Actinic keratosis (AK) is the main precursor of invasive cutaneous squamous cell carcinoma (cSCC). Since it is impossible to predict which lesions will progress to cSCC, early treatment of AK is crucial. Although AK treatments are effective, some are associated with local skin reactions that may impact treatment compliance and effectiveness. The aim of this modified Delphi study was to review the efficacy and safety of the different AK treatments, gain an understanding of the dermatologists’ perspectives on their use, and provide guidelines for clinical practice. This document corresponds to a modified Delphi consensus survey, based on a literature review and a single round of questionnaire. The Delphi questionnaire was completed by 73 dermatologists from Germany, Italy, and Spain. Agreement was achieved for 78% of statements, while 11% showed discrepancies or were rejected. Key findings emphasize the importance of patient-centered approaches and treatment attributes beyond efficacy (e.g. tolerability or adherence). Understanding the mechanisms of action of treatments is vital for managing patients’ and clinicians’ expectations and optimizing outcomes. Alternative strategies for evaluating efficacy, including the Actinic Keratosis Area and Severity Index (AKASI) score and lesion reduction from baseline, were also highlighted.