Being outdoors in summer is a great part of life in Australia but it's also the reason Australians have extremely high rates of sun damage and skin cancer. To protect your skin use the Sunsmart UV Alert Guide to look up daily UV levels and sun protection recommendations. It's a great way to plan your activities and sun protection to maximise your skin safety. You can look up the UV Alerts from this website, or download an application to your smartphone.

To maximise your skin safety follow this Australian Cancer Council advice:

• minimise sun exposure when the SunSmart UV Alert is >3
• minimise sun exposure between 10am and 3pm when UV levels reach their peak
• seek shade
• wear a hat that covers the head, neck and ears
• wear sun protective clothing
• wear close-fitting sunglasses
• and wear an SPF30+ sunscreen

If you've ever doubted the effectiveness of sunscreen, the video below is an amazing demonstration of how you look to the sun with and without sunscreen. Please take the time to watch it - and keep watching until the sunscreen goes on!

When you're applying sunscreen be sure to ask someone for assistance if there are exposed areas of your skin that you cannot reach - otherwise you may find yourself in pain with sunburn like this man pictured on the left. Ouch! Sunburn increases your risk of melanoma, squamous cell carcinoma and basal cell carcinoma, as well as ageing your skin prematurely - so if you can't find someone to help you apply sunscreen then keep your shirt on!

The Sunsmart UV alert guide can also be found at the Sunsmart website.

Skin Checks

The Australian Cancer Council recommends that all adults, particularly those aged 40 and over, should:

• become familiar with their skin
• check all areas of their skin, including skin not normally exposed to the sun
• look for changes in shape, colour or size, or a new spot – if you notice anything unusual, see your doctor straight away
• seek assistance from others to check difficult to see areas, such as their back.

You should have your skin checked at least once a year; if you are at high risk of skin cancer then checking your skin at least every 3 months is wise. This Body Map, a mirror and the Sunsmart 5 steps for skin self-examination are very useful tools to help you perform a skin self-examination. Many people find that doing a skin check with a close friend or family member makes it easier to see difficult areas (like behind your ears, and on your back).

To help you know what you are looking for Sunsmart has produced a 2 page PDF guide to skin cancers, warning signs and harmless spots that can be viewed here: How to check for skin cancers.

If you have any concerns about your skin always seek assistance from a qualified health professional. Where there is doubt or uncertainty about a skin lesion a biopsy is a reliable method of determining what treatment you need.

 

 

 

What is squamous cell carcinoma?

Squamous cell carcinoma (SCC) is a type of skin cancer. It arises from keratinocytes (a particular type of cell) in the skin. It is a malignant condition that has the potential to spread around the body. Luckily if caught early the condition is usually fully treated with surgery.

What is SCC in situ (Bowen’s disease)?

Squamous cell carcinoma in situ (SCC in situ, Bowen’s disease) is an early form of SCC that is yet to invade to the dermal layer of the skin. It is a pre-malignant condition, which means that SCC in situ is a tumour that has not yet developed the capacity to spread. In some instances SCC in situ can be successfully treated with 5-fluorouracil cream; it can also be treated surgically. Speak with your surgeon about what treatment options are most appropriate in your individual circumstances.

What is a keratoacanthoma?

A keratoacanthoma is thought to be a “good” or "favourable" version of a squamous cell carcinoma. They tend to grow rapidly and are indistinguishable from a SCC when you look at them on the skin. Because they are indistinguishable from a rapidly growing SCC the recommended treatment is to have them excised and the tissue examined by a pathologist. Only then can the correct diagnosis be made. If left alone a true keratoacanthoma will regress after it goes through its rapid growth phase, but it may leave a visible scar (which remains even after the anxiety about the uncertainty of the diagnosis settles).

Appearance

SCCs are commonly raised and scaly. However, they can have variable appearances – they may instead look like an ulcer. Other tumours like a keratoacanthoma, SCC in situ or basal cell cancer may be indistinguishable from an SCC when examined on the skin.

Some people have considerable sun damage and have a variety of scaly patches of skin (called "solar keratosis" or "actinic keratosis"). In this instance a worrying sign is a rapid or progressive change in the size of a scaly raised patch, or if the patch becomes sore, inflamed or red.

Treatment

The majority of favourable SCCs can be excised with a margin of 4mm or more, which gives a very high chance of achieving complete clearance. If the pathology results show that the microscopic margin is less than 1mm your surgeon will usually recommend further excision to reduce the risk of recurrence. If you have an aggressive type of SCC a larger margin of surrounding skin is usually excised. The prognosis is best for SCCs that are small, well defined, excised early, excised completely and not invading nerves or other structures.

In some instances treatment can be performed through curettage or dry ice. These are valuable treatment methods, especially in people who regularly develop new skin lesions. A downside of this type of treatment is that you cannot be sure if the SCC has been completely removed. If a SCC recurs after curettage or dry ice it is sensible to have it excised surgically, so that a pathologist can examine the specimen and confirm whether the SCC has been completely removed.

Surgery can be done under local anaesthetic, or under sedation anaesthetic, or general anaesthetic. If the BCC is small it will likely be excised and the skin edges stitched together. If it is bigger then a skin flap or skin graft may be required. Your surgeon will explain the options, risks and benefits of each type of reconstruction to you.

Once the cancer is excised the tissue is sent to a pathologist and examined under the microscope to determine if the cancer has been completely excised and how much of a clear margin around the cancer has been achieved. These results are not obtained at the time of surgery, so if the results show that the cancer has not been completely excised your surgeon will recommend additional surgery so that a complete excision can be achieved. This is important to reduce the chance of the cancer coming back.

During your recovery you should keep your hand elevated higher than your heart to reduce swelling and keep your dressings dry and intact. A sling may be helpful in keeping your hand elevated. The surgery is not usually particularly painful and usually over the counter medications such as paracetamol and/or ibuprofen will be sufficient to keep you comfortable. Your surgeon may place a splint on your hand to reduce movement during the healing stage, to prevent you stretching out the wound in the first 1-2 weeks. Your surgeon will usually be able to predict this before the operation so you can plan how much time off work or how much assistance at home you will need.

Can I use an anti-cancer cream?

An anti-cancer cream with the active ingredient of 5-fluorouracil is effective in treating SCC in situ, but is not recommended for the treatment of squamous cell carcinoma. If you are treating an SCC in situ with 5-fluorouracil cream and it is not getting better I would suspect that it has progressed to be a SCC (progressed from a pre-malignant tumour to a malignant cancer).

Spread

Spread to lymph nodes occurs in around 2-5% of people and is more likely to happen in people with larger skin cancers, inadequate excisions, multiple recurrences and a variety of specific pathological features (in SCCs that look “bad” under the microscope).

If you have symptoms or signs to suggest that your skin cancer has spread to the lymph nodes this will need to be investigated and treated. Your surgeon will be able to advise you about this.

Risk factors

The main risk factors for the development of squamous cell carcinoma are chronic exposure to UV light and immunosuppression.

Will I need radiotherapy or chemotherapy?

It is unusual to need radiotherapy for a simple SCC – radiotherapy (and, to a lesser extent, chemotherapy) is generally reserved as an additional treatment for very extensive skin cancers that have spread to the lymph nodes or have invaded deep structures (like bone or muscle).

Follow up

You will have post op visits scheduled to learn the pathology results, check the wound, remove any non-dissolving sutures, receive advice about scar management and answer any questions you have. Sutures on the hand and fingers are usually removed after 10-14 days. After the wound is healed you will also have follow-up visits scheduled to check for recurrence of the SCC. The frequency and duration of these follow-up visits will depend on multiple factors including your pathology results, how far away you live from your surgeon and whether your GP is happy to be involved in the follow-up.

Complications

It is rare to have significant complications from this type of surgery. Possible complications include:

• incomplete excision of the skin cancer, requiring further surgery
• infection, usually requiring antibiotics in tablet form
• bleeding, which is usually a nuisance rather than a major complication
• bad/visible/worse-than-expected scarring
• partial or complete loss of a skin graft (uncommon, may require further surgery)
• wound breakdown (uncommon, may require further surgery)
• recurrence of the cancer in the same area in the subsequent months or years

Prevention

Once you have had one skin cancer it is wise to take steps to prevent the development of future skin cancers. Often patients who have had a skin cancer tell me, incorrectly, that they don’t see any point to starting to protect their skin from the sun because they’ve already had large amounts of sun exposure during their lifetime. We know that limiting sun exposure after you develop your first (or hundredth) skin cancer will reduce the likelihood of you developing further skin cancers. So do be SunSmart and heed the “Slip! Slop! Slap!” message – but equally don’t become so scared of the sun that it stops you from enjoying life in Australia.

For more information and recommendations on skin cancer prevention please click here.

Basal cell carcinoma (BCC) the most common but least dangerous type of skin cancer. It develops from cells in the basal layers of the epidermis.

Appearance

There are different types of basal cell carcinomas so not every BCC looks the same. They commonly have raised borders, a pearly central area and visible small blood vessels. They may be scaly or look like a scar or chronically inflamed patch of skin. Some BCCs are pigmented, but this is unusual.

Risk factors

Risk factors for the developing basal cell carcinoma are chronic exposure to UV light, fair skin, immunosuppression and the rare conditions xeroderma pigmentosum and Gorlin syndrome.

Surgical Treatment

The majority of BCCs are favourable and can be removed surgically with a margin of 2-3mm of surrounding skin with a very high chance of complete clearance. If the pathology results show that the microscopic margin is less than 0.5mm your surgeon will usually recommend further excision to reduce the risk of recurrence. If you have an aggressive type of BCC a larger margin of surrounding skin is usually excised. The prognosis is best for BCCs that are small, well defined, excised early, excised completely and not invading nerves or other structures.

Surgery can be done under local anaesthetic, or under sedation anaesthetic, or general anaesthetic. If the BCC is small it will likely be excised and the skin edges stitched together. If it is bigger then a skin flap or skin graft may be required. Your surgeon will explain the options, risks and benefits of each type of reconstruction to you.

Once the cancer is excised the tissue is sent to a pathologist and examined under the microscope to determine if the cancer has been completely excised and how much of a clear margin around the cancer has been achieved. These results are not obtained at the time of surgery, so if the results show that the cancer has not been completely excised your surgeon will recommend additional surgery so that a complete excision can be achieved. This is important to reduce the chance of the cancer coming back.

During your recovery you should keep your hand elevated higher than your heart to reduce swelling and keep your dressings dry and intact. A sling may be helpful in keeping your hand elevated. The surgery is not usually particularly painful and usually over the counter medications such as paracetamol and/or ibuprofen will be sufficient to keep you comfortable. Your surgeon may place a splint on your hand to reduce movement during the healing stage, to prevent you stretching out the wound in the first 1-2 weeks. Your surgeon will usually be able to predict this before the operation so you can plan how much time off work or how much assistance at home you will need.

Scar prevention

For information on scars and prevention after surgery please click here.

Can I use an anti-cancer cream instead of surgery?

There is a cream that can be applied 5 times a week for 6 weeks to treat superficial basal cell carcinoma. The active ingredient is imiquimod, which is prescribed and sold under the tradename of Aldara.

Imiquimod is an immune modulator which activates the immune system to cause death of the BCC cells. Studies show a success rate of around 80% in clearing the BCC at 5 years. It is ineffective in 5% of the population, because these 5% lack a certain type of cell receptor that is needed for the active ingredient to work.

Using an anti-cancer cream to treat BCCs is a valid option. However, you need to have a biopsy to ensure that your BCC is of the superficial type, then apply the cream for 6 weeks and you will need follow up for a couple of years to ensure that the BCC has been adequately treated. For these reasons I almost always recommend surgical treatment of basal cell carcinomas, because I believe it offers my patients the most reliable and predictable outcome.

Will I need radiotherapy or chemotherapy?

It is unusual to need radiotherapy for a simple BCC – radiotherapy is generally reserved as an additional treatment for very extensive skin cancers. You will not need chemotherapy. Rarely BCCs are treated with radiotherapy only; there are downsides to this and it is not the usual approach to treatment.

Follow up

You will have post op visits scheduled to learn the pathology results, check the wound, remove any non-dissolving sutures, receive advice about scar management and answer any questions you have. Sutures on the hand and fingers are usually removed after 10-14 days. After the wound is healed you will also have follow-up visits scheduled to check for recurrence of the BCC. The frequency and duration of these follow-up visits will depend on multiple factors including your pathology results, how far away you live from your surgeon and whether your GP is happy to be involved in the follow-up.

The good news about BCCs is that they are not known for spreading (metastasizing) to other body sites. Once the BCC is treated you do not have to worry that it will appear in your lymph nodes or other organs. It is important, however, that you perform regular skin checks and seek medical attention if you have any new skin lesions or spots. If you have developed one BCC there is a reasonable chance that you will develop another during your lifetime.

Complications

It is rare to have significant complications from this type of surgery. Possible complications include:

• incomplete excision of the skin cancer, requiring further surgery
• infection, usually requiring antibiotics in tablet form
• bleeding, which is usually a nuisance rather than a major complication
• bad/visible/worse-than-expected scarring
• partial or complete loss of a skin graft (uncommon, may require further surgery)
• wound breakdown (uncommon, may require further surgery)
• recurrence of the cancer in the same area in the subsequent months or years

Prevention

Once you have had one skin cancer it is wise to take steps to prevent the development of future skin cancers. Often patients who have had a skin cancer tell me, incorrectly, that they don’t see any point to starting to protect their skin from the sun because they’ve already had large amounts of sun exposure during their lifetime. We know that limiting sun exposure after you develop your first (or hundredth) skin cancer will reduce the likelihood of you developing further skin cancers. So do be SunSmart and heed the “Slip! Slop! Slap!” message – but equally don’t become so scared of the sun that it stops you from enjoying life in Australia.

 For more information and recommendations on skin cancer prevention please click here.

"Efudix®" is the brand name of a cream that contains fluorouracil. Fluorouracil (5-FU) is a chemotherapy agent that has been used in the treatment of cancer for many decades. It is prescribed as a topical treatment for the skin conditions solar keratosis and Bowen's disease (also called squamous cell carcinoma in situ or intraepidermal squamous cell carcinoma).

Solar keratoses and Bowen's disease are common precancerous skin conditions that are the result of sun damage. Even if you have been careful about sun exposure in recent years, you may have accumulated sufficient ultraviolet (UV) exposure that you are at risk of continuing to develop these conditions in the future.

Solar keratoses

Solar keratoses initially start as small tan, brown, or reddish-brown scaly patches on the skin. They commonly occur on sun-exposed areas of skin (face, ears, bald scalps, hands, forearms and legs). Without treatment a small number of solar keratoses can develop into squamous cell cancer (SCC).

Bowen's disease (Squamous Cell Carcinoma in situ)

Bowen's disease appears as a dull red, raised, crusted, scaly patch or plaque. They commonly occur on sun-exposed areas of skin (face, ears, bald scalps, hands, forearms and legs).

How does fluorouracil work?

Fluorouracil interferes with cell reproduction. Because the precancerous cells grow faster than normal cells they are more susceptible to the fluorouracil, so the fluorouracil will clear the solar keratoses and SCC in-situ (Bowen's disease) and leave the normal skin intact.

How do I apply the cream?

There are a variety of regimens described for using fluorouracil cream. Most of these involve applying it once or twice a day, for 3-4 weeks. The cream can be applied with a clean finger, a gloved finger or a non-metal applicator. The cream can be applied to any area of skin (as directed by your doctor), but you should take care to avoid the eyes. Wash your hands thoroughly after each use.

What can I expect?

It is very important to understand that your skin will react during the treatment. Some people have a mild reaction, others have a severe reaction. The reaction involves redness, inflammation, irritation, crusting and peeling. If you are using the fluorouracil cream on your face you may find that the redness and inflammation makes you self conscious and that you do not wish to be seen in public while your face looks like this.

The reaction is a sign that the treatment is working. You may develop redness and inflammation in nearby areas of skin that did not appear to have any abnormalities. This is because there may be abnormal cells in your skin that were not visible. If you have many abnormal cells and lesions you can expect to develop more redness and inflammation than a person who has a single area of abnormality.

If you have a severe reaction, especially if you develop ulceration, it may be appropriate to reduce the frequency with which you are applying the cream. If this is your first time using fluorouracil cream it is a good idea to plan a routine check in with your doctor after 2 weeks of treatment. If you develop significant pain and/or ulceration during the treatment then temporarily stop using the cream and request an urgent review with your doctor. If you stop applying the cream your skin will gradually return to normal. If you have already been using the cream for 3 or 4 weeks your doctor may advise that you can stop using the cream; if you have only been using it for 1 or 2 weeks you may be advised to recommence treatment with a reduced frequency of application. 

It usually takes 2-4 weeks for your skin to return to normal after you finish applying the fluorouracil cream. This varies according to the duration of your therapy and the severity of your skin reaction.

Other side effects are rare, but it is possible to develop areas of depigmentation at the site of the original lesions, sun sensitivity and new small blood vessels (telangiectasia). True allergy to the cream is very unusual. Occasionally patients develop systemic symptoms such as mild nausea, loss of appetite and tiredness during treatment.

Contraindications

Do not use fluorouracil cream if you are pregnant or breast feeding.

Other tips for use

• Avoid sun exposure throughout and immediately after treatment (mandatory). It is preferable to use this therapy during winter months for this reason.

• Take care if applying the cream to the fold between the nose and cheek, as this area is prone to irritation.

• Consider treating a single area at a time. For instance, rather than treating both hands simultaneously you may wish to try treating your left hand first, and your right hand after you have finished treatment of the left. If you prefer to sleep on your side you may find it better to treat each side of your face separately. That said, some patient say that it's better to treat the whole face at once and get it over and done with, rather than prolonging the experience.

• Where possible, try to avoid starting treatment of your face in the weeks immediately before an important social engagement (like your daughter's wedding).

• Sometimes severe inflammation and ulceration can be helped by applying a prescription anti-inflammatory cream (only use this on the advice of your doctor).

• Do not use other creams, lotions or cosmetics on the area of skin you are treating with fluorouracil cream.

• If you forget to apply the cream one day then simply recommence use the following day. Do not double the dose or apply it more frequently to make up for it.

• Only use the cream on the direction of a doctor - do not use left over cream to treat other spots on yourself or others, even if you are sure they are exactly the same thing.

• Do not cover the areas of treatment unless your doctor specifically advises you to do so.

• Avoid application to the mouth, eyes, vagina and anus as these mucous membranes are prone to inflammation, ulceration and possibly even tissue necrosis (tissue death).

• Treatment is very effective, but may need to be repeated in the future if new skin lesions (solar keratoses or SCC in situ) develop.

• If a solar keratosis or SCC in situ does not clear with therapy it will definitely require biopsy and usually require surgical excision; until proven otherwise assume that the reason it has not cleared is because it is a skin cancer.

• Seek advice from your doctor or pharmacist if you have any queries.

• If you are searching for information online please note that Efudix® is called Efudex® in the United States.

Further resources

Product information

Patient blogs on Efudix experiences

Patient story and photos - Lisa, aged 42 (nose)

Patient story and photos - John during July and August 2009 (face)

Patient story and photos - Kirstie, aged 31 (face)

Patient photo - Glenyce after 3 weeks of treatment (face)

 

Melanoma is responsible for most skin cancer deaths and is unfortunately on the increase, but over 95% of melanomas can be cured if they are detected and treated early. Australia has the highest rate of melanoma in the world; one in 14 Australian males and 1 in 22 females will develop melanoma in their lifetime (to age 85).

Who is at risk?

Melanoma can occur at any age but is rare before puberty. Individuals who are at highest risk are those who:

• are over 55 years old (6 out of 10 melanomas occur in people aged >55)
• have fair skin that burns easily, freckles and does not tan
• have had severe sunburns in the past, especially in childhood
• have many moles on their body, especially irregular moles (called "dysplastic naevi")
• have naturally fair or red hair, with blue or green eyes
• have a family history of melanoma
• have been previously diagnosed with other types of skin cancers (including melanoma, basal cell carcinoma and squamous cell carcinoma)

The development of melanoma is heavily related to UV exposure. Painful or blistering sunburns increase your risk of melanoma. Intermittent sun exposure (such as sun holidays) increase your risk more than stable levels of sun exposure. Solarium use may increase your risk of melanoma, so avoid sun beds and tanning salons.

A risk calculator has been developed that allows Australians to calculate your risk of developing melanoma in the next 5 years.

Click here for the calculator developed for members of the general public

Click here for the calculator developed for health professionals

Prevention 

Follow the Australian Cancer Council advice: avoid sunburn by minimising sun exposure when the SunSmart UV Alert exceeds 3 and especially between 10am and 3pm when UV levels reach their peak. Seek shade, wear a hat that covers the head, neck and ears, wear sun protective clothing and close-fitting sunglasses, and wear an SPF30+ sunscreen. You can use the Sunsmart UV alert guide in the left hand column of this website to find out what today's UV levels and sun protection recommendations are - it can also be seen at the sunsmart.com.au website or you can download an iPhone app.

Skin Checks

The Australian Cancer Council recommends that all adults, particularly those aged 40 and over, should:

• become familiar with their skin
• check all areas of their skin, including skin not normally exposed to the sun
• look for changes in shape, colour or size, or a new spot – if you notice anything unusual, see your doctor straight away
• seek assistance from others to check difficult to see areas, such as their back.

You should have your skin checked at least once a year; if you are at high risk of skin cancer then checking your skin at least every 3 months is wise. This Body Map and the Sunsmart 5 steps for skin self-examination are very useful tools to help you perform a skin self-examination. You will also need a mirror, and many people find that doing a skin check with a close friend or family member makes it easier to see difficult areas (like behind your ears, and on your back). To help you know what you are looking for Sunsmart has produced a 2 page PDF guide to skin cancers, warning signs and harmless spots that can be viewed here: How to check for skin cancers.

If you have any concerns about your skin always seek assistance from a qualified health professional. For skin lesions where there is doubt or uncertainty a biopsy is a reliable method of determining what treatment you need.

What does a melanoma look like?

Melanomas do not all look the same, as you can see from the images on this page. They often have the following features:

• Asymmetry
• Border irregularity
• Colour variation
• Diameter (large - greater than 6mm)
• Elevated (although early melanomas can be completely flat)
• Firm
• Growing

Melanomas are not all brown, black or pigmented. Some melanomas are pink.

 Click here to read information about melanoma treatment.

Melanomas (left) versus normal moles (right)