There are many different kinds of surgery for basal cell and squamous cell skin cancers. The options for surgery depend on how large the cancer is, where it is on the body, and the specific type of skin cancer. In most cases the surgery can be done in a doctor’s office or hospital clinic using a local anesthetic (numbing medicine). For skin cancers with a high risk of spreading, surgery sometimes will be followed by other treatments, such as radiation or chemotherapy.
This is similar to an excisional biopsy , but in this case the diagnosis is already known. For this procedure, the skin is first numbed with a local anesthetic. The tumor is then cut out with a surgical knife, along with some surrounding normal skin. The remaining skin is carefully stitched back together, leaving a small scar.
Curettage and electrodesiccation
This treatment removes the cancer by scraping it with a curette (a long, thin instrument with a sharp looped edge on one end), then treating the area with an electric needle (electrode) to destroy any remaining cancer cells. This process is often repeated. Curettage and electrodesiccation is a good treatment for superficial (confined to the top layer of skin) basal cell and squamous cell cancers. It will leave a small scar.
Mohs surgery (microscopically controlled surgery)
Using the Mohs technique, the surgeon removes a very thin layer of the skin (including the tumor) and then checks the sample under a microscope. If cancer cells are seen, the next layer is removed and examined. This is repeated until the skin samples are found to be free of cancer cells. This process is slow, often taking several hours, but it means that more normal skin near the tumor can be saved. This creates a better appearance after surgery
Lymph node surgery
If lymph nodes near a non-melanoma skin cancer (especially a squamous cell or Merkel cell carcinoma) are growing larger, doctors will be concerned that the cancer might have spread to these lymph nodes. The nodes may be biopsied or removed in a more extensive operation called a lymph node dissection. The nodes are then looked at under a microscope for signs of cancer. This type of operation is more involved than surgery on the skin, and usually requires general anesthesia (where you are asleep).
Lymphedema, a condition in which excess fluid collects in the legs or arms, is a possible long-term side effect of a lymph node dissection. Lymph nodes in the groin or under the arm are part of the lymph system, which normally helps drain fluid from the legs and arms. If the lymph nodes are removed, fluid may build up, causing these limbs to swell. If severe enough, it can cause skin problems and an increased risk of infections in the limb. Elastic stockings or compression sleeves can help some people with this condition.
Skin grafting and reconstructive surgery
After removing large non-melanoma skin cancers, it may not be possible to stretch the nearby skin enough to stitch the edges of the wound together. In these cases, healthy skin may be taken from another part of the body and grafted over the wound to help it heal and to restore the appearance of the affected area. Other reconstructive surgical procedures can also be helpful in some cases.
Other forms of local therapy for basal and squamous cell skin cancers
Several techniques other than surgery can be used to treat basal and squamous cell skin cancers that have not spread to lymph nodes or other parts of the body. Some of these treatments are described as types of surgery since they destroy a targeted area of body tissue. But these techniques don’t use scalpels or cut into the skin.
For this treatment, the doctor applies liquid nitrogen to the tumor to freeze and kill the cells. After the dead area of skin thaws, it may swell, blister and crust over. The wound may take a month or two to heal and will leave a scar. The treated area may have less color after treatment.
Cryosurgery is used most often for pre-cancerous conditions such as actinic keratosis and for small basal cell and squamous cell carcinomas.
Photodynamic therapy (PDT)
This treatment uses a special liquid drug that is applied to the skin. The drug collects in the tumor cells over the course of several hours or days and makes the cells sensitive to certain types of light. A special light source is then focused on the tumor(s), which makes the cells die. A possible side effect of PDT is that it can make a person’s skin very sensitive to sunlight for some time, so precautions may be needed to avoid severe burns.
PDT can be used to treat actinic keratoses. But its exact role in treating non-melanoma skin cancers, if any, still needs to be determined.
Chemotherapy uses drugs that kill cancer cells. Topical chemotherapy means that an anti-cancer medicine is placed directly on the skin (usually in a cream or ointment) rather than being given by mouth or injected into a vein.
The drug most often used in topical treatment of actinic keratoses, as well as some basal and squamous cell skin cancers, is 5-fluorouracil, or 5-FU (Efudex®, Carac®, others). It is typically applied to the skin once or twice a day for several weeks.
When applied directly on the skin, 5-FU kills tumor cells near the skin’s surface, but it cannot reach cancer cells that may have grown deeply into the skin or spread to other organs. For this reason, treatment with 5-FU generally is used only for pre-cancerous conditions such as actinic keratosis and for some very superficial skin cancers.
Because it is only applied to the skin, the drug does not spread throughout the body, so it doesn’t cause the same side effects that can occur with systemic chemotherapy (treatment that affects the whole body). But it can make the treated skin red and very sensitive for a few weeks, which can be quite bothersome for some people. Other topical medicines can be used to help relieve this. 5-FU also increases the skin’s sensitivity to sunlight, so treated areas must be protected from the sun to prevent sunburn for a few weeks after use of this cream.
A gel containing the drug diclofenac (Solaraze®) is sometimes used to treat actinic keratoses. This drug belongs to the non-steroidal anti-inflammatory drugs (NSAIDs), a group that includes pain relievers such as aspirin and ibuprofen. The gel is usually applied twice daily for 2 or 3 months. It may cause less severe skin reactions than 5-FU, but it also may take longer to work.
A newer gel used to treat actinic keratosis, ingenol mebutate (Picato®), might work more quickly than other topical gels. It is applied to the skin daily for 2 or 3 days. The gel can cause bothersome skin reactions, but these usually begin to go away within a week of starting treatment.
Immune response modifiers
Certain drugs can boost the body’s immune system response against the cancer, causing it to shrink and go away.
Imiquimod (Zyclara®, others) is a cream that can be applied to actinic keratoses and some very early basal cell cancers. It is not a chemotherapy drug. Instead, it causes the immune system to react to the skin lesion and destroy it. It is typically applied at least a few times a week for several weeks, although schedules can vary. Like other topical gels, it can cause severe skin reactions in some people. It can also cause flu-like symptoms.
Interferon is a man-made version of an immune system protein. It can be injected directly into the tumor to boost the immune response against it. It may be used occasionally when surgery is not possible, but it may not be as effective as other treatments.
This relatively new approach uses a beam of laser light to vaporize cancer cells. It is sometimes used for actinic keratosis, squamous cell carcinoma in situ (involving only the epidermis) and for very superficial basal cell carcinomas (those only on the surface of the skin). It is not yet known if this type of treatment is as effective as standard methods of treatment, and it is not widely used.
For this technique, the doctor applies a small amount of trichloracetic acid (TCA) or a similar chemical to the skin tumor, killing the tumor cells over the course of several days. This approach is sometimes used to treat actinic keratosis.
Radiation therapy for basal and squamous cell skin cancers
Radiation therapy uses high-energy rays (such as x-rays) or particles (such as photons, electrons, or protons) to kill cancer cells. The radiation is focused from outside the body onto the tumor.
When radiation therapy is used to treat cancers on the skin, it is often done with a type of radiation called electron beam radiation. It uses a beam of electrons that only penetrate as far as the skin. This helps limit the side effects to other organs and body tissues.
Getting radiation treatment is much like getting an x-ray, but the radiation is stronger and aimed more precisely at the cancer. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time – getting you into place for treatment – takes longer.
If a tumor is very large or is on an area of the skin that makes surgery difficult, radiation may be used as the primary (main) treatment instead of surgery. Primary radiation therapy is often useful for some patients who, because of poor general health, cannot have surgery. Radiation therapy can often cure small non-melanoma skin cancers and can delay the growth of more advanced cancers. Radiation is also useful when combined with other treatments. It is particularly useful for Merkel cell carcinoma.
In some cases, radiation can be used after surgery as an adjuvant (additional) treatment to kill any small areas of remaining cancer cells that may not have been visible during surgery. This lowers the risk of cancer coming back after surgery. Radiation may also be used to help treat non-melanoma skin cancer that has spread to lymph nodes or other organs.
Side effects of radiation can include skin irritation, redness, drying, and hair loss in the area being treated. With longer treatment, these side effects may get worse. After many years, new skin cancers sometimes develop in areas previously treated by radiation. For this reason, radiation usually is not used to treat skin cancer in young people. Radiation is also not recommended for people with certain inherited conditions (such as basal cell nevus syndrome or xeroderma pigmentosum), who may be at higher risk for new cancers, or for people with connective tissue diseases (such as lupus or scleroderma), which radiation might make worse.
Systemic chemotherapy for basal and squamous cell skin cancers
Systemic chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein or given by mouth. These drugs travel through the bloodstream to all parts of the body. Unlike topical chemotherapy, systemic chemotherapy can attack cancer cells that have spread to lymph nodes and other organs.
One or more chemotherapy drugs may be used to treat squamous cell carcinoma or Merkel cell carcinoma that has spread. Chemo drugs such as cisplatin, doxorubicin, 5-fluorouracil (5-FU), topotecan, and etoposide are given intravenously (into a vein), usually once every few weeks. They can often slow the spread of these cancers and relieve some symptoms. In some cases, they may shrink tumors enough so that other treatments such as surgery or radiation therapy can be used.
Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to side effects.
The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are taken. These side effects may include:
Loss of appetite
Nausea and vomiting
Increased risk of infection (from too few white blood cell counts)
Easy bruising or bleeding (from too few blood platelets)
Fatigue (from too few red blood cells)
These side effects usually go away once treatment is finished. Some drugs may have specific effects that are not listed above, so be sure to talk with your cancer care team about what you might expect in terms of side effects.
There are often ways to lessen these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Tell your medical team about any side effects or changes you notice while getting chemotherapy so that they can be treated promptly.
Targeted therapy for basal and squamous cell skin cancers
Doctors have found some of the gene changes that make skin cancer cells different from normal cells, and they have begun to develop drugs that attack these changes. These targeted drugs work differently from standard chemotherapy drugs. They may work in some cases when chemotherapy doesn’t. They may also have less severe side effects. Doctors are still learning the best way to use these drugs to treat skin cancers.
An example of a targeted drug is vismodegib (ErivedgeTM), which can be used to treat some advanced or recurrent basal cell skin cancers. It is very rare for basal cell cancers to reach an advanced stage, but when they do, these cancers can be hard to treat. Most basal cell cancers have mutations (changes) in genes that are part of a cell signaling pathway called hedgehog. The hedgehog pathway is crucial for the development of the embryo and fetus and is important in some adult cells, but it can be overactive in basal cell cancers. Vismodegib targets a protein in this pathway.
Vismodegib is a pill, taken once a day. In people with basal cell cancers that have spread or come back after surgery and other local treatments, it has been shown to help shrink tumors in about a third of patients, although it’s not yet clear if it helps people live longer.
Side effects can include muscle spasms, joint pain, hair loss, fatigue, problems with taste, poor appetite and weight loss, nausea and vomiting, diarrhea, and constipation. Vismodegib can also cause women to stop having their periods for a time.
Because the hedgehog pathway affects fetal development, this drug should not be taken by women who are pregnant or could become pregnant. It is not known if it could harm the fetus if it is taken by a male partner. Anyone on this drug should use reliable birth control during and after treatment.
Treating basal cell carcinoma
Basal cell carcinoma very rarely spreads to other parts of the body, although it can grow into nearby tissues if not treated. Several methods can be used to remove or destroy these cancers. The choice may depend on factors such as the tumor size and location, and the patient’s age, general health, and preferences.
All of the treatment methods listed here can be effective. The chance of the cancer coming back (recurring) ranges from less than 5% for Mohs surgery to up to 15% or higher for some of the others, but this depends on the size of the tumor. Small tumors are less likely to recur than larger ones. Even if the tumor does recur, it can often still be treated effectively.
Curettage and electrodesiccation
Curettage and electrodesiccation is a common treatment for basal cell carcinomas smaller than 1 centimeter (slightly less than a half inch) across. It might need to be repeated to help make sure all of the cancer has been removed.
Simple excision (cutting the tumor out) is often used to remove basal cell carcinomas, along with a margin of normal skin.
Mohs surgery has the best cure rate for basal cell carcinoma. It is especially useful in treating large tumors, tumors where the edges are not well-defined, tumors in certain locations (such as on or near the nose, eyes, ears, forehead, scalp, fingers, and genital area), and those that have come back after other treatments. However, it is also more complex, time-consuming, and expensive than other methods.
Radiation therapy is often a good option for treating patients who might not be able to tolerate surgery and for treating tumors on the eyelids, nose, or ears – areas that can be hard to treat surgically. It is also sometimes used after surgery if it is not clear that all of the cancer has been removed.
Immune response modifiers, photodynamic therapy, or topical chemotherapy
These treatments are sometimes considered as options for treating very superficial tumors (tumors that have not extended too deeply under the skin surface). Close follow-up is needed because these treatments do not destroy any cancer cells that are deep under the surface.
Cryosurgery can be used for some small basal cell carcinomas but is not recommended for larger tumors or those on certain parts of the nose, ears, eyelids, scalp, or legs.
Targeted therapy for advanced basal cell cancers
In rare cases where basal cell cancer spreads to other parts of the body or can’t be cured with surgery or radiation therapy, the targeted drug vismodegib (ErivedgeTM) can often shrink or slow the growth of the cancer. This drug is taken daily as a pill.
Treating squamous cell carcinoma of the skin
Most squamous cell skin cancers are found and treated at an early stage, when they can be removed or destroyed with local treatment methods. Small squamous cell cancers can usually be cured with these treatments – the recurrence rate is similar to that for basal cell cancers. Larger squamous cell cancers are harder to treat, and the chance of recurrence for fast-growing cancers can be as high as 50% for large, deep tumors.
In rare cases, squamous cell cancers may spread to lymph nodes or distant sites. If this happens, further treatment with radiation therapy and/or chemotherapy may be needed.
Simple excision (cutting out the tumor, along with a small margin of normal skin) is often used to treat squamous cell carcinomas.
Curettage and electrodesiccation
Curettage and electrodesiccation is sometimes useful in treating small squamous cell carcinomas (less than 1 cm across), but it is not recommended for larger tumors.
Mohs surgery has the highest cure rate. It is especially useful for squamous cell carcinomas larger than 2 cm (about 4/5 inch) across or with poorly defined edges, for tumors that have come back after other treatments, for cancers that are spreading along nerves under the skin, and for cancers on certain areas of the face or genital area.
Radiation therapy is often a good option for patients with large cancers, especially in areas where surgery is difficult (eyelids, ears, or nose), or for patients who may not be able to tolerate surgery. It is not used as much as an initial treatment in younger patients because of the possible risk of long-term problems.
Radiation is sometimes used after surgery (simple excision or lymph node dissection) if all of the cancer was not removed (if the surgical margins were positive), or if there is a chance that some cancer may remain.
Radiation can also be used to treat cancers that have come back after surgery and have become too large or deep to be removed surgically.
Cryosurgery is used for some early squamous cell carcinomas, especially in people who can’t have surgery, but is not recommended for larger invasive tumors or those on certain parts of the nose, ears, eyelids, scalp, or legs.
Treating advanced squamous cell cancers
Lymph node dissection: Removing regional (nearby) lymph nodes is recommended for some squamous cell carcinomas that are very large or deeply invasive and in cases where the lymph nodes feel enlarged and/or hard. After the lymph nodes are removed, they are looked at under a microscope to see if they contain cancer cells. In some cases, radiation therapy might be recommended after surgery.
Systemic chemotherapy: Systemic chemotherapy is an option for patients with squamous cell cancer that has spread to lymph nodes or distant organs. In some cases it is combined with surgery or radiation therapy.
Treating actinic keratosis
Actinic keratosis is often treated because it can turn into squamous cell cancer. But because this risk is low, treatments are generally aimed at avoiding scars or other disfiguring marks as much as possible.
Actinic keratosis is commonly treated with either cryosurgery or topical creams or gels such as fluorouracil (5-FU), imiquimod, diclofenac, or ingenol mebutate. These treatments destroy the affected area of the epidermis, the outermost layer of the skin. Simply destroying the affected parts of the epidermis usually cures actinic keratosis.
Other localized treatments (shave excision, curettage and electrodesiccation, photodynamic therapy, laser surgery, chemical peeling) are also sometimes used.
Treating Bowen disease
Bowen disease (squamous cell carcinoma in situ) is usually treated by simple excision. Curettage and electrodesiccation, radiation therapy, topical fluorouracil 5-FU, and cryosurgery are other options. Laser surgery or topical therapy may be considered in special situations.
Treating Merkel cell carcinoma
Merkel cell carcinomas have a tendency to spread to the lymph nodes or distant sites, so imaging tests (such as CT, MRI, or PET scans) may be done to look for possible areas of spread.
These cancers are first treated with wide local excision (removal of the cancer and a wide margin of normal skin) or Mohs surgery. This is often followed by radiation therapy to the affected area to reduce the risk of cancer coming back.
Even if the lymph nodes do not seem enlarged, many doctors recommend a sentinel lymph node biopsy to look for possible spread of cancer to the lymph nodes. For this procedure, the lymph node that would most likely contain cancer if it has spread (known as the sentinel node) is removed and looked at. When possible, this should be done before surgery on the skin. If the sentinel node contains cancer, a full lymph node dissection (removal of all of the nearby nodes), radiation therapy to the nodes, or a combination of the two is usually done. If many lymph nodes contain cancer cells, adjuvant (additional) chemotherapy may be recommended as well.
If nearby lymph nodes are enlarged when the cancer is diagnosed, a fine needle aspiration (FNA) biopsy may be done to determine if they contain cancer. If cancer is found, treatment options include a lymph node dissection, radiation therapy to the area, or a combination of the two. Adjuvant treatment with chemotherapy may also be considered.
For cancers that have spread to or recur in distant sites, surgery, radiation therapy, chemotherapy, or some combination of these may be used. These treatments may relieve symptoms or shrink these cancers for a time, but they rarely cure Merkel cell carcinoma that has spread beyond the skin.
Overall, the 5-year survival rate (the percentage of patients who live at least 5 years after diagnosis) for Merkel cell carcinoma is about 60%. It is much higher if the cancer is found early as opposed to having spread to the lymph nodes or distant parts of the body.
What will happen after treatment for basal and squamous cell skin cancers?
For most people with basal or squamous cell skin cancers, treatment will remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer growing or coming back. (When cancer comes back after treatment, it is called recurrent cancer or a recurrence.) This is a very common concern in people who have had cancer.
It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives.
For small number of people with more advanced cancers, it may never go away completely. These people may get regular treatment with radiation therapy, chemotherapy, or other treatments to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty.
If you have completed treatment, your doctors will still want to watch you closely and will likely recommend that you examine your skin once a month and protect yourself from the sun. Family members and friends can also be asked to watch for new lesions in areas that are hard to see.
If skin cancer does recur, it is most likely to happen in the first 5 years after treatment. People who have had skin cancer are also at high risk for developing another one in a different location, so close follow-up is important.
You should have follow-up exams as advised by your doctor. Your schedule for follow-up visits will depend on the type of cancer you had and on other factors. Different doctors may recommend different schedules.
For basal cell cancers, visits are often recommended about every 6 to 12 months.
For squamous cell cancers, visits are usually more frequent – often every 3 to 6 months for the first few years, followed by longer times between visits.
During your follow-up visits, your doctor will ask about symptoms and examine you for signs of recurrence or new skin cancers. For higher risk cancers, such as squamous cell cancers that had reached the lymph nodes, he or she may also order imaging tests such as CT scans. If skin cancer does recur, treatment options might depend on the size and location of the cancer, what treatments you’ve had before, and your overall health.
Follow-up is also needed to check for possible side effects of certain treatments. This is the time for you to ask your health care team any questions and to discuss any concerns you might have. Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be permanent. Don't hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.
What’s new in research and treatment of basal and squamous cell skin cancers?
Research into the causes, prevention, and treatment of non-melanoma skin cancer is under way in many medical centers throughout the world.
Basic skin cancer research
Scientists have made a great deal of progress in recent years in learning how ultraviolet (UV) light damages DNA, and how this causes normal skin cells to become cancerous. Researchers are working to apply this new information to strategies for preventing and treating skin cancers.
Most skin cancers can be prevented. The best way to reduce the number of skin cancers and the pain and loss of life from this disease is to educate the public about skin cancer risk factors, prevention, and detection. It is important for health care professionals and skin cancer survivors to remind others about the dangers of excess UV exposure (from the sun and from man-made sources such as tanning beds) and about how easily they can protect their skin from UV radiation.
The American Academy of Dermatology (AAD) sponsors annual free skin cancer screenings throughout the country. Many local American Cancer Society offices work closely with AAD to provide volunteers for registration, coordination, and education efforts related to these free screenings.
Preventing genital skin cancers
Squamous cell cancers that start in the genital region account for almost half of the deaths from this type of skin cancer. Many of these cancers may be related to infection with certain types of human papilloma virus (HPV), which can be spread through sexual contact. Limiting the number of sexual partners a person has and using safer sex practices such as wearing condoms may therefore help lower the risk of some of these cancers.
In recent years, vaccines have been developed to help protect against infection from some types of HPV. The main intent of the vaccines has been to reduce the risk of cervical cancer, but they may also lower the risk of other cancers that might be related to HPV, including some squamous cell cancers.
An area of active research is the field of chemoprevention (using drugs to reduce cancer risk). Chemoprevention is likely to be more useful for people at high risk of skin cancers, such as those with certain congenital conditions (such as basal cell nevus syndrome), a history of skin cancer, or those who have received organ transplants, rather than for people at average risk of skin cancer.
The most widely studied drugs so far are the retinoids, which are drugs related to vitamin A. They have shown some promise in reducing the risk of squamous cell cancers but can have side effects, including possibly causing birth defects. For this reason they are not widely used at this time, except in some people at very high risk. Further studies of retinoids are under way.
Other compounds are being looked at to reduce the risk of basal cell skin cancers in people at high risk. Drugs called hedgehog pathway inhibitors, which affect the activity of genes such as PTCH and SMO, may help some people with basal cell nevus syndrome. The targeted drug vismodegib (ErivedgeTM), taken daily as a pill, has been shown to lower the number of new basal cell cancers and shrink existing tumors in people with this syndrome. The drug does have some side effects, including taste loss and muscle cramps, which might make it hard for some people to take every day. Further research on this and similar drugs is under way.
Current local treatments are successful for the vast majority of non-melanoma skin cancers. Still, even some small cancers can be hard to treat if they're in certain areas. Newer forms of non-surgical treatment such as new topical drugs, photodynamic therapy, and laser surgery may help reduce scarring and other possible side effects of treatment. Studies are now under way to determine the best way to use these treatments, and to try to improve on their effectiveness.
Treating advanced disease
Most basal and squamous cell skin cancers are found and treated at a fairly early stage, but some may spread to other parts of the body. These cancers can often be hard to treat with current therapies such as radiation and chemotherapy.
Several studies are testing newer targeted drugs for advanced squamous cell cancers. Cells from these cancers often have too much of a protein called EGFR on their surfaces, which may help them grow. Drugs that target this protein, such as erlotinib (Tarceva) and gefitinib (Iressa), are now being tested in clinical trials. A drug that targets different cell proteins, known as dasatinib (Sprycel), is also being studied for advanced skin cancers.