Treatment Options for Your Skin Cancer

Hello, my name is Dr. Thomas Knackstedt, and I’m a board-certified dermatologist and Mohs surgeon at Peak Skin Center. In this video, I want to provide an introduction to the different treatment options that exist for skin cancer.

It’s easy to go down the rabbit hole—either online or through conversations with family and friends—about the many treatment options available. For the most part, choosing the right treatment should be a nuanced discussion between you and your physician. There are many factors that go into deciding which treatment option is best, including your personal preferences, the location of the cancer, how aggressive it is, and fundamentally, what type of skin cancer it is.

Treatment options differ for basal cell carcinoma, squamous cell carcinoma, and melanoma, so we must tailor and target treatment to the specific cancer.

In general terms, some thin, early basal cell and squamous cell cancers—particularly those that are in situ or superficial, meaning they are confined to the top layer of the skin—can be treated with topical creams. These medications are able to penetrate the skin adequately to treat small, superficial cancers. There are several different types of creams, and while they work in slightly different ways, they typically cause redness and inflammation in the treatment area. Most need to be applied once or twice daily for about six weeks.

The main benefit of topical treatment is that it avoids an in-office procedure or surgery. The downside is that treatment is prolonged, and unlike some other options, there is no microscopic confirmation that the cancer has been completely removed—you are relying on the effectiveness of the medication.

Some cancers that are slightly deeper than those typically treated with creams can be managed using destructive methods. Like topical treatments, these methods do not involve sending tissue to pathology for microscopic evaluation, but they are typically completed in a single office visit. Destruction can be performed in different ways, most commonly by aggressively freezing the cancer with liquid nitrogen or, after numbing the area, performing a scrape-and-burn procedure using a curette and an electrocautery device to destroy remaining cancer cells. Both approaches leave an open wound that usually heals over three to six weeks, depending on the patient and the location on the body. Both the cure rate and the cosmetic appearance after healing are generally inferior to a surgical removal.

Beyond these options, we indeed have surgical treatments. In dermatology, the two most common surgical approaches are conventional excision and Mohs micrographic surgery. There are several differences between the two, but I’ll focus on the key distinctions.

With a conventional excision, the cancer is removed, the wound is repaired or bandaged, and the tissue is sent to a pathologist for evaluation. Seven to fourteen days later, we receive confirmation as to whether the cancer was completely removed with clear margins.

With Mohs surgery, the tissue is examined under the microscope in real time during the procedure. As a Mohs surgeon, I am trained not only in the surgical removal of skin cancer, but also in the pathology required to interpret the tissue myself. This allows us to track the cancer as the procedure progresses, and we do not repair the wound until all the cancer has been removed. That is why Mohs surgery is considered the gold standard for many types of skin cancers.

While that process sounds very appealing, it’s important to use Mohs surgery in the appropriate setting. Like any medical tool, it provides the greatest benefit when used according to established guidelines and evidence. Mohs surgery is typically reserved for cancers with more aggressive features, cancers located in cosmetically or functionally important areas such as the head and neck, and cancers in areas that are difficult to repair or heal, such as the lower leg or shin.

Depending on the size, location, and behavior of the cancer, Mohs surgery may or may not offer a benefit over conventional excision. That decision is something we carefully discuss with patients as part of the treatment planning process.

Another important distinction is how margins are evaluated. In a conventional excision, the tissue is examined using a sampling technique often referred to as “bread loafing,” where only portions of the margin are assessed. With Mohs surgery, the tissue is processed in a way that allows evaluation of the entire outer edge and base of the specimen in a single section. This results in near 100% margin evaluation, which contributes to the high cure rates associated with Mohs surgery.

There are also a few additional treatment options that are used less frequently. Some low-grade, early, or small skin cancers—particularly in patients who are not good surgical candidates—can be treated with intralesional injections, where a chemotherapy medication is injected directly into the cancer, or with superficial radiation therapy. These options generally do not have the same depth of long-term data or decades of experience as the treatments discussed earlier, but they may still play a role in select cases.

Some tumors may be treated with radiation. This approach may be appealing to individuals hesitant to undergo a surgical procedure. However, it’s important to understand the limitations of superficial radiation therapy. From a logistical standpoint, it’s important to recognize that this treatment is delivered over a longer time period, requiring visits multiple times per week for several weeks. While radiation does not create a surgical scar, it’s critical to recognize that it does irreversibly change the color and texture of the skin. Areas treated with radiation are identified by others as appearing different from healthy skin and this outcome should not be ignored when comparing radiation outcomes to those of a surgical scar. Lastly, the effectiveness of radiation has not been fully studied in high quality studies the way surgical procedures have.

Ultimately, there are many possible approaches to treating skin cancer, and the best option depends on a combination of medical factors and patient preferences. Be sure to have a thorough discussion with your dermatology provider or dermatologic surgeon to determine the treatment plan that’s right for you.

If you or a loved one requires treatment for a skin cancer, consult with a board-certified dermatologist at Peak Skin Center. With experienced dermatologists across Cary, Apex, Holly Springs, and Fuquay-Varina, we provide treatments tailored to your needs. Schedule an appointment at one of our locations to discuss your skin cancer treatment and receive compassionate care in a comfortable environment.