Basal Cell Carcinoma

Skin cancer is one of the most common cancers in the world. Non-melanoma skin cancer refers to a group of cancers that slowly develop in the upper layers of the skin.

The term 'non-melanoma' distinguishes these more common kinds of skin cancer from the less common skin cancer known as melanoma, which spreads faster in the body.

The first sign of non-melanoma skin cancer is usually the appearance of a lump or patch on the skin that doesn't heal after a few weeks.

In most cases, cancerous lumps are red and firm, while cancerous patches are often flat and scaly.

See your GP if you have any skin abnormality that hasn't healed after four weeks. Although it is unlikely to be skin cancer, it is best to be sure.

Symptoms

The main symptom of non-melanoma skin cancer is the appearance of a lump or discoloured patch on the skin that doesn't heal.

The lump or discoloured patch is the cancer, sometimes referred to as a tumour.

Non-melanoma skin cancer most often appears on areas of skin which are regularly exposed to the sun, such as the face, ears, hands and shoulders.

Basal cell carcinoma

Basal cell carcinoma (BCC) usually appears as a small red or pink lump, although it can be pearly-white or 'waxy' looking. It can also look like a red, scaly patch.

The lump slowly grows and may become crusty, bleed or develop into a painless ulcer.

Squamous cell carcinoma

Squamous cell carcinoma (SCC) appears as a firm pink lump and may have a flat, scaly and crusted surface.

The lump is often tender to touch, bleeds easily and may develop into an ulcer.

Bowen's disease

Bowen's disease is a very early form of skin cancer, sometimes referred to as "squamous cell carcinoma in situ". It develops slowly and is easily treated. 

The main sign is a red, scaly patch on the skin which may itch. It most commonly affects elderly women and is often found on the lower leg. However, it can appear on any area of the skin.

Types of non-melanoma skin cancer

Non-melanoma skin cancers usually develop in the outermost layer of skin (epidermis) and are often named after the type of skin cell from which they develop.

The two most common types of non-melanoma skin cancer are:

• basal cell carcinoma – starts in the cells lining the bottom of the epidermis and accounts for about 75% of skin cancers
• squamous cell carcinoma – starts in the cells lining the top of the epidermis and accounts for about 20% of skin cancers

Although not classed as non-melanoma skin cancers, actinic keratoses and Bowen's disease may sometimes develop into squamous cell carcinoma if left untreated.

Why does it happen?

Non-melanoma skin cancer is mainly caused by overexposure to ultraviolet (UV) light. UV light comes from the sun, as well as artificial sunbeds and sunlamps.

In addition to UV light overexposure, there are certain things that can increase your chances of developing non-melanoma skin cancer, such as:

• a family history of the condition
• pale skin that burns easily
• a large number of moles or freckles

Causes

Most skin cancer is caused by ultraviolet (UV) light damaging the DNA in skin cells. The main source of UV light is sunlight.

Sunlight contains three types of UV light:

• ultraviolet A (UVA)
• ultraviolet B (UVB)
• ultraviolet C (UVC)

UVC is filtered out by the Earth's atmosphere but UVA and UVB damage skin over time, making it more likely for skin cancers to develop. UVB is thought to be the main cause of non-melanoma skin cancer.

Artificial sources of light, such as sunlamps and tanning beds, also increase your risk of developing skin cancer.

Repeated sunburn, either by the sun or artificial sources of light, will make your skin more vulnerable to non-melanoma skin cancer.

Family history

Research suggests that if you have two or more close relatives who have had non-melanoma skin cancer, your chances of developing the condition may be increased.

Increased risk

Certain factors are believed to increase your chances of developing all types of skin cancer, including:

• pale skin that does not tan easily
• red or blonde hair
• blue eyes
• older age
• a large number of moles
• a large number of freckles
• an area of skin previously damaged by burning or radiotherapy treatment
• a condition that suppresses your immune system, such as HIV
• medicines that suppress your immune system (immunosuppressants), commonly used after organ transplants
• exposure to certain chemicals, such as creosote and arsenic
• a previous diagnosis of skin cancer

Who is affected?

Non-melanoma skin cancer is one of the most common types of cancer in the world. There are more than 100,000 new cases of non-melanoma skin cancer every year in the UK.

Non-melanoma skin cancer affects slightly more men than women.

Diagnosis

Your GP can examine your skin for signs of skin cancer. They may refer you to a skin specialist (dermatologist) or a specialist plastic surgeon if they are unsure or suspect skin cancer.

The specialist will examine your skin again and will perform a biopsy to confirm a diagnosis of skin cancer.

A biopsy is an operation that removes some affected skin so it can be studied under a microscope.

A diagnosis of non-melanoma skin cancer will usually begin with a visit to your GP who will examine your skin and decide whether you need further assessment by a specialist.

Some GPs take digital photographs of suspected tumours so they can email them to a specialist for assessment.

Biopsy

If skin cancer is suspected, you may be referred to a skin specialist (dermatologist) or specialist plastic surgeon. The specialist should be able to confirm the diagnosis by carrying out a physical examination.

However, they will probably also perform a biopsy – a surgical procedure where either a part or all of the tumour is removed and studied under a microscope. This is usually carried out under a local anaesthetic, meaning you will be awake, but the affected area will be numbed so you won't feel pain.

This allows the dermatologist or plastic surgeon to determine what type of skin cancer you have and whether there is any chance the cancer could spread to other parts of your body.

Sometimes, skin cancer can be diagnosed and treated at the same time. In other words, the tumour can be removed and tested and you may not need further treatment because the cancer is unlikely to spread.

It may be several weeks before you receive the results of a biopsy.

Further tests

If you have basal cell carcinoma (BCC), then you usually won't require further tests, as the cancer is unlikely to spread.

However, in rare cases of squamous cell carcinoma, further tests may be needed to make sure the cancer has not spread to another part of your body.

These tests may include a physical examination of your lymph nodes (glands found throughout your body). If cancer has spread, it may cause your glands to swell.

If the dermatologist or plastic surgeon thinks there is a high risk of the cancer spreading, it may be necessary to perform a biopsy on a lymph node. This is called a fine needle aspiration (FNA).

During FNA, cells are removed using a needle and syringe so they can be examined. Finding cancerous cells in a nearby lymph node would suggest the squamous cell carcinoma has started to spread to other parts of your body.

Treating non-melanoma skin cancer

Surgery is the main treatment for non-melanoma skin cancer. This involves removing the cancerous tumour and some of the surrounding skin.

Other treatments for non-melanoma skin cancer include cryotherapy, creams, radiotherapy, chemotherapy and a treatment known as photodynamic therapy (PDT).

Treatment for non-melanoma skin cancer is generally successful as, unlike most other types of cancer, there is a considerably lower risk that the cancer will spread to other parts of the body.

It is estimated that basal cell carcinoma will spread to other parts of the body in less than 0.5% of cases. The risk is slightly higher in cases of squamous cell carcinoma, which spreads to other parts of the body in around 2-5% of cases.

Treatment for non-melanoma skin cancer is completely successful in approximately 90% of cases.

Surgery is the main treatment for non-melanoma skin cancer, although it may depend on your individual circumstances.

Overall, treatment is successful for more than 90% of people with non-melanoma skin cancer.

People with cancer should be cared for by a team of specialists that often includes a dermatologist, a plastic surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a pathologist and a specialist nurse.

If you have non-melanoma skin cancer, you may see several (or all) of these professionals as part of your treatment.

When deciding what treatment is best for you, your doctors will consider:

• the type of cancer you have
• the stage of your cancer (how big it is and how far it has spread)
• your general health

Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions you would like to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

The National Institute for Health and Care Excellence (NICE) has produced healthcare guidelines about NHS skin cancer services. These outline NICE’s main recommendations on how, over the coming years, people with skin cancer or melanoma should be treated.

Want to know more?

• NICE: improving outcomes for people with skin tumours including melanoma

Surgical excision

Surgical excision is an operation to cut out the cancer along with surrounding healthy tissue to ensure the cancer is completely removed.

It may be done in combination with a skin graft, if it's likely to leave significant scarring. A skin graft involves removing a patch of healthy skin, usually from a part of your body where any scarring cannot be seen, such as your back. It is then connected, or grafted, to the affected area.

In many cases, this operation is enough to cure skin cancer.

Curettage and electrocautery

Curettage and electrocautery is a similar technique to surgical excision, but is only suitable for cases where the cancer is quite small.

The surgeon will use a small, spoon-shaped blade to remove the cancer and an electric needle to remove the skin surrounding the wound. The procedure may need to be repeated two or three times to ensure the cancer is completely removed.

Cryotherapy

Cryotherapy uses cold treatment to destroy the cancer. It is sometimes used for non-melanoma skin cancers in their early stages. Liquid nitrogen is used to freeze the cancer, and this causes the area to scab over.

After about a month, the scab containing the cancer will fall off your skin. Cryotherapy may leave a small white scar on your skin.

Mohs micrographic surgery

Mohs micrographic surgery (MMS) is used to treat non-melanoma skin cancers when:

• it's felt there is a high risk of the cancer spreading or returning
• the cancer is in an area where it would be important to remove as little skin as possible, such as the nose or eyes

It involves removing the tumour bit by bit, as well as a small area of skin surrounding it. This minimises the removal of healthy tissue and reduces scarring.

Each time a piece of tissue is removed, it is checked for cancer. The procedure may need to be repeated two or three times to ensure the cancer is completely removed.

Chemotherapy

Chemotherapy involves using medicines to kill cancerous cells. In the case of non-melanoma skin cancer, chemotherapy is only recommended when the tumour is contained within the top layer of the skin.

This type of chemotherapy involves applying a cream containing cancer-killing medicines to the affected area. As only the surface of the skin is affected, you will not experience the side effects associated with other forms of chemotherapy, such as vomiting or hair loss. However, your skin may feel sore for several weeks afterwards.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) is used to treat basal cell carcinoma, Bowen's disease and actinic keratoses. It involves using a cream which makes the skin highly sensitive to light.

After the cream has been applied, a strong light source is shone onto the affected area of your skin, which kills the cancer. PDT may cause a burning sensation and around 2% of people who have this treatment will be left with some superficial scarring.

Imiquimod cream

Imiquimod cream is a treatment for basal cell carcinoma with a diameter of less than 2cm (0.8 inches). It's also used to treat actinic keratoses. Imiquimod encourages your immune system to attack the cancer in the skin.

Common side effects of imiquimod include redness, flaking or peeling skin and itchiness.

Less common and more serious side effects of imiquimod include blistering or ulceration of your skin.

Wash the cream off and contact your GP if your skin blisters or you develop ulcers after using it.

Radiotherapy

Radiotherapy involves using low doses of radiation to destroy the cancer. The level of radiation involved is perfectly safe. However, your skin may feel sore for a few weeks after radiotherapy.

Radiotherapy is sometimes used to treat basal cell and squamous cell carcinomas if:

• surgery would be unsuitable
• the cancer covers a large area
• the area is difficult to operate on

Radiotherapy is sometimes used after surgical excision to try to prevent the cancer coming back. This is called adjuvant radiotherapy.

Complications

If you have had non-melanoma skin cancer in the past, there is a chance the condition may return. The chance of non-melanoma skin cancer returning is increased if your previous cancer was widespread and severe.

If your cancer team feels there is a significant risk of your non-melanoma skin cancer returning, you will probably require regular check-ups to monitor your health. You will also be shown how to examine your skin to check for tumours.

Prevention

Non-melanoma skin cancer is not always preventable, but you can reduce your chances of developing the condition by avoiding overexposure to UV light.

You can help protect yourself from sunburn by using sunscreen, dressing sensibly in the sun and limiting the time you spend in the sun during the hottest part of the day.

Sunbeds and sunlamps should also be avoided.

Regularly checking your skin for signs of skin cancer can help lead to an early diagnosis and increase your chances of successful treatment.

The best way to prevent all types of skin cancer is to avoid overexposure to the sun.

A few minutes in the sun can help maintain healthy levels of vitamin D, essential for healthy bones, but it's important to avoid getting sunburn.

Once you are burnt, the damage has already been done to your skin as it has received a dangerous level of radiation. Every time the skin is exposed to radiation, this increases the chance of a cancer occurring, possibly many years in the future.

Some simple steps to manage your sun exposure are outlined below.

Avoid the sun when it is at its hottest

The sun is usually at its hottest between 11am and 3pm, but can also be very strong and have potentially damaging effects at other times.

Do not spend long periods in the sun during the day. Make sure you spend time in the shade and cover up with clothes as well as sunscreen.

Dress sensibly

If you cannot avoid spending long periods of time in the sun – for example, if you work outdoors – wear clothes that will provide protection from the sun.

This should include a hat to protect your face and scalp, and sunglasses to protect your eyes. When buying sunglasses, look for:

• the CE or British Standard mark (BS EN 1836: 2005)
• a UV 400 label
• a label saying the glasses give 100% UV protection

Use sunscreen

When buying sunscreen, make sure it is suitable for your skin type and blocks both ultraviolet A (UVA) and ultraviolet B (UVB) radiation. A sun protection factor (SPF) of at least 15 is recommended.

Sunscreen should be applied around 15 minutes before you go into the sun and reapplied every two hours. If you are planning to spend time in the water, use a waterproof sunscreen.

Take extra care to protect babies and children. Their skin is much more sensitive than adult skin and repeated exposure to sunlight could lead to skin cancer developing in later life. Before going out into the sun, make sure your children are dressed appropriately and are wearing a hat and a high SPF sunscreen.

Tan sensibly

Most health professionals will tell you to avoid sunbathing altogether because even a tan can increase your risk of developing skin cancer.

However, if you are determined to get a tan, do it gradually by limiting the amount of time you spend in the sun each day and by wearing sunscreen.

When you begin to tan, limit your exposure to the sun to 30 minutes, then gradually increase it by five or 10 minutes a day.

Sunbeds and sunlamps

The British Association of Dermatologists is the UK's leading professional body on skincare. It advises that people should not use sunbeds or sunlamps.

Sunbeds and lamps can be more dangerous than natural sunlight because they use a concentrated source of ultraviolet (UV) radiation.

UV radiation can increase your risk of developing melanomas – the most dangerous type of skin cancer. Sunbeds and sunlamps can also cause premature skin ageing.

If you continue to use sunbeds or sunlamps, the Health and Safety Executive (HSE) has issued advice on the health risks linked to UV tanning equipment, such as sunbeds, sunlamps and tanning booths. It recommends you do not use UV tanning equipment if:

• you have fair, sensitive skin that burns easily or tans slowly or poorly
• you have a history of sunburn, particularly in childhood
• you have lots of freckles or red hair
• you have lots of moles
• you are taking medicines or using creams that make your skin sensitive to sunlight
• you have a medical condition made worse by sunlight
• you have had skin cancer or someone in your family has had skin cancer
• sunlight has already badly damaged your skin

The HSE's advice also includes important points to consider before you decide to use a sunbed. For example, if you use a sunbed, the operator should advise you on your skin type and how many minutes you should use the machine for.

It is now illegal for under-18s to use sunbeds. The Sunbeds (Regulation) Act, which came into force in April 2011, prevents those under 18 from:

• being allowed to use tanning salons and sunbeds at premises including beauty salons, leisure centres, gyms and hotels
• being offered the use of a sunbed
• being allowed to be in an area reserved for sunbed users

Check your skin

As well as staying safe in the sun, you should regularly check your skin for any abnormalities that do not improve after a few weeks. This can help lead to an early diagnosis and improve the chances of successful treatment.

Read more about the signs of non-melanoma skin cancer.

Want to know more?

• Cancer Research UK: SunSmart.
• HSE: Reducing health risks from the use of ultraviolet (UV) tanning equipment (PDF, 93kb).