1. Detection and Treatment of Non-Melanoma Skin Cancers
Toby Maurer, MD
University of California, San Francisco

2. Basics of Skin Cancer Large majority caused by sun exposure
Often sun exposure before age 20
Persons who burn easily and tan poorly are at greatest risk

5. Sunscreen Don’t forget sun-protective clothing Physical sunscreen
zinc oxide and titanium dioxide
thick and more waterproof
fewer allergic reactions
Chemical sunscreens
burns if gets into eyes
more comedonegenic

6. Sunscreen Apply 1/2 hr. before going out
May need to reapply every 2-3 hours
especially if going in water
Be liberal with amount
UVA protection probably added benefit

7. Non-Melanoma Skin Cancers
Basal cell carcinoma (BCC)
Actinic keratosis (AK)
Squamous cell carcinoma (SCC)

8. Basal Cell Carcinoma (BCC)
Who is at Risk?
Age 20+
Fair-skinned persons
Sun-exposed sites
over 50% on face

15. Clinical Features of BCC
Pearly papule with telangiectasia (face, ears forehead, neck)
Scaly red patch (back, chest, legs of women)
Sclerotic (scarlike) lesion
Pigmented in pigmented races (blacks, etc.)
May erode or ulcerate

16. Diagnosis of BCC: Shave or Punch Biopsy

17. Differential Diagnosis of BCC
Intradermal Nevus
Sebaceous hypersplasia
Fibrous Papule (angiofibroma)
Eczema
Melanoma

28. Recommended Treatment of BCC
Surgical excision (head and neck)
Curettage and desiccation (trunk)
Radiation therapy (debilitated pt)
Microscopically controlled surgery (Mohs)
Recurrent/sclerotic BCC’s
BCC’s on eyelid and nasal tip

29. Aldara (Imiquimod) Topical therapy designed for wart treatment
Upregulates interferon and down regulates tumor necrosis factor
Seems to have efficacy in superficial BCC’s
Do Not use in BCC’s that are nodular or invasive

30. Topical Treatment of Skin Cancer
Imiquimod 5% cream can effectively treat superficial BCC’s and SCC in situ
Treatment regimen is 5X per week for 6-10 weeks depending on the host reaction
Efficacy is relatively high (75%-85%)
Scarring may be reduced compared to surgery
Other possible uses: Extramammary Paget’s, lentigo maligna (trials needed)

31. Topical Treatment of Skin Cancer
Patient selection is the key
Biopsy to confirm diagnosis before TX

32. Treatments NOT Recommended
Cryotherapy
Topical chemotherapy
- 5 Fleurourical (Efudex)
Radiation therapy (age < 65)

33. When to Refer It depends on your surgical skills > 1 cm
Sclerotic BCC
Recurrent BCC
Eyelid BCC

34. Actinic Keratosis (AK)
Who is at risk?
Over age 35-40
Fair-skinned persons
Sun-exposed sites
Face, forearms, hands, upper trunk
History of chronic sun exposure

35. Clinical Features of AK
Red, adherent, scaly lesions, usually < 5mm
Sandpapery, rough texture
Tender when touched or shaved
Thick, warty character (cutaneous horn)

40. Diagnosis of AK Diagnosis Differential Diagnosis Clinical features
Shave or punch biopsy
Differential Diagnosis
BCC/SCC
Seborrheic keratosis
Wart

43. Treatment of AK Cryotherapy Topical chemotherapy/chemical peel
Efudex (5FU crème) 2x’s/day x 6 wks or Imiquimod-3X’s /wk and 3 mos.
When to refer?
Too extensive for local treatment
Consider biopsy or referral with any lesion that doesn’t resolve with cryotherapy

45. Make sure you know what you are treating
Be very careful with pigmented lesions

46. Rule of thumb for cryotherapy:
make sure lesion resolves after one month
if not, refer or biopsy to rule out malignancy

47. Squamous Cell Carcinoma (SCC)
Who is at risk?
Age 50+
Chronic sun exposure
Head, neck, lower lip, ears, dorsal hands, trunk
Special circumstances
Immunosuppression (organ transplant)
Radiation therapy

48. Clinical Features of SCC
Papule, nodule or tumor
Non-healing erosion or ulcer
Cutaneous horn (wart-like lesion)
Fixed, red, scaling patch/plaque (Bowen’s-SCC-in-situ)

54. Differential Diagnosis of SCC
Actinic keratosis
Wart
Seborrheic keratosis
BCC
Eczema or psoriasis

61. How to Diagnose Punch or excisional/incisional biopsy
Shave biopsy for flat, non-elevated lesion

62. Treatment of SCC Recommended treatment Treatments NOT recommended
Excision
Radiation therapy ( debilitated pt)
Treatments NOT recommended
Curettage and desiccation
Topical chemotherapy

63. When to Refer SCC’s may metastasize
Low threshold for biopsy and referral
Regularly check draining lymph nodes
High risk SCC’s

64. High-risk SCC’s Lip Temple
Immunocompromised host (i.e. organ transplant)
Area of previous radiation therapy