Skin Cancer Info
TREATMENTS
Cryotherapy
What is cryotherapy?
The term ‘cryotherapy’ literally means ‘treatment using low temperature’, and refers to the removal of skin lesions by freezing them. The most common agent used by doctors is liquid nitrogen.
What is liquid nitrogen?
Liquid nitrogen is the liquid state of gaseous nitrogen, which occupies 78% of the air we breathe. Liquid nitrogen is extremely cold, boiling at minus 196°c. It is necessary to store and transport it in special flasks.
What conditions can be treated with cryotherapy?
A wide variety of superficial benign lesions can be treated with cryotherapy, but it is most commonly used to remove actinic keratoses (an area of sun-damaged skin found predominantly on sun-exposed parts of the body), viral warts, seborrhoeic keratoses and other benign lesions. Occasionally, your dermatologist may suggest using cryotherapy to treat small skin cancers such as basal cell carcinomas and Bowen’s disease.
What does the procedure involve?
Cryotherapy is done during the course of a routine out-patient consultation with your dermatologist, or by your general practitioner or their nurse, without any special preparation.
Whilst liquid nitrogen is usually applied to the skin by using a spray gun, a metal probe or a cotton bud can sometimes be used instead of the spray gun.
Cryotherapy does not normally require a local anaesthetic, and the procedure itself lasts a matter of seconds; the precise time depending on the thickness and size of the lesion. The frozen skin becomes white and takes one to two minutes to thaw to normal skin temperature. Your doctor may suggest that the process is repeated once the skin has thawed out.
Over the succeeding few days, a scab will form, and this will take one to two weeks (and occasionally a little longer, especially on the legs) to come away. Usually, the treated area will eventually look normal, although scarring and discolouration is possible, particularly on the legs.
Depending on the nature of the lesion, more than one treatment may be necessary, and this is usually repeated at regular intervals.
How should the treated area be cared for?
Your doctor will explain how s/he would like you to care for the treated areas. It is usually suggested that they are kept dry until a scab forms, and your doctor may suggest that Vaseline is applied. If wetted the scabs should be patted dry with a soft towel or tissue.
It is important not to pick at the scab as this will encourage scarring. A dressing or plaster is not usually necessary, but may be advisable if the treated area is prone to being traumatized or rubbed by clothing.
What are the side effects of this treatment?
Immediate side effects:
- Pain – cryotherapy is usually well-tolerated, but can sometimes be painful if a deep freeze has been necessary (i.e. to treat a basal cell carcinoma). This discomfort can occur both at the time of treatment and for a variable time thereafter. Painkillers (such as paracetamol) taken for the first 24 hours may relieve that discomfort; also taking an analgesic an hour or so prior to anticipated treatment can reduce the discomfort.
- Swelling and redness – this is a normal immediate response to freezing the skin, and usually settles after two to three days; your doctor may apply a steroid ointment to the treated area to reduce this. For a short while the treated area may ooze a little. Cryotherapy close to the eyes may induce prominent puffiness of the lower eyelids which settles within days.
- Blistering – this is also a common consequence of cryotherapy and blisters settle after a few days as the scab forms. Some people blister more easily than others and the development of blisters does not necessarily mean that the skin has been frozen too much. Occasionally the blisters may become filled with blood; this is harmless and only if a blister was very uncomfortable would it be necessary to puncture it, using a sterile needle.
- Infection – uncommonly, infection can occur, resulting in increased pain and the formation of pus: this may require topical antiseptic or antibiotic therapy.
Subsequent side effects:
- Scarring – rarely, a scar will form, especially if a deep freeze has been necessary (i.e. to treat a basal cell carcinoma).
- Pigmentation changes – the skin at and around the treatment site may lighten or darken in colour, especially in dark-skinned people. This usually improves with time, but may be permanent.
- Numbness – if a superficial nerve is frozen, it may result in numbness of the area of skin supplied by that nerve. Normal feeling usually returns within a matter of months.
Treatment may not be effective, or the condition may recur.
Where can I get more information about cryotherapy?
dermnetnz.org/procedures/cryotherapy.html
Curettage and cautery
Curettage
Curettage is a procedure in which the dermatology doctor/nurse scrapes off a skin lesion using a sharp blade called a curette. Cautery is the method that is used to stop the bleeding and seal the wound.
What does it involve?
The doctor/nurse will explain to you why your skin lesion needs treatment and the procedure involved. The person performing the procedure will inject some local anaesthetic into the area surrounding the lesion to be treated (this causes a tingling discomfort which will last only a few moments). This will make the skin go numb so no pain should be felt during the procedure. You may feel a pushing sensation but this should not be painful. The skin lesion is then scraped off with a sharp ring blade (curette). Bleeding is then stopped with either cautery or driclor.
Benefits
- To enable diagnoses and removal of skin lesion, with minimal scarring.
- What happens to the lesion after it is removed?
- The lesion will be sent to a pathology laboratory for analysis unless you are told otherwise
Risks
- Scarring – It is impossible to cut or curette the skin without scarring in some way. However, certain individuals sometimes have an abnormal response to the skin healing and as a result may gat larger, raised scars than usual. This is known as keloid or hypertrophic scarring. The risk is higher on the shoulders, upper back and chest, or if you have a family history of such scars. This can be treated but the thickening may be permanent. Scars from curettage are usually flat and/or slightly depressed and white, they are a similar size and shape to that of the original skin lesion. The doctor/nurse performing the procedure will however, endeavour to keep scarring to a minimum.
- Infection – as with any procedure, there is a small risk of infection, the risks of which will be explained to you before and after surgery, and what to do if the wound becomes infected (read after care following surgery at the end of the this leaflet).8 800 1234
5-Fluorouracil (Efudix)
What is 5-FU and how does it work?
5-FU cream is a treatment which destroys sun-damaged cells in the skin by blocking an enzyme called thymidylate synthetase that is highly active in these cells, thus causing their death and sparing the normal cells. It has been in use for about 50 years.
In the UK, a 5% 5-FU cream is available (trade name Efudix®), but other formulations are on the market in other countries.
What skin conditions are treated with 5-FU cream?
5-FU cream is licensed for the use of sun-damage in the form of superficial pre-cancerous and cancerous skin conditions, such as actinic keratoses, Bowen’s disease or superficial basal cell carcinoma. It is also sometimes used for other, non-licensed indications, for example viral warts.
Will 5-FU cream cure my skin condition?
Depending on your skin complaint, 5-FU cream may cure or improve it, but it does not work for everybody. If you have more severe sun-damage, you may require repeated treatment courses in the future to maintain the improvement.
How often should I use 5-FU cream?
How often or for how long you should use 5-FU cream will depend on your skin condition and other factors, for example which part of your skin is affected or if you also have another skin complaint such as eczema. 5-FU cream can for example be applied once or twice a day, for 3 weeks or longer. Your doctor will recommend a treatment schedule to you.
If you have widespread sun-damage, then the treatment area should be broken up into smaller areas, and treated in a piecemeal fashion.
What time of day should I apply 5-FU cream?
If you are asked by your doctor to use 5-FU cream once a day, you should apply it at night: if twice daily, morning and night. Make sure you always clean your skin prior to the application of the cream.
After 20 minutes or so, you may then apply an additional moisturizer. You can also use make-up to cover the redness, but you may find this uncomfortable.
Only cover 5-FU cream with a plaster if advised by your doctor, otherwise leave the treated area open.
You should wash your hands thoroughly after application of the cream.
When should I not apply 5-FU cream?
5-FU cream should not be used on the eyelids, and not on the lips, unless specifically prescribed by your doctor for use in that area.
Do not use 5-FU cream if you are allergic to any ingredients, for example parabens.
Do not apply 5-FU cream if you are pregnant or breastfeeding.
What are the common side effects of 5-FU cream?
Within 3-5 days, skin treated with 5-FU cream usually becomes inflamed, and can get intensely red and sore. Even normal looking skin may be affected, because the cream also treats abnormal cells where the sun-damage is not yet visible. The skin may weep, peel, crack or even blister. This is a normal response to 5-FU. If the skin becomes very sore or uncomfortable please stop using the Efudix cream temporarily. Bathe the area with water, then dry and apply Vaseline daily to settle the skin. Once the skin has settled you can re-start using the Efudix cream as directed. Your doctor may prescribe a steroid cream to settle the inflammation. Whilst the skin is inflamed, there is a risk that it might become infected, and if you have any concerns regarding this you should consult your doctor.
5-FU cream makes your skin more sensitive to light, and therefore you should protect your skin during and for a while after treatment.
What are the rare side effects of 5-FU cream?
If you have a severe reaction to 5-FU cream, the treated area may become ulcerated. This risk is highest on the legs.
Following a severe reaction, there is a small risk of scarring.
Rarely, patients can be allergic to 5-FU cream and develop a severe allergic skin rash.
Where can I get more information about 5-FU cream?
Links to patient support groups:
Imiquimod (Aldara)
What is imiquimod, and how does it work?
Imiquimod is a topical immuno-modulator. The cream may work in several different ways, such as recognising abnormal cells and causing inflammation to remove them, but the exact mechanism in which the immune system is activated by imiquimod is not yet known.
In the UK, a 5% imiquimod cream is available (trade name Aldara®).
What skin conditions are treated with imiquimod cream?
Imiquimod cream is licensed for the treatment of sun-damage in the form of superficial pre-cancerous (actinic keratoses), cancerous skin conditions (superficial basal cell carcinoma) and genital viral warts. Imiquimod has been used with some success for many other conditions such as viral warts on non-genital skin, molluscum contagiosum, keloid scarring, different pre-cancerous lesions such as Bowen’s disease, actinic porokeratosis, vulval intra-epithelial neoplasia and lentigo maligna.
Will imiquimod cream cure my skin condition?
Imiquimod cream can cure or improve many skin problems but does not work for everybody. If Imiquimod works for your condition, your skin usually gets worse (red and sore) before it gets better. The redness and soreness settles about 2 weeks after stopping the treatment. If used for sun-damage, the skin will eventually appear much smoother. If you have more severe sun-damage, you may require repeated treatment courses in the future to maintain the improvement.
How often should I use imiquimod cream?
How often or for how long you should use imiquimod cream will depend on your skin condition. For actinic keratoses, the licensed usage is for 3 nights a week (e.g. Monday, Wednesday and Friday), but only for 4 weeks with one further course of treatment after one month if necessary. In superficial basal cell carcinoma, the recommended use is Monday to Friday night, with a weekend break, for 6 weeks. In genital warts, imiquimod can be used for up to 16 weeks, on 3 nights a week. Your doctor will discuss a treatment schedule with you.
If you have widespread sun-damage, then the treatment area should be broken up into smaller areas, not using more than one sachet per application (12.5 mg). For example, first complete treatment of the scalp, then treat the face. The more cream is used in any application, the more severe the side effects.
What dose should I take?
You should usually apply Imiquimod cream it at night and wash it off in the morning. Make sure you always clean your skin prior to the application of the cream. Cut a corner of the sachet and squeeze some cream onto your finger to apply it to the affected area. Also put some cream on about a centimetre of healthy looking skin around the affected area.
After 20 minutes or so, you may then apply an additional moisturizer. You can also use make-up to cover the redness, but may find this uncomfortable.
In general, you should not cover the treated area with a plaster, unless advised otherwise by your doctor.
You should wash your hands thoroughly after application of the cream.
When should I not apply imiquimod cream?
- Imiquimod cream should not be used on the eyelids, and generally not on the lips, unless specifically prescribed by your doctor for use in that area.
- Do not use imiquimod cream if you are allergic to any of the ingredients.
- Do not apply imiquimod cream if you are pregnant or breastfeeding.
What are the common side effects of imiquimod cream?
Within 3 to 5 days, the skin treated with imiquimod cream can get red and sore. Even normal looking skin may be affected, because it may contain invisibly abnormal cells. The skin may weep, peel, crack or even blister and then scab over. The area may be itchy or sore, painful and burn. This is caused by the abnormal cells dying and a sign that the treatment is working. The skin reaction tends to be worst in week 2 to 3 of application.
With a severe reaction, some patients develop flu-like symptoms such as swollen lymph nodes, aches of the muscles, joints, back or head or mild fever and generally feeling unwell. Taking paracetamol can be helpful.
If the skin or general reaction becomes too severe, it is appropriate to stop the cream for a week or so before restarting it again.
As the abnormal cells die, the skin barrier becomes damaged and therefore susceptible to wound infection. If there is doubt whether you have a normal treatment reaction or a wound infection, please see your doctor.
What are the rare side effects of imiquimod cream?
If you have a severe reaction to imiquimod cream, the treated area may become ulcerated. This risk is highest on the legs. The skin pigmentation may be increased or decreased following severe inflammation. Rarely, this change in pigmentation can be permanent.
Following a severe reaction, there is a small risk of scarring and hair loss.
Imiquimod cream activates the immune system, and very rarely there have been reports of pre-existing auto-immune disease flaring up.
Rarely, a patient can be allergic to Imiquimod cream and develop a severe allergic skin rash.
Where may I find more information on imiquimod cream?
http://dermnetnz.org/treatments/imiquimod.html
www.emedicinehealth.com/drug-imiquimod_topical/article_em.htm
Mohs surgery
Photodynamic therapy (PDT)
What is photodynamic therapy?
Photodynamic therapy (PDT) is a technique for treating skin cancers and sun-damaged skin which might one day turn cancerous (pre-cancers). In PDT a special light activates a cream which has been applied to the lesion (affected area of skin). This treatment kills the abnormal cells in the skin.
How does photodynamic therapy work?
PDT involves the use of a light-sensitive chemical (called a photosensitiser). This photosensitiser is, by itself, harmless. When light of a certain wavelength (usually red light) is shone onto skin to which the photosensitiser has been applied, the photosensitiser is activated. This causes changes in the oxygen molecules within the sun-damaged skin cells. These “excited” oxygen molecules kill the cells. Only the area of skin exposed to the light source will be affected and inflamed; after the inflammation clears it should be cured.
What skin conditions can be treated with photodynamic therapy?
PDT can be used to treat various skin conditions including:
- Thin basal cell carcinomas
- Bowen’s disease (in situ squamous cell carcinoma), a pre-cancer.
- Actinic (solar) keratoses – early sun-damage, a pre-cancer
What does photodynamic therapy for skin lesions involve?
PDT is an outpatient procedure, and will be done by your doctor or nurse. It takes several hours to complete. The first step is to apply a cream containing the photosensitiser to the area that needs to be treated. If necessary, any loose scale or crusts will be removed first. A dressing will then be applied over the cream and you will be asked to return in about 3 hours. This wait is to allow the photosensitiser to be absorbed and to be converted into the active chemical by the skin. The cream is then wiped off and the area cleaned. A bright coloured light is then shone onto the treatment area for approximately 10 to 45 minutes (the precise time will be determined by your doctor or nurse depending on the light source). After the treatment has been completed, a dressing will be applied for a minimum of 2 days, to prevent any further exposure to light.
How should the treated area be cared for?
Your doctor or nurse will explain how you should care for the treated areas. It is usually suggested that, after the dressing has been removed, you can wash, bathe or shower as usual. Do not rub the treated area, but gently pat it dry. Within a few days, a scab will form, and healing will take several weeks (depending on which part of the body has been treated).
Care must be taken not to scratch the area or accidentally dislodge the scab during the healing process. The use of a suitable sunscreen (SPF 30) following the procedure, especially during outdoor activities, is essential.
What reasons might prevent you having photodynamic therapy?
- PDT is not recommended if you are pregnant.
- The PDT cream may contain peanut oil, so tell your doctor and nurse if you are allergic to peanuts.
- PDT is not recommended if you have porphyria (a light-sensitive disorder, where the patient is producing the same photosensitiser used in PDT and is present in the blood, skin and other tissues of the body).
Do I need to avoid anything whilst having photodynamic therapy?
Care should be taken not to get the dressing wet when bathing or showering.It is advisable to avoid swimming until the treated area is fully healed.
What are the potential side effects of photodynamic therapy?
The short-term side effects of phototherapy include:
Pain. When the red light is shone onto the skin, the treated area may hurt. If it is too uncomfortable, your doctor or nurse may suggest pausing treatment for a while, or a local anaesthetic injection may be recommended. After completion of treatment, discomfort and itching may last for a few days, and may require pain-killers.
Inflammation. The treated area may initially become pink and puffy, and may ooze a little: this is a normal reaction. It settles within a few days.
Blistering and ulceration. The treated area may occasionally blister or ulcerate.
Infection. If the treated area becomes red, swollen and painful, an infection may have developed, and you should contact your doctor.
Potential long-term side effects of phototherapy include:
Scarring. There may be some scarring after PDT.
Colour change. The skin may be left darker or paler after PDT.
Treatment may not be effective, or the condition may come back again. If this happens, you may be offered further PDT, or an alternative type of treatment may be recommended.
Top sun safety tips
Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
Spend time in the shade between 10am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn. Keep babies and young children out of direct sunlight.
When choosing a sunscreen look for a high protection’ SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole or patch of skin. If your GP is concerned about your skin, make sure you see a Consultant Dermatologist – an expert in diagnosing skin cancer.
Where can I get more information about photodynamic therapy?
You can find more information about photodynamic therapy on the following websites:
www.cancerbackup.org.uk/Treatments/Othertreatments/Photodynamictherapy
http://dermnetnz.org/procedures/photodynamic-therapy.html
Radiotherapy
What is radiotherapy?
Radiotherapy is the use of X-rays to destroy cancerous cells. In the context of the skin, it is predominantly used to treat basal cell carcinomas and squamous cell carcinomas although other conditions may also benefit from the therapy.
When is radiotherapy used?
- When the cancer is too large or in a difficult site for surgery.
- When the patient does not want surgery or is not fit enough for surgery.
- When radiotherapy will usually give a better cosmetic result than surgery (for instance, when the nose is involved).
- When there has been a big operation to remove the cancer and it is considered that radiotherapy might reduce the risk of recurrence.
Where will you receive the treatment?
Radiotherapy for skin cancer is generally given as an outpatient procedure in a Clinical Oncology Unit. Generally, you will not need to be admitted to hospital. Several outpatient visits are usually required.
What is the duration of the treatment?
For small cancers the treatment is often over a period of approximately 2 weeks, whilst for relatively larger cancers, particularly squamous cancers, it is about 4 weeks.
Planning your treatment
When you come for radiotherapy, the area of the skin to be treated will be marked using ink by a consultant oncologist. These ink marks will be used to line up the machine each time you are treated. Usually a photo is taken with the ink marks around the cancer but you may be asked to keep these marks until the treatment has been completed. Sometimes it is necessary to make a plastic mask that rests on your face to define where the treatment is to be given. A special metal cut-out may be used to treat the cancer and protect the rest of the skin.
Having your treatment
At the beginning of your treatment you may be given a written information leaflet on how to care for yourself during radiotherapy. The actual treatment only takes a few minutes. The radiographer will position you on a couch and make sure that you are comfortable, because you have to lie very still during the treatment. If your skin cancer is near your eye or teeth, a small lead shield will be applied during treatment to protect these areas from the radiation. You will be left alone while you have your treatment, but the radiographer will be able to hear and see you.
You will not be able to see or feel the radiotherapy as it is not painful.
Radiotherapy does not make you radioactive. It is perfectly safe to be with other people, including children, throughout your course of treatment.
Are there any side effects?
Radiotherapy for skin cancer only affects the area treated. You will not feel sick or tired from the treatment, or lose your hair, unless your skin cancer is in an area covered by hair. You should be able to continue your usual activities or work throughout your treatment, and any side effects you experience will be monitored regularly by a doctor/radiotherapist. The side effects normally occur in the latter part of the treatment and may continue for some weeks after completion. After the treatment, the affected skin will become red and sore – similar to sunburn. This reaction can take several weeks to settle. The area may become crusty and scab over, sometimes more than once. When the scab finally falls off, there will be good skin underneath. Sometimes a crust can form a second time before healing is complete. Scarring from radiotherapy is usually mild, but over years the scar tends to become paler (any such scarring may benefit from skin camouflage assistance; further information can be found on the BAD website under ‘Patient Support Groups’).
Where can I get more information about radiotherapy?
Web links to detailed leaflets:
CancerHelp UK
www.cancerhelp.org.uk
Macmillan Cancer Support
89 Albert Embankment
London SE1 7UQ
Helpline (for emotional support): 0808 808 2020
Helpline (for information): 080
Tuebingen
Techniques of 3D-Histology („Tuebinger Torte“ and „Muffin technique“)
Matthias Möhrle
Excision
„Tübinger Torte“ (Tuebingen Cake) and “Muffin Technique”
Intraoperatively a small incision or a suture is placed for topographical orientation, usually at 12:00 o’clock (most cranial point).
The tumor and the safety margin are removed en bloc. The incision is made perpendicularly to the surface of the skin which is preferable for defect closure.
Margin
„Tübinger Torte“ (Tuebingen Cake) and “Muffin Technique”
Using 3D-Histology the safety margin may range from 1 to 10 mm. The margin depends on various factors:
1. Tumour size. The larger a tumour the bigger a safety margin may be chosen to avoid multiple stages of excision.
2. Localisation. The delicate and aesthetically important the localision the smaller an initional safety margin will be chosen to spare healthy tissue.
3. Tumour type. An infiltrative tumour type justifies a larger initial safety margin.
Macroscopic preparation
„Tübinger Torte“ (Tuebingen Cake)
In 1984, this method was published by Breuninger and collegues (‘histologic control of excised tissue edges’) and later became popular under the name “Tübinger Torte”.
From the surgical specimen (tumour and safety margin excised en bloc) a narrow (1-2mm) lateral marginal strip is cut around the full perimeter of the tumour border, beginning with the above mentioned topographical mark at 12 o’clock. The strip is then laid flat on the peripheral side and cut into pieces which are placed in routine cassettes for histological evaluation (figure 1: 1 and 1).
Subsequently a horizontal section is cut from the bottom of the excised specimen and likewise prepared flat in a histology cassette (figure 1: 3).
Strips of the tumour are placed in histology cassettes as well (figure 1: 4). For topographical orientation dye marks can be used.
The method uses routine overnight paraffin fixation, thus reducing time and costs. The specimens, which may be fixed for 2 h in a formalin solution at 60 ° C, are available 20 h later, and provide a complete three-dimensional view of the excision margins.
Figure 1: “Tubinger Torte”
“Muffin Technique”
The Muffin technique had been refined and named Muffin technique by Moehrle & Breuninger in 2006; a similar technique (“Flunder Technik”) had been introduced by Breuninger & Holzschuh in 1994.
Deep incisions at 12 o’clock and 6 o’clock relative to the body axis are made.
Then a narrow lateral strip is cut without dissecting the base.
Using dissecting scissors the central part is removed without cutting into the base.
Similar to the peeling off of a muffin’s paper mould these margins can be folded laterally to a horizontal plane.
The specimen is placed in a routine cassette for horizontal fixation. For topographical orientation dye marks can be used.
The cassettes may be fixed for 2 h in a formalin solution at 60 ° C. Histological slides are available 20 h later, and provide a complete three-dimensional view of the excision margins of the tumour on one single slide.
The Muffin technique may be used for specimens up to 2 cm in diameter.
Figure 2: “Muffin Technique”
Similar to Mohs technique, it is not possible to evaluate the distance between the tumor and the incision margin neither using the “Tuebinger Torte” nor using the “Muffin technique”.
Indications
Common indications include basal cell carcinoma (especially infiltrative types), recurrent basal cell carcinomas, or neural infiltrating variants, as well as squamous cell carcinoma that have infiltrated the subcutis or have moderate to poor differentiation.
Dermatofibrosarcoma protuberans, lentigo maligna, lentigo maligna melanoma, acral lentiginous melanoma, and Merkel cell carcinoma are also indications as are erythroplasia of Queyrat, extramammary Paget disease, and Bowen’s disease. The paraffin section method is preferred in most cases, given then tumor extensions may be better evaluated than with cryostat procedures. This applies in particular to squamous cell carcinoma, Merkel cell carcinoma, and extramammary Paget’ disease. Micrographic surgery using paraffin sections is especially important for recurrent tumors, dermatofibrosarcoma protuberans, lentigo maligna melanoma, and acrolentiginous melanoma.
3D histology should be used for malignant tumors at critical sites or when it is expected that more complex closure techniques will be needed and thus complete tumor removal must be ensured prior to wound closure. The more problematic the tumor and the affected site, the more important is the choice of such a highly sensitive 3D histology to confirm free margins.
Continuous visualization of the lateral and basal margins, without any diagnostic gaps is independent of the diameter of the excised tumor.
In tumors that have infiltrated the bone, the procedure is of limited use. Osseous components might be decalcified and can then be histologically examined.
Literature
Breuninger H.
Histologic control of excised tissue edges in the operative treatment of basal-cell carcinomas.
J Dermatol Surg Oncol 1984; 10: 724–728
Möhrle M, Breuninger H.
The Muffin technique–an alternative to Mohs’ micrographic surgery.
J Dtsch Dermatol Ges. 2006; 4: 1080-4
Moehrle M, Breuninger H, Rocken M.
A confusing world: what to call histology of three-dimensional tumour margins?
J Eur Acad Dermatol Venereol. 2007; 21: 591-5
Löser C, Rompel R, Breuninger H, Möhrle M, Häfner HM, Kunte C, Hassel J,
Hohenleutner U, Podda M, Sebastian G, Hafner J, Konz B, Kaufmann R.
Microscopically controlled surgery (MCS).
CONDITIONS
Actinic keratoses (AK)
What are actinic keratoses?
Actinic keratoses are areas of sun-damaged skin found predominantly on sun-exposed parts of the body, particularly the backs of the hands and forearms, the face and ears, the scalp in balding men and the lower legs in women. The terms actinic and solar are from Greek and Latin, respectively, for ‘sunlight-induced’, and the term keratosis refers to thickened skin. They are usually harmless but there is a very small risk of some actinic keratoses progressing to a form of skin cancer called squamous cell carcinoma (see Patient Information Leaflet on Squamous Cell Carcinoma). Actinic keratoses are not contagious.
What causes actinic keratoses?
They are caused by excessive sun exposure over many years (from sunbathing, sunbed use, outdoor work or recreational activities) and are therefore more common in older people. Fair-skinned, blue-eyed, red- or blonde-haired individuals, who burn easily in the sun but tan poorly, are at particular risk.
Are actinic keratoses hereditary?
No, but some of the factors that increase the risk of getting actinic keratoses such as a tendency to burn rather than tan, and freckling, do run in families.
What are the symptoms of actinic keratoses?
They often cause little trouble. Many affected individuals are not aware of them at all. The affected skin feels rough and dry. However, if an actinic keratosis starts to grow into a lump, becomes itchy, tender or starts to bleed, medical advice should be sought as these changes could indicate the development of skin cancer (a squamous cell carcinoma).
What do actinic keratoses look like?
Actinic keratoses can be variable in appearance, even differing from one another within a single individual. At first they can be hard to see, and are more easily felt, being rough, like sandpaper. They may grow up to a centimetre or two in diameter. Some are skin coloured, others are pink, red or brown. They can become raised, hard and warty, and may even develop a small horny outgrowth. The surrounding skin often looks sun-damaged – blotchy, freckled and wrinkled.
How are actinic keratoses diagnosed?
Usually the appearance of an actinic keratosis is sufficient to enable the diagnosis to be made, but in cases of doubt, for example if an early skin cancer is suspected, a sample (or the whole lesion) may be removed under a local anaesthetic for microscopic examination in the laboratory.
Can actinic keratoses be cured?
Yes – but others may develop in the future from the surrounding sun-damaged skin.
How can actinic keratoses be treated?
It is advisable to protect the skin from further sun damage (for example, by wearing a hat, long sleeves and a sunscreen with a high sun protection factor). Occasionally, small actinic keratoses may go away spontaneously, but generally it is advisable to treat them as there is a small risk that some might transform into a skin cancer.
Treatments used for actinic keratoses:
Freezing with liquid nitrogen (Cryotherapy). This is an effective treatment which does not normally leave a scar, but it can be painful. (see Patient Information Leaflet on Cryotherapy)
Surgical removal. This requires local anaesthetic, after which the actinic keratosis can be scraped off with a sharp spoon-like instrument (a curette), or it can be cut out and the wound closed with stitches. Surgical removal leaves a scar but provides a specimen that can be analysed in the laboratory to confirm the diagnosis.
Creams. Courses of creams containing drugs called 5-fluorouracil or imiquimod are useful treatments for actinic keratoses, especially if there are a lot of them. These preparations appear to selectively destroy the abnormal cells in sun-damaged skin. However, they often cause a good deal of temporary inflammation of the treated areas. Diclofenac and retinoic acid are other drugs in cream or ointment form that are helpful when applied to actinic keratoses.
Photodynamic therapy. A chemical is applied to the affected area, which is then treated with the correct wavelength of visible light. This treatment is only available in certain hospitals (see Patient Information Leaflet on Photodynamic Therapy).
What can I do?
Protecting your skin from the sun will reduce the number of new actinic keratoses you get, and also reduce the risk of getting a sun-induced skin cancer. You should be extra cautious in the sun by following these recommendations:
Protect yourself from the sun, from 11 a.m. to 3 p.m., especially in sunny weather.
Wear protective clothing – hats, long sleeves, long skirts or trousers.
Apply a sunscreen regularly, of sun protection factor 30 or above (and able to block both UVA and UVB light), to exposed skin before going into the sun, and re-apply according to the manufacturer’s recommendations, especially after swimming, when you are out in the sun.
Protecting your children from the sun in the same way may reduce their risk of developing actinic keratoses.
Avoid sunbeds.
Examine your own skin every few months and see your doctor if an actinic keratosis starts to itch, bleed, or thicken, in case it has changed into a skin cancer (a squamous cell carcinoma).
Where can I find out more about actinic keratoses?
Web links to detailed leaflets:
www.skincarephysicians.com/actinickeratosesnet
www.emedicine.com/derm/topic9.htm
Basal cell carcinoma (BCC)
What is a basal cell carcinoma?
A basal cell carcinoma (BCC) is a type of skin cancer. There are two main types of skin cancer: melanoma and non-melanoma skin cancer. BBC is a non-melanoma skin cancer, and is the most common type (> 80%) of all skin cancer (skin cancer incidence is < 1%) in the UK. BCC are sometimes referred to as ‘rodent ulcers’.
What causes basal cell carcinoma?
The commonest cause is too much exposure to ultraviolet (UV) light from the sun or from sunbeds. BCC can occur anywhere on your body, but is most common on areas that are often exposed to the sun, i.e. your face, head, neck and ears. It is also possible for a BCC to develop where burns, scars or ulcers have damaged the skin. BCC is not infectious.
BCC mainly affects fair skinned adults, but other skin types are also at risk. Those with the highest risk of developing a basal cell carcinoma are:
People with pale skin who burn easily and rarely tan (generally with light coloured or red hair, although some may have dark hair but still have fair skin).
Those who have had a lot of exposure to the sun, such as people with outdoor hobbies or outdoor workers, and people who have lived in sunny climates.
People who use sun beds or sunbathe.
People who have previously had a basal cell carcinoma.
Are basal cell carcinomas hereditary?
Apart from a rare familial condition called Gorlin’s syndrome, BCCs are not hereditary. However some of the things that increase the risk of getting one (e.g. a fair skin, a tendency to burn rather than tan, and freckling) do run in families.
What does a basal cell carcinoma look like?
BCC can vary greatly in their appearance, but people often first become aware of them as a scab that bleeds occasionally and does not heal completely. Some BCC are very superficial and look like a scaly red flat mark; others have a pearl-like rim surrounding a central crater. If left for years the latter type can eventually erode the skin causing an ulcer; hence the name “rodent ulcer”. Other BCC are quite lumpy, with one or more shiny nodules crossed by small but easily seen blood vessels. Most BCC are painless, although sometimes can be itchy or bleed if caught on clothes or picked up.
How will my basal cell carcinoma be diagnosed?
Sometimes the diagnosis is clear from its appearance. If further investigation is necessary to confirm the diagnosis then a small area of the abnormal skin (a biopsy) or the entire lesion (an excision biopsy) may be cut out and examined under the microscope. You will be given a local anaesthetic beforehand to numb the skin.
Can basal cell carcinomas be cured?
Yes, BCCs can be cured in almost every case, although treatment becomes complicated if they have been neglected for a very long time, or if they are in an awkward place, such as near the eye, nose or ear.
BCCs never spread to other parts of the body except very rarely (fewer than 1 in 20) if neglected for years, when it may spread to draining lymph nodes. Hence, although it is a type of skin cancer it never endangers life.
How can a basal cell carcinoma be treated?
The commonest treatment for BCC is surgery. Usually, this means cutting away the BCC, along with some clear skin around it, using local anaesthetic to numb the skin. The skin can usually be closed with a few stitches, but sometimes a small skin graft is needed.
Other types of treatment include:
Difficult or neglected BCC – Mohs micrographic surgery. This involves the excision of the affected skin that is then examined under the microscope straight away to see if all the BCC has been removed. If any residual BCC is left at the edge of the excision further skin is excised from that area and examined under the microscope and this process is continued until all the BCC is removed. The site is then usually covered with a skin graft. This is a time consuming process and only undertaken for certain BCC in difficult anatomical areas if simple surgery is not suitable.
Radiotherapy – shining X-rays onto the area containing the BCC.
Very superficial BCC:
Curettage and cautery – the skin is numbed with local anaesthetic and the BCC is scraped away (curettage) and then the skin surface is sealed by heat (cautery).
Cryotherapy – freezing the BCC with liquid nitrogen.
Creams – these can be applied to the skin. The two most commonly used are 5-fluorouracil (5-FU) and imiquimod.
Photodynamic therapy – a special cream is applied to the BCC which is taken up by the cells that are then destroyed by exposure to a specific wavelength of light. This treatment is only available in certain dermatology departments.
Surgical excision is the preferred treatment, but the choice of other treatments depends on the site and size of the BCC, the condition of the surrounding skin and number of BCC to be treated (some people have multiple ) as well as the overall state of health of each person to be treated.
What can I do?
Treatment will be much easier if your BCC is detected early. BCC can vary in their appearance, but it is advisable to see your doctor if you have any marks or scabs on your skin which are:
growing
bleeding and never completely healing
changing appearance in any way
Check your skin for changes once a month. A friend or family member can help you particularly with checking areas that you cannot easily inspect, such as your back.
You can also take some simple precautions to help prevent a BCC appearing:
Top sun safety tips:
Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
Spend time in the shade between 10am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn. Keep babies and young children out of direct sunlight.
When choosing a sunscreen look for a high protection’ SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole or patch of skin. If your GP is concerned about your skin, make sure you see a Consultant Dermatologist – an expert in diagnosing skin cancer. Your doctor can refer you for free through the NHS.
Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
Where can I get more information?
http://www.skincancer.org/basal-cell-carcinoma.html
www.intelihealth.com/IH/ihtIH/WSIHW000/9339/9528.html
http://emedicine.medscape.com/article/276624-overview
http://www.dermnetnz.org/lesions/basal-cell-carcinoma.html
Bowen's disease
What is Bowen’s disease?
Bowen’s disease is also known as intraepidermal squamous cell carcinoma, and is a growth of cancerous cells that is confined to the outer layer of the skin. It is not a serious condition, and its importance rests on the fact that, occasionally, it can progress into an invasive skin cancer (squamous cell carcinoma). For this reason, dermatologists usually treat, or at least monitor, Bowen’s disease.
What causes Bowen’s disease?
Most cases of Bowen’s disease develop as a result of long-term sun exposure. Very occasionally, Bowen’s disease may be seen in the context of previous radiotherapy, following chronic arsenic ingestion (very rare nowadays) or on the genitalia in association with the virus that causes warts (the human papillomavirus). Bowen’s disease is neither infectious, nor due to an allergy.
Is it hereditary?
No, but some of the factors that increase the risk of getting it, such as a fair skin and a tendency to burn in the sun, do run in families.
What are its symptoms?
Often there are no symptoms, although the surface crusting may catch on clothing.
What does it look like?
A patch of Bowen’s disease starts as a small red scaly area, which grows very slowly. It may reach a diameter of a few centimetres across. It commonly occurs on sun-exposed skin, especially the head, hands and lower legs. More than one lesion may be present. The development of an ulcer or lump on a patch of Bowen’s disease may indicate the formation of invasive squamous cell carcinoma.
How will it be diagnosed?
A patch of Bowen’s disease can look rather like other skin conditions, such as psoriasis. For this reason a biopsy may be needed to make the diagnosis.
Can it be cured?
Yes. As Bowen’s disease is confined to the surface of the skin, there are a variety of ways in which this can be achieved (see below).
How can it be treated?
A number of treatments are available for Bowen’s disease:
Freezing with liquid nitrogen. This is done in the clinic. It causes redness, puffiness, blistering or crusting, and may be slow to heal. It can be done in stages for large areas of Bowen’s disease.
Curettage. This involves scraping off the abnormal skin under a local anaesthetic. The area then heals with a scab, like a graze.
Excision. The abnormal skin can be cut out, under local anaesthetic, provided it is not too large. Usually this involves stitching the skin, which, depending on the size and location of the patch can result in scarring. If this method of treatment is chosen, you will be informed about the possibility of a scar and any other potential complications.
5-fluorouracil (Efudix) cream. This is a cream that may control or eradicate the disorder. There are various different ways of using it, and, if it is felt to be the best treatment, the doctor who sees you will explain these to you. Efudix works by killing the abnormal skin cells. This means that the skin will become red and look worse during treatment, and will then heal after the end of the course of treatment, once the abnormal cells have gone.
Imiquimod (Aldara) cream. This was originally developed for the treatment of genital warts, but imiquimod cream has been found useful in treating Bowen’s disease. It also causes inflammation of the skin during treatment.
Photodynamic therapy. A chemical is applied to the skin that makes the cells in the patch of Bowen’s disease sensitive to particular wavelengths of light. Light from a special lamp is then shone onto the lesion. This treatment can be painful and cause inflammation; however any inflammation should disappear within a few days.
A particular problem with Bowen’s disease is that it is frequently found on the lower leg – where the skin is often tight and sometimes quite fragile, especially in older patients. Healing there is slow. Many factors, therefore, play a part in selecting the right treatment:
- The size and thickness of the patch
- The number of patches
- The presence of swelling of the legs
- The general state of the skin on the legs
If the affected area is judged to be thin and not likely to cause problems soon, your dermatologist may simply suggest that it is kept under observation in a clinic, or in some cases by yourself or by your GP.
What can I do?
From now on, you should take sensible precautions to prevent additional patches of Bowen’s disease developing. This means wearing clothing that protects you against the sun, avoiding strong sunlight, and using a sun block with a sun protection factor (SPF) of at least 30.
Check your skin regularly for new patches.
The smaller your patch of Bowen’s disease is, the better the results of treatment are likely to be. If you think another one is developing, see your doctor about it promptly.
If your patch changes in any way (e.g. bleeds, ulcerates or develops a lump) contact your doctor as soon as possible as this could be the start of an invasive skin cancer.
Where can I get more information about Bowen’s disease?
Web link to detailed leaflet:
www.emedicine.com/derm/topic59.htm
www.dermnetnz.org/lesions/bowen.html
Dermatofibrosarcoma protuberans (DFSP)+
What are the aims of this leaflet?
This leaflet has been written to help you understand more about dermatofibrosarcoma protuberans. It tells you about what it is, what causes it, what can be done about it and where you can find out more about it.
What is dermatofibrosarcoma protuberans?
Dermatofibrosarcoma protuberans is a very rare type of skin cancer. It usually occurs on the trunk of the body, for example the chest and shoulders, however it can also occur on the limbs and in some cases on the head and neck. It is thought to develop in the deep layer of the skin (the dermis) and can invade deeper tissue such as fat and muscle. Although it grows slowly, it can be quite extensive and can have a high recurrence rate even if removed by surgery. Dermatofibrosarcoma protuberans can, however, be cured if completely removed with a wide margin of normal tissue. Dermatofibrosarcoma protuberans only very rarely spreads to other parts of the body.
What causes dermatofibrosarcoma protuberans?
It is not clear what causes this type of skin cancer. It is thought that trauma or injury to the skin may be predisposing factors.
Is dermatofibrosarcoma protuberans hereditary?
There is no evidence to suggest that dermatofibrosarcoma protuberans is hereditary. It occurs in people of all races and ages, however evidence suggests that it is most likely to occur in people between the ages of 20 and 50.
What do dermatofibrosarcoma protuberans look like?
Dermatofibrosarcoma protuberans is usually slow growing, painless and appears as a thickened area of skin and/or lump which is attached to the underlying skin. It can range in colour from flesh coloured to pinkish/brown and occasionally can even be bluish. It can also present as a soft indented area on the skin which can make diagnosis difficult. If left for several years the dermatofibrosarcoma protuberans can ulcerate.
What are the symptoms of dermatofibrosarcoma protuberans?
The symptoms of a dermatofibrosarcoma protuberans are usually very subtle, if any at all. The patient may notice a thickened/discoloured patch of skin, an indented area or a lump increasing in size. A dermatofibrosarcoma protuberans is generally painless, so it is usually a change in size or colour that alerts the person to their presence.
How is dermatofibrosarcoma protuberans diagnosed?
Due to its rarity, the diagnosis is often delayed. It may be mistaken for a number of other skin conditions. If dermatofibrosarcoma protuberans is suspected, a piece of abnormal skin will be removed and tested (biopsied) to confirm the diagnosis.
Can dermatofibrosarcoma protuberans be cured?
Dermatofibrosarcoma protuberans can be cured if completely removed. However, it can recur even after surgical intervention. Regular follow-ups post-treatment are therefore required to monitor the skin.
How can dermatofibrosarcoma protuberans be treated?
Surgical excision (removal) is the most common and effective treatment for dermatofibrosarcoma protuberans. There are two main types of surgical procedure used:
A wide excision – this involves removal of the lesion with an extra margin of normal skin around the edges to ensure no abnormal cells are left behind. The wound will then be reconstructed (closed) using the most suitable method. This may happen under local or general anaesthetic depending on the size and location of the dermatofibrosarcoma protuberans.
Mohs’ micrographic surgery – this is a specialised surgical technique (usually performed by a dermatologist) whereby the dermatofibrosarcoma protuberans is surgically removed in stages under local anaesthetic. The abnormal tissue will be removed and examined under the microscope overnight. A dressing is placed over the wound until the results are ready, and if there are any remaining abnormal cells this process is repeated until the dermatofibrosarcoma protuberans has been completely removed. The wound will then either be repaired by the dermatologist or a plastic surgeon, depending on the size and location of the wound.
Extremely rarely, dermatofibrosarcoma protuberans may spread to other parts of the body. If this has occurred, further treatment may be required such as radiotherapy or chemotherapy.
Self care (what can I do?)
Due to the subtle clinical appearance of dermatofibrosarcoma protuberans, it can be difficult for even health professionals to detect. It is advisable that you do regular checks of your scar at home and if you have any suspicious areas or changes in the scar you should contact your GP or dermatologist.
Where can I get more information about dermatofibrosarcoma protuberans?
Links to patient support groups:
Macmillan Cancer Support
89 Albert Embankment
London
SE1 7UQ
Helpline (for emotional support): 0808 808 2020
Helpline (for information): 0808 800 1234
Website: www.macmillan.org.uk
The Rarer Cancers Foundation
The Great Barn
Godmersham Park
Canterbury
Kent, CT4 7DT
Tel: 0122 773 8279
Helpline: 0800 334 5551
Email: helpline@rarercancers.org.uk
Website: http://www.rarercancers.org.uk
Web links to detailed leaflets:
Lentigo maligna and melanoma in situ
What are lentigo maligna and melanoma in situ?
Lentigo maligna and melanoma in situ are the very earliest stage of a skin cancer called melanoma.
The word ‘melanoma’ comes from the Greek word ‘melas’, meaning black. Melanin is the dark pigment that gives the skin its natural colour.
Melanin is made in the skin by pigment cells called melanocytes. After our skin is exposed to sunlight, the melanocytes make more melanin, and so the skin becomes darker.
Melanocytes sometimes grow together in harmless groups or clusters, which are known as moles. Most people have between 10 and 50 moles and often they are darker than the surrounding skin.
Melanomas can arise in or near to a mole, but can also appear on skin that looks quite normal. They develop when the skin pigment cells (melanocytes) become cancerous and multiply in an uncontrolled way. They can then invade the skin around them and may also spread to other areas such as the lymph nodes, liver and lungs.
‘In situ’ means that the cancer cells have not had the opportunity to spread to anywhere else in the body. There are cancer cells in the top layer of the skin (the epidermis) but they are all contained in the area in which they began to develop. They have not started to spread or grow into deeper layers of the skin and have not become invasive. This is why some doctors call in situ cancers ‘pre cancer’. The prognosis is excellent.
Lentigo maligna is a type of melanoma in situ. It is a slow growing lesion that appears in areas of skin that get a lot of sun exposure, such as the face or upper body. Because it grows slowly it can take years to develop. Similar to melanoma in situ, lentigo maligna has not spread and is only in the top layer of skin.
Both melanoma in situ and lentigo maligna are cured with surgery. However if not treated with appropriate surgery, they can develop into an invasive cancer. This is why it is important to have them removed with an adequate surgical margin and to know about preventative measures you can take which will lower your risk of these conditions occurring again in the future.
What causes lentigo maligna and melanoma in situ?
The most important preventable cause is exposure to too much ultraviolet light in sunlight, especially during the first 20 years of life. They are especially common in white-skinned people who live in sunny countries. The use of artificial sources of ultraviolet light, such as sun beds, also raises the risk of getting a melanoma.
Some people are more likely to get a melanoma than others:
About 7,000 people in the UK get diagnosed with melanoma each year. It is more common in women than men. It is a very rare cancer in children, but it is the second most common cancer in people aged 15 to 34.
The risk is increased if another family member has had a melanoma.
People who have already had one melanoma are at an increased risk of getting another one.
Some people have many unusual (atypical) moles. They tend to be larger than ordinary moles, to be present in large numbers, and to have irregular edges or colour patterns. The tendency to have these moles can run in families and carries an increased risk of getting a melanoma.
People who burn easily in the sun are particularly at risk. They occur most often in fair-skinned people who tan poorly. Often they have blond or red hair, blue or green eyes, and freckle easily. They are less common in dark-skinned people.
Past episodes of severe sunburn, often with blisters, and particularly in childhood, increase the risk of developing them. However, not all of them are due to sun exposure, and some appear in areas that are normally kept covered.
People with many (more than 50) ordinary moles, or with a very large dark hairy birthmark, have a slightly higher than average chance of developing a melanoma.
People with a damaged immune system (e.g. as a result of an HIV infection or taking immunosuppressive drugs, perhaps after an organ transplant) have an increased chance of getting a melanoma.
Are lentigo maligna and melanoma in situ hereditary?
About 1 in 10 of people with a melanoma has family members who have also had one. There are several reasons for this. Fair skin is inherited, while atypical moles and a tendency to have large numbers of ordinary moles also run in families.
What are the symptoms of lentigo maligna and melanoma in situ?
Lentigo maligna may appear as a long-standing discoloured patch, most commonly on the face, which slowly enlarges and develops darker areas. Many melanomas start as minor changes in the size, shape or colour of an existing mole (see below); others begin as a dark area that can look like a new mole. Most in situ (very early) melanomas do not cause any symptoms, but tingling or itching may occur. If a lentigo maligna or an in situ melanoma is not treated early, later it could become hard and lumpy, and bleed, ooze or crust.
What do lentigo maligna and melanoma in situ look like?
All melanomas do not look the same, and there are several different types. The ABCDE system (below) tells you some of the things to look out for.
A melanoma may show one or more of the following features:
Asymmetry – the two halves of the area differ in their shape.
Border – the edges of the area may be irregular or blurred, and sometimes show notches.
Colour – this may be uneven. Different shades of black, brown and pink may be seen.
Diameter – most melanomas are at least 6 mm. in diameter.
Evolution – rapid change in a pre-existing mole.
Melanomas can appear on any part of the skin but they are most common in men on the body, and in women on the legs. Lentigo maligna is common in areas of skin that get a lot of sun exposure, such as the face or upper body.
How is the diagnosis of lentigo maligna or melanoma in situ made?
If you are at all worried about changes in a mole, or about a new area of pigmentation appearing on your skin, you should see your family doctor. The ABCDE changes listed above can sometimes be found in completely harmless conditions, and your doctor may be able to put your mind at rest. However, if there is still any doubt, your doctor will usually refer you to a specialist (a dermatologist or a surgeon with a special interest in pigmented lesions) who will examine the area and decide whether it needs to be removed.
If the mole needs to be examined under a microscope, the whole of the suspicious area will then be removed under a local anaesthetic (a procedure known as excision) and sent to the laboratory to be examined. If the area is too large to remove easily, a sample of it (an incisional biopsy) will be taken. If a melanoma is found, the pathology report will provide valuable information that will help to plan the next step in treatment.
Can lentigo maligna and melanoma in situ be cured?
Yes, the outlook for lentigo maligna and melanoma in situ is excellent. It is very rare for them to come back because they were ‘in situ’, therefore they will not have had an opportunity to spread elsewhere in the body.
How should lentigo maligna and melanoma in situ be treated?
At present, the treatment for lentigo maligna and melanoma in situ is surgical. There is no other treatment of proven benefit, and usually no other tests are needed. Most people who have had a lentigo maligna, or melanoma in situ, removed will need another operation to try to prevent the melanoma from coming back at the original site. During the operation, some healthy skin will be removed from around the original scar to make absolutely sure that all of the melanoma has been taken away, and this makes the scar larger than before. Occasionally a skin graft will be needed.
The British Association of Dermatologists and other health organisations such as NICE (National Institute for Health and Clinical Excellence) state that people who have had a lentigo maligna and melanoma in situ do not need any follow up visits with their specialist. This is because in situ melanomas are very unlikely to come back once the area has been removed. Due to the excellent prognosis of lentigo maligna and melanoma in situ, you will usually be seen once again in clinic and then discharged.
What can I do?
Once your melanoma has been treated, you should be able to get back to a normal lifestyle quite quickly. You should also take a few sensible precautions to stop yourself getting another one:
You should look at all areas of your skin monthly for moles that are growing, or changing in the ways listed in the ABCDE rules (see above). If you find any worrying changes, contact your doctor immediately.
You must also protect yourself from too much sun. This means that you need to be careful to avoid sunbathing, sunburn and tanning. You can do this by covering yourself up and using sun protection creams, especially if on holiday in a hot country.
Covering up is better than using a sunscreen. Wear long sleeves, use a hat when out in the sun, and wear long trousers rather than shorts. Use clothing with a tight weave that will block ultraviolet light. Avoid the sun particularly from 11 a.m. until 3 p.m. – when its rays are strongest. Seek shade whenever possible. Use a high factor sunscreen (factor 30 or above) on areas you can’t cover. A broad spectrum one is best, as it will block both types of ultraviolet radiation (UVA and UVB). Put it on half an hour before going out and reapply it at least every 2 hours, but don’t use these sunscreens as an excuse to stay out in the sun or not to bother with protective clothing. Do not use sun beds and tanning lamps. Share sun advice and other information with blood relatives as they also may be at increased risk of getting a melanoma. In particular, protect your children from the sun, as exposure during childhood seems to be particularly damaging.
Top sun safety tips:
Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
Spend time in the shade between 10am and 3pm when it’s sunny.
When choosing a sunscreen look for a high protection’ SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
Keep babies and young children out of direct sunlight
The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole or patch of skin. If your GP is concerned about your skin, make sure you see a Consultant Dermatologist – an expert in diagnosing skin cancer. Your doctor can refer you for free through the NHS.
Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
It may be worth taking Vitamin D supplement tablets (available from health food stores) as strictly avoiding sunlight can reduce Vitamin D levels
Having had a melanoma does have some practical disadvantages. It can be difficult to obtain life or health insurance, particularly for the first five years after your diagnosis. It can also be difficult to obtain a mortgage. However, some insurance companies will be flexible so long as it is confirmed to them that you only had a lentigo maligna or a melanoma in situ that was not invasive and was completely excised.
Where can I find more information about lentigo maligna and melanoma in situ?
This leaflet may not have answered all of your questions, but we hope it has helped. It is completely normal not to remember what your doctor or the nursing staff tells you initially at diagnosis. For this reason, they often say the same things to you a number of times. In many departments, a skin cancer specialist nurse is available to go through the information in more detail and to act as a contact link for patients when needed.
Links to patient support groups:
Macmillan Cancer Support
89 Albert Embankment
London, SE1 7UQ
Tel: 0808 808 2020 / 0808 800 1234
Web: www.macmillan.org.uk
Cancer Research UK
PO Box 123, Lincoln’s Inn Fields
London, WC2A 3PX
Tel: 020 7242 0200
Web: www.cancerhelp.org.uk
Other useful websites:
Melanoma
What is a melanoma?
Cutaneous malignant melanoma is a cancer of the pigment cells of the skin. If it is treated early, the outlook is usually good. It is not contagious.
The word ‘melanoma’ comes from the Greek word ‘melas’, meaning black. Melanin is the dark pigment that gives the skin its natural colour. Melanin is made in the skin by pigment cells called melanocytes. After our skin is exposed to sunlight, the melanocytes make more melanin, and so the skin becomes darker.
Melanocytes sometimes grow together in harmless groups or clusters, which are known as moles. Most people have between 10 and 50 moles and often they are darker than the surrounding skin.
Melanomas can come up in or near to a mole, but can also appear on skin that looks quite normal. They develop when the skin pigment cells (melanocytes) become cancerous and multiply in an uncontrolled way. They can then invade the skin around them and may also spread to other areas such as the lymph nodes, liver and lungs.
What causes melanoma?
The most important preventable cause is exposure to too much ultraviolet light in sunlight, especially during the first 20 years of life. There is lots of evidence linking melanoma to this, and melanomas are especially common in white-skinned people who live in sunny countries. The use of artificial sources of ultraviolet light, such as sun beds, also raises the risk of getting a melanoma.
Some people are more likely to get a melanoma than others:
People who burn easily in the sun are particularly at risk. Melanoma occurs most often in fair-skinned people who tan poorly. Often they have blond or red hair, blue or green eyes, and freckle easily. Melanomas are less common in dark-skinned people.
Past episodes of severe sunburn, often with blisters, and particularly in childhood, increase the risk of developing a melanoma. However, not all melanomas are due to sun exposure, and some appear in areas that are normally kept covered.
People with many (more than 50) ordinary moles, or with a very large dark hairy birthmark, have a higher than average chance of getting a melanoma.
Some people have many unusual (atypical) moles (known as ‘dysplastic naevi’). They tend to be larger than ordinary moles, to be present in large numbers, and to have irregular edges or colour patterns. The tendency to have these ‘dysplastic naevi’ can run in families and carries an increased risk of getting a melanoma.
The risk is raised if another family member has had a melanoma.
People who have already had one melanoma are at an increased risk of getting another one.
People with a damaged immune system (e.g. as a result of an HIV infection or taking immunosuppressive drugs, perhaps after an organ transplant) have an increased chance of getting a melanoma.
Are melanomas hereditary?
About 1 in 10 of people with a melanoma have family members who have also had one. There are several reasons for this. Fair skin is inherited; dysplastic naevi can run in families, as can a tendency to have large numbers of ordinary moles.
What are the symptoms of melanoma?
Melanomas may not cause any symptoms at all, but tingling or itching may occur at an early stage. Some melanomas start as minor changes in the size, shape or colour of an existing mole (see below): others begin as a dark area that can look like a new mole. Later on a melanoma may feel hard and lumpy, and bleed, ooze or crust up.
What does a melanoma look like?
All melanomas do not look the same, and there are several different types. The ABCD system (below) tells you some of the things to look out for.
A melanoma may show one or more of the following features:
Asymmetry – the two halves of the area differ in their shape.
Border – the edges of the area may be irregular or blurred, and sometimes show notches.
Colour – this may be uneven. Different shades of black, brown and pink may be seen.
Diameter – most melanomas are at least 6 mm. in diameter.
Melanomas can appear on any part of the skin but they are most common in men on the body, and in women on the legs.
How is a melanoma diagnosed?
If you are at all worried about changes in a mole, or about a new area of pigmentation appearing on your skin, you should see your family doctor. TheABCD changes listed above can sometimes be found in completely harmless conditions, and your doctor will often be able to put your mind at rest quickly. However, if there is still any doubt, your doctor will usually refer you to a specialist (a dermatologist or a surgeon with a special interest in pigmented lesions) who will examine the area, perhaps with a special instrument (a dermatoscope), and decide whether it needs to be removed. The only way in which the diagnosis of a melanoma can be made firmly is by looking at the suspected area under microscope in the laboratory.
If the mole needs to be examined further, the whole of the suspicious area will then be removed under a local anaesthetic (an excision biopsy) and sent to the laboratory to be examined. If the area is too large to remove easily, a sample of it (a biopsy) will be taken. If a melanoma is found, the biopsy specimen will provide valuable information about its type and depth that will help to plan the next step in treatment.
Can a melanoma be cured?
Yes: three quarters of the people who have a melanoma removed will have no further problems. However it is crucial for a melanoma to be removed as early as possible – before it has had time to spread deep into the skin or to other parts of the body. The thinner the melanoma is when it is removed; the better is the survival rate. This is why a doctor should examine anyone with a suspicious mole or blemish as soon as possible. In a small minority of people the melanoma may have spread but further surgery or chemotherapy can often help to control this.
How can a melanoma be treated?
At present, the treatment for melanoma is surgical. There is no other treatment of proven benefit, and usually no other tests are needed. Radiotherapy is of little benefit, and various drugs have been tried, but with limited success only.
Most people who have had a melanoma removed will need another operation to try to prevent the melanoma from coming back at the original site. During the operation, some healthy skin will be removed from around the original scar to make absolutely sure that all of the melanoma has been taken away, and this makes the scar larger than before. Occasionally a skin graft will be needed.
“Sentinel node biopsy” may be discussed with some people. In this, a small sample of the nearest lymph node is taken as an additional procedure when the melanoma is being removed. However sentinel node biopsy is not used routinely, and is usually performed only as part of a research study: it is not an essential part of treatment.
After your operation you will be followed up regularly in the outpatient clinic. There are three main reasons for this:
- To make sure the tumour has not come back or spread
- To detect any other skin cancers
- To provide you with support and information
At the clinic your scar will be checked, and your neck, groin and armpits will also be examined for lumps to detect any spread to the lymph nodes there. Any other moles that you are concerned about will be examined and, if you have large numbers of moles, an eye will be kept on these too. Photographs of these moles may be taken and kept in your hospital notes. When you come back to the clinic, they will allow your doctors to compare the way your moles look now with how they looked before.
If your melanoma was at a very early stage when it was removed, you may need to be seen only once more in the follow-up clinic. Otherwise you will be reviewed 3-monthly for at least 3 years. If you develop problems between clinic appointments, you should consult your family doctor who will arrange for an earlier hospital appointment if this is necessary.
What can I do?
Once your melanoma has been treated, you should be able to get back to a normal lifestyle quite quickly. You should also take a few sensible precautions to stop yourself getting another one:
You should look at all areas of your skin monthly for moles that are growing, or changing in the ways listed in the ABCD rules (see above). There is no way that you can memorise all your existing moles, but you will notice subconsciously if any mole begins to change or if a new mole develops. It is as if someone has moved something in one of your rooms at home – it looks wrong. If you find any worrying changes, contact your doctor immediately.
You must also protect yourself from too much sun. This does not mean that you can’t ever go on a sunny holiday again; it just means that you need to be careful to avoid sunbathing and burning. You can do this by covering yourself up and using sun protection creams.
Covering up is better than using a sunscreen. Wear long sleeves, use a hat when out in the sun, and wear long trousers rather than shorts. Use clothing with a tight weave that will block ultraviolet light. Avoid the sun particularly from 11 a.m. until 3 p.m. – when its rays are strongest. Seek shade whenever possible. Use a high factor sunscreen (factor 30 or above) on areas you can’t cover. A broad spectrum one is best, as it will block both types of ultraviolet radiation (UVA and UVB). Put it on half an hour before going out and reapply it at least every 2 hours, but don’t use these sunscreens as an excuse to stay out in the sun or not to bother with protective clothing. Avoid sun beds and tanning lamps. Share sun advice and other information with blood relatives as they also may be at increased risk of getting a melanoma. In particular, protect your children from the sun, as exposure during childhood seems to be particularly damaging.
Top sun safety tips
Protect the skin with clothing, including a hat, T shirt and UV protective sunglasses
Seek shade between 11am and 3pm when it’s sunny
Use a sunscreen of at least SPF 30 which also has high UVA protection
Keep babies and young children out of direct sunlight
The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole – if your GP is concerned about your skin, make sure you see a Consultant Dermatologist (on the GMC register of specialists), the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS.
Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
Having had a melanoma does have some practical disadvantages. It can be difficult to obtain life or health insurance, particularly for the first five years after your diagnosis. It can also be difficult to obtain a mortgage.
Where can I find out more information about melanoma?
This leaflet will probably not have answered all your questions, but we hope it has helped. More information is available in the Sun Awareness section of this website.
Other sources of information
Macmillan Cancer Support
89 Albert Embankment
London, SE1 7UQ
Tel: 0808 808 2020 / 0808 800 1234
Web: www.macmillan.org.uk
Cancer Research UK
PO Box 123
Lincoln’s Inn Fields
London, WC2A 3PX
Tel: 020 7242 0200
Web: www.cancerhelp.org.uk
Other useful websites:
Moles (melanocytic nevi)
What are the aims of this leaflet?
This leaflet has been written to help you understand more about melanocytic naevi. It tells you what they are, what causes them, what can be done about them, and where you can find out more about them.
What are melanocytic naevi?
The lay term for a melanocytic naevi is a “mole”. The word ‘melanocytic’ means that they are made up of the cells (melanocytes) which produce the dark pigment (melanin) that gives the skin its normal colour. Melanocytes cluster together to form naevi. In other words, moles are localised and benign accumulations of melanocytes.
Some moles (congenital melanocytic naevi) are present at birth. Most come up later (acquired melanocytic naevi). Most people have at least one acquired mole and many people have several moles. Some come up in early childhood, and others come up later, particularly during adolescence and pregnancy. Some even go away in old age.
What causes melanocytic naevi?
Their cause is not fully understood. A genetic factor is likely. Another factor is exposure to too much sun in childhood, as those who grow up in the sunniest countries tend to have the most moles. Moles are most common in people with fair skin.
Are melanocytic naevi hereditary?
A tendency to have many ordinary melanocytic naevi runs in some families. ‘Dysplastic naevi’ (see below), in particular, tend to run in families.
What are the symptoms of melanocytic naevi?
Usually there are none. Some people do not like the appearance of their moles. Raised moles may catch on things. Moles may become sore and inflamed after hairs have been plucked out of them.
What do melanocytic naevi look like?
Those that are present at birth (congenital melanocytic naevi) are seldom less than 1 cm in diameter but can be much larger. They grow in proportion with you as you grow. They are dark and tend to become more raised and hairy with age.
There are three main types of acquired melanocytic naevi:
- Junctional melanocytic naevi are flat, and usually circular. Their colour is usually even, and ranges from mid to dark brown.
- Compound melanocytic naevi are raised brown bumps, most of which are hairy. Some have a slightly warty surface.
- Dermal melanocytic naevi are raised, often hairy, bumps, looking like compound naevi, but are more pale coloured.
In childhood, most moles are of the junctional type. Later in life some become raised and more hairy.
There are several other, less common, types of mole. They include the ‘blue naevus’ (a harmless mole that has a dark blue colour), the ‘halo naevus’ (a mole surrounded by a pale ring which may gradually go away by itself), and ‘dysplastic naevi’ (these are usually multiple, with irregular pigmentation and shape, and run in some families. They have a greater tendency than most moles to change into a melanoma, which is a cancer of moles).
How will melanocytic naevi be diagnosed?
Most moles can be recognised easily by their appearance. If there are any worries over the diagnosis, particularly over the possibility of a melanoma (see below), your doctor will arrange for the mole to be removed and checked in the laboratory. It may occasionally be hard to tell a mole from a ‘seborrhoeic keratosis’ (a harmless dark warty area that is common in older people).
Can melanocytic naevi be cured?
Yes. They can be removed surgically if necessary, but most are best left alone.
How can melanocytic naevi be treated?
There are three main reasons for removing moles:
- The most important reason is doubt about the diagnosis. The mole then has to be checked under the microscope. The main worry is usually whether or not the mole is a melanoma. The changes that suggest this are described in more detail in the British Association of Dermatologists’ information leaflet entitled Melanoma. In brief, they include changes in size (getting bigger), shape (becoming asymmetrical with an irregular ragged edge) or colour (an uneven colour with different shades of black brown or pink). Suggestive symptoms include itching and a tendency to bleed, ooze or crust. melanomas.
- The mole has become a nuisance by catching on clothing or being cut while shaving.
- Cosmetic reasons.
If there is any doubt about the diagnosis, the mole should be cut out completely under a local anaesthetic. Other techniques can be used for moles being removed because of their cosmetic appearance or have become a nuisance. These include shaving the mole off, if it is raised (shave excision) and then touching the raw area left behind with a hot point (cautery).
What can I do?
If you have a large number of moles:
- You should examine your skin monthly for moles that are growing, or changing in the ways described above. If you find any worrying changes, or one that is clearly different from the rest, you must contact your doctor immediately.
- You must also protect yourself from too much sun exposure. This does not mean that you can’t ever go on a sunny holiday again; it just means that you need to be careful to avoid sunbathing and burning. You should cover yourself up and use sun protection creams.
- To cover up wear long sleeves, use a hat when out in the sun, and wear long trousers rather than shorts. Use clothing with a tight weave that will block ultraviolet light.
- Avoid the sun particularly from 10a.m. until 3p.m. when sunrays are the strongest. Seek shade whenever possible.
- Use a high factor sunscreen (minimum sun protection factor 30) on areas you can’t cover. A broad spectrum one is best, as it will block both types of ultraviolet radiation (UVA and UVB). Put it on half an hour before going out and reapply it at least every 2 hours, but don’t use these sunscreens as an excuse to stay out in the sun or not to bother with protective clothing.
- Avoid sun beds and tanning lamps.
Where can I get more information about melanocytic naevi?
Web links to detailed leafets:
www.dermnetnz.org/lesions/naevi.html
www.emedicine.com/DERM/topic289.htm
Seborrheic keratoses
What are seborrhoeic keratoses?
Seborrhoeic keratoses are also known as seborrhoeic warts, and as basal cell papillomas. The term ‘senile wart’ has now been dropped as it caused offence and because they are not only seen in the elderly, but also in other age groups. Seborrhoeic keratoses are very common harmless, often pigmented, growths on the skin (see below).
What causes seborrhoeic keratoses?
Despite their name, seborrhoeic keratoses are nothing to do with sebaceous glands or viral warts:
- They are benign growths due to a build up of ordinary skin cells.
- They usually start to appear after the age of 40 years, although they can appear in younger people.
- The majority of older people will have a few seborrhoeic keratoses, while some will have large numbers.
- They are not infectious and do not become malignant.
Are seborrhoeic keratoses hereditary?
No, however the tendency to have a higher number of seborrhoeic keratoses can run in families. For example, if your father or mother had many seborrhoeic keratoses, you are more likely to have an increased number.
What are the symptoms of seborrhoeic keratoses?
Seborrhoeic keratoses are harmless, but are often considered to be a nuisance. They can itch, become inflamed, and catch on clothing. Many people dislike the look of them, particularly when they occur on the face.
What do seborrhoeic keratoses look like?
Seborrhoeic keratoses have a rough surface, and range in colour from golden brown to mid brown to almost black. They can affect anyone, but on dark- skinned people they can also appear as multiple small dark brown or black bumps, especially on the face and the neck; in such a case this is called Dermatosis Papulosa Nigra.
Small flat seborrhoeic keratoses can often become more raised and larger as the years go by. Their size varies from less than one centimetre to several centimetres across. They give the impression that they are stuck onto the surface of the skin; however some look like small pigmented skin tags.
Seborrhoeic keratoses occur most often on the trunk, but they are also common on the head and neck. Their numbers vary, and one person may have just one seborrhoeic keratosis whilst others can have hundreds. Once present, they usually stay, and new ones often appear over the years.
How are seborrhoeic keratoses diagnosed?
Seborrhoeic keratoses are much more common than skin cancers, however a very dark seborrhoeic keratosis can look similar to a melanoma. It is therefore important that either a general practitioner or specialist checks any pigmented lesions to ensure that the correct diagnosis is made.
Seborrhoeic keratoses can cause worry by becoming inflamed or bleeding. If there is any doubt, a skin biopsy can be done to confirm the diagnosis.
Can seborrhoeic keratoses be cured?
Individual seborrhoeic keratoses can be treated successfully in the ways listed below. However, new seborrhoeic keratoses will continue to appear.
How can seborrhoeic keratoses be treated?
As seborrhoeic keratoses are so common (most people after middle age having at least a few) it would be impossible to routinely treat every individual and every single keratosis. Most need no treatment anyway as they are harmless and cause no symptoms, however for those who wish to have some or all of their keratoses removed it may be possible to have them treated by a general practitioner or dermatologist. Treatment can occur by either freezing them with liquid nitrogen (cryotherapy), or scraping them off (curettage) under a local anaesthetic.
Such treatments may not be funded by the local NHS service. A further drawback is that these procedures may cause altered pigmentation or scarring of the treated skin; thus they are usually restricted to seborrhoeic keratoses that are persistently troublesome.
What can I do?
Always contact your doctor if you are worried about a pigmented spot that is changing in any way.
Where can I get more information about seborrhoeic keratoses?
Web link to detailed leaflet:
http://emedicine.medscape.com/article/1059477-overview
www.dermnetnz.org/dna.sk/sk.html
Squamous cell carcinoma (SCC)
What is a squamous cell carcinoma?
A squamous cell carcinoma is a type of skin cancer. There are two main types of skin cancer: melanoma and non-melanoma skin cancer. Squamous cell carcinoma (SCC) is a non-melanoma skin cancer, and the second most common type of skin cancer in the UK.
What causes a squamous cell carcinoma?
The most common cause is too much exposure to ultraviolet (UV) light from the sun or from sunbeds. This causes certain cells (keratinocytes) in one the outer layer of the skin (the epidermis) to grow out of control into a tumour.
SCC can occur on any part of your body, but is most common on areas that are exposed to the sun, i.e. your head and neck (including the lips and ears) and the backs of your hands. SCC can also develop where the skin has been damaged by X-rays, ulcers, burns and on persistent chronic wounds and old scars. SCC is not contagious.
Who is most likely to have a squamous cell carcinoma?
SCC mainly affects the following groups:
- Older people – even those who tend to avoid the sun
- Builders, farmers, surfers, sailors and people who often are out in the sun, can develop a SCC when they are quite young.
- Those with a fair skin are more at risk of developing SCC than people with a darker skin.
- Anyone who has had a lot of ultraviolet (UV) light treatment for skin conditions such as psoriasis will also be at increased risk of getting an SCC.
- Those whose immune system has been suppressed by medication taken after an organ transplant, or by treatment for leukaemia or a lymphoma.
Are squamous cell carcinomas hereditary?
No, they are not; but some of the things that increase the risk of getting one, such as fair skin, a tendency to burn rather than tan, and freckling, do run in families.
What does a squamous cell carcinoma look like?
SCC can vary greatly in their appearance, but most SCC usually appears as a scaly or crusty area of skin or lump, with a red, inflamed base. SCC are often tender, but some small SCC are not painful.
How will my squamous cell carcinoma be diagnosed?
If your doctor thinks that the mark on your skin needs further investigation, you will be referred to a skin specialist who will decide whether or not it is an SCC. To confirm the diagnosis, a small piece of the abnormal skin (a biopsy), or the whole area (an excision biopsy), will be cut out and examined under the microscope. You will be given a local anaesthetic beforehand to numb the skin.
Can a squamous cell carcinoma be cured?
Yes, SCC can be cured if they are detected early. If an SCC is left untreated for too long there is a small risk (2-10 %) that it may spread to other parts of the body, and this can be serious.
How can a squamous cell carcinoma be treated?
Surgery is the first choice of treatment and several different methods are available. To select the right one, your surgeon will take into account the size of the SCC, where it is, what type it is, and how long you have had it. The most common surgical technique is simply to cut the SCC away, along with some clear skin around it, using local anaesthetic to numb the skin. The skin can usually be closed with a few stitches, but sometimes a small skin graft is needed.
Other types of treatment include:
Early small thin SCC:
Curettage and cautery – first the SCC is scraped away (curettage) then the skin surface is sealed (cautery). This is a reasonable treatment for small SCC
Cryotherapy – freezing the SCC off, as you would a wart, usually with liquid nitrogen.
Large, difficult, or spreading SCC:
Advanced surgery, using the Mohs’ technique, which is undertaken only in specialist centres, and then only for difficult or recurring SCC. This involves the excision of the affected skin that is then examined under the microscope straight away to see if all the SCC has been removed. If any residual SCC is left at the edge of the excision further skin is excised from that area and examined under the microscope and this process is continued until all the SCC is removed. The site is then usually covered with a skin graft (should a skin graft be necessary skin camouflage can assist greatly in colour toning the skin graft to match your natural skin tone, making the skin graft less obvious)
The removal of lymph nodes – this is unusual but may be needed if there are concerns that the SCC has spread.
Radiotherapy (treatment with X-rays) may be used if the SCC is large or in an awkward place. You may be offered this on its own or alongside surgery. Radiotherapy may also be used to relieve symptoms when SCC has spread to other parts of the body.
Chemotherapy (treatment with drugs) is only used when a SCC has spread to other parts of the body.
What can I do?
Treatment will be much easier if your SCC is detected early. SCC can vary in their appearance, but it is advisable that you should see your doctor if you have any marks on your skin which are:
growing
bleeding and never completely healing
changing appearance in any way
You can also take some simple precautions to help prevent a SCC appearing:
Top sun safety tips:
Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
Spend time in the shade between 10am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn. Keep babies and young children out of direct sunlight.
When choosing a sunscreen look for a high protection’ SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole or patch of skin. If your GP is concerned about your skin, make sure you see a Consultant Dermatologist – an expert in diagnosing skin cancer. Your doctor can refer you for free through the NHS.
Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
Where can I get more information?
http://www.skincancer.org/squamous-cell-carcinoma.html
www.intelihealth.com/IH/ihtIH/WSIHW000/8297/24556/211186.html
http://www.dermnetnz.org/lesions/squamous-cell-carcinoma.html
www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/SCC%20Guidelines%20Final%20Aug%2009.pdf