SummaryActinic keratosis (AK) is considered a chronic and recurring in situ skin neoplasia, with a possible transformation into invasive squamous cell carcinoma (SCC). Among others, predominant risk factors for development of AK are UV‐light exposure and immunosuppression. Basal epidermal keratinocyte atypia (AK I) and proliferation (PRO score) seem to drive malignant transformation, rather than clinical appearance of AK (Olsen I–III). Due to the invasiveness of punch biopsy, those histological criteria are not regularly assessed. Non‐invasive imaging techniques, such as optical coherence tomography (OCT), reflectance confocal microscopy (RCM) and line‐field confocal OCT (LC‐OCT) are helpful to distinguish complex cases of AK, Bowen's disease, and SCC. Moreover, LC‐OCT can visualize the epidermis and the papillary dermis at cellular resolution, allowing real‐time PRO score assessment. The decision‐making for implementation of therapy is still based on clinical risk factors, ranging from lesion‐ to field‐targeted and ablative to non‐ablative regimens, but in approximately 85% of the cases a recurrence of AK can be observed after a 1‐year follow‐up. The possible beneficial use of imaging techniques for a non‐invasive follow‐up of AK to detect recurrence or invasive progression early on should be subject to critical evaluation in further studies.