What is a BCC?

BCCs are skin cancers that are caused by sun exposure. They are the least dangerous but most common out of the skin cancers. However if they are untreated they can result in local destruction leading to disfigurement.

Where do they occur?

They often occur on areas of sun exposure, face shoulders, head and neck. Those who have occupations where they have experienced a lot of sun exposure are at particular risk and those with fair skin.

How should I avoid BCC?

Cover up areas exposed to the sun, try to use High Factor Sun lotions. Avoid tanning salons.

How do BCCs present?

Different types of BCC can present (Superficial, Nodular, Morpheic), the appearances may vary.

An area of ulceration, that fails to heal

A red patch on the skin that fails to heal

A shiny raised nodule, with small thread like vessels running through it

A diffuse white, scar like area which has a very ill defined edge.

Non Surgical Treatments

Topical ointments - Efudix cream - chemotherapeutic agent effective against superficial BCCs

Cryotherapy - the BCC is frozen - disadvantage of this technique not tissue is taken for biopsy

Radiotherapy

Photodynamic therapy (PDT) - light therapy is used to kill skin cancer cells

Should I stop anticoagulation medication?

Ideally these should be stopped before the operation (Clopidrogrel, Aspirin , Warfarin , Rivoroxabin).

What does surgery involve?

Many BCCs require surgical excision with a margin of normal tissue (3-4mm).This is a day case local anaesthetic procedure and rarely do patients require general anaesthesia unless the case involves complex reconstructive work.

If it is a cosmetically sensitive area with an ill defined BCC, I often refer to colleagues to perform Moh’s micrographic surgery. This technique preserves cosmetically sensitive tissue. Most defects can be closed primarily but if this is not possible a skin graft or a local tissue flap may be needed (see pictures).

I remove sutures at 1 week and patients skin grafts and flaps are checked at the same time.

What are complications of surgery?

Poor scarring

Distorting facial structures

Infection

Delayed healing

Graft loss

Flap loss

Bleeding

Wound breakdown

Facial Nerve injury

Incomplete excision - 5% risk

Further surgery

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What is SCC?

Second commonest type of skin cancer secondary to sun exposure. SCCs can appear as scaly red patches, open sores, rough, thickened or wart-like skin, or raised growths with a central depression. These skin cancers often develop on areas of skin regularly exposed to the sun, such as the face, ears, hands, shoulders, upper chest and back.

What are the risk factors for SCC?

Unprotected exposure

Weakened immune system

History of skin cancer

Pale skin

Chronic infections

Precancerous lesions such as Actinic Keratosis

What is Bowen’s disease?

Bowen's disease is a precancerous form of Squamous cell carcinoma SCC sometimes referred to as squamous cell carcinoma in situ. It develops slowly and can be treated with surgical excision.

Surgical Treatment of SCC

Surgery is the main treatment for SCC, and involves removing the cancerous tumour and some of the surrounding skin.

What does surgery involve?

Most often the tumour can be removed under local anaesthesia and closed directly. If however the SCC is left untreated it can cause significant skin damage that may need reconstructive surgery. The defects can be closed with local tissue flaps or skin grafts (See pictures).

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What is Malignant Melanoma?

Melanoma is a type of skin cancer that can be serious. It can come in different severities and there is a risk that It can spread to other organs in the body.

How does it present?

The most common sign of melanoma is the appearance of a new mole or a change in an existing mole. This can happen anywhere on the body, but the most commonly affected areas are the back in men and the legs in women. Melanomas are uncommon in areas that are protected from sun exposure, such as the buttocks and the scalp. In most cases, melanomas have an irregular shape and are more than 1 colour. They can present on the face, limbs, back (See Pictures)

The mole may also be larger than normal and can sometimes be itchy or bleed. Patients should look out for a mole that gradually changes shape, size or colour.

What are the types of Melanoma?

Superficial spreading melanoma - Most common - these usually grow outwards

Nodular melanomas - usually appear as a changing lump on the skin

Lentigo maligna melanoma - usually present in older patients and start with a freckle that is usually darker than a normal freckle

Acral lentiginous melanoma - usually grown on palms of hands and soles of feet - they can sometimes involve around the nail complex

Amelanotic melanoma - have no colour and present as red lesions

What causes Melanoma?

Skin cells develop abnormally due to UV radiation from the sun. Evidence suggests that sun exposure can cause melanoma. One is at increase chance, if they have pale skin, a high number of moles, a family member who has had melanoma. 16000 people a year are diagnosed with melanoma each year in the UK.

What happens if a mole looks suspicious?

If the mole has Asymmetry, Border irregularity, Colour variation and an increased Diameter (ABCD), an excision biopsy is performed under local anaesthesia. It is important to look for these changes.

Asymmetry

Border

Colour

Diamater

Enlargement

The pneumonic ABCDE is useful for analysis.

How to prevent melanoma?

Avoid sunbeds and sun exposure, particularly if you have pale skin and moles.

Make sure you regularly check your skin

Use high SPF sunscreen

How do you treat Melanoma?

The main treatment for melanoma is surgery. At early stages of the disease surgical treatment is successful and curative.

At an advanced stage surgical treatments may not be effective and treatment is mainly used to slow the spread of the melanoma. Certain novel medications can be used that target specific genetic changes in the melanoma or medicines that use the body’s immune system against the melanoma.

What does surgery involve?

Once biopsy confirmation is made, you will have a wide local excision (WLE) of the melanoma scar. The width of the excision will depend on the depth of the melanoma. In some cases up to 2cm - often the defects can be closed primarily but in some scenarios a split thickness skin graft will be needed to cover the wound or a local flap . One type of common flap is a Keystone Perforator flap (see Pictures)

At the same time as this WLE, you will also have a sentinel node biopsy. This test can provide prognostic information and can ascertain if the melanoma has spread to the lymph glands. If it is positive you will be referred for consideration of further oncological treatment.

Surgery if performed as a day case general anaesthetic procedure.