Skin Cancer

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Nearly all skin cancers are treatable if caught early. Surgery is the first step in treating almost all types of skin cancers. Conventional surgery (removing the entire cancerous area at one time) is not often used for basal and squamous cell skin cancers. There are many types of specific surgeries to treat skin cancer. A doctor will determine the most appropriate surgery for the patient depending on the size, depth, and location of the skin cancer and the overall health of the patient.

Many basal and squamous cell skin cancers can be removed from the skin quickly and easily. Sometimes, the biopsy removes the cancer completely, and no further treatment is necessary. In other cases, doctors use surgery, radiation therapy, topical chemotherapy, photodynamic therapy (treatment with drugs that become active when exposed to light),or a combination of methods to treat basal and squamous cell skin cancers.

Clinical research is currently being conducted to evaluate methods to treat melanoma, the most serious form of skin cancer. The usual treatment for melanoma includes surgery, radiation therapy, chemotherapy, or a combination. Other methods to treat melanoma are being studied, including vaccines and small molecules that target specific growth pathways in the tumor.

One other type of skin disease is called actinic keratosis—a precancerous condition of thick, scaly patches of skin. Even though actinic keratosis is not cancer, it is treated because it may develop into cancer. Treatment of actinic keratosis may include methods similar to those for nonmelanoma skin cancers, such as topical chemotherapy, cryosurgery, electrodesiccation, laser surgery, and photodynamic therapy.

  • Surgery for basal cell carcinoma and squamous cell carcinoma
  • Treatment for melanoma
  • Skin grafts
  • Radiation therapy
  • Topical therapies
  • Photodynamic therapy
  • Surgery for Basal and Squamous Cell Skin Cancers

    Basal and squamous cell skin cancers are usually excised using the following surgical techniques:

    • Moh's surgery
    • Cryosurgery
    • Laser surgery
    • Electrodesiccation
    • Moh's Surgery

      Moh's surgery is a procedure where very thin individual layers of cancerous tissue are removed one at a time and immediately examined under a microscope. If cancerous cells can be seen in the layer, the surgeon then continues shaving off layers of the tumor one at a time until all cancerous tissue has been removed. It causes less scarring and has a shorter healing period than removing the entire area at once.

      Because it is very controlled, Moh's surgery may achieve the highest cure rate for many skin cancers. For both basal and squamous cell cancers, Moh's surgery cure rates can be up to 99 percent and 97 percent, respectively. For recurrent basal and squamous cell cancers, Moh's surgery cure rates are up to 94 percent and 90 percent, respectively. These cure rates are generally higher than traditional surgery that removes the entire tumor at once.

      Moh's surgery is an outpatient procedure usually performed under local anesthesia, occasionally with mild sedation. Patients generally avoid general anesthesia, return home immediately, and have a rapid recovery. This can be a significant benefit for older patients, who also are the ones most susceptible to skin cancers.

      Cryosurgery

      In cryosurgery, a surgeon applies liquid nitrogen or argon gas to the cancerous tissue to freeze and destroy it. The tissue is then allowed to thaw, and additional freeze-thaw passes may be repeated. Cryotherapy is typically performed with more pressure and for a longer period for skin cancers than it is for benign lesions.

      Cryosurgery is less invasive than conventional surgery. It involves only a small incision or insertion of the cryoprobe through the skin. Consequently, pain, bleeding, and other complications of surgery are minimized. Sometimes, cryosurgery can be done using only local anesthesia.

      Because physicians can focus cryosurgical treatment on a limited area, they can avoid the destruction of nearby healthy tissue. The treatment can be safely repeated and may be used along with standard treatments such as surgery, chemotherapy, hormone therapy, and radiation. Cryosurgery may offer an option for treating cancers that are considered inoperable.

      The major disadvantage of cryosurgery is the uncertainty surrounding its long-term effectiveness. While cryosurgery may be effective in treating tumors the physician can see by using imaging tests (tests that produce pictures of areas inside the body), it can miss microscopic cancer spread. Furthermore, because the effectiveness of the technique is still being assessed, some insurers may not cover it.

      Cryosurgery does have side effects, although they may be less severe than those associated with traditional surgery or radiation therapy. When used to treat skin cancer, cryosurgery may cause scarring and swelling; if nerves are damaged, loss of sensation may occur, and, rarely, it may cause a loss of pigmentation and loss of hair in the treated area. In rare cases, cryosurgery may interact badly with certain types of chemotherapy. Although the side effects of cryosurgery may be less severe than those associated with other surgeries or radiation, more studies are needed to determine the long-term effects. Data from these studies will allow physicians to compare cryosurgery with standard treatment options such as surgery, chemotherapy, and radiation. Moreover, physicians continue to examine the possibility of using cryosurgery in combination with other treatments.

      Laser Surgery

      Laser devices for skin cancer destroy and vaporize tissue under local anesthesia. The laser uses an intense, focused beam of light to destroy skin cancer tissue. The laser destruction, plus the body's immune response to the injury, results in a blistered wound that takes several weeks to heal.

      The laser can be set to remove the skin in controlled layers; the depth will depend on the depth of the cancer. The surgeon may remove the top layer only or the top layer plus the next deeper layer, and so on. Because the laser treats without direct skin contact, it can be aimed at difficult-to-reach locations such as between the toes. Laser therapy may leave white scars similar to cryotherapy, but if only a superficial pass is performed, then there may be no scarring at all. Deeper skin removal leaves an open wound that requires meticulous care until healing is complete.

      Laser therapy also has several limitations. The laser device is expensive and requires specialized training. It is used in many situations, most commonly:

      • to treat superficial skin cancers
      • to treat precancers
      • to reduce scars following skin cancer surgery
      • to treat a variety of noncancerous skin growths.
      • Electrodesiccation

        Otherwise known as "scraping and burning," electrodessication uses a scraping instrument (curet) and electrical currents to destroy and burn a skin cancer under local anesthesia. The abnormal area is treated along with a rim of surrounding skin called a safety margin. Electrodesiccation is usually a fast and simple outpatient procedure, taking 10 to 20 minutes. Several passes are performed, resulting in a shallow wound that heals by itself after several weeks.

        Electrodesiccation is effective for small and superficial skin cancers. The extent of skin cancers, and whether they might be small enough to treat with electrodesiccation, is determined by a biopsy. The curet allows a physician to "feel" the extent of skin cancer involvement, as skin cancer tissue is often more friable, or crumbly feeling, and easily scraped, compared with normal skin. Electrodesiccation is convenient for both the physician and the patient because there is less activity restriction than with other surgeries.

        More than most techniques for skin cancer, the effectiveness of electrodesiccation greatly relates to the physician's experience. A wound from electrodesiccation may take many weeks to heal, depending on the wound's size, depth, and location. During that time, the patient needs to perform wound care. The scar that results from electrodesiccation is often white, shiny, and occasionally thick to touch, which may or may not be a problem depending on location and personal preference.

        Treatment for Melanoma

        Almost all early-stage melanomas can be successfully treated, many with surgery alone. Melanoma can also spread beyond the original cancer site to the lymph nodes. When cancer has spread to the lymph nodes, it is also more likely to spread to other organs. Melanoma that has spread to the lymph nodes may be treated with surgery, chemotherapy, or immunotherapy, which stimulates the body's immune response. Melanoma that has metastasized beyond the lymph nodes requires more aggressive treatment. Patients with metastatic melanoma are strongly encouraged to participate in clinical trials because current treatment is not very effective for most patients. For more information on clinical trials, see the usnews.com module on Clinical Trials.

        Prognosis for melanoma depends on the thickness and location of the cancer, the overall health of the patient, and whether the melanoma has spread to lymph nodes and/or nearby organs. If the cancer is less than about 4 millimeters thick and has not spread to the lymph nodes, it can usually be treated with surgery. However, if cancer is found in nearby lymph nodes, the affected nodes are removed along with the melanoma. This treatment may be followed by radiation or immunotherapy, or other treatments currently being studied in clinical trials.

        This section contains more information on:

        • Stages of melanoma
        • Surgery for melanoma less than 1 mm thick
        • Surgery for melanoma more than 1 mm thick
        • Metastatic melanoma (stage IV)
        • Immunotherapy
        • Stages of Melanoma

          When you are diagnosed with melanoma, your doctor will tell you what stage melanoma you have. "Stage" is a way to describe the severity of a cancer by incorporating information about its location, size, whether it has spread to nearby lymph nodes, and whether it has metastasized to other parts of the body. In the case of melanoma, stages I and II are based mainly on the thickness of the cancer and how many layers of skin it has invaded. Stages III and IV are based on how far the melanoma has spread from the skin. Staging is based on a combination of physical examination, biopsy, and investigation of the lymph nodes and other parts of the body.

          After melanoma has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body.

          Melanoma in situ, or stage 0, does not reach below the surface of the skin.

          Stage IA melanoma is less than 1 millimeter thick and has not ulcerated. It is most likely present only in the top layer of the skin.

          Stage IB melanoma also may be less than 1 millimeter thick but has ulcerated (become an open sore) and may have grown into deeper layers of the skin.

          Stage IIA melanoma is either 1 to 2 millimeters thick with ulceration or 2 to 4 millimeters thick with no ulceration.

          Stage IIB melanoma is either 2 to 4 millimeters thick with ulceration or more than 4 millimeters thick without ulceration.

          Stage IIC melanoma is more than 4 millimeters thick with ulceration.

          Stage III melanoma has spread to the lymph system or directly into the lymph nodes near the cancer, and may also have spread directly from the original tumor to areas more than 2 centimeters away (but not to farther lymph nodes).

          Stage IV melanoma has metastasized to more distant lymph nodes and/or to other organs.

          Surgery for Melanoma Less Than 1 Millimeter Thick

          A thin melanoma—one that is less than 1 millimeter thick (stage 1A or 1B)—is usually treated with a wide local excision of the skin, in which the surgeon cuts out the melanoma and an area around it. The amount of skin that is removed and the degree of scarring relate to the size of the lesion or mole. Generally, these patients do not need adjuvant therapy such as chemotherapy, immunotherapy, or radiation therapy.

          Depending on the size of the melanoma, the local excision may be an in- or outpatient procedure, usually with local anesthesia. The area may require stitches, and recovery can last a few weeks. The severity of the scar depends on the size, depth, and location of the melanoma.

          Surgery for Melanoma More Than 1 Millimeter Thick

          Melanomas 1 millimeter or more in thickness are considered somewhat more serious than thin melanomas because they are more likely to spread to other areas of the body. For larger melanomas, in addition to a wide local excision, a surgeon will often do a lymph node biopsy to check whether the cancer cells have spread. In a lymph node biopsy, lymph nodes in the area of the cancer are surgically removed to see whether they contain cancer. Your surgeon may opt to do a sentinel lymph node biopsy, in which only the closest lymph node to the tumor is removed to check for cancer. If the lymph node closest to the tumor is cancer free, then the other lymph nodes do not need to be checked or removed.

          While treatment of melanoma on an arm and leg used to sometimes include amputation of the limb, this is rarely necessary these days. However, in some cases, melanoma on a finger or toe may still be treated by amputation of a digit, according to the American Cancer Society.

          After lymph nodes are removed, some people may experience lymphedema, a condition where fluid builds up in the limbs. Lymphedema is usually treated using compression garments to prevent or reduce fluid buildup. Diuretics and anticoagulants are not helpful and make the problem worse. Lymphedema often causes infections because the fluid gathers in one place for an extended time. Antibiotics are often used to prevent and/or treat infection in persons who experience lymphedema. Sometimes, patients are directed to eat protein-rich foods and have the swollen area massaged by someone who is trained in lymphedema treatment.

          Metastatic Melanoma (Stage IV)

          At this stage, melanoma has spread into distant skin or lymph nodes or other organs such as the lungs, liver, or brain. Surgeons do not usually operate to remove these metastases. Even if large metastases can be removed, there are very likely smaller ones in other places that would be missed. However, treatment may still be able to improve symptoms and extend life. A doctor may recommend systemwide chemotherapy or immunotherapy to improve a patient's quality of life.

          Systemic chemotherapy uses cancer drugs to attack cancer cells. However, these drugs also kill some normal cells, which can cause many unwanted side effects. Side effects depend on many factors, including the location of the tumor and the type and extent of the treatment, but may include hair loss, nausea, vomiting, diarrhea, mouth sores, fatigue, and a suppressed immune system. These side effects may not be the same for each person and may even change from one treatment session to the next.

          Immunotherapy

          A number of immunotherapy medications may be injected into the skin to treat skin cancers. The most commonly used is interferon-alpha. Interferon works by stimulating the body's immune response to destroy skin cancer tissue. The tumor progressively shrinks. The destruction is relatively specific, and healthy tissue is usually spared. Redness, inflammation, and flulike symptoms may occur as part of the immune system response. It may take a series of injections, spaced several months apart, to eradicate a larger skin cancer.

          Interferon can also be used for people whose melanoma has spread beyond the original cancer site to one or more lymph nodes, in order to prevent or delay melanoma recurrences. In this case, it is given for a year to decrease the risk that melanoma will return. For the first four weeks, a high dose of interferon is administered intravenously five days a week; for the rest of the year, a lower dose is injected under the skin three days a week, usually by the patient.

          Almost all patients experience mild-to-moderate side effects, although some patients experience more severe side effects, including flulike symptoms, headache, fever, chills, liver function abnormality, and low blood counts. Many patients who have interferon therapy for melanoma experience depression, which can be controlled with medication. Other frequently occurring side effects were nausea, vomiting, depression, thinning of hair, and diarrhea. The flulike symptoms may be troublesome, but only rarely are they debilitating. Many patients who have interferon therapy for melanoma fall into depression, which can be controlled with medication; however, a minority of patients may have severe depression and suicidal ideation. Most of these side effects are reversible and subside if the injections are stopped.

          Skin Grafts

          If a large area of skin must be removed during surgery, a skin graft may be done to reduce scarring. In a skin graft, the surgeon first numbs and then removes a patch of healthy skin from another part of the body, such as the upper thigh, and then uses it to replace the skin that is removed to cover the wound from surgery. This is done at the same time as the skin cancer surgery. The surgeon first numbs and then removes a patch of healthy skin from another part of the body. The patch is then used to cover the area where skin cancer was removed. If you have a skin graft, you may have to take special care of the area until it heals.

          The time it takes to heal after surgery is different for each person. You may be uncomfortable for the first few days. However, medicine can usually control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief. For any type of surgery, including skin grafts, it is important to follow your doctor's advice on bathing, shaving, exercise, or other activities. Depending on the extent of your graft, you may need from several days to several weeks to resume normal activities.

          Surgery nearly always leaves some type of scar. The size and color of the scar depend on the size of the cancer and how your skin heals.

          Radiation Therapy

          Radiation therapy may be used to treat all types of skin cancers—basal and squamous cell, and melanoma.

          Radiation therapy uses high-energy photons (X-rays) to destroy tissue. It targets the tumor site as well as a surrounding margin of skin. Shields are custom made for each patient to protect as much of the nontargeted tissue as possible. The therapy is spread over several visits per week for many weeks.

          Radiation therapy can be adjusted to be superficial or deeply penetrating, which means it can treat a variety of tumors. Properly performed, radiation therapy can achieve high cure rates with little or no scarring. Patients who have multiple lesions in one region of skin may have radiation therapy instead of surgery. It is an excellent alternative when surgery would be too deforming or risky for the patient. Radiation therapy may also be used after surgery for patients who have residual cancer in the tissue. Radiation therapy may be combined with chemotherapy, in chemoradiation, for advanced tumors.

          For very high-risk skin cancers, which are those that have spread to lymph nodes or nerves, radiation therapy may be used after surgery to increase the chance for cure. While the skin is healing, weeping wounds, blisters, pain, and burnlike reactions may occur and require intense wound care. In the longer term, radiated skin is thinner, smoother, fibrotic (scarlike), and lighter in color than normal skin. It is also hairless and has difficulty healing if injured. Irradiated skin is also particularly susceptible to infection. Many patients feel tired during radiation treatment but are still able to work and enjoy their normal activities.

          Rare complications may include necrosis of bone. The risk of secondary cancers induced by radiation is very low, and these cancers usually do not occur until 20 years or more after radiation. Because of that possibility, radiation is not the first choice to treat skin cancers in younger patients.

          Topical Therapy

          If your skin cancer is confined to only the top layers of the skin (determined by a biopsy), then topical therapy may be appropriate. These superficial cancers include some squamous cell cancers in situ, also known as Bowen's disease, and superficial basal cell cancers. In situ means that a lesion is confined to the epidermis, the top layer of skin. Topical therapy is not appropriate for more aggressive skin cancers.

          Imiquimod (IMQ) and/or 5-fluorouracil (5FU) are two such topical creams for skin cancers. IMQ works by stimulating your body's own immune system to destroy cancerous cells (topical immunotherapy). 5FU works as a topical chemotherapy, preventing rapidly dividing cells from growing. Both creams cause significant redness and inflammation and need to be used for many weeks to be effective. Occasionally, these creams may be recommended in addition to surgery for maximal success.

          The advantage of topical treatment is the relative lack of scarring compared with surgery. Treated skin is less sun-damaged in appearance than skin treated with other methods, such as radiation, and putting cream on the area treats nearby precancers at the same time. Skin may look red, raw, and inflamed for the duration of treatment. If you do not follow the wound care prescribed, then your skin may develop itching, burning, infections, and pain. This treatment, which you apply at home, is usually avoided in the hot summer months because heat and humidity can be uncomfortable on inflamed skin and the therapy makes your skin extra sensitive to sun.

          Photodynamic Therapy

          Basal and squamous cell skin cancers may be treated with photodynamic therapy. Photodynamic therapy is treatment with drugs that become active when exposed to light. In photodynamic therapy, the cancerous area is covered with a drug-containing cream or injected with a drug. Cancer cells hold the drug longer than do normal cells. Several hours or days after the drug is given, the cancerous skin treated with the photosensitizer is then exposed to various light sources, which causes a destructive reaction similar to a bad sunburn. Because the drug is gone from normal cells by the time they are exposed to light, the reaction is confined to the cancer cells.

          As with topical therapies, photodynamic therapy causes relatively little scarring compared with surgery. However, your skin is extremely light sensitive, and vigorous sun avoidance is essential to prevent a blistering burn. Your skin remains light-sensitive for 24 to 48 hours and takes several days to a week to heal. Several sessions of photodynamic therapy may be needed to treat the skin cancer. The treatment also can be painful, and pain medications may be needed.

          Some disadvantages may include red, raw, and inflamed skin for the duration of treatment. If you do not follow the wound care prescribed, then your skin may develop itching, burning, and pain, and may become susceptible to infection. This treatment is usually avoided in the hot summer months because of potential discomfort from heat and humidity and light sensitivity.

          Last reviewed on 7/21/09

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