Actinic or solar keratoses (AK) are growths that whiter-skinned, more mature (wiser?) folk can make on their sun-exposed skin. They appear on faces, hands, forearms, ears and other parts that have had a bit of sun exposure over time, as red, poorly defined, flat areas with crusty, stuck-on scales.

There has long been a debate about how medically significant they are, because a few of them can transform slowly, not overnight, into squamous (SKWAY-mus) cell skin cancers or carcinomas. But which ones will change, and what are their chances for changing, are the questions with no clear answers, like so much in this life.

The dead cell layer on our skin is called keratin (KER-a-tin). The suffix “osis” means condition of whatever. There are many keratosis labels used descriptively. The word actinic (ak-TIN-ik), from Greek actinos for ray, means related to rays. The word solar you need no “enlightening” about. The first attempt to define them was by Walter Freudenthal in 1926, who called them keratoma (“oma” lump of) senilis. They originally were thought to be just another brand of barnacle burgeoning over bodies because of birthdays, not related to skin cancer at all.

In 1958, the brilliant dermatologist/pathologist Herman Pinkus first described their microscopic nature scientifically. He coined the adjective actinic. In the 1960s, another famous dermatopathologist, Walter Lever, labeled them “actinic keratoses (plural), or squamous cell carcinoma, grade ½, in situ (in place),” meaning not to have invaded into the lower skin regions as an actual cancer would. It was assumed from wide experience with these that squamous cell cancers in sun-exposed areas had a low possibility of spreading internally and killing.

For years treatments were mostly some fashion of tissue destruction, be it frying with electric needles or freezing with liquid nitrogen or CO2, or filleting with a scalpel. It was usually done to the suspicious, troublesome or disfiguring ones, not all. Then, in the 1990s, the Health Care Financing Administration (now called Centers for Medicare and Medicaid), the federal government financial judges, declared that actinic keratoses were cosmetic growths, not evolving cancers. It seemed a patently obvious move to avoid paying for their treatment. The legal battleground, I recall, was Florida, where dermatology won a rather bloody victory to be compensated for treatments.

That initiated the age of “all of these are bad for you.” They all must go: Take no prisoners.

Uh, hold it. Studies were done and are still being done that roughly calculate the real risk.  As I was ripping into some of my infamous medical paper piles to cull that one article from each issue that I can’t live without (but has been buried there a couple years patiently awaiting my reading), I came across a 2007 one with the headline “Actinic keratoses not so really ominous.”

It discussed a presentation by Paul Salmon, a New Zealand dermatologist, at the 65th annual American Academy of Dermatology meeting. He said, “We have all been taught from residencies that actinic keratoses have an impending preprogrammed progression to squamous cells, and that we must treat them for the patient’s good. Yet the literature shows that less that 0.1  percent will actually do so.” He cited as the only scientifically credible study one by Robin Marks in 1986, which showed a probable risk of 1:2,000 and no more for sure than 1:1,000. Another reference to the same point in a 2008 (now dissected) publication was from Dr. Martin Weinstock of Brown University, Rhode Island, who said “While a small number of actinic keratoses progress to cancer, a substantial number regress.”

These comments reinstate some perspective to the pervasive paranoia. There are reasons to treat actinic keratoses, if symptomatic, cosmetically compromising or suspicious for cancer, meaning biopsy sometimes. But annihilating them all will not save lives. I have seen a host of white German, Norwegian, or Polish farmers in their 80s and 90s with actinic keratoses and nary a squamous cell cancer. On the contrary there are the cursed few who are bedeviled by bunches of actinic keratoses that have morphed into bad guys.

We need to individualize, not generalize, our thoughts on each actinic keratosis, and treat accordingly. It would be the same as saying that all your kids are brilliant (We know ours are, right?), or bad apples, which can seem the case on a few days. The simplest summary I feel is, if you have questions about your crispy cutaneous critters, have your friendly smiling dermatologist take a look to see whether any need barbecuing. (Cajun style is the only menu choice.)

Frank Bures is a dermatologist in Winona.