Comparative Analysis of Clinical, Dermoscopic, and Confocal Microscopy Scores for Assessing Severity of Actinic Keratosis

Background: Actinic keratosis (AK) is a common UV-induced intraepidermal neoplasm and a precursor to cutaneous squamous cell carcinoma (cSCC). Accurate, non-invasive assessment of AK severity is crucial for early intervention and risk stratification. Objective: To evaluate the relationship between clinical severity of AK, as defined by the Olsen grading scale, and predefined dermoscopic and reflectance confocal microscopy (RCM) features. Methods: This cross-sectional study enrolled 50 patients with clinically diagnosed AK at a tertiary dermatology center between April 2024 and July 2025. Each lesion was assessed clinically using the Olsen scale (grades 1-3), dermoscopically (five features scored 0-3; total score 0-15), and via RCM (five RCM parameters scored 0-3; total score 0-15). Statistical correlations between clinical grade and imaging features were analyzed using Pearson's χ² test with effect size metrics. Results: Diffuse erythema (p < 0.001), micro-erosions (p = 0.002), strawberry pattern (p = 0.038), and scales (p = 0.012) correlated significantly with Olsen grade, whereas vessels (p = 0.566) did not. All five RCM parameters showed strong associations with clinical severity. Composite dermoscopic and RCM scores correlated with Olsen grade (both p < 0.001). Abnormal honeycomb pattern, parakeratosis, inflammation, and solar elastosis were the best RCM predictors of high dermoscopic severity (all p < 0.001); conversely, erosions, erythema, and scales were the strongest dermoscopic predictors of high RCM severity (all p < 0.001). Conclusions: This study demonstrates strong, statistically significant associations between clinical, dermoscopic, and confocal features of AK. This supports the integration of multimodal scoring into unified AK severity frameworks.