Squamous cell carcinoma of the skin: symptoms, treatment and outlook

BAD says most SCCs are low risk and can be cured, and that surgery is usually the recommended treatment: the SCC is removed with a margin of normal skin around it under local anaesthetic and the skin closed with stitches, sometimes with a skin graft. Other surgical methods include curettage and cautery, which scrapes the SCC away, and in some circumstances Mohs micrographic surgery, a specialised technique. Radiotherapy, delivering a beam of X-rays to the skin over several sessions, can also be used. For advanced SCC, or SCC that has spread, a combination of surgery, radiotherapy and/or chemotherapy may be used.

The NHS adds that targeted medicines or immunotherapy may be used if skin cancer is in more than one place, has spread to deeper layers or other parts of the body, or surgery and radiotherapy are not possible, and that photodynamic therapy is sometimes used when the cancer is thin and has not spread deeper. A team including a clinical nurse specialist will plan your care.

The NHS says the treatment you have depends on the type of skin cancer, where it is, whether it has spread and your general health. Cryosurgery, where the affected skin is frozen and forms a scab that drops off a few weeks later, is listed among the surgical methods for non-melanoma skin cancer. If a large area of skin is removed, a skin graft may be needed to cover it.

The NHS says radiotherapy may sometimes be recommended if the cancer covers a large area, if its location makes surgery difficult, if you are too unwell for surgery or if it has spread to the lymph glands, and sometimes after surgery to reduce the chance of the cancer coming back. A chemotherapy cream is sometimes used for skin cancers that only affect the top layer of skin, usually once or twice a day for 3 to 4 weeks.

The British Association of Dermatologists (BAD) explains that squamous cell carcinoma is a type of cancer that can occur in several parts of the body, but this page concerns SCC arising in the skin. It is a non-melanoma skin cancer. BAD says non-melanoma skin cancer accounts for 20% of all cancers and 90% of all skin cancers, and SCC accounts for 23% of non-melanoma skin cancers, making it the second most common skin cancer in the UK after basal cell carcinoma.

The NHS describes basal cell carcinoma as the most common type, which rarely spreads, and SCC as a less common type that sometimes spreads, which is why further staging tests may be needed in some SCC cases.

BAD says SCCs vary in appearance, but most look scaly or crusty, raised and rough, because they begin in the outer layer of the skin. Underneath the scale there may be an ulcer that bleeds easily, and an ulcer caused by something else that fails to heal may be a sign. SCCs can be sore or tender and can bleed, but not always. They can occur on any part of the skin, but are more common on sun-exposed sites such as the head, ears, lip, neck and back of the hands.

The NHS says the main symptom of non-melanoma skin cancer is a growth or unusual patch on the skin, and advises seeing a GP if a growth is getting bigger or has changed colour or texture, or if an area hurts, itches, bleeds, crusts or scabs for more than 4 weeks. BAD advises looking out for scaly, red and raised areas that are new, increasing in size, changing appearance, not healing as expected or forming a recurrent scab.

• A scaly, crusty, raised or rough patch or lump, often on the head, ears, lip, neck or back of the hands.

• An ulcer under the scale that bleeds easily, or an ulcer that does not heal.

• A growth that is getting bigger or has changed colour or texture.

• An area that hurts, itches, bleeds, crusts or scabs for more than 4 weeks.

BAD says the most important cause is too much exposure to ultraviolet light from the sun or other sources, which can change the DNA of skin cells in the outer layer of the skin so that they grow out of control. UV damage can cause SCC directly, or can produce a scaly area called actinic keratosis or Bowen disease that can change into SCC if not treated. SCC can also develop in skin damaged by other forms of radiation, in burns, in persistent chronic ulcers and wounds, and in old scars, and certain wart viruses can contribute. SCC itself is not contagious, and it is not inherited, although risk factors such as fair skin and a tendency to burn are.

People at greater risk include those with suppressed immune systems, either through medicines such as methotrexate, ciclosporin and azathioprine or through illnesses such as leukaemia or HIV, and people who have had an organ transplant. Others at risk include people who burn easily, those with significant cumulative UV exposure such as outdoor workers and people who have lived near the equator, older people with lifelong sun exposure, and people with conditions such as albinism and xeroderma pigmentosum.

• Long-term or intense UV exposure, including outdoor work.

• Immunosuppression, including after organ transplant.

• Fair skin that burns easily.

• Pre-cancerous sun damage such as actinic keratosis or Bowen disease.

• Chronic ulcers, burns, old scars or radiation-damaged skin.

Non-melanoma skin cancer includes more than one type, and scaly patches that are not yet cancer can look similar. The table summarises what the NHS and BAD say about each.

If your doctor thinks an area of skin needs further investigation you will be referred to a specialist such as a dermatologist. BAD says the NHS aims for you to receive a specialist appointment within 2 weeks of referral, which may be in person or by examination of clinical photographs. SCC does not have many distinguishing features under a dermatoscope, so to confirm the diagnosis a small piece of the abnormal skin (a biopsy) or the whole area (an excision biopsy) is removed under local anaesthetic and examined under the microscope by a pathologist. BAD says results are usually available within a week to ten days, while the NHS says non-melanoma excision biopsy results should be available in 2 to 4 weeks.

The NHS says further tests to see how deep the cancer is and whether it has spread (staging) may include a CT or MRI scan, tests on lymph glands and blood tests, and that you may not need them: they depend on the type of skin cancer. Because SCC sometimes spreads, tests may be needed for some.

BAD says that current guidelines state patients with SCC at low risk of getting a second one do not need specialist follow-up, whereas higher-risk SCCs should be followed up regularly for 1 to 2 years by the specialist team. It also reports that within five years of treatment for a low-risk SCC there is about a 40% chance of another one developing, and within five years of a higher-risk SCC the risk may be as high as 80%. Examining your skin from time to time is strongly advised, and you should see your GP or dermatologist about any scaly, red and raised areas that are new, growing, changing or not healing.

BAD adds that reducing UV exposure reduces risk. Protect skin with clothing and a hat that shades face, neck and ears and UV-protective sunglasses, spend time in shade between 11am and 3pm in sunny weather, keep babies and young children out of direct sun, and use SPF 30 or more with UVA protection applied generously 15 to 30 minutes before going out and reapplied every two hours and after swimming. Treating scaly sun damage (actinic keratosis and Bowen disease) may reduce SCC risk, and there is some evidence that oral nicotinamide may reduce the formation of actinic keratoses, a decision for your specialist.

The NHS says it is important to get any symptoms of non-melanoma skin cancer checked by a GP, and that finding it early can mean it is easier to treat. See a GP if you have a growth on your skin that is getting bigger or has changed colour or texture, or a growth or area of skin that hurts, itches, bleeds, crusts or scabs for more than 4 weeks.

The NHS says you may get an urgent referral for tests or to see a specialist if the GP thinks you have symptoms that could be cancer, and that this does not definitely mean you have cancer. The GP may ask to take a photograph to send to a dermatologist. Tell them if the area has recently changed and if you or your family have had skin cancer before. A new mole or a change in an existing mole needs checking too, because it may be a sign of melanoma.

On the NHS, a GP refers you to a specialist such as a dermatologist. BAD says the NHS aims for you to receive an appointment within 2 weeks of referral, which may be in person or through examination of clinical photographs. Surgery is usually under local anaesthetic, and a team including a clinical nurse specialist looks after you through diagnosis and treatment.

Some people choose to see a private dermatologist or surgeon for assessment or removal, with tissue sent for examination under the microscope. Whichever route you take, ask whether the cancer is considered low or high risk, whether the edges were clear, what follow-up is recommended and how that will be shared with your GP. People on immunosuppressant medicines or who have had an organ transplant are at greater risk and should mention it to the team.