The following is a guide to the management of BCCs and SCCs. It is intended for usage by doctors in deciding ideal management options for their patients.
Basal and squamous cell carcinoma – a short guide to treatment **
Treatment | Invasive SCC & keratoacanthoma | Superficial BCCs & SCC in situ (Bowen’s) | Nodular & other BCCs | Actinic keratoses |
Surgical excision (Most cases will be amenable to simple excision and direct primary closure) | Treatment of choice for almost all SCCs. Minimum clinical margin of 4mm. Greater margin for higher risk tumours. | Benchmark treatment but often non excisional treatments are appropriate. See options below | Treatment of choice except for tumours to be considered for margin control approach. Minimum 3mm but usually 4mm clinical margin. | Not a treatment of choice unless there is doubt over diagnosis and invasive SCC to be excluded. |
Margin control surgery including Mohs surgery and “Slow Mohs” | Occasional usage, especially for difficult tumours on “H zone” ## | Not applicable - excessive | Mohs is benchmark approach for recurrent, poorly defined or > 1 cm on H zone ## or on the rest of face when both poorly defined and > 1 cm in diameter. | Not applicable - excessive |
Delineating curettage followed by surgical excision | As an alternative when Mohs surgery is contemplated. Supervised training in this specialised technique is essential. | Not applicable - excessive | As an alternative when Mohs surgery is contemplated. Contraindicated on nose. Supervised training is essential. | Not applicable – excessive |
Cryotherapy (Requires histologic confirmation and follow up except when used for Actinic keratoses) | Contraindicated Efficacy inadequate | Prolonged 30 sec freeze with 3mm margin or freeze / thaw / freeze with 3mm margin. Better combined with curettage prior to cryotherapy. Avoid on face | Contraindicated Efficacy inadequate | Benchmark approach for individual lesions. 5-10 second freeze cycle directly to the lesion. Unsuitable for field change. |
Curettage (Training essential. Always send curettings for histology. Follow up essential) | Contraindicated Efficacy inadequate | Serial curette often appropriate. Consider supplementary ablation of further tissue layer with cryotherapy or diathermy | Efficacy poor. Consider only for very small well defined nodular BCCs when excisional surgery not appropriate | Not a treatment of choice – consider when hyperkeratotic or diagnosis in doubt. |
Caution with keratoacanthoma. Technique difficult. |
Non surgical management options
Imiquimod (Aldara ®) ∞∞ TGA Approved (Follow up essential) | Not TGA approved Efficacy inadequate based on clinical trials | Not TGA approved for Bowen’s | Not TGA approved Efficacy inadequate based on clinical trials | Suitable for field change on face & scalp, treating ¼ of face at a time. Minimum 3 times per week for 4 weeks. |
Consider for biopsy proven superficial BCCs when not on H zone ## & when surgery inappropriate |
5 fluorouracil (Efudix ®) ∞∞ TGA Approved (Follow up essential) | Not TGA approved and efficacy inadequate based on clinical trials | Not TGA approved for superficial BCC | Not TGA approved Efficacy inadequate based on clinical trials | Suitable for field change. Twice daily for 2 to 4 weeks. Regular reviews needed. |
Suitable for Bowen’s when localised & biopsy proven when surgery inappropriate |
Diclofenac (Solaraze ®) ∞∞ TGA Approved | Not TGA approved and efficacy inadequate based on clinical trials | Not TGA approved and efficacy inadequate based on clinical trials | Not TGA approved Efficacy inadequate based on clinical trials | Suitable for field change but efficacy limited. Twice daily for 90 days. |
Photodynamic therapy ∞∞ TGA Approved MAL - Metvix (Galderma) | Contraindicated Not TGA approved Efficacy inadequate | When localised biopsy proven, not on H zone ## & surgery considered inappropriate | Consider only for very thin nodular BCCs not on H zone ## | Suitable for field change to face and scalp ∞∞ |
Photodynamic therapy ∞∞ ALA – inc: Tru PDT (Allmedic) Photodynamix therapy ACP – 5 ALA Photocure | Contraindicated Not TGA approved Safety & efficacy concerns | Contraindicated Not TGA approved Safety & efficacy concerns | Contraindicated Not TGA approved Safety & efficacy concerns | Contraindicated Not TGA approved Safety & efficacy concerns |
Superficial X Ray therapy (Largely when patient declines surgery) | Consider when biopsy proven and surgery inappropriate in older patients in difficult locations | Contraindicated – excessive | Consider when biopsy proven and tumour well defined only when surgery inappropriate in older patients | Contraindicated – excessive |
Radium weed (Euphorbia peplis), Milk vetch, Alovera | Contraindicated Efficacy inadequate Not TGA approved | Contraindicated Efficacy inadequate Not TGA Approved | Contraindicated Efficacy inadequate Not TGA Approved | Contraindicated Efficacy inadequate Not TGA Approved |
PEP005 - Peplin (Ingenol Mebutate) | Contraindicated Efficacy inadequate Not TGA Approved | Contraindicated Trials pending Not TGA approved | Contraindicated Efficacy inadequate Not TGA Approved | Contraindicated Trials pending Not TGA approved |
** This guide is a short ready reference guide only and should not be considered comprehensive.
## “H zone” refers to the skin on or immediately adjacent to the ears, lips, nose and mouth.
∞∞ Only prescribe for TGA approved indications and consult product information on dosage schedules.
Dr. Anthony Dixon