There are several effective options available for the treatment of skin cancer and pre-skin cancerous lesions. These treatment options depend on several factors, including skin cancer type, its size, the stage of the skin cancer, its location on the body, and the overall health of the patient. Common options for skin cancer and pre-cancer treatment include liquid nitrogen, a scrape and burn procedure called electrodessication and curettage, topical chemotherapy and immunotherapy, radiation, excisional surgery, or Mohs micrographic surgery. The latter three options provide the highest cure rates for the treatment of skin cancer.
Liquid nitrogen (LN2) is commonly used to treat pre-cancerous lesions (actinic keratosis), with a very high cure rate. It can also be used to treat superficial skin cancers (superficial basal cell carcinoma). LN2 has a temperature of -196 degrees Fahrenheit, which when applied to a pre-cancerous lesion, damages, and kills the cells. The treatment area may blister, which will then heal on its own. LN2 can be applied using a cotton-tipped applicator or as a spray. Some lesions may need to be treated more than one time.
Medications such as 5-fluorouracil (5-FU, Efudex) and Imiquimod (Aldara or Zyclara) may be appropriate for the treatment of pre-cancerous lesions and very thin, superficial basal cell carcinoma. 5-FU is a form of topical chemotherapy, which inhibits DNA synthesis, in turn killing fast-growing cells such as the abnormal cells in actinic keratoses and basal cell carcinoma. Typically, this medication is applied twice daily to the cancer for several weeks. During the treatment period, the treated skin becomes significantly inflamed as the cancer cells are destroyed. Once the treatment is completed, the area begins to heal. Imiquimod (Aldara or Zyclara) is a form of topical immunotherapy, which works by activating the body’s innate immune system to attack the skin cancer. Typically, this medication is also applied over a several week period. Similar to 5-FU, during the treatment period, the treated skin becomes significantly inflamed as the cancer cells are destroyed. Once the treatment is completed, the area begins to heal. For superficial basal cell carcinoma, cure rates with topical agents have been reported to be around 80%.
Photodynamic therapy (PDT) is a treatment that use a special drug, Aminolevulinic acid (ALA or Levulan®), which is a photosensitizing agents, along with light to kill pre-cancerous and cancerous cells. ALA only works after they it has been activated or “turned on” by certain kinds of light. PDT may also be called photoradiation therapy, phototherapy, or photochemotherapy. With regard to efficacy, PDT works well on pre-cancerous lesions, especially when combined with liquid nitrogen. It is less effective on treating skin cancer.
A typical treatment protocol begins with the application of ALA directly to the skin. This “incubation” period may be as short at 15 minutes to over 1 hour. During this time, the drug is absorbed by the precancerous and/or cancerous cells. Once incubation is complete, light is applied to the area to be treated. The light, typically blue light, causes the drug to react with oxygen, which forms a chemical that kills the cells. PDT might also kill precancerous and cancer cells by alerting and activating the immune system. PDT has various pros and cons. Please call and visit our office to discuss PDT in more detail.
Radiation treatment is a non-surgical option with a high cure rate (over 90%). It is typically most appropriate for patients who are not candidates for surgery because of health problems, patients who have very large tumors that would require disfiguring surgery, and patients with unrealistic cosmetic expectations. Radiation therapy may also be used in addition to surgery for high-risk skin cancers, particularly those with tumor invasion of nerves and vessels. Radiation therapy is not performed in one setting; rather, it typically requires up to 30 separate treatments, usually performed daily over a period of several weeks. During the treatment period, side effects such as fatigue, erythema, and/or blistering may occur. Radiation therapy is best performed by a radiation oncologist.
CURETTAGE AND ELECTRODESSICATION (ELECTROSURGERY)
Also referred to as a “scrape and burn,” this treatment option is appropriate for shallow and non-aggressive skin cancers. Using local anesthesia, the treatment area is first numbed. The physician/surgeon then scrapes off part or all of the lesion with a curette (an instrument with a sharp, ring-shaped tip), then burns the tumor site with an electrocautery needle to stop the bleeding and kill any remaining cancer cells. This process is repeated several times (typically three times in the same session), scraping and burning a deeper layer of tissue each time to help ensure that no tumor cells remain. The treated area heals in by nature as a shallow wound. The technique can produce cure rates approaching those of surgical excision for superficially invasive skin cancers without high-risk characteristics. However, it is not recommended for any invasive or aggressive skin cancers. It is also not recommended for high-risk or difficult sites, such as the eyelids, genitalia, lips and ears, or any other cosmetic sites (especially those around the face) that would be left with cosmetically undesirable results, since the procedure leaves a sizable, hypopigmented scar.
Excisional surgery involves removing, or excising, the entire cancerous tumor along with a surrounding border of presumably normal skin as a safety margin. The size of the safety margin is predicated by the original size of the skin cancer. The surgical site is first marked using a surgical marker (typically in a football/elliptical shape), then numbed with local anesthesia, and prepped in a sterile fashion. Using a scalpel, the marked area is excised or cut out and skin is then closed or stitched back together. The wound is typically sutured with two layers of stitches. The top layer is removed in 1-2 weeks. The bottom layer dissolves on its own in 2-3 months. The surgical site is then bandaged using a pressure dressing. The excised tissue is sent to a laboratory for examination of the margins to verify that all cancerous cells have been removed. If the lab finds evidence of skin cancer beyond the safety margin, the patient may need to return for another surgery. For tumors discovered at an early stage that have not spread beyond the tumor margin, excisional surgery is frequently the only treatment required.
MOHS MICROGRAPHIC SURGERY
Mohs micrographic surgery is considered the gold standard for skin cancer treatment, particularly for skin cancers in cosmetically and functionally important areas around the eyes, nose, lips, ears, scalp, fingers, toes or genitals. Mohs surgery is also recommended for skin cancers that are large, aggressive or growing rapidly, that have indistinct edges or that have recurred after previous treatment. Developed by Dr. Frederic Mohs, Mohs surgery is a highly specialized technique used to completely remove skin cancers. The procedure is performed under local anesthesia, in stages, in which the Mohs surgeon is also the pathologist and the cosmetic/reconstructive surgeon. Through direct microscopic examination and specialized marking techniques, Mohs surgery removes only cancerous areas, and preserves as much healthy skin as possible, leaving the smallest possible scar. It provides the highest cure rates among all skin cancer treatment options, as well as the best cosmetic outcome. Learn more about Mohs micrographic surgery.