Skin Cancer Types & Treatments
There are many different skin cancers, but the vast majority are either:
– Basal cell carcinoma (BCC)
– Squamous cell carcinoma (SCC)
Treatment of skin cancer is dictated by the type, anatomical location and patient preference.
Basal cell carcinoma (BCC)
BCC is the most common form of skin cancer. It typically forms on sun exposed skin. BCC do not spread to other parts of the body (metastasis) but slowly grow invading into the surrounding skin and any nearby structures. There are different histological (appearance under the microscope) types of BCC; superficial, nodular, infiltrative, sclerosising, micronodular and others. The best treatment option depends on the type of BCC and its location on your body. Treatment options include:
– No treatment- some can be left
– Topical treatment with imiquimod cream
– Photodynamic therapy
– Curettage and cautery
– Excision biopsy
– Mohs micrographic surgery
Whichever treatment you choose, things to consider and to ask your doctor are:
1 – What is the risk of the BCC coming back (recurrence rate)? There is always the small risk of the BCC regrowing. This risk is higher with some treatments over others.
2 – What type of scar will I have or will I need a skin graft? Some procedures can be performed to leave minimal scarring. Skin grafts are often unsightly, especially on the nose. Ensure your surgeon can offer you a great cosmetic result.
3 – Will I need to have more than one operation to remove my BCC? When a BCC is at risk of incomplete excision you may be told a further procedure is likely. The exception to this is Mohs micrographic surgery where the complete removal of BCC is the norm with the risk of recurrence being a very rare event.
Squamous cell carcinoma (SCC)
Squamous cell carcinoma is the second most common type of skin cancer. Unlike basal cell carcinomas, SCCs can spread to other parts of the body. The risk of this occurring depends on several factors; size, its location and its sub-type. SCCs commonly present on sun damaged skin as a tender pink/red lump which may ulcerate. Generally they grow quickly over several weeks. The treatment for SCC is nearly always an operation to have them removed under local anaesthetic.
Malignant melanoma is the most serious form of skin cancer arising from the pigment producing cells in the skin known as melanocytes. It is the most common cause of skin cancer death worldwide. Prognosis from melanoma is dictated by features established under the microscope (histological parameters) and if there is any evidence it has spread. Melanoma can spread to other parts of the body and can lead to death. Current treatment options for melanoma that has spread (metastatic melanoma) have improved dramatically over the last 5 years with the advent of immunotherapy medications.
Treatments for skin cancers
Imiquimod, also known as Aldara, is a cream that can be used to treat low risk superficial skin cancer and precancerous lesions and therefore avoid the need for surgery. Response rates are inferior to surgery and therefore its use should be limited to low risk lesions where recurrence is not going to be of a major concern. The cream comes in small sachets that are typically applied daily for up to 6 weeks depending on the lesion. Side effects are common and can be marked ranging from skin inflammation around the lesion to flu-like illness with muscle aches and pains. Your doctor should fully inform you of these side effects before commencing treatment
Efudix cream is licensed for treating solar keratoses. Efudix selectively destroys all precancerous cells in the top layers of the skin thereby avoiding the need for surgery. Typically it is applied twice a day for 3 weeks producing a red rash at the site of application. The end result is a crusted area that slowly returns to normal healthy skin over a further few weeks. It is usually prescribed in the winter months as the cream can increase your risk of sunburn if applied during the summer.
Photodynamic therapy (PDT)
Photodynamic therapy (PDT) is a treatment that uses a combination of a photosensitizing agent applied directly onto the skin along with light either day light or a blue light emitted from a medical lamp. A combination of the two lead to destruction of the cancer cells.
Over a certain amount of time the drug is absorbed by the cancer cells. Then light is applied to the area to be treated. The light causes the drug to react with oxygen, which forms a chemical that kills the cells. PDT can be used to treat superficial variants of BCC, actinic keratosis, squamous cell carcinoma-insitu (Bowens disease).
Also referred to as liquid nitrogen or freezing therapy. Liquid nitrogen is delivered using a precise spray directly onto the skin lesion. It can be used to treat both benign and cancerous lesions. Depending on the lesion treated the area will be left with a white (depigmented) scar. In the initial 24 hours a large blister often forms. Pain is minimal after 48 hours. The advantage of cryosurgery is being able to treat a large number of lesions in one clinic and its relative inexpense to invasive procedures.
Curettage and cautery (C&C)
Performed under local anaesthetic C&C is a simple technique used to remove benign warts, seborrheic keratosis, actinic keratosis, squamous cell carcinoma insitu (Bowens disease) and low risk basal cell carcinomas. Depending on how it is performed C&C wounds are often slow to heal over several weeks, painful at first eventually leaving a hypopigmented scar.
Excision biopsy is performed under local anaesthetic typically to remove concerning skin lesions that are either skin cancer or possible skin cancer. This technique aims to remove the entire lesion to allow accurate diagnosis and also definitive treatment. Excision biopsy is the preferred treatment for most basal cell carcinomas off the face (for facial lesions consider Mohs micrographic surgery), squamous cell carcinomas, suspicious or changing moles and other types of skin cancer.
Mohs micrographic surgery (MMS)
MMS is considered the ‘gold standard’ treatment for skin cancer on cosmetically sensitive sites such as the central face or in situations where persevering as much normal healthy skin as possible is crucial such as on fingers and genitals. To understand the technique please watch the patient video produced by Dr Toby Nelson’s college the American college of Mohs surgery:
Dr Toby Nelson is one of only a handful of Mohs surgeons in Europe to have completed a fellowship affiliated to the ACMS. He owes this prestigious accreditation to his close friends, trainers and mentors Dr Paul Salmon and Neil Mortimer of the Skin Centre, New Zealand
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