Short guide to choices when managing BCCs and SCCs

Treatment

Invasive SCC & keratoacanthoma

Superficial BCCs & SCC in situ (Bowen’s)

Nodular & other BCCs

Actinic keratoses

Surgical excision

(Most cases will be amenable to simple excision and direct primary closure)

Treatment of choice for almost all SCCs.  Minimum clinical margin of 4mm.  Greater margin for higher risk tumours.

Benchmark treatment but often non excisional treatments are appropriate.  See options below

Treatment of choice except for tumours to be considered for margin control approach.  Minimum 3mm but usually 4mm clinical margin.

Not a treatment of choice unless there is doubt over diagnosis and invasive SCC to be excluded.

Margin control surgery including Mohs surgery and “Slow Mohs”

Occasional usage, especially for difficult tumours on “H zone” ^##

Not applicable - excessive

Mohs is benchmark approach for recurrent, poorly defined or > 1 cm on H zone ^## or on the rest of face when both poorly defined and > 1 cm in diameter.

Not applicable - excessive

Delineating curettage followed by surgical excision

As an alternative when Mohs surgery is contemplated.  Supervised training in this specialised technique is essential.

Not applicable - excessive

As an alternative when Mohs surgery is contemplated.  Contraindicated on nose.  Supervised training is essential.

Not applicable – excessive

Cryotherapy

(Requires histologic confirmation and follow up except when used for Actinic keratoses)

Contraindicated

Efficacy inadequate

Prolonged 30 sec freeze with 3mm margin or freeze / thaw / freeze with 3mm margin.  Better combined with curettage prior to cryotherapy. 

Avoid on face

Contraindicated

Efficacy inadequate

Benchmark approach for individual lesions.  5-10 second freeze cycle directly to the lesion.  Unsuitable for field change.

Curettage

(Training essential.

Always send curettings for histology.

Follow up essential)

Contraindicated

Efficacy inadequate

Serial curette often appropriate.  Consider supplementary ablation of further tissue layer with cryotherapy or diathermy

Efficacy poor.

Consider only for very small well defined nodular BCCs when excisional surgery not appropriate

Not a treatment of choice – consider when hyperkeratotic or diagnosis in doubt.

Imiquimod

(Aldara ®) ^∞∞

(Follow up essential)

Not TGA approved

Efficacy inadequate based on clinical trials

Not TGA approved for Bowen’s

Not TGA approved

Efficacy inadequate based on clinical trials

Suitable for field change on face & scalp, treating ¼ of face at a time.  Minimum 3 times per week for 4 weeks.

Consider for biopsy proven superficial BCCs when not on H zone ^## & when surgery inappropriate

5 fluorouracil

(Efudix ®) ^∞∞

(Follow up essential)

Not TGA approved and efficacy inadequate based on clinical trials

Not TGA approved for superficial BCC

Not TGA approved

Efficacy inadequate based on clinical trials

Suitable for field change.  Twice daily for 2 to 4 weeks.  Regular reviews needed.

Suitable for Bowen’s when localised & biopsy proven when surgery inappropriate

Diclofenac

(Solaraze ®) ^∞∞

Not TGA approved and efficacy inadequate based on clinical trials

Not TGA approved and efficacy inadequate based on clinical trials

Not TGA approved

Efficacy inadequate based on clinical trials

Suitable for field change but efficacy limited.  Twice daily for 90 days.

Photodynamic therapy ^∞∞

TGA Approved

^{MAL -  Metvix (Galderma)}

Contraindicated

Efficacy inadequate

Not TGA approved

Consider when localised biopsy proven, not on H zone ^## and surgery inappropriate

Consider only for very thin nodular BCCs not on H zone ^##

Suitable for field change to face and scalp ^∞∞

Photodynamic therapy ∞∞

ALA

Tru PDT (Allmedic)

Photodynamix therapy

ACP – 5 ALA

Photocure

Contraindicated

Not TGA approved

Safety & efficacy unknown

Contraindicated

Not TGA approved

Safety & efficacy unknown

Contraindicated

Not TGA approved

Safety & efficacy unknown

Contraindicated

Not TGA approved

Safety & efficacy unknown

Superficial X Ray therapy

(Largely when patient declines surgery)

Consider when biopsy proven and surgery inappropriate in older patients in difficult locations

Contraindicated - excessive

Consider when biopsy proven and tumour well defined only when surgery inappropriate in older patients

Contraindicated - excessive

Radium

weed (Euphorbia

peplis), Milk vetch, Alovera

Contraindicated

Efficacy inadequate

Not TGA approved

Contraindicated

Efficacy inadequate

Not TGA approved

Contraindicated

Efficacy inadequate

Not TGA approved

Contraindicated

Efficacy inadequate

Not TGA approved

PEP005 - Peplin (Ingenol

Mebutate)

Contraindicated

Efficacy inadequate

Contraindicated

Trials pending

Not TGA approved

Contraindicated

Efficacy inadequate

Contraindicated

Trials pending

Not TGA approved