Understanding Scalp Skin Cancer: Risks, Prevention, Diagnosis, and Best Treatment Options

Your hair is your crowning glory, but most of its beauty is rooted in your scalp’s health. Your locks can only be lustrous when your scalp is in good shape.

Notably, the scalp has biological functions more critical than its cosmetic role. This thick soft tissue sheet cushions your brain from trauma. Its sensory function alerts you about environmental dangers. The scalp also serves as a path for lymphatic vessels that clear inflammation from various parts of your head. However, skin cancer on scalp areas, hidden or visible, can disrupt these vital functions.

People unaware that scalp cancer can happen may not recognize it immediately when they see it. Vigilance is thus key to its timely detection and treatment. Who is at risk for this condition? Is it easy to get rid of once it hits? Even better, how can you prevent scalp cancer? Health vigilance, including that of the scalp, can protect you from serious illness. So read on to learn more about this condition.

What Are the Parts of the Scalp, and Why Is It Important to Know?

The scalp has 5 layers, easily recalled with the acronym “SCALP.” These layers, from superficial to deep, are the following:

• “S” stands for the “skin” covering the scalp’s outermost portion.
• “C” stands for “connective tissue” that is dense and tough. This layer has a rich nerve and blood supply.
• “A” stands for “aponeurosis” (specifically, the “galea aponeurosis”), the strong connective tissue fibers where facial and head muscles attach.
• “L” represents the “loose connective tissue” layer, which doctors can manipulate when covering scalp defects during reconstructive surgery.
• “P” stands for “pericranium,” a tough fibrous layer attaching the scalp to the skull underneath.

Scalp skin differs from the skin in other body regions as it has more hair follicles and sebaceous (oil) glands. Lymphatic vessels abound in the scalp, clearing the head tissues of inflammatory particles. Scalp lymph flows toward lymph node regions near the ears and in the neck.

Cancer can form from any of the tissues making up the scalp. Most tumors develop from cancerous skin cells, though malignancies of the blood vessels, connective tissues, muscles, and other cell types can also arise. The scalp’s blood and lymphatic vessels also make it a frequent destination for cancer spread from remote sites, such as the breast.

What Is Scalp Skin Cancer?

Cancers generally have the following characteristics that make them unique from other diseases:

• Their growth rate far exceeds the normal for their tissue type.
• The transformation from noncancerous to cancerous tissue usually has a trigger. However, once formed, cancer continues to grow even without further stimulation.
• Cancerous transformation starts with a genetic mutation in a mature cell, which younger cells inherit during cell division.

• Malignant tumors need a continuous blood supply to keep growing.
• Cancerous cells exhibit various abnormalities when viewed under the microscope, including size and shape variation and structural disorganization.
• Cancer cells can invade neighboring tissues, causing destruction or malignant transformation.

Scalp cancers may be classified in various ways, but the most basic method is identifying their tissue of origin. For example, cancers arising from typical skin cells are called “keratinocyte cancers,” which include basal cell and squamous cell carcinoma. Malignancies originating from the skin’s pigment-forming cells, the melanocytes, are called “melanoma.”

Angiosarcomas arise from cancerous blood vessels. Blood cancers like leukemia can seed in the skin. Atypical fibroxanthomas develop from malignant connective tissue and so on.

What Cancer Types Can Develop on the Scalp?

Most scalp cancers are keratinocyte cancers. Basal cell carcinoma is the most common scalp cancer, followed by squamous cell carcinoma.

Both tumor types grow slowly and rarely spread to distant sites. Growth often involves the superficial skin layers first before the deeper structures. Basal cell and squamous cell cancers have excellent cure rates and cosmetic outcomes if caught early. However, neglected keratinocyte cancers can involve the skull, and even the brain, potentially causing various complications.

Melanoma is rarer than the other two. However, this tumor is highly aggressive and produces the most fatalities of all skin cancer types. Malignancies can also arise from the scalp’s blood vessels, nerve endings, connective tissues, hair follicles, and other tissue types, though these tumors are rare. As mentioned, metastasis from distant sites like the breast can also occur.

Who Is at Risk for Scalp Skin Cancer?

UV radiation, most often from sun exposure, is implicated in the development of most skin cancer cases. UV exposure can cause DNA mutations that trigger the malignant transformation of scalp cells. Chronic, heavy UV exposure in the following settings increases one’s risk of developing scalp skin cancer:

• Outdoor occupations such as farming, fishing, and landscaping
• Outdoor sports like soccer, tennis, and swimming
• UV phototherapy and tanning bed use
• Living closer to the equator
• Living at high altitudes

Most malignant scalp tumors develop in people age 50 or older, related to cumulative UV exposure in one’s lifetime. Hair loss can make people prone to developing scalp skin cancer, underscoring the hair’s UV-protective role. Men are more susceptible than women due to their shorter hairstyles, less sunscreen use, and occupations, as more men work outdoors than women.

Genetics also determine scalp cancer proneness. For example, individuals born with light-colored skin and hair are more likely to develop malignant scalp moles, basal cell carcinoma, and squamous cell carcinoma than people with skin and hair of color. Light skin and hair contain less melanin, the skin’s UV-protective pigment, than skin and hair of color.

Xeroderma pigmentosum is a genetic condition that makes affected individuals susceptible to UV skin damage and skin cancer. Some families are prone to familial cancer syndromes, such as familial atypical multiple mole melanoma (FAMMM) syndrome.

Environmental agents that can cause skin cancer include cigarettes, coal tar, and high-energy radiation. Inborn and acquired immunodeficiencies make people prone to any cancer type. Drugs that suppress immunity, increase photosensitivity, or damage the DNA (e.g., cancer chemotherapy) can also cause scalp cancer.

High-risk human papillomavirus (HPV) infection sometimes gives rise to skin squamous cell carcinoma. Chronic inflammation, as happens in large burn scars, nonhealing ulcers, and autoimmune skin disorders like psoriasis, also increases scalp cancer risk.

How Do You Protect Your Scalp from Skin Cancer?

The same general skin cancer-preventive measures can help you avoid scalp skin cancer. These measures include the following:

• Using sun protection, especially wearing wide-brimmed hats and seeking shade
• Treating precursor lesions like actinic keratosis
• Increasing antioxidants like niacinamide and vitamin A in the diet
• Enhancing immunity
• Changing immunosuppressive regimens in patients on immunosuppression
• Performing self-skin examinations regularly
• Going regularly to dermatologist visits
• Controlling chronic inflammatory conditions, such as psoriasis and lupus

The American Cancer Society recommends a simple approach to self-skin examination, which you can perform in your bathroom. First, stand before a large mirror and carefully inspect your face, ears, neck, chest, and belly. Women should check beneath their breasts. Examine your underarms, both sides of your arms, hands, fingers, and under your fingernails.

While seated, check the front of your thighs, shins, feet, toes, and beneath your toenails. Use a hand mirror to view the soles of your feet, calves, and backs of your thighs, as well as your genital area, buttocks, back, neck, and ears. For your scalp, use a comb or hair dryer to part your hair and check the skin beneath.

A yearly self-skin exam may suffice for most individuals. People with a higher skin cancer risk, such as those with a prior chemotherapy history, may benefit from more frequent self-skin checks.

How Do You Know If You Have Cancer of the Scalp?

Scalp cancer has variable signs and symptoms due to the diversity of the possible lesion types. However, basal cell and squamous cell carcinoma, the two most common scalp cancers, often present initially with a nonhealing, ulcerated lesion that may itch and bleed with minimal trauma. The front of the scalp is most often affected, although the tumors may also grow in other scalp areas.

Basal cell skin cancer has several different types. Some look skin-colored with broken capillaries, while others may be dark brown, black, or red. The tumors are typically slow-growing and may be single or multiple. Some basal cell cancer lesions reach greater than 2 centimeters in size before diagnosis.

By comparison, squamous cell skin cancer usually has crusted, thick, firm skin. These tumors often grow within 8 weeks. The lesions may be skin-colored to red and raised or flat. Tumors arising from HPV infection may appear wart-like. Squamous cell carcinoma lesions may grow greater than 1 centimeter in size before diagnosis.

Melanoma is a pigmented tumor that you may distinguish from a common scalp mole by the “ABCDE” melanoma recognition guide:

• Asymmetry
• Borders that are irregular
• Color that is not even
• Diameter greater than 6 mm
• Evolving, elevating, or expanding

Melanoma pigmentation varies, but gray, red, blue, and white are considered ominous for this lesion type.

Not all scalp cancers look the same. However, finding a nonhealing, fast-growing, firm lesion in a sun-exposed area, such as the scalp, in a person with an increased risk for skin cancer should raise suspicion for this condition. Pus, blood, and hair loss may be observed in the affected area.

Headache and stroke-like symptoms like numbness and muscle weakness may indicate that the scalp lesion has spread to the brain. Manifestations like on-and-off fever, poor appetite, and unintentional weight loss may signify a more widespread involvement.

How Do Dermatologists Diagnose Scalp Skin Cancer?

Board-certified dermatologists are skin disease specialists. These providers usually start their clinical evaluation by noting the lesion’s development and asking about accompanying signs and symptoms. They may inquire about your past medical, social, and family history, among other things, to determine your scalp cancer risk factors and create a mitigation plan.

After taking your medical history, they will examine the lesion and proceed to the rest of their physical examination. Suspicious skin growths usually necessitate inspecting other body parts to look for remote spread, especially if the dermatologist is considering cancer. But don’t worry. Highly trained dermatologists perform this part of the medical evaluation professionally, with great regard for your privacy.

If the initial clinical findings suggest cancer, you may be scheduled for a biopsy to identify the lesion type. Imaging tests like the CT scan and MRI may also be recommended after cancer confirmation to determine the involvement of other organs, such as the brain and lymph nodes.

Your dermatologist may order additional tests, depending on the other things they find during evaluation. If you have a chronic medical condition, your skin specialist may require medical clearance from your other physicians to ensure the safety of your treatments.

What Are the Treatment Options for Scalp Skin Cancer?

Surgery is the therapeutic cornerstone of scalp cancer. However, the ultimate choice depends on various factors, most importantly, the lesion type, disease extent, and patient preferences and surgical fitness. The different scalp cancer treatment options are discussed below.

Surgery for Scalp Cancer Treatment

Mohs micrographic surgery, or simply “Mohs surgery,” is the gold standard for treating skin-confined tumors. This procedure entails removing the lesion bit by bit, with microscopic examination of every piece, until a slim layer of the normal tissue surrounding the tumor is obtained.

Excising this thin, normal tissue margin does two things. First, the Mohs surgeon confirms right then and there that the tumor has been taken out entirely, having microscopically confirmed that the last excised piece has no more tumor cells. Second, it allows the Mohs surgeon to spare as much normal tissue as possible while eliminating the cancer cells.

Thus, Mohs surgery offers the highest cure rates—conversely, the lowest recurrence rates—and the best cosmetic results among all skin cancer therapies. Mohs surgeons are board-certified dermatologists specially trained to perform Mohs procedures.

However, Mohs surgery is unavailable in some geographic locations, and some people may find the treatment costly. An alternative to Mohs surgery is wide local excision (WLE), which cuts out the tumor along with a large piece of the surrounding, normal-appearing tissue. The specimen is then sent to a histopathology lab for analysis, particularly to check if the edges are cancer-free.

WLE of scalp cancer may be performed by a general surgeon or otolaryngologist in the absence of a Mohs doctor or if the scalp tumor encroaches into deeper tissues. This procedure may also be offered to patients looking for an affordable Mohs treatment alternative.

WLE has fairly high cure rates, though still considerably lower than Mohs surgery. WLE does not always produce tumor-free borders despite removing a large piece of tissue, unlike Mohs procedures. Cutting out a substantial piece of normal tissue may also compromise the treated area’s appearance or function.

Mohs surgery is recommended for basal cell carcinoma, squamous cell carcinoma, early-stage melanoma, and rare skin-confined tumors. WLE may be used for advanced melanoma and scalp tumors invading the skull and brain. You may read our article comparing Mohs surgery and WLE to learn more about the differences between these procedures.

Cryosurgery and curettage with electrodesiccation are two other surgical techniques that may be attempted on low-grade, superficial basal cell and squamous cell carcinoma. These procedures are inexpensive but render low cure rates and poor cosmetic outcomes.

Cryosurgery blasts the tumor with cold, liquid nitrogen. Curettage with electrodesiccation scoops out the lesion with a surgical device and cauterizes the site with a handheld electric instrument to control bleeding. Neither procedure allows for checking the lesion’s margins for tumor clearance.

The most common side effects of surgical procedures are short-lived postoperative redness, swelling, and pain. Bruising may also occur in bruise-prone individuals. However, bad scarring, pigmentation changes, severe bleeding, and infection may result if inexperienced providers perform surgery.

Topical Therapy for Scalp Cancer Treatment

Patients with low-grade, shallow tumors who cannot tolerate surgery may try the topical treatments imiquimod and 5-fluorouracil (5-FU) under medical supervision. Imiquimod induces the skin’s local immunity to get rid of tumor cells. Meanwhile, 5-FU disrupts cancer cell proliferation.

These medications may not be used on highly invasive tumors due to high failure rates. Local irritation is the most common side effect of these topical skin cancer drugs.

Radiation Therapy for Scalp Cancer Treatment

Exposure of the scalp cancer to ionizing radiation can kill off malignant cells. Radiation therapy may be used when histopathology shows that WLE or other treatments have failed to eliminate the cancer. Radiotherapy may also be offered if the tumor is widespread or inoperable (for example, invading large blood vessels and nerves). It may also be attempted in patients who are poor surgical candidates or opt not to undergo surgery.

Radiation therapy is highly effective against skin cancer. However, the treated tissues often deteriorate over time. Radiotherapy is a feasible surgical alternative for older patients, who often have fewer cosmetic concerns, but not younger individuals. Additionally, secondary cancers may develop as late complications of radiation exposure.

Other Scalp Cancer Treatment Modalities

Chemotherapy is not the standard of care for skin cancer. However, it may be used to treat metastatic disease or clean up residual tumor cells after WLE if radiotherapy cannot be performed.

Chemotherapeutic agents that have been used on widespread basal cell carcinoma include paclitaxel and carboplatin. Methotrexate has been given to patients with metastatic squamous cell carcinoma.

Dacarbazine treatment may be attempted in patients with metastatic melanoma skin cancer. Biologic agents such as interferon and ipilimumab may also be used in such cases.

Generally, chemotherapeutic agents’ side effects include vital organ damage, secondary cancers, hormonal imbalance, and profound immunosuppression. Advanced skin cancer is usually treatment-resistant.

Photodynamic therapy (PDT) involves applying a photosensitizer onto the skin before exposing the area to enhanced blue or red light. This modality has been tried on low-grade basal cell carcinoma. It can target multiple lesions at once with little cosmetic damage. However, PDT’s cure rates are low while recurrence rates are high, making it less important in the scalp cancer therapeutic arsenal.

Interprofessional Care in Scalp Cancer Treatment

Many patients with scalp cancer benefit from interprofessional care when more than one specialist renders their expertise to achieve optimal health outcomes for patients. As mentioned, most individuals with scalp malignancies are older than 50 and, thus, usually already have chronic medical conditions. Some have skin tumors invading the skull and brain, necessitating coordination between the Mohs surgeon, otolaryngologist, neurosurgeon, and oncologist.

The Mohs surgeon’s role is pivotal in interprofessional teams caring for patients with scalp cancer. As dermatologists, these specialists contribute to the early detection and treatment of skin diseases and give valuable skin health maintenance advice. As surgeons, their rare expertise gives them an edge when treating skin cancers, as only the Mohs procedure can give the best possible outcomes when dealing with such conditions.

What Is the Prognosis for Skin Cancer on the Scalp?

The prognosis of scalp skin cancer depends on various aspects.

Factors that improve survival include good immunity, lack of lymph node involvement, young age, complete tumor removal, superficial invasion, keratinocyte cancer type, and negative family history of skin cancer. Conversely, immunosuppression, deep invasion, distant spread, old age, incomplete tumor removal, melanoma type, and genetic predisposition negatively impact prognosis.

Mohs surgery cure rates reach 99% for keratinocyte cancers and 98% for early-stage melanoma. By comparison, WLE cure rates are only as high as 96% for keratinocyte cancers and 85% for early-stage melanoma.

How Can You Prevent Scalp Skin Cancer Recurrence?

Long-term care consisting of the following measures can help prevent scalp cancer recurrence:

• Follow up with your provider as advised. Post-skin cancer treatment follow-ups allow your specialist to monitor surgical wound healing, treatment side effects, cosmetic improvement, and potential recurrence.
• Maintain good skin care, including sun protection, good hygiene, and topical antioxidant use, as your provider recommends.
• Control chronic skin conditions, such as psoriasis, that may trigger skin cancer development.
• Perform regular self-skin examinations, especially since an episode of skin cancer can increase the odds of another one.

Notably, choosing the right dermatologist for your skin condition is just as important as getting the right treatments. Only a highly experienced skin disease expert can ensure the effectiveness and safety of your skin cancer therapy.

Scalp Skin Cancer: Key Takeaways

Scalp cancer mostly originates from malignant skin cells. UV radiation is the most important inciting factor of scalp cancers, though genetics, immunity, and chronic inflammation can also increase one’s susceptibility to this condition. As with all other diseases, prevention is the best way to deal with scalp cancer. Sun protection, regular self-skin exams, immunity enhancement, and skin inflammation control are key to avoiding scalp malignancies.

Scalp cancers are highly treatable, especially if detected early. The Mohs surgical technique is the treatment of choice for these tumors because it offers the best health and cosmetic outcomes compared to alternatives. Long-term posttreatment care minimizes the chances of recurrence and improves survival, with the most important measures being regular dermatologist follow-ups, good skin care, control of chronic skin disorders, and regular self-skin exams.

Finally, trust only a board-certified Mohs surgeon to get rid of scalp skin cancer for good. Only a bona fide skin cancer specialist can accurately diagnose this time-sensitive condition and ensure your treatment works hitch-free.

Frequently Asked Questions

Is Scalp Cancer Curable?

Yes, scalp cancer is curable. However, the best results are obtained when the condition is treated early. Delaying therapy leads to complications, such as vital organ involvement, and reduces treatment responsiveness and survival.

What Can Be Mistaken for Scalp Skin Cancer?

The list of conditions that can be mistaken for scalp skin cancer is long. However, the distinction is more crucial in some cases than others because of the vital differences in their treatment approaches. Examples include the following:

• Viral warts, which can resemble squamous cell cancer. Treatments range from home remedies like salicylic acid to more sophisticated technologies like laser surgery, which are not advisable in skin cancer therapy.
• Psoriatic plaques, which may look like basal cell or squamous cell carcinoma. Psoriasis may be treated with steroids, which can worsen skin cancer.
• Benign moles, which can resemble some dome-shaped melanoma lesions. Simple excision or laser therapy without postsurgical histopathology may suffice for a common mole but not melanoma lesions, where margin status (whether tumor-free or not) must always be determined.

Only a bona fide skin expert can ensure the accuracy of a skin disease diagnosis. If you have a suspicious lesion unresponsive to the usual skin treatments, ask your primary care provider for a referral to a reputable board-certified dermatologist.

Does Hair Grow Back After Scalp Skin Cancer Surgery?

Hair can grow back after scalp cancer Mohs surgery if the technique is properly performed. However, factors like defect size, skin graft or flap quality, and the Mohs surgeon’s skill can impact the speed and amount of hair regrowth. For the best results, entrust your procedure to a board-certified Mohs surgeon with a solid track record in the field.

Restore Your Crowning Glory After Scalp Cancer Treatment

Scalp cancer is a skin issue that must be remedied immediately to avoid complications. However, the wrong surgical technique can lead to treatment failure and a visible scalp defect that can leave patients self-conscious. If this dilemma is making you hesitate to seek treatment, let BHSkin Dermatology’s Mohs surgeons help.

BHSkin Dermatology has some of LA’s award-winning board-certified dermatologists. Our skin disease specialists have helped many patients successfully get rid of scalp cancer with barely any trace. Visit us at our Glendale or Encino clinic or use our telederm portal for your first consultation.

Book your appointment today!

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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