Page 70 - IDF Journal 2023

IDF – Webinar Series IDF News – Spring 2023
Recent Advances in the Management of Non-melanoma Skin Cancer
70
Dr Sunil Chopra
Non-melanoma skin cancer presents both diagnostic
and treatment challenges
in the clinical dermatology setting. This review will
focus on actinic keratosis (AK), squamous cell carcinoma (SCC), and basal cell carcinoma (BCC). In all cases, exposure to sunlight
is a major risk factor and leads to these malignancies occurring on exposed skin. Non-melanoma skin cancers are rarely life-threatening, but they can cause considerable distress to patients, particularly when they occur on the face, neck and head. Damage to facial features or ears through malignant tissue damage or ablative surgery can lead to permanent disfigurement.
Actinic keratosis
Actinic keratosis is the most common pre-malignant skin disease, particularly
in pale-skinned populations. It presents initially as dry scaly skin, which is due to intra-epidermal dysplasia of histologically atypical keratinocytes. As it develops, the skin can become inflamed and painful, but it is often asymptomatic and, if untreated, the dysplasia can penetrate the entire thickness of the skin. At this stage it is known as Bowen’s Disease.
A pre-existing AK lesion is a major risk factor for the development of SCC. AKs on the lips and ears are at particular risk so the diagnosis of AK needs to be established at the earliest opportunity.
The preferred first-line treatment for AK is topical. Topical treatments for AK include 5-fluorouracil (5-FU) cream, imiquimod cream, diclofenac gel, and light- activated (photodynamic) therapy using aminolevulinic acid.
Topical treatment with 5-FU cream is often used for multiple AKs present on the scalp or forehead. 5-FU is an anti- metabolite used in cancer chemotherapy. The treatment produces inflammation, and the skin can become very painful and red (see Figure 1). Imiquimod cream is
an immune response modifier and also causes an inflammatory response (see Figure 2).
Topical treatment of AK is the preferred first-line treatment for smaller lesions and widespread multiple lesions. Patient compliance for self-administered topical treatments is of concern and non- compliance is exacerbated when the
Figure 1. Inflammatory response following 4 weeks’ treatment of multiple actinic keratoses with 5-fluorouracil cream (twice daily for
4 weeks).
Figure 2. Inflammatory response following 3 weeks’ treatment of multiple actinic keratoses with imiquimod (thrice weekly for
3 weeks).
treatment causes a painful inflammatory response. AK lesion recurrence is frequently observed. Surgical treatments for AK may be preferred for large, deep lesions or where topical treatment has failed. Surgical treatments for AK include cryotherapy, curettage and cautery, and surgical excision.
Squamous cell carcinoma
SCC can arise in different parts of the body such as the oral cavity, oesophagus and lungs. It most commonly occurs
on the skin, and it is the second most common form of skin cancer. It is characterised by abnormal, accelerated growth of squamous cells. Most SCCs are curable if treated early. Risk factors for development of skin SCC include
sun damage, thermal burns to the skin, smoking (especially for SCC of the lip), persistent leg ulcers, immunosuppression