Skin cancer (non-melanoma)

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.

Speak to your GP if you have any skin abnormality that hasn't healed after 4 weeks. Although it is unlikely to be skin cancer, it is best to be sure.

Read more about the symptoms of non-melanoma skin cancer

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 2 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

Read more about the causes of non-melanoma skin cancer

Who is affected?

Non-melanoma skin cancer is one of the most common types of cancer in the world. It 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.

Your GP may refer you urgently, within 2 weeks, for squamous cell skin cancer. Basal cell skin cancers usually don't need an urgent referral but you should still see a specialist within 18 weeks. Read a guide to NHS waiting times.

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.

Read more about diagnosing non-melanoma skin cancer

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 to 5% of cases.

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

Read more about treating non-melanoma skin cancer

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.

Read more about sunscreen and sun safety

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.

When to seek medical advice

If you develop a lump, lesion or skin discolouration that hasn't healed after 4 weeks, speak to your GP. While it is unlikely to be cancer, it is best to be sure.

Read further information:

• Cancer Research UK: Skin cancer symptoms
• Macmillan: Symptoms of skin cancer

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 3 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 2 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

Read further information:

• Cancer Research UK: Skin cancer risks and causes.
• Macmillan: Risk factors and causes of skin cancer.

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.

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of skin cancer and refer people for the right tests faster. To find out if you should be referred for further tests for suspected skin cancer, read the NICE 2015 guidelines on Suspected Cancer: Recognition and Referral.

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.

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.

Read further information:

• 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 2 or 3 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.

Electrochemotherapy

Electrochemotherapy is a possible treatment for non-melanoma skin cancer. It may be considered if:

• surgery isn't suitable or hasn't worked
• radiotherapy and chemotherapy haven't worked

The procedure involves giving chemotherapy intravenously (directly into a vein). Short, powerful pulses of electricity are then directed to the tumour using electrodes.

These electrical pulses allow the medicine to enter the tumour cells more effectively and cause more damage to the tumour. The procedure is usually carried out using general anaesthetic (where you're asleep) but some people may be able to have local anaesthetic (where you're awake but the area is numbed).

Depending on how many tumours need to be treated, the procedure can take up to an hour to complete. The main side effect is some pain where the electrode was used, which can last for a few days and may require painkillers.

It usually takes around 6 weeks for results to appear and the procedure usually needs to be repeated.

Your specialist can give you more detailed information about this treatment option.

Read the NICE (2013) guidelines on Electrochemotherapy for metastases in the skin.

Read further information:

• Cancer Research UK: Treating skin cancer.
• Macmillan: Treatment for skin cancer.