The Evolving Landscape of Actinic Keratosis: Field Therapy, New Drugs, and Future Directions.

Actinic keratosis (AK) is a dynamic manifestation of chronic ultraviolet injury and a marker of field cancerization, but individual lesions and patients differ substantially in risk. Contemporary management therefore requires lesion-level triage, assessment of field burden, selection of a regimen the patient can complete, and longitudinal prevention rather than a uniform preference for either lesion- or field-directed therapy. This narrative review evaluates advances reported primarily from 2024 through June 2026. Recent evidence supports expanded treatment-area labeling and growing real-world experience with tirbanibulin; indoor and simulated-daylight photodynamic therapy (PDT); laser-assisted PDT; and low-irradiance, abbreviated-incubation, or simultaneous-illumination protocols designed to reduce pain. Short-course topical fluorouracil/calcipotriene has gained mechanistic and expert-consensus support, whereas diclofenac remains a slower and generally less efficacious option for selected patients. Nicotinamide, previously shown to be effective in immunocompetent patients, has not demonstrated benefit in solid organ transplant recipients, and systemic retinoids or capecitabine remain reserved for carefully selected high-risk populations. Senescence-directed glutathione peroxidase 4 (GPX4) modulation, interleukin-1 pathway targets, immune checkpoint blockade, and human papillomavirus vaccination are scientifically important but remain investigational for routine AK prevention. A risk-adapted blended strategy-biopsy when invasion is suspected, lesion-directed treatment for appropriate confirmed AKs, field treatment when subclinical burden is clinically meaningful, and cyclical therapy to aid prevention and provide surveillance for high-risk patients-best reflects current evidence.