Skin Cancer, Nonmelanoma

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
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• Nonmelanoma skin cancer is almost always cured when it is found early and treated. So it is important to see your doctor if you think you may have it.
• Show your doctor any skin growths that change in color, shape, or size. Skin cancer usually starts as a growth, a sore that does not heal, or a change in a wart or mole.
• Your doctor will use a biopsy to find out if you have skin cancer. This means taking a sample of the growth and sending it to a lab to see if it contains cancer cells.
• Your doctor will want to remove all of the cancer. There are several ways to do this. The most common way is to numb your skin so that it does not hurt, then cut out the cancer. You will be awake while this is done.
• After you have had skin cancer, you are more likely to get it again. Check your skin often, and see your doctor regularly for checkups.
• Skin cancer is usually caused by too much time in the sun. You can prevent it by being careful. Stay out of the sun at midday, when the sun’s rays are strongest. Wear sunscreen or other sun protection. Do not use tanning booths or sunlamps.

Is this topic for you?

This topic is about nonmelanoma skin cancer, including basal cell cancer and squamous cell cancer. For information about melanoma skin cancer, see the topic Skin Cancer, Melanoma.

What is nonmelanoma skin cancer?

Skin cancer is the abnormal growth of cells in the skin. It is the most common type of cancer. It is almost always cured when it is found early and treated. So it is important to see your doctor if you have changes in your skin.

Most skin cancers are the nonmelanoma type. There are two main types of nonmelanoma skin cancer:

• Basal cell carcinoma. Most nonmelanoma cancers are this type. It can damage deeper tissues, such as muscles and bones. It almost never spreads to other parts of the body.
• Squamous cell carcinoma. This type is less common. It often starts in skin that has been injured or diseased. It sometimes spreads to other parts of the body.

What causes it?

Nonmelanoma skin cancer is usually caused by too much sun. Using tanning beds or sunlamps too much can also cause it.

How is nonmelanoma skin cancer diagnosed?

Skin cancer usually appears as a growth that changes in color, shape, or size. This can be a sore that does not heal or a change in a wart or a mole. These changes usually happen in areas that get the most sun—your head, neck, back, chest, or shoulders. The most common place for skin cancer is your nose.

Your doctor will use a biopsy to find out if you have skin cancer. This means taking a sample of the growth and sending it to a lab to see if it contains cancer cells.

What increases my risk for nonmelanoma skin cancer?

If you have light skin that sunburns easily, you are more likely to get skin cancer.

Your risk is higher if you are male or if you are over 40. Your risk is higher if others in your family have had it or if you have had it before.

You may also be more likely to get it if you have been exposed often to strong X-rays, to certain chemicals (such as arsenic, coal tar, and creosote), or to radioactive substances (such as radium).

How is it treated?

Your doctor will want to remove all of the cancer. There are several ways to do this. The most common way is to numb your skin so that it does not hurt, then cut out the cancer. You will be awake while this is done.

This surgery almost always cures nonmelanoma skin cancer.

After your treatment, you will need regular checkups, because having skin cancer once means you are more likely to get it again.

Can nonmelanoma skin cancer be prevented?

You can prevent it by being careful in the sun. Stay out of the sun at midday, when the sun’s rays are strongest. Wear sunscreen or other sun protection. Do not use tanning booths or sunlamps.

Frequently Asked Questions

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	Protecting your skin from ultraviolet radiation and skin cancer

Nonmelanoma skin cancer is usually caused by overexposure to the sun and its ultraviolet (UV) rays. Overexposure to UV rays can result from:

• Having severe sunburn and blistering, especially during childhood.
• Spending a lot of time in the sun over many years.
• Using tanning beds or sunlamps, which are artificial sources of UV rays.

Other possible causes of skin cancer include repeated exposure to X-rays, certain chemicals (such as arsenic, coal tar, creosote), and radioactive substances (such as radium). Skin cancer may also be caused by ionizing radiation treatments for skin conditions such as eczema, psoriasis, or acne.^{1, 2}

Nonmelanoma skin cancer may appear as a change in the skin, such as a growth, an irritation or sore that does not heal, or a change in a wart or a mole.

Basal cell carcinoma usually affects the head, neck, back, chest, or shoulders. The nose is the most common site. Basal cell carcinoma occurs three times as often as squamous cell carcinoma.³ There are several types of basal cell carcinoma, including nodular, superficial, and sclerosing (morpheaform). They look different, but they all need the same treatment. Signs of basal cell carcinoma can vary depending on the type and may include skin changes such as a:

• Firm, pearly bump with tiny blood vessels in a spiderlike appearance (telangiectasias).
• Red, tender, flat spot that bleeds easily.
• Small, fleshy bump with a smooth, pearly appearance, often with a depressed center.
• Smooth, shiny bump that may look like a mole or cyst.
• Scarlike patch of skin, especially on the face, that is firm to the touch.
• Bump that itches, bleeds, crusts over, and then repeats the cycle and has not healed in 3 weeks.
• Change in the size, shape, or color of a wart or a mole.

Squamous cell carcinoma usually affects the face, head, or neck. Signs of squamous cell carcinoma include any:

• Persistent, firm, red bump on sun-exposed skin.
• Patch of skin that feels scaly, bleeds, or develops a crust. The patch may get bigger over a period of months and form a sore.
• Skin growth that looks like a wart.
• Sore that does not heal or an area of thickened skin on the lower lip, especially if you smoke or use chewing tobacco or your lips are often exposed to the sun and wind.

Other conditions, such as actinic keratosis, may have symptoms similar to skin cancer. It is important to have any new or persistent skin change evaluated by your health professional.

Nonmelanoma skin cancer usually develops slowly, invading and destroying nearby tissues. It may take months or years for basal cell or squamous cell carcinomas to develop. Because of this slow growth, skin cancer can often be detected and treated early in its development, increasing the chance for a cure.

• Basal cell carcinoma can invade normal skin tissue and damage deeper tissues, such as muscles and bones, and affect the appearance of the skin. Basal cell carcinoma very rarely spreads (metastasizes) to other parts of the body. If basal cell carcinoma comes back (recurs), it may grow faster and cause more tissue damage.
• Squamous cell carcinoma usually grows faster than basal cell carcinoma.⁴ It often develops in injured or diseased skin areas.¹ Squamous cell carcinoma can be disfiguring. Squamous cell carcinoma is more invasive than basal cell and can spread from the scalp, ears, eyelid, nose, or lip to other areas of the body. From 2% to 6% of squamous cell carcinomas spread to other parts of the body.⁵

Basal cell and squamous cell carcinomas are curable if they are detected and treated early. If skin cancer becomes more advanced, treatment will depend on the stage of cancer.

After you have one skin cancer, you are more likely to have another new skin cancer develop. Between 35% and 50% of people diagnosed with one basal cell carcinoma develop a new skin cancer within 5 years.¹ People who have had nonmelanoma skin cancer may have an increased risk of developing other skin cancers, including melanoma.

Another type of skin condition with symptoms similar to nonmelanoma skin cancer is actinic keratosis. Although not a skin cancer, actinic keratosis may be a sign of sun-damaged skin and may lead to skin cancer. In some cases, an untreated actinic keratosis may develop into squamous cell carcinoma.

Risk factors for nonmelanoma skin cancer include:^{6, 1}

• Having a skin type that sunburns easily. People with light skin color, freckles, blond or red hair, and blue or light-colored eyes have sensitive skin and are prone to sunburn.
• A history of severe sunburns, especially during childhood.
• A family history of skin cancer or a personal history of skin cancer.
• Celtic ancestry, such as Irish or Scottish.
• Being older than 40.
• Living close to the equator, where the sun's ultraviolet (UV) rays are stronger.
• Working outside without protecting your skin from the sun.
• Xeroderma pigmentosum, a rare genetic disorder that causes extreme sensitivity to ultraviolet radiation.
• Being male. Men develop skin cancer more often than women.
• Smoking.
• Repeated exposure to X-rays, certain chemicals (such as arsenic, coal tar, creosote), and radioactive substances (such as radium).
• Scars from severe burns or inflammatory skin conditions.

Basal cell and squamous cell carcinomas can occur in people with dark skin, but these cancers are much more common in people with light skin.

The risk of squamous cell carcinoma is increased in people who have had organ transplants and take medications to prevent rejection of the new organ.⁴

Call your health professional if you have an irritated or irregular skin growth. This includes any:

• Firm, pearly bump with tiny blood vessels in a spiderlike appearance (telangiectasias).
• Red, tender, flat spot that bleeds easily.
• Small, fleshy bump with a smooth, pearly appearance, often with a depressed center.
• Smooth, shiny bump that may look like a mole or cyst.
• Scarlike patch of skin, especially on the face, that is firm to the touch.
• Bump that itches, bleeds, crusts over, and then repeats the cycle and has not healed in 3 weeks.
• Change in a wart or a mole, including a change in size, shape, or color.
• Area of normal skin that quickly changes shape or appearance.

Be sure to show your health professional any skin growths that concern you so that they can be evaluated and treated if necessary.

Watchful Waiting

Watchful waiting, or surveillance, is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. Watchful waiting is not appropriate if you suspect that you have nonmelanoma skin cancer. The earlier skin cancer is detected, the sooner it can be effectively treated.

Who To See

Health professionals who can examine and diagnose a suspicious skin growth include:

• Family medicine physicians.
• Dermatologists.
• Nurse practitioners.
• Physician assistants.
• Internists.
• Pediatricians.

Health professionals who can remove a large skin growth or one in a noticeable area while minimizing scars that may result from surgery include:

• Dermatologists.
• Plastic or reconstructive surgeons.
• General surgeons.

To prepare for your appointment, see the topic Making the Most of Your Appointment

Nonmelanoma skin cancer is diagnosed by:

• Your medical history. Your health professional will ask when the skin change occurred, whether you have been exposed to substances (such as arsenic) that can cause skin cancer, and whether you have any personal or family history of skin cancer.
• A physical examination of the skin growth. Your health professional can often tell what a skin growth is by looking at it. After examination, he or she may decide to monitor changes in the skin growth or take a sample of the skin growth for further testing.
• A skin biopsy. This is usually done when an area of skin has changed color, shape, size, or appearance or has not healed and skin cancer is suspected. A skin biopsy also may be done if the cause of a skin problem is not easily identified.

Early Detection

Take steps to detect skin cancer early:

• Examine your skin once a month, and ask your health professional to look at any suspicious skin growths.
• Talk to your health professional about your own personal risk for skin cancer so that you understand the precautions that you need to take.
• Have your health professional look for any suspicious skin growths during any health examination.

The goals of treatment for nonmelanoma skin cancer are to:

• Remove the entire skin cancer and a margin of skin tissue around the cancer to reduce the chance of recurrence.
• Preserve nearby skin tissue that is free of cancer and minimize scarring after surgery.

Initial treatment

Treatment for nonmelanoma skin cancer depends on the size and location of the cancer, whether it is basal cell or squamous cell, and your age and overall health. Because skin cancer usually grows slowly, it often can be detected and successfully treated early in its development.

The most common treatment is surgery to destroy or remove the entire skin growth, including a margin of cancer-free tissue around the growth. Most surgical treatments are very effective, with cure rates from 85% to over 95%.³

The main types of surgery are:

• Complete excision. Excision removes the skin cancer along with some healthy skin tissue around it (margin).
• Curettage and electrosurgery. Curettage uses a spoon-shaped instrument (curet) to scrape off the skin cancer. Electrosurgery with an electric current may be done after curettage to burn the skin tissue to control bleeding and destroy any remaining cancer cells.
• Mohs micrographic surgery. The Mohs procedure removes skin cancer one layer at a time and examines these layers under a microscope immediately after they are removed. This method allows for a close examination of each layer of skin to identify skin margins that are free of cancer during the surgery. It has a cure rate of over 95% for basal cell skin cancer and over 92% for squamous cell skin cancer.^{7, 8}
• Cryosurgery. Cryosurgery destroys the skin cancer by freezing it with liquid nitrogen.

Each of these treatments has advantages and disadvantages. Discuss your options with your health professional.

Laser surgery is not commonly used for nonmelanoma skin cancers. Lasers destroy surface (superficial) nonmelanoma skin cancers and actinic keratoses with an intense beam of light. The laser beam can also be used as a scalpel to remove (excise) a skin cancer. Currently, laser surgery is an expensive form of treatment.

Radiation therapy may be recommended for people who may not be able to have surgery.

Ongoing treatment

Follow-up treatment for nonmelanoma skin cancer includes skin self-exams and regular exams by your health professional. These exams are extremely important to reduce the risk of the cancer returning (recurrence).

Treatment for recurrent skin cancer is usually less successful than treatment for primary skin cancer. Most recurrences happen in the first 2 to 5 years. Your health professional may schedule you for exams as often as every 3 to 6 months for the first 2 years and yearly after that, especially for squamous cell carcinoma.

Treatment if the condition gets worse

Surgery is usually very effective treatment for both basal and squamous cell carcinoma. Chemotherapy may be used to destroy cancer cells in the small number of people who have skin cancer that has spread (metastasized) to other organs in the body.

What To Think About

Precancer skin growths, such as actinic keratoses that grow slowly, should be treated early to reduce the risk of developing squamous cell skin cancer.⁹

For more information about specific skin cancer treatment, see the following topics:

• Skin Cancer, Nonmelanoma — Health Professional Information [NCI PDQ]
• Skin Cancer, Nonmelanoma — Patient Information [NCI PDQ]

Most nonmelanoma skin cancer can be prevented by protecting your skin from the sun and ultraviolet (UV) radiation.

• Limit your exposure to the sun, especially from 10 a.m. to 4 p.m. (hours of peak ultraviolet exposure).
• Wear protective clothing, including a wide-brimmed hat, a long-sleeved shirt, and pants.
• Wear sunglasses that block UV rays.
• Use a sunscreen that has a sun protection factor (SPF) of at least 15 every day, all year, even when it is cloudy. Sunscreens that say "broad-spectrum" can protect the skin from ultraviolet A and B (UVA and UVB) rays. Sunscreens come in lotions, gels, creams, and ointments.
• Use lip balm or cream that has sun protection factor (SPF) to protect your lips from getting sunburned or developing cold sores.
• Avoid tanning booths and sunlamps, which emit UV radiation and can cause skin damage.

Skin protection for children

Children and babies should be protected from the sun. You should start protecting your child from the sun when he or she is a baby. Because children and teens spend a lot of time outdoors playing, they get most of their lifetime sun exposure in their first 18 years.

• Teach your children that it is important to protect their skin from the sun.
• Have your children wear protective clothing, sunglasses, and a hat when they are in the sun.
• Have your children wear sunscreen. Choose a sunscreen with SPF 25 or SPF 30. Follow the instructions on the sunscreen. Reapply sunscreen after 2 hours in the sun or water, even if the sunscreen is waterproof.
• Keep babies younger than 6 months out of direct sunlight.

Some people believe that a tan may protect them against a sunburn and skin damage. But the amount of sun exposure needed to get a tan can by itself cause skin damage.

For more information, see:

Protecting your skin from the sun and ultraviolet radiation.

Home treatment after removal of a skin cancer includes regular use of skin protection measures to prevent a return (recurrence) of nonmelanoma skin cancer and regular exams to watch for suspicious skin changes.

Perform a skin self-exam once a month.

• Check your skin and skin growths for any changes in color, shape, size, or appearance.
• Look for any diseased area of skin that has not healed.
• Report any suspicious changes in your skin to your health professional.

Certain medications, such as some antibiotics or diuretics, can make your skin more sensitive to the sun's rays. Ask your health professional about this potential side effect of your medications, and take extra precautions if necessary.

Medications are rarely used to treat nonmelanoma skin cancer. Surgery is the most common treatment.

Medication Choices

Medications that may be used to treat nonmelanoma skin cancer include:

• Fluorouracil (5-FU). 5-FU cream or solution is used to treat actinic keratoses and basal cell carcinoma that is limited to the top layer of skin (superficial).
• Imiquimod 5% cream (Aldara). Imiquimod is used to treat superficial basal cell cancer on the skin of the body, neck, arms, or legs, but it is not approved for treating the face. Surgery is still considered the best treatment because it is generally more effective. People treated with imiquimod should have regular follow-up visits with their health professional to make sure the skin cancer is gone.¹⁰

Chemotherapy may be used to destroy cancer cells in the small number of people who have basal or squamous cell carcinoma that has spread (metastasized) to other organs in the body, though metastasis is rare.

What To Think About

The effectiveness of treatment with medications for nonmelanoma skin cancer is not fully known. Studies are currently being done on the following medications to determine their effectiveness.

• Interferon is a substance produced by the body that helps the immune system fight disease more effectively.
• Tretinoin (Retin-A) cream is derived from vitamin A and is one of a class of substances called retinoids. Tretinoin cream may prevent new skin cancers in people who have an increased risk of developing skin cancer.

Surgery is the most common and most successful method of treating nonmelanoma skin cancer. The goals of surgery are to:

• Remove the entire skin cancer and a margin of healthy skin tissue around the cancer to reduce the chance of recurrence.
• Preserve nearby skin tissue that is free of cancer and minimize scarring after surgery.

Surgery Choices

The main types of treatment for nonmelanoma skin cancer include:

• Complete excision. Excision removes the skin cancer along with some healthy skin tissue around it (margin).
• Curettage and electrosurgery. Curettage uses a spoon-shaped instrument (curet) to scrape off the skin cancer. Electrosurgery with an electric current may be done after curettage to burn the skin tissue to control bleeding and destroy any remaining cancer cells.
• Mohs micrographic surgery. The Mohs procedure removes skin cancer one layer at a time and examines these layers under a microscope immediately after they are removed. This method allows for a close examination of each layer of skin to identify skin margins that are free of cancer during the surgery. It has a cure rate of over 95% for basal cell skin cancer and over 92% for squamous cell skin cancer.^{7, 8}
• Cryosurgery. Cryosurgery destroys the skin cancer by freezing it with liquid nitrogen.
• Laser surgery, which is not commonly used. Lasers destroy surface (superficial) nonmelanoma skin cancers and actinic keratoses with an intense beam of light. The laser beam can also be used as a scalpel to remove (excise) a skin cancer. Currently, laser surgery is an expensive form of treatment.

Each type of treatment has advantages and disadvantages. Discuss your options with your health professional.

What To Think About

If squamous cell carcinoma has spread to the lymph nodes, surgery to remove the affected lymph nodes (lymphadenectomy) may be done. Radiation or chemotherapy may be recommended after surgery.

Radiation therapy for nonmelanoma skin cancer may be recommended for people who may not be able to have surgery because of the location of the skin cancer. Radiation therapy may also be a treatment choice if age or other health conditions make surgery too risky. Radiation therapy is most often used for older adults. It may lead to other skin cancers in younger people as they age.

Topical photodynamic therapy (PDT), a process of applying medications and special lighting to affected skin areas, is currently under study as a treatment for nonmelanoma skin cancer. Researchers believe PDT may be effective in treating superficial basal cell carcinoma and early squamous cell carcinoma.¹¹

Organizations

• Skin Cancer, Melanoma

Citations

1. American Cancer Society (2006). Nonmelanoma Skin Cancer. Available online: http://documents.cancer.org/118.00/118.00.pdf.

2. Halpern AC, Myskowski PL (2005). Malignant cutaneous tumors. In DC Dale, DD Federman, eds., ACP Medicine, section 2, chap. 10. New York: WebMD.

3. National Cancer Institute (2005). Skin Cancer (PDQ): Treatment. Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/skin/healthprofessional/allpages.

4. Aasi SZ, Leffell DJ (2005). Cancer of the skin. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., vol. 2, pp. 1717–1744. Philadelphia: Lippincott Williams and Wilkins.

5. Martinez J-C, Otley CC (2001). The management of melanoma and nonmelanoma skin cancer: A review for the primary care physician. Mayo Clinic Proceedings, 76(12): 1253–1265.

6. American Cancer Society (2006). Cancer Facts and Figures 2006, pp. 1–56. Atlanta: American Cancer Society. Available online: http://www.cancer.org/docroot/STT/stt_0.asp.

7. Carucci JA, Leffell DJ (2003). Basal cell carcinoma. In IM Freedberg et al., eds., Fitzpatrick's Dermatology in General Medicine, 6th ed., pp. 747–754. New York: McGraw-Hill.

8. Grossman D, Leffell DJ (2003). Squamous cell carcinoma. In IM Freedberg et al., eds., Fitzpatrick's Dermatology in General Medicine, 6th ed., pp. 737–747. New York: McGraw-Hill.

9. Dinehart SM (2000). The treatment of actinic keratoses. Journal of American Academy of Dermatology, 42: S25–S28.

10. U.S. Food and Drug Administration (2004). Aldara (imiquimod) for superficial basal cell carcinoma. Available online: http://www.fda.gov/bbs/topics/news/2004/NEW01088.html.

11. Morton CA, et al. (2002). Guidelines for topical photodynamic therapy: Report of a workshop of the British Photodermatology Group. British Journal of Dermatology, 146: 552–567.

Other Works Consulted

• U.S. Preventive Services Task Force (2003). Counseling to prevent skin cancer: Recommendations and rationale. MMWR, 52(RR15): 13–17.