; 95%CI, 0.91–1.04; p=0.41), it is less effective for grade 3 lesions (RR, 0.87; 95%CI, 0.81–9.94; p<0.001).43

Similarly, for immunosuppressed patients, panelists advised using conventional therapies such as cryotherapy, curettage, 5-FU, and both conventional and daylight-PDT, given the reduced efficacy of alternative therapies, the higher risk of cSCC, and the lack of clinical trials evaluating newer therapies in this population.44,45

Finally, panelists emphasized the importance of incorporating the patient's perspective into treatment decisions, as motivation and engagement strongly influence adherence.46 A cross-sectional study showed that patients prioritize preventing AK progression to cSCC but also value cosmetic outcomes and treatment convenience—especially in older adults.47 In line with these observations, experts recommend patient education on self-examination and treatment administration, along with periodic follow-up, which may improve adherence and optimize therapeutic outcomes.