Limited data are available on the prevalence and risk factors of actinic keratoses (AKs). Within the Rotterdam Study, full-body skin examinations were performed among participants aged 45 years or older to estimate the age- and sex-standardized prevalence of AK and its associated risk factors. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for associations between risk factors and the presence of 1-3, 4-9, and ≥ 10 AKs. Of the 2,061 inspected cohort members (mean age 72 years), 21% had 1-3, 9% had 4-9, and 8% had ≥ 10 AKs. AK prevalence was 49% (95% CI: 46-52%) for men and 28% (26-31%) for women. Male gender, older age, light pigmentation status, severe baldness, skin wrinkling, and high tendency for sunburn were significantly associated with extensive actinic damage (≥ 10 AKs) in the multivariate analyses. Especially bald males were at an increased risk of severe actinic skin damage (adjusted OR=7.0 (3.8-13.1)). The prevalence of AK is very high, especially among elderly bald males. The prevention and management of AK is a true challenge for patients, physicians, and health-care policymakers.