Squamous Cell Carcinoma Treatment Options

Cutaneous squamous cell carcinoma is the second most common skin cancer in the US. Most occur in sun-exposed areas, making early detection and total cure possible.

Mohs micrographic surgery remains the gold standard of therapy because it has the highest cure rate and renders the best cosmetic results. But the patient’s medical status and resource limitations can sometimes make it the less ideal choice.

This article discusses the different squamous cell carcinoma treatment options and how they compare to Mohs surgery.

But first…

How Does Squamous Cell Skin Cancer Develop?

A huge majority of cutaneous squamous cell carcinoma cases result from chronic UV exposure. UV radiation mutates the DNA, damaging the skin and causing premature wrinkles, unwanted pigment, spider veins and actinic keratoses. Cancer develops with continued exposure. Melanin protects from UV damage, so individuals with skin of color are less vulnerable.

Early detection is crucial to successful treatment. But how do you know if people you care about have the beginnings of this condition? The easiest way is to do a self-skin check.

What Is the Difference between Actinic Keratosis and Squamous Cell Carcinoma?

Actinic keratosis is a benign lesion, though it is considered premalignant. It is the precursor of squamous cell skin cancer. Once it grows, it has a 6-10% chance of turning into a full-blown tumor after 10 years. However, up to 25% of cases go away on their own within a year of minimizing UV exposure. That should give you plenty of time to keep it from becoming cancerous.

Actinic keratoses are scaly, reddish, firm, raised skin patches with poorly defined borders. They may resemble other skin blemishes, but you can tell them apart by their sandpaper-like roughness. They can occur singly or in multiples in sun-exposed locations and are typically accompanied by other signs of UV damage.

By comparison, squamous cell carcinoma has distinct edges. It may be round or irregularly shaped, raised or ulcerated, depending on the subtype. Patients usually complain of a non-healing skin lesion that bleeds even with the slightest trauma.

Tumors resulting from sun exposure are usually slow-growing. Meanwhile, highly aggressive types are frequently associated with other risk factors, such as a personal history of cancer and receiving chemotherapy, immunosuppression, chronic skin trauma, etc.

How Do Doctors Treat Squamous Cell Cancer of the Skin?

Cutaneous squamous cell carcinoma cases rise every year. But more people survive and live normal lives because of treatment advances, public awareness and early detection.

There are various ways of treating this condition. Ideally, you would want one that does the following:

• Eliminate the tumor in a single round of therapy. Recurrent lesions tend to be treatment-resistant.
• Minimize the risk of recurrence or metastatic spread. Squamous cell skin cancer grows slowly, but treatment delay or failure significantly reduces the odds of success and long-term survival.
• Restore the area’s function, making sure that you go back to your normal after the treatment.
• Provide the best possible cosmetic outcome to maintain your quality of life.

Mohs surgery satisfies all these requirements, but not every patient is fit to have it. After a thorough medical exam, your doctor will help you decide the best therapeutic option and tailor it to your needs.

Mohs Micrographic Surgery

With Mohs surgery, the physician cuts away the lesion in thin layers until it is completely removed along with a thin cancer-free margin. This treatment preserves the greatest amount of normal tissue, so it produces the best cosmetic outcomes. Mohs surgeons are board-certified dermatologists specializing in this procedure.

Is Mohs Surgery Painful?

Your dermatologist will give you pain medication before the treatment, so it is virtually painless. But you may need oral painkillers afterward because of postop inflammation.

What Is the Downtime for Mohs Surgery?

Mohs surgery recovery usually takes 1-2 weeks, depending on the lesion’s location and extent and your health status. Your dermatologist will give you instructions for proper wound care to help you recover fast.

What Are the Side Effects of Mohs Treatment?

The postop wound is small, but there will be some pain, swelling and redness because of inflammation. A small number of patients develop an allergic reaction to the local anesthetic. Otherwise, the procedure’s complication rate is only less than 2%.

What Are the Advantages of the Mohs Technique?

Mohs surgery has the highest cure rate for both first-time and recurrent squamous cell carcinoma. It spares the greatest amount of healthy tissue, so there’s little scarring and functional impairment.

Mohs treatment may be used on:

• High-risk patients, e. g. those with a history of cancer or immunosuppression, etc.
• High-risk tumors, e. g. aggressive type, size > 2 cm, in spread-prone locations, etc.
• Low-risk tumors

The Mohs surgeon microscopically examines each cut-out layer during the session. You don’t have to wait long for the reconstruction of the surrounding tissue. The doctor will do it once confirming that the entire lesion is gone along with a minimal cushion of healthy skin.

Mohs procedures typically use local anesthesia, sparing patients from the systemic complications of general anesthesia, e. g. nausea, vomiting, shortness of breath, drowsiness, etc.

What Are Mohs Surgery’s Disadvantages?

Mohs treatment is quite expensive. But it is cost-effective in the long run since it greatly diminishes the odds of recurrence and metastatic spread. Besides that, not all geographic areas have Mohs specialists.

Simple Surgical Excision

Your doctor will cut out the cancerous tissue with a wide margin to remove as much of it as possible. Tissue analysis is done afterward to check if the borders are tumor-free. Reconstruction is done separately after confirming that the entire lesion has been taken out.

Does Simple Surgical Excision Hurt?

This treatment is also painless because of anesthesia. As in other surgical procedures, you may need oral analgesics for postop inflammation.

What Is the Downtime for Simple Surgical Excision?

It is usually 2 weeks or longer, also depending on the lesion’s location and severity and your health status. Good surgical wound care helps speed up recovery.

What Are the Side Effects of Simple Tumor Excision?

As in other surgical treatments, the side effects of this procedure are those related to anesthesia use and postop inflammation. The type of pain medication given to you depends on the tumor’s location and extent. Local anesthesia may not be the best option for some lesions.

What Are the Advantages of Simple Tumor Excision?

Simple excision has a low risk of infection, bleeding and bruising. It may cost less than a Mohs procedure if done in an office setting.

Compared to electrodesiccation and curettage, healing is quicker, and the cosmetic result is better. Postop tissue analysis lets you know if the cancer is aggressive and if there are remaining cancer cells in the edges.

What Are the Disadvantages of Simple Tumor Excision?

Simple excision has a lower cure rate than Mohs surgery, so it is considered mostly for low-risk cases. The chances of scarring and recurrence are higher, and reconstruction is delayed. All these risks can potentially make it less cost-effective than the Mohs procedure.

Electrodesiccation and Curettage

With this procedure, the doctor cauterizes the tumor and its blood vessels, then scoops them out afterward.

Is Electrodesiccation and Curettage Painful?

Your doctor will give you some numbing medication so you won’t feel any pain during the treatment.

What Is the Downtime for Electrodesiccation and Curettage?

It is usually 2 weeks or longer, depending on tumor size and location and your health status.

What Are the Side Effects of Electrodesiccation and Curettage?

The side effects of this procedure are similar to those of other surgical treatments.

What Are the Advantages of Electrodesiccation and Curettage?

Electrodesiccation and curettage is the least expensive of all squamous cell skin cancer treatments. It is an affordable remedy for low-risk tumors.

What Are the Disadvantages of Electrodesiccation and Curettage?

Compared to Mohs surgery and simple excision, this skin cancer treatment generally has a longer downtime and a higher risk of scarring and recurrence. No postop tissue examination is done, so there is no way to confirm if the entire tumor has been removed.

Electrodesiccation and curettage of tumors in hairy areas may lead to lymph node involvement and more distant spread.

Cryotherapy

Here, the doctor uses liquid nitrogen to freeze and destroy the tumor.

Does Cryotherapy Sting?

You may feel some discomfort during the treatment, but most patients do not require pain medication. Some may experience tenderness and swelling postop.

What Is the Downtime for Cryotherapy?

It is usually 1-2 weeks, though it depends on the lesion’s severity and location and your physical status.

What Are the Side Effects of Cryotherapy?

Cryotherapy’s side effects are similar to those of other surgical procedures. Pain medications cannot complicate the treatment if none is used.

What Are Cryotherapy’s Advantages?

This procedure is inexpensive and is preferred for patients who cannot have radiation therapy or surgical removal of the tumor.

What Are Cryotherapy’s Disadvantages?

Aside from its lower cure rate, cryotherapy is cosmetically inferior to other squamous cell carcinoma treatments. It also risks nerve damage in thin-skinned areas like the fingers. There is no postop tissue exam, so you cannot confirm if the entire tumor is gone.

Photodynamic Therapy

With this procedure, the dermatologist applies a photosensitizing agent, typically aminolevulinic acid, before burning the tumor with powerful blue light beams.

Does Photodynamic Therapy Hurt?

The procedure causes discomfort despite skin cooling, so you may need some numbing medication during your session.

What Is the Downtime for Photodynamic Therapy?

Downtime is minimal.

What Are the Side Effects of Photodynamic Therapy?

Photodynamic therapy may cause redness, swelling, crusting, blistering, bruising or bleeding of the treatment area. These side effects are usually mild and resolve on their own, but you should call your dermatologist if they become intolerable.

What Are the Advantages of Photodynamic Therapy?

This procedure offers even better cosmetic results than surgery. It can treat broad skin areas in one session. It is appropriate for both actinic keratoses and early-stage, low-risk squamous cell skin cancer.

What Are the Disadvantages of Photodynamic Therapy?

Skin photosensitivity may last 1-2 days after aminolevulinic acid application. You may have to stay indoors or use sunblock during this time to minimize complications.

Photodynamic therapy has lower cure rates than skin cancer surgery. Also, there is no postop tissue inspection for tumor margin clearance.

Radiation Therapy

With this treatment, the doctor uses very powerful invisible light to kill cancerous tissue. Squamous cell skin cancer patients need 15-30 sessions, usually scheduled daily on weekdays, to divide the dose and minimize skin damage. Radiotherapy destroys local blood vessels and immune cells, so the treated skin deteriorates over time. Confirmation of tumor margin clearance is not done.

Is Radiotherapy Painful?

That depends on the type of treatment. External-beam radiotherapy is painless, but brachytherapy (internal radiation therapy) hurts if done without anesthesia.

What Is Radiotherapy’s Downtime?

Downtime from this treatment stems from radiation fatigue, which may last for weeks to months after the treatment stops. The duration depends on the total dose you get and your physical status.

What Are the Side Effects of Radiation Therapy?

Radiotherapy’s immediate side effects are fatigue and signs of local tissue destruction, e. g. hair loss if done on the scalp, mouth sores if done around the lips, etc. These are treatable or go away spontaneously after some time.

As for long-term complications, the treated skin gradually breaks down within 20-30 years. Vulnerable individuals may develop secondary cancers. Radiation can affect nearby vital organs.

What Are Radiotherapy’s Advantages?

This treatment has a high cure rate but is reserved for inoperable tumors, such as those invading the nerves or vital organs. It is also used when surgery cannot remove the cancer cells completely.

Radiation therapy is a good option for older patients as they are less likely to suffer from its long-term complications.

What Are the Disadvantages of Radiotherapy?

Radiation therapy is the most expensive squamous cell skin cancer treatment. It is inferior to surgery in terms of long-term cosmesis and recurrence rates. It is not recommended for young patients and those genetically prone to developing radiation-induced malignancies.

Last-Resort Squamous Cell Skin Cancer Treatments

Topical chemotherapy uses agents like 5-fluorouracil, imiquimod and ingenol gel mebutate. These meds have low cure rates, so they have FDA approval only for actinic keratoses. However, physicians may use them off-label, or without FDA clearance, for skin cancer if all other methods are contraindicated. Side effects vary but are usually tolerable.

Systemic chemotherapy and immunotherapy, both with great risks for serious adverse effects, are reserved only for widespread and extremely resistant tumors.

Here is a table comparing the different squamous cell carcinoma treatments.

Your physician should help you decide the best course of action. As always, working with the best guarantees the best results.

How Long Can You Live with Squamous Cell Skin Cancer?

The prognosis of this condition is excellent, with the cure rate approaching 99-100% if diagnosed and treated early. But therapeutic success significantly wanes for widespread and recurring lesions, high-risk subtypes and if the patient has poor health status. Once the malignancy spreads outside the skin, the chances of surviving after five years fall below 50% even with aggressive intervention.

Patients require frequent follow-ups during the first 5 years after treatment because 95% of those who experience recurrences do so within this time.

Individuals with a first-time lesion have a 30-50% chance of developing another nonmelanoma skin cancer in 5 years and generally a higher melanoma risk. Reducing UV exposure and other modifiable risk factors greatly reduces these odds.

Early-stage squamous cell skin cancer treated with photodynamic therapy

Conclusion

Cutaneous squamous cell carcinoma is a very treatable condition. But as in all other cancers, promptness of action largely determines therapeutic success.

Mohs surgery is currently the best form of treatment for this tumor. It is not suitable for all patients, but alternatives are available for those who cannot have it.

Finally, entrust your skin cancer treatment only to highly qualified medical professionals to ensure the best possible outcome.

Have a Suspicious Skin Lesion? Let LA’s Best Dermatologists Take Care of It

Time is of the essence when dealing with squamous cell carcinoma. So if you have a suspicious skin growth, there’s nothing else to do but have a doctor take a look.

But don’t get just any doctor. Choose one with extensive experience in identifying and treating all sorts of skin problems, especially cancer.

At BHSkin Dermatology, our award-winning skincare specialists skillfully get rid of skin cancer every day. Trust them to give you the best possible chance of beating this worrisome condition.

Act fast to nip the big C in the bud. Book your appointment today.

Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online