Treatment for skin cancer

Surgery to remove the cancer (surgical excision) is the most common treatment for invasive BCC and SCC. Most small skin cancers are removed by a GP or a dermatologist in their consulting rooms. A surgeon may treat more complex cases.

The doctor will inject a local anaesthetic to numb the affected area, then cut out the skin cancer and some nearby normal-looking tissue (margin).  The recommended margin is usually between 2 mm and 10 mm depending on the type and location of the skin cancer.

A pathologist checks the margin for cancer cells to make sure the cancer has been completely removed. The results will be available in about a week. If cancer cells are found at the margin, you may need further surgery or radiation therapy.

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Mohs micrographic surgery

Mohs micrographic surgery is usually done under local anaesthetic by a dermatologist or a Mohs specialist. It is used to treat skin cancers that have begun to spread deep into the skin. It can also be used for cancers in areas that are hard to treat, such as near the eye or on the nose, lips and ears.

This procedure is done in stages. The doctor removes the cancer little by little and checks each section of tissue under a microscope. They keep removing tissue until they see only healthy tissue under the microscope. Mohs surgery aims to reduce the amount of healthy skin that is removed with the cancer.

Only some skin cancers are suitable for Mohs surgery. This technique costs more than other types of surgery. Special equipment and training are needed so it’s available only at some hospitals or clinics.

Repairing the wound

Most people will be able to have the wound closed with stitches. You will have a scar. This should be less noticeable over time. The area around the excision may feel tight and tender for a few days.

If you have a large skin cancer removed, your doctor will talk with you about what type of reconstruction is suitable for your wound. There are two main ways to do this:

• skin flap – nearby loose skin and underlying fatty tissue is moved over the wound and stitched
• skin graft – a piece of skin is removed from another part of the body (called the donor site) and stitched over the wound. The donor site may be stitched closed, or it may be dressed and allowed to heal by itself.

Skin flaps and grafts may be performed in the doctor’s office but are sometimes done as day surgery in hospital under a local or general anaesthetic. The affected area will heal over a few weeks.

Whether you have an excision or Mohs surgery, sometimes you may need a more complex reconstructive procedure. This can involve more than one reconstruction technique, surgery that is done in stages, and a longer stay in hospital.

Curettage and electrodesiccation (also known as cautery) is used to treat some BCCs, small SCCs, and areas of SCC in situ (Bowen’s disease). This may be done by a GP or dermatologist.

The doctor will give you a local anaesthetic and then scoop out the cancer using a small, sharp, spoon-shaped instrument called a curette.

Low-level heat will be applied to stop the bleeding and destroy any remaining cancer. The wound should heal within a few weeks, leaving a small, flat, round, white scar. Some people may have cryotherapy after curettage to destroy any remaining cancer cells.

Cryotherapy, or cryosurgery, is a procedure that uses extreme cold (liquid nitrogen) to remove sunspots, some small BCCs and SCC in situ (Bowen’s disease).

The GP or dermatologist sprays liquid nitrogen onto the sunspot or skin cancer and a small area of skin around it. You may feel a burning or stinging sensation, which lasts a few minutes. The liquid nitrogen freezes and kills the abnormal skin cells and creates a wound. In some cases, the procedure may need to be repeated.

The treated area will be sore and red. A blister may form within a day. A few days later, a crust will form on the wound. The dead tissue will fall off after 1–6 weeks, depending on the area treated. New, healthy skin cells will grow and a scar may develop. The healed skin will probably look paler than the surrounding skin.

Some skin spots and cancers can be treated with creams or gels that you apply to the skin. These are called topical treatments. They may contain immunotherapy or chemotherapy drugs, and are prescribed by a doctor. You should use these treatments only on the specific spots or areas that your doctor has asked you to treat. Don’t use leftover cream to treat new spots that have not been assessed by your doctor.

Immunotherapy cream

A cream called imiquimod is a type of immunotherapy that causes the body’s immune system to destroy cancer cells.

Imiquimod is used to treat sunspots and superficial BCCs. Your doctor will explain how to apply the cream and how often. For superficial BCCs, the cream is commonly applied directly to the affected area at night, usually five days a week for six weeks.

Within days of starting imiquimod, the treated skin may become red, sore and tender to touch. The skin may peel and scab over before it gets better. Some people have pain or itching in the affected area, fever, achy joints, headache and a rash.

If you experience any of these more serious side effects, stop using the cream and see your doctor immediately.

Chemotherapy cream

A cream called 5-fluorouracil (5-FU) is a type of chemotherapy drug. It is used to treat sunspots and, sometimes, SCC in situ (Bowen’s disease).

5-FU works best on the face and scalp. Your GP or dermatologist will explain how to apply the cream and how often. Many people use it twice a day for 2–3 weeks. It may need to be used for longer for some skin cancers.

While using the cream, your skin will be more sensitive to UV radiation and you will need to stay out of the sun. The treated skin may become red, blister, peel and crack, and feel uncomfortable. These effects will usually settle within a few weeks of treatment finishing.

Photodynamic therapy (PDT) uses a cream that kills cancer cells when a special light is applied. It is used to treat sunspots, superficial BCCs and SCC in situ (Bowen’s disease).

After gently scraping the area to remove any dry skin or crusting, the doctor applies a cream to the skin. After three hours, light is shined onto the area for about eight minutes. The area is covered with a bandage. For skin cancers, PDT is usually repeated 1–2 weeks later.

Side effects can include redness and swelling, which usually ease after a few days. PDT commonly causes a burning, stinging or tender feeling in the treatment area, particularly to the face. Your doctor may treat these side effects with a cold water spray or pack, or give you a local anaesthetic to help ease any discomfort.

Radiation therapy uses a controlled dose of radiation to kill or damage cancer cells. It is used as the main treatment for BCCs or SCCs that are not suitable to be removed surgically, for large areas, or for people not fit enough for surgery. Sometimes radiation therapy is also used after surgery to reduce the chance of the cancer coming back or spreading.

Radiation therapy to treat skin cancer is given externally. It can be done using different techniques and types of radiation. The treatment team will work out the best technique for your situation. You may have a separate planning session so the radiation therapy team can work out the best position for your body during treatment. Your treatment will usually start within a couple of weeks of this appointment. During each treatment session, you will lie on a table under the radiation machine. Once you are in the correct position, the machine will rotate around you to deliver radiation to the area containing the cancer. The entire process can take 10–20 minutes, but the treatment itself takes only a few minutes.

Your treatment plan will depend on the type, size and position of the cancer, and your overall health and wellbeing. This means that the number of treatments can vary. Some people will have five sessions a week for several weeks, others may have a much shorter course.

Skin in the treatment area may become red, dry and sore 2–3 weeks after treatment starts. This soreness may get worse after treatment has finished but it usually improves within six weeks. The treatment team will recommend creams to use to make you more comfortable.

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A very small number of BCCs and SCCs spread to the lymph nodes or other areas of the body (advanced cancer). Your doctor will explain your treatment options depending on where the cancer is located.

Options may include surgery, radiation therapy or drug therapies such as immunotherapy, targeted therapy or chemotherapy. You may have a combination of treatments.

To work out if the skin cancer has spread, your doctor will feel nearby lymph nodes and may recommend a biopsy of the lymph nodes and imaging scans. Your surgeon will talk to you about the risks and benefits of a lymph node biopsy.