When the diagnosis is skin cancer, it's important to move quickly. Your COSC dermatologist will consider the type of skin cancer you have, the location of the cancer, and other health conditions before recommending a course of treatment.
There are a variety of treatment options available, including:
- Topical treatments
- Photodynamic therapy
- Electrodessication & Curettage (ED&C)
- Mohs micrographic surgery
Topical Treatments for Skin Cancer
Topical treatments are typically used for low-grade, superficial cancers such as superficial basal cell carcinoma, or precancers (actinic keratoses). The gels or creams are applied to the affected areas in different regimens depending on the medication and location of application.
Imiquimod works by stimulating the immune system to eliminate dangerous cells. It is often applied for two to six weeks and does cause significant irritation.
5-Fluorouacil is a topical chemotherapeutic drug that also causes local irritation and dermatitis and is applied one to two times daily for two to six week.
Diclofenac is a non-steroidal anti-inflammatory gel that's applied two times daily for three months and is mainly used for precancers. It typically causes very minor redness and irritation.
Ingenol Mebutate is a gel also used for precancers. It's applied for two to three days and also causes redness and irritation, but rarely blisters and doesn't scar.
Side effects of the topicals can vary, but may include redness, scabbing (crusting), peeling, burning and mild itching. The redness will fade over time, but may last a month or more. Overall, if used as directed there is little to no scarring risk. They will not work on some cancers or thick precancers.
Cryosurgery is a freezing technique that uses liquid nitrogen applied to the skin for a few seconds to destroy the desired lesion. Patients will feel a burning sensation during the application and a blister will form. The blister will gradually turn into a crust that peels off over a few weeks. There is the potential for pigment loss (white scar) at the treatment site.
Photodynamic therapy (also referred to as PDT, or Blu-U) is another treatment for the patient who has widespread actinic keratoses (precancers) on the face, scalp or ears. This treatment involves the application of a topical medicine (Levulan) to the targeted area. The patient must wait for 90 minutes to allow the medication to penetrate the skin. The treated area is then exposed to the Blu-U blue light illuminator for approximately 17 minutes, which causes a reaction to occur, destroying the precancerous cells.
The patient must avoid sunlight and intense indoor lighting for 48 hours post treatment due to severe sensitivity to light sources which could worsen the reaction to an undesirable amount. Redness, scaling and swelling are common reactions and usually resolve within 4 weeks. There is very little to no scarring risk, and PDT can be used to treat a large number of lesions.
Electrodessication and Curettage (ED & C)
This process is typically used to treat low-risk, superficial skin cancers. The area is numbed with a local anesthetic, and then curetted (abraded using the difference in texture of the diseased skin to determine the size and depth) and cauterized using an electric needle that chars the skin. The area is not sutured, so there are no physical restrictions following the procedure, and the open wound is left to heal on its own. Daily wound care is required until the site heals, usually as a round white scar.
Recurrences can occur, especially along the periphery of the wound, so ED&C is not recommended for high-risk cancers or lesions in high-risk locations.
There is no specimen sent to the lab afterwards.
Excision involves the removal of the cancer with a scalpel by "cutting it out."
After the cancer site is anesthetized, the physician will remove the lesion with an added margin of healthy skin and close the site with sutures.
The excised area is usually about three times longer than the diameter of the cancer and its surrounding margin, depending on the location and the cancer, often about 5 mm margin.
There are layers of sutures under the skin that will dissolve and a layer of sutures on the skin surface that we'll remove in our office within a week or two of the excision. The site usually heals as a linear scar. There are restrictions during the healing phase to avoid bleeding and opening the wound.
We send the excised tissue to a dermatopathologist who reviews part of the specimen to determine if the margins appear clear.
Mohs Micrographic Surgery
Mohs surgery is the most advanced type of surgery for skin cancer. It's also the most effective with up to a 99% cure rate. Mohs surgery is only performed for certain types of cancers in certain locations. It's often the primary choice for cancers on the head and neck, and is recommended for high-risk cancers, cancers in locations that are important for cosmetic appearance or function, recurrent cancers, large cancers, and cancers that grow rapidly or have poorly defined borders. Your doctor will help to determine if you are eligible for this procedure.
This cancer treatment technique involves removing the cancer in stages, often with only a 1-2 mm margin, using local anesthesia. The excised tissue is analyzed immediately while the patient waits, and if any cancer remains on the margin, the physician will remove more small sections of tissue until the margins are clear. Mohs surgery spares more healthy skin, minimizing the size of the wound and the scar. Since 100% of the margin is evaluated, the cure rate is improved.
Our Mohs surgeon completed an accredited fellowship that allows her to act as the surgeon, pathologist, and reconstruction expert. There is no facility fee or operating room fee at our office and the entire procedure is performed the same day. It is a longer procedure, so you must allot for the entire day.
Mohs micrographic surgery is more expensive than simpler procedures, but overall less costly than radiation or repeating procedures several times for recurrent cancers. Please visit the American College of Mohs Surgery website for more information.
Radiation is primarily used to treat patients who are either non-surgical candidates, or have large tumors or lymph node or nerve involvement. It is also used as secondary treatment if there are positive margins or concern for residual cancer. We generally use radiation therapy to treat skin cancers in older patients, as it can lead to an increased risk for new skin cancers at the treated site several years later.
Radiation therapy can cause local skin changes, but is usually not disfiguring and doesn't cause an open wound. It can be more costly than other treatment options.