About this ebook

This eBook is about the two most common types of skin cancer – basal cell carcinoma and squamous carcinoma (SCC) of the skin, also called cutaneous squamous cell carcinoma. They are called non-melanoma skin cancers. This eBook is for anyone diagnosed with these types of skin cancers.

The other main type of skin cancer is called melanoma. This is a less common type of skin cancer. This eBook does not have information about melanoma. We have another booklet about this called Understanding melanoma with treatment and surgery.

The eBook explains how skin cancer is diagnosed and treated. It also has information about what to expect after treatment finishes, preventing further skin cancers and getting support. We hope it helps you deal with some of the questions or feelings you may have.

We cannot give advice about the best treatment for you. You should talk to your doctor, who knows your medical history.

How to use this eBook

This eBook is split into sections to help you find what you need. You do not have to read it from start to finish. You can use the contents list to help you.

It is fine to skip parts of the eBook. You can always come back to them when you feel ready.

At the end of the eBook, there are details of other organisations that can help.

Quotes

In this eBook, we have included quotes from people who have had skin cancer, which you may find helpful. Some are from our Online Community. The others are from people who have chosen to share their story with us. This includes Dom, who is on the cover of this eBook. To share your experience, visit macmillan.org.uk/shareyourstory

For more information

If you have more questions or would like to talk to someone, call the Macmillan Support Line free on 0808 808 00 00, 7 days a week, 8am to 8pm, or visit macmillan.org.uk

If you would prefer to speak to us in another language, interpreters are available. Please tell us, in English, the language you want to use.

If you are deaf or hard of hearing, call us using NGT (Text Relay) on 18001 0808 808 00 00, or use the NGT Lite app.

We have some information in different languages and formats, including audio, eBooks, easy read, Braille, large print and translations. To order these, visit macmillan.org.uk/otherformats or call 0808 808 00 00.

The skin and cancer

What is cancer?

Cells are tiny building blocks that make up the body’s organs and tissues. Cells receive signals from the body, telling them when to grow and when to divide to make new cells. This is how our bodies grow and heal. These cells can become old, damaged or no longer needed. When this happens, the cell gets a signal from the body to stop working and die.

Sometimes these signals can go wrong, and the cell becomes abnormal. The abnormal cell may keep dividing to make more and more abnormal cells. These can form a lump, called a tumour.

Cells forming a tumour

Not all tumours are cancer. Doctors can tell if a tumour is cancer by taking a small sample of cells from it. This is called a biopsy. The doctors examine the sample under a microscope to look for cancer cells.

A tumour that is not cancer (a benign tumour) may grow, but it cannot spread to anywhere else in the body. It usually only causes problems if it grows and presses on nearby organs.

A tumour that is cancer (a malignant tumour) can grow into nearby tissue.

Sometimes cancer cells spread from where the cancer started (the primary site) to other parts of the body. They can travel around the body in the blood or through lymph fluid which is part of the lymphatic system. When these cancer cells reach another part of the body, they may grow and form another tumour. This is called a secondary cancer or a metastasis.

Some types of cancer start from blood cells. Abnormal cells can build up in the blood, and sometimes the bone marrow. This is where blood cells are made. These types of cancer are sometimes called blood cancers.

The lymphatic system

The lymphatic system helps protect us from infection and disease. It is made up of fine tubes called lymphatic vessels. These vessels connect to groups of small lymph nodes throughout the body. The lymphatic system drains lymph fluid from the tissues of the body before returning it to the blood.

The lymphatic system has different functions:

- It drains fluid from the body’s tissues into the blood.

- It contains white blood cells called lymphocytes, which fight infection.

- It gets rid of any waste that cells make.

The skin

The skin does many things. It:

- protects the body from injury and infection

- helps to control body temperature

- helps to control fluid loss

- gets rid of waste substances through the sweat glands.

The skin is divided into two main layers. The outer layer is the epidermis and the layer underneath is the dermis. Below these is a deeper layer of fatty tissue.

The epidermis contains several types of cells. Most of the epidermis is filled with cells called keratinocytes, which are also called squamous cells. The lowest layer of the epidermis is called the basal layer. It contains rounder cells called basal cells. This layer also contains skin cells called melanocytes. Melanocytes produce a substance called melanin. This is what gives skin its natural colour.

Structure of the skin

Types of skin cancer

There are three main types of skin cancer:

- basal cell carcinoma

- squamous cell carcinoma of the skin

- melanoma.

Basal cell and squamous cell carcinoma are different from melanoma. They are called non-melanoma skin cancers.

This eBook is about non-melanoma skin cancers. We have separate information about melanoma in our booklet Understanding melanoma with treatment and surgery and on our website.

Basal cell carcinoma

Basal cell carcinoma (BCC) is the most common type of skin cancer. About 80 in 100 (80%) of skin cancers diagnosed in the UK are BCCs. BCC starts in the basal cells. Basal cells are found in the bottom (basal) layer of the epidermis. BCCs are sometimes called rodent ulcers. Most BCCs are very slow-growing skin cancers and almost never spread to other parts of the body. Nearly everyone who has treatment for a BCC is completely cured.

A small number of BCCs may come back in the same area of skin after treatment. This called a local recurrence.

Occasionally, BCCs grow more quickly. If left to grow, they may spread into the deeper layers of the skin and sometimes to the bones.

Squamous cell carcinoma of the skin

Squamous cell carcinoma of the skin is sometimes called cutaneous squamous cell carcinoma (CSCC). It is the second most common type of skin cancer in the UK. It develops from the squamous cells, which are in the outer layer of the skin. Most people treated for SCC of the skin are completely cured. Usually, SCCs are slow-growing skin cancers. They may spread to other parts of the body if they are left untreated for a long time. Sometimes they can grow more quickly and spread at an earlier stage.

Melanoma

Melanoma develops from the melanocytes. It is a less common type of skin cancer. Melanoma behaves differently to BCC and SCC. It can grow quickly and needs to be treated early. We have separate information about melanoma.

Rarer types of non-melanoma skin cancer

There are some other rare types of skin cancer:

- Merkel cell carcinoma

- Kaposi’s sarcoma

- cutaneous T-cell lymphoma (CTCL)

- sarcoma.

Less than 1 in 100 (1%) of all skin cancers in the UK are these rarer types of skin cancer.

We have more information about these cancers on our website.

Causes and risk factors of skin cancer

There are certain things that can increase the chance of developing skin cancer. These are called risk factors. Having one or more risk factors does not mean you will get skin cancer. And not having risk factors does not mean you will not develop it.

Most skin cancers are associated with overexposure to the sun. But other factors can increase your risk as well.

Sun exposure

Ultraviolet (UV) light from the sun is the main cause of most skin cancers. UV light damages the DNA (genetic material) in our skin cells and can cause skin cancer. Skin damage can occur due to exposure to the sun over a long period of time, or to being exposed to too much sun and getting sunburnt.

Because we are living longer, we are exposed to more sun during our lifetime. This means skin cancer is more common than it used to be. Skin cancer is more common in people over the age of 40 and becomes more common with age. But the number of younger people developing skin cancer is also rising.

The risks of developing skin cancer from sun exposure is greater among some groups of people:

- People with a history of sunburn or overexposure to the sun in childhood and young adulthood have a greater risk of developing BCC or SCC, or melanoma. Skin damage caused in childhood will not usually appear until many years later.

- People who work outdoors – for example, farm workers, builders and gardeners – have a greater risk. This is because they are exposed to the sun for long periods of time.

- All types of skin are at risk of sun damage and skin cancer. But skin cancer is more common in fair-skinned people, who tend to burn easily or go red or freckle in the sun and whose skin does not tan. This is because they have less melanin. This is the protective layer in the skin.

People with darker skin have a lower risk of developing BCC or SCC. This is because they have more melanin in their skin. However, they are still at risk – particularly of getting a skin cancer where the body has less direct sun exposure.

Actinic keratosis (AK)

Actinic keratosis (AK) is also called solar keratosis. It is a crusty skin growth caused by damage from exposure to UV light.

AK affects mainly the face, scalp and hands. If left untreated, it may develop into SCC of the skin.

Sunbeds

Using sunbeds and sunlamps increases the risk of developing some skin cancers. The risk increases the more you use a sunbed or sunlamp. It also increases if you were young when you started using them.

Previous skin cancers

If you have had a skin cancer before, you are more at risk of getting another one. This could be in the same place as before (a local recurrence). Or it could develop somewhere else on your body.

Bowen’s disease

Bowen’s disease is sometimes called squamous cell carcinoma in situ. It is a very early form of slow-growing skin cancer. It is caused by the growth of cancerous cells in the outer layer of the skin (epidermis). If left untreated, Bowen’s disease may occasionally develop into squamous cell carcinoma of the skin.

We have more information about Bowen’s disease on our website.

Previous radiotherapy treatment

If you have had radiotherapy treatment for other conditions, you may develop skin cancer later in life. It is more likely to develop in the area that received the treatment.

Lowered immunity

People who have a weakened immune system (lowered immunity) have a higher risk of developing skin cancer. This includes people who:

- have had a kidney, liver, heart or lung transplant and take drugs that lower their immunity (immunosuppressants)

- have HIV or HPV

- have some types of blood cancer, such as chronic lymphocytic leukaemia (CLL).

People with lowered immunity are more likely to develop SCC. They are also more likely to develop BCC and melanoma compared with the general population.

If you take drugs that suppress your immune system, the benefit of taking them usually outweighs the risk of developing skin cancer. But it is important that you see your GP regularly to check for early signs of skin cancer.

Exposure to chemicals

Another possible, rare cause of non-melanoma skin cancer is overexposure to certain chemicals, usually at a workplace. If you might be at risk from chemicals at your workplace, you should wear protective clothing and use protective equipment. Always follow the manufacturer’s instructions when using chemicals at home.

Genetic conditions

A genetic condition is when someone inherits a faulty gene from their parents. If you inherit a faulty gene, it increases your risk of developing certain health problems. Although most skin cancers are not caused by genetic conditions, some rare conditions carry a higher risk of developing skin cancer. These include:

- Gorlin syndrome

- xeroderma pigmentosum (XP).

Gender

Men have a slightly higher risk of developing non-melanoma skin cancers than women. This may be because men are more likely than women to work outdoors.

Signs and symptoms

BCCs and SCCs both can vary in how they look. They are usually painless and grow slowly. But sometimes they may grow quickly. They can appear anywhere on your body.

Symptoms of basal cell carcinoma

BCCs are more likely to develop on skin that is regularly exposed to the sun, especially on the face, head and neck.

BCCs may:

- be smooth and pearl coloured

- look waxy

- look like a firm, red lump or look sunken in the middle

- look like a pearly brown or black lump if you have darker skin

- look like a flat, red spot that is scaly and crusty

- look like a pale scar that is not healing

- begin to heal but never completely heal

- feel itchy and bleed sometimes

- develop a crust or scab

- develop into a painless ulcer.

Symptoms of squamous cell carcinoma

SCCs usually develop in areas that have been damaged by sun exposure. In people with pale skin, they are mainly found on the:

- face

- neck

- bald scalps

- shoulders

- arms

- backs of hands

- lower legs.

In people with darker or black skin, SCCs are more likely to affect areas that have less, or no, sun exposure. These include the lower legs, torso, genitals and areas where there has been long-term scarring – for example, after a burn to the area.

SCCs may:

- look scaly

- have a hard, crusty scab

- look pink or red

- have a raised area of skin

- feel tender to touch

- bleed sometimes.

What to do if you notice skin changes

If you notice anything unusual on your skin, make an appointment to show the area to your GP.

It might help to take a photograph of anything unusual, so you can check for any changes. Remember that there are many other skin conditions that are not cancer, especially in older people.

It can be more difficult to notice changes if you have darker skin. This is because symptoms of skin cancer may be less obvious than they are for people with paler skin.

If you notice any changes, such as a sore area that does not heal, make an appointment with your GP.

Diagnosing skin cancer

How skin cancers are diagnosed

If you have symptoms, contact your GP. They will examine you. If they think your symptoms could be caused by cancer, they will refer you to a hospital for specialist advice and treatment.

Sometimes, a specially trained GP may be able to remove the affected area. But most people with suspected skin cancer are referred to a skin specialist at their local hospital. A doctor who specialises in treating skin diseases is called a dermatologist.

Your GP will decide how quickly you need to see the dermatologist after looking at your symptoms. This will be based on their experience and national guidelines.

If they think you have an SCC, you will usually see the dermatologist as an urgent referral. This usually means within 2 weeks. This is the usual waiting time for this type of skin cancer.

If your GP suspects that you have a BCC, you will usually be seen within 18 weeks. This is because nearly all BCCs are slow-growing and unlikely to change during this time.Sometimes, your GP may refer you to see the dermatologist as an urgent referral if they think you need to be seen sooner.

Your GP can explain the referral process to you.

‘I noticed I had a tiny scab on my face. It was about the size of a buttonhole and just wouldn’t go away. Even when I washed my face. I would describe it as a black mark. It kept bleeding and would scab up but never hurt.’ Dominic, diagnosed with skin cancer

At the hospital

The dermatologist will examine the affected area of skin. They will also ask you questions about how long you have had it, and any changes you may have noticed. They will be able to learn a lot from a simple examination.

They may use an instrument such as a dermatoscope to look more closely and examine the skin. It looks like a magnifying glass with a light.

The dermatologist will usually also check the rest of your skin to see if you have any other unusual areas.

Biopsy

It is not always possible to tell the difference between skin cancers and benign (non-cancerous) conditions just by examining the skin. Your doctor may advise that you have a sample of tissue taken. This is called a biopsy.

A biopsy is a simple procedure you can have done as a day patient in the outpatient department. The doctor will give you a local anaesthetic to numb the area. Then they will remove all or part of the affected area and send it to the laboratory. A doctor who specialises in analysing cells (pathologist) will then look at it under a microscope.

Different types of biopsy are used to diagnose skin cancer:

- Incision biopsy – The doctor removes a small piece of the abnormal area, using a surgical knife. They then use stitches to close the small wound.

- Excision biopsy – This is like an incision biopsy, except the whole abnormal area is removed. The doctor will also remove a small margin of healthy tissue around the abnormal area.

- Punch biopsy – The doctor uses a small round cutting instrument to remove a sample of skin. You might need stitches to close the area.

- Shave biopsy – The doctor uses an instrument to shave off the top layer of the affected area of skin. The wound forms a scab and heals without the need for stitches.

Further tests

If the biopsy shows you have a skin cancer, your doctor will usually check other areas of your skin. This is to see if there are other possible areas of skin cancer.

If you have a BCC, you probably will not need any further tests, as long as the cancer has been completely removed. This is because BCCs almost never spread.

If you have had treatment for skin cancer before, further tests are important to check whether it has come back.

If you have an SCC, your doctor may feel the lymph nodes close to the cancer to check whether any are enlarged. This is because SCCs can occasionally spread.

Your doctor may recommend that you have an operation to take samples of the nearby lymph nodes. They will only do this if they think the cancer may have spread there, which is rare.

You may have some scans if your doctor thinks that the cancer has started to spread. These can include:

- an ultrasound

- a CT scan

- an MRI scan

- a PET scan.

These scans are not usually needed when you are first diagnosed. Your doctor will explain more about these tests to you. We have more information about tests and scans on our website.

Waiting for test results

Waiting for test results can be a difficult time. It may take from a few days to a couple of weeks for the results of your tests to be ready. You may find it helpful to talk with your partner, your family or a close friend. Your specialist nurse or a support organisation can also provide support. You may find it helpful to talk to one of our cancer support specialists on 0808 808 00 00 (7 days a week, 8am to 8pm).

Your data and the cancer registry

When you are diagnosed with cancer in the UK, some information about you, your cancer diagnosis and your treatment is collected in a cancer registry. This is used to plan and improve health and care services. Your hospital will usually give this information to the registry automatically. There are strict rules to make sure the information is kept safely and securely. It will only be used for your direct care or for health and social care planning and research.

Treating skin cancer

Treatment overview

Most people who have a BCC or SCC are cured with treatment. There are different types of treatment. The treatment you are offered will depend on:

- the type of skin cancer

- the size of the skin cancer

- where it is on your body

- the biopsy results

- whether you have had skin cancer before

- your general health.

Surgery

Surgery is an important treatment for many skin cancers. There are different types of surgery that may be used.

Cryotherapy

Cryotherapy is a treatment that destroys cancer cells by using liquid nitrogen to freeze them. It is a very quick way of treating actinic keratoses and small, low-risk skin cancers, such as superficial BCCs.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) destroys cancer cells by using light sources combined with a light-sensitive drug. The light-sensitive drug is sometimes called a photosensitising agent.

Chemotherapy cream

Chemotherapy cream contains a drug called fluorouracil or 5FU (Efudix®). It can be used to treat some early superficial BCCs.

Immunotherapy cream

An immunotherapy cream called imiquimod (Aldara®) can be used to treat some early superficial BCCs.

Radiotherapy

Radiotherapy may be used instead of surgery for BCCs and SCCs. This might be when surgery is not possible, as it would cause too much damage to the surrounding tissue or have a poor cosmetic outcome. Radiotherapy for skin cancer can be done as external beam radiotherapy or brachytherapy.

Sometimes radiotherapy may be given after surgery if there is a risk cancer cells are still present.

How treatment is planned

In most hospitals, a team of specialists will talk to you about the treatment they feel is best for you. They are called a multidisciplinary team (MDT). For skin cancer, the MDT will usually include:

- a dermatologist – a doctor who treats skin problems

- a plastic surgeon – a doctor who does surgery to repair or reconstruct tissue and skin

- a medical oncologist – a doctor who uses chemotherapy and other anti-cancer drugs to treat people with cancer

- a clinical oncologist – a doctor who uses radiotherapy, chemotherapy and other anti-cancer drugs to treat people with cancer

- a skin cancer clinical nurse specialist (CNS) – a nurse who gives information about cancer, and support during treatment

- radiologists – doctors who look at scans and x-rays to diagnose problems

- pathologists – doctors who look at cells or body tissue under a microscope to diagnose cancer.

These specialists will talk to you about your treatment options. They will tell you what to expect and can answer any questions you have. You may be asked if you would like to take part in a clinical trial.

Giving your permission (consent)

Doctors need your permission (consent) before you have any treatment. They will give you all the information you need to make your decision.

You can give consent in writing when you sign a form that your doctor gives you, agreeing to a treatment. Or it can be a spoken (verbal) agreement with your doctor. Your doctor records your consent in your patient notes.

You may decide not to have treatment even when your doctor advises you to have it. If you refuse treatment, your decision must be respected. But your doctor needs to make sure you have all the information you need to make your decision. You need to understand all your treatment options and what will happen if you do not have the treatment. Always talk to your doctor about any concerns you have, so they can give you the best advice.

Second opinion

A second opinion is an opinion from a different doctor about your treatment. If you think you want a second opinion, talk to your specialist doctor or GP first. Tell them your concerns or ask them to explain anything you do not understand. This might help reassure you.

If you still want a second opinion, you can ask your specialist doctor or GP to arrange it. They are usually happy to do this. You may have to travel to another hospital to get a second opinion. Getting a second opinion could delay your treatment. Check with your doctor if this delay could be harmful to you.

If the doctor you see for the second opinion gives you the same advice, this can reassure you. Sometimes they give you other treatment options to think about.

We have more information about getting a second opinion on our website.

Surgery

Surgery is the most common treatment for skin cancer. The type of surgery you have depends on the size of the cancer and where it is.

If you have a small cancer, the doctor can usually remove (excise) it with a local anaesthetic. Or they may use a technique to destroy the cells, called curettage and electrocautery.

A larger skin cancer is more likely to be removed while you are under a general anaesthetic. The area of skin removed may be replaced with a skin graft or skin flap.

A type of surgery called Mohs micrographic surgery is also sometimes used. This is also called a margin-controlled excision. This is when layers of skin are removed one at a time and examined under a microscope. The layers are removed until all the cancer is gone.

Excision

Most small skin cancers are removed in a minor operation called an excision. The surgeon or dermatologist will remove (excise) the cancer and some normal-looking skin around it. The normal-looking skin is checked under a microscope to make sure that the cancer has completely gone.

Most excisions are done using a local anaesthetic and you can go home the same day. You will have a dressing over the wound. You may have stitches that need to be removed 5 to 14 days after your operation or once the wound has healed. Sometimes surgeons use dissolvable stitches that do not need to be removed.

Your hospital team will explain how to take care of the wound and the dressing. If necessary, they can arrange for a district nurse to change your dressing at home. Or they may advise you to go to your GP surgery or return to the hospital to have the dressing changed.

‘Within 20 minutes, the cancer was out and all done. I was a bit tearful but glad it was over.’ Dominic, diagnosed with skin cancer

Skin grafts and skin flaps

If the cancer is large or has spread, a larger area of skin may need to be removed. You may need skin graft surgery or, less commonly, skin flap surgery to cover the wound.

Skin grafts

A skin graft is a healthy layer of skin that is taken from another part of the body. The layer of skin is then placed over the area where the skin cancer was removed. The place where the skin is taken from is called the donor site. The place where it is moved to is called the grafted area. The amount of skin that is taken depends on the size of the area to be covered. Your doctor or specialist nurse will tell you more about this.

The donor site

You will have a dressing on the donor site to protect it from infection. How long the site takes to heal will vary. It can depend on how much skin was removed and where it was taken from. It may take up to 2 weeks to heal, but it can take longer. Your surgeon will discuss this with you. The donor site can often feel more uncomfortable than the grafted area. You may need to take regular pain relief for a while.

The grafted area

The graft may be stapled, stitched or glued in place. Sometimes it may simply be laid onto the area. Your surgeon will discuss this with you.

You will have a dressing over the area. This will be left in place while the graft heals. As the skin graft heals, it will connect to the surrounding blood supply. This usually takes 5 to 7 days. The area will look red and swollen to begin with. But eventually it will fully heal, and the redness will fade.

After skin graft surgery

After a skin graft, you can usually go home on the same day. But some people need to have a short stay in hospital. This depends on where the graft is on the body and how big it is.

Try to rest for the first couple of weeks after surgery. You will need to allow time for the graft to heal properly. The grafted area will be quite fragile to begin with. It is important not to put pressure on it or rub or brush against it. You may need to take some time off work until it has healed. If you have young children, you may need some extra help at home until you feel able to do the things you normally do.

You may need to have your stitches removed 5 to 14 days after your operation. But you may have stitches that dissolve and do not need to be removed.

Both the grafted and donor areas will develop scars. These should gradually fade. The grafted skin may also look different from the surrounding skin. This will improve over time. Your hospital team can tell you more about what to expect.

‘I have had four skin grafts. As soon as the dressing was off, I was told to use suncream during the day and to always hydrate the area with a good face cream. The skin does not have the same oil glands as normal skin.’ Miranda, diagnosed with skin cancer

Skin flaps

A skin flap is when a slightly thicker layer of skin is used. The skin is usually taken from an area very close to where the cancer has been removed. The flap is cut away but left partly connected so it still has a blood supply. It is moved to cover the wound and stitched in place. You may need to stay in hospital for a few days after skin flap surgery.

Skin flap surgery is very specialised. You may have to travel to a hospital that specialises in doing it. If you need a skin flap, your doctor can tell you more about it.

Mohs micrographic surgery

Mohs micrographic surgery is a specialised surgery. It is sometimes called a margin-controlled excision. Your doctors will refer you to a centre that specialises in this type if surgery if they think you might need it.

During Mohs surgery, the surgeon removes the cancer in thin layers. They look at these layers under a microscope during the operation. They continue to remove layers until no cancer cells can be seen in the tissue. This technique makes sure that all the cancer cells are removed and that only a very small amount of healthy tissue is removed. It is often done under local anaesthetic. You are usually allowed to go home the same day.

You may also need to have a skin graft or skin flap to cover the wound.

Mohs surgery can be used for:

- skin cancers that have come back in the same place after removal

- skin cancers that could not be fully removed

- faster-growing types of skin cancer that have begun to spread into the surrounding area

- skin cancers on the face, where it is important to remove as little tissue as possible to leave the smallest possible scar

- some large skin cancers – for example, if they are larger than 2cm.

Curettage and electrocautery

Some people have treatment using curettage and electrocautery. This involves scraping away the cancer and using heat or electricity to stop any bleeding. It is usually only used for skin cancers that are small.

First, the doctor or nurse gives you a local anaesthetic to numb the area. Once the area is numb, the doctor scrapes away the cancer using an instrument called a curette. They then use an electrically heated loop or needle to stop any bleeding from the wound (cauterise the wound). This also destroys any remaining cancer cells.

Cryotherapy

Cryotherapy removes cancer by freezing it. It is sometimes called cryosurgery. This treatment is occasionally used for small skin cancers that only affect the surface layers of the skin. It is commonly used for actinic keratoses.

The doctor sprays liquid nitrogen onto the area to freeze it. It can be painful – some people describe it as feeling like a bee sting.

After treatment, the area may ache or throb for a few minutes. After about 1 hour or so, it is common for the area to blister. The blister may become filled with blood and may be painful. Your doctor or nurse may need to drain the fluid from the blister using a sterile needle. But the top of the blister should be left intact.

About 2 weeks after your treatment, the scab drops off. You may have a white scar in the area. You may need more than one cryotherapy treatment to get rid of the cancer completely.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) uses laser or light sources combined with a light-sensitive drug to destroy cancer cells. It is mainly used for superficial BCCs and Bowen’s disease. PDT can be helpful if the skin cancer has developed directly over bone, such as on the shins or hands.

Before treatment, the doctor or nurse may remove any scabs from the area. Then they put a cream that contains a light-sensitive drug onto the area. They usually cover this with a dressing. You then wait for around 3 hours before having the light treatment. This allows the cream to soak into the layers of the skin.

Next, the doctor or nurse cleans the area. Then they shine a special light directly onto your skin. The light treatment usually lasts between 8 and 45 minutes, depending on the light source they use. Some people may find they get a stinging or burning feeling in the treatment area. Tell your doctor or nurse if you are uncomfortable. They can give you something to help.

After this, a dressing is put over the area to cover it and protect it from light. This stays on for up to 48 hours after your treatment. Your doctor or nurse will give you instructions about this before you leave hospital.

After having PDT, a crust usually forms over the treated area. This crust falls off naturally after a few weeks, leaving the healed, new skin underneath.

You may need 2 sessions spread 1 to 2 weeks apart. Your doctor or nurse will explain how you will have the treatment and how many sessions you may need.

Chemotherapy cream

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. Chemotherapy cream or lotion can be put directly onto the skin cancer. This is called topical chemotherapy.

Usually a drug called fluorouracil (Efudix®) is used to treat non-melanoma skin cancers. Fluorouracil is sometimes called 5FU. Your doctor, nurse or a pharmacist will give you the cream to put on at home and explain how to apply it.

You put the cream on either once or twice a day. The area can usually be left uncovered. But your doctor or nurse may advise you to cover the area with a waterproof dressing after putting on the cream. Follow the instructions they give you.

Treatment is usually for 4 weeks. The treatment should make the skin red and inflamed. The area may become sore and leak fluid. If the skin reaction is particularly severe, the treatment may be paused or sometimes stopped.

Your doctor may prescribe a steroid cream to help with the inflammation. The skin usually takes about 2 weeks to fully heal after you finish the treatment. But it can take longer.

Try to protect the treated area from the sun, as it can make the inflammation worse. Usually, there are no other side effects with this type of chemotherapy.

Immunotherapy cream

Immunotherapy is the name given to cancer treatments that use the body’s immune system to attack cancer cells.

An immunotherapy cream called imiquimod (Aldara®) stimulates the immune system. Doctors may use it to treat some small, superficial BCCs. It is usually used in areas where surgery may be difficult or if you have more than one cancer.

Your doctor, nurse or a pharmacist will give you the cream to put on at home. They will explain how to put it on and how often to use it. You usually put the cream on once a day, 5 days a week, for 6 weeks.

You may feel a burning or tender feeling in the area being treated. This is most common at the start of treatment. Some redness or crusting of the skin usually occurs during the treatment. But there should be no permanent scarring. If the skin reaction is very strong, your doctor may give you a steroid cream to help. It is normal for redness and some crusting to continue for about 2 weeks after the treatment has finished.

Occasionally, the immunotherapy cream may cause shivers and other flu-like symptoms. If this happens, tell your doctor or specialist nurse. They may advise you to stop using it.

Your MDT can give you more detailed instructions on how to use your immunotherapy cream. They can also help manage any side effects.

Radiotherapy

Radiotherapy uses x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells.

Radiotherapy is particularly useful if surgery might be difficult or disfiguring. For example, it may be used for skin cancers that:

- affect parts of the face, such as the nose

- affect large areas

- are deep in the skin.

But radiotherapy is not recommended for young people. This is because it can cause skin changes that may become more noticeable over time.

Radiotherapy is occasionally used when a non-melanoma skin cancer has spread to other places. This can include lymph nodes or an organ such as the lungs.

You have radiotherapy in the hospital outpatient department. Depending on the type and size of skin cancer, you may only have 1 treatment session. But usually several sessions are needed. You may have radiotherapy each day, 5 days of the week, for 1 or more weeks. Your doctor will discuss your treatment plan with you.

Radiotherapy treatment affects only a small area of skin being treated and does not make you feel unwell. The treated skin will be red and inflamed for up to 1 month after treatment. During this time, it will look as though the treatment has made things worse rather than better. This is normal. After a few more weeks, the area dries up and forms a crust or scab. Over time, the scab peels away, leaving healed skin underneath.

At first, this new skin will look pinker than the skin around it. But it should gradually fade to look more like the skin around it. If you have fair skin, the treated area may become slightly paler. If you have dark skin, the area may get darker or paler.

If you have radiotherapy to an area where hair grows, it will cause the hair in the treated area to fall out. This is often permanent. You can talk to your doctor about whether your hair is likely to grow back after treatment.

Radiotherapy for skin cancer does not make you radioactive. This means it is safe for you to be around other people, including children and pregnant women, during your treatment.

We have more information about radiotherapy in our booklet Understanding radiotherapy and on our website.

We have more information about hair loss in our booklet Coping with hair loss and on our website.

Less commonly used treatments for skin cancer

The following treatments are less commonly used. Doctors may sometimes use these treatments if a skin cancer has spread.

Surgery to remove lymph nodes

If there is evidence that a squamous cell carcinoma (SCC) has spread, you may need to have some lymph nodes removed.This operation is called a lymph node dissection or a lymphadenectomy. It is done to see if there are any cancer cells in the lymph nodes. If cancer cells are present, removing the lymph nodes can help to prevent them from spreading further. This is a large operation and is done under a general anaesthetic.

Only a small number of people who have SCCs need this operation. It is not done for people who have basal cell carcinomas (BCCs), as these almost never spread to the lymph nodes.

After a lymphadenectomy, you will have tubes (drains) coming from the wound to allow fluid to drain away. These will be removed a few days after the operation.

Sometimes, removing the lymph nodes can affect the drainage of lymph fluid. This may cause permanent swelling of the affected area. This is called lymphoedema. We have more information about lymphoedema on our website.

Targeted therapies

Targeted therapies are drugs that find and attack cancer cells. They may sometimes be used when a BCC or SCC has spread. Because it is rare for a BCC to spread, targeted therapies are rarely used.

Doctors may use targeted therapies if skin cancer has spread deeper into the skin and surgery or radiotherapy is not suitable. When cancer has spread beyond where it started, it is called advanced or metastatic cancer.

If an SCC has spread, your doctor may discuss using a drug called cemiplimab (Libtayo®). Cemiplimab is a type of targeted therapy known as an immunotherapy drug. It uses the immune system to find and attack cancer cells.

Your doctor can tell you if a targeted therapy is appropriate for you.

We have more information about targeted therapies on our website.

Chemotherapy

Chemotherapy is very rarely used to treat non-melanoma skin cancers. It is occasionally used when someone has a skin cancer that has spread from the original site. It is usually given into a vein (intravenously). Different types of chemotherapy may be used depending on the type of skin cancer.

Clinical trials

Clinical trials are medical research studies involving people. Doctors may use cancer clinical trials to:

- test new treatments to see if they work better than current treatments

- find which treatments have fewer side effects

- find new ways to combine treatments to see if they work better

- test new cancer drugs to find out more about them and their side effects

- improve the way treatments are given to try to reduce side effects.

Results from clinical trials can improve cancer treatments and help people live longer. Trials can also look at improving things like diagnosis and symptom management.

Taking part in a trial

Your cancer doctor or specialist nurse may talk to you about taking part in a clinical trial. Or you could ask them if there are any trials suitable for you.

Usually, cancer clinical trials happen in several hospitals around the country. You may have to travel to take part in a trial.

A research nurse or doctor will give you information about the trial. It is important to understand what is involved before you agree (consent) to take part. You can ask the research nurse or doctor any questions you have.

They will also explain the possible benefits and any possible risks of the trial. Clinical trials are designed to be as safe as possible. The researchers will monitor you closely during and after the trial.

If you decide not to take part in a trial, your cancer doctor and specialist nurse will respect your decision. You do not have to give a reason for not taking part. Your decision will not change your care. Your cancer doctor will give you the standard treatment for the type and stage of cancer you have.

We have more information in our booklet Understanding cancer research trials (clinical trials).

After treatment

After treatment for skin cancer – follow-up

Many people who have surgery for BCCs and very early-stage SCCs do not need long-term follow-up care. But your doctor may want you to have regular check-ups for a time. This is to make sure that treatment has been successful and the cancer has not come back. You can also talk to your doctor about any problems or worries you may have.

Once you have had a skin cancer, you have a higher risk of developing it again in the same area (a recurrence). You are also more at risk of developing another one somewhere else on your skin.

It is important to regularly check your skin for any new symptoms or changes that could be cancer. Using a mirror can help if there are areas you cannot see easily, such as your back. Or you can ask a relative or friend, if you feel comfortable doing so. If you have any problems, or notice any new symptoms in between check-ups, tell your doctor as soon as possible.

Share your experience

When treatment finishes, you may want to share your thoughts, feelings and advice with other people. This can be especially helpful for others with skin cancer who are about to start their treatment. Just hearing about how you coped, what side effects you had and how you managed them is very helpful to someone in a similar situation.

We can help you share your story. Call us on 0808 808 00 00 or read about becoming a Cancer Voice on our website.

‘I know it’s daunting, and I was so anxious before the surgery but I am so pleased now. You can hardly tell it’s only been 3 months.’ Tracey, diagnosed with skin cancer

Preventing further skin cancers

Protecting yourself from the sun is even more important after you have had treatment for skin cancer. Here are some suggestions on how you can protect your skin:

- The best protection is to cover up. Wear clothing made of cotton or natural fibres that have a close weave. These give you more protection against the sun.

- Keep your arms and legs covered by wearing long-sleeved tops and trousers. Wear a wide-brimmed hat to protect your face and neck.

- Use suncream with a high sun protection factor (SPF) of at least 30. Choose one that protects against UVA and UVB, with four or five stars. Follow the instructions on the bottle and re-apply as recommended, particularly after swimming. Remember to apply suncream on and behind your ears.

- Many people do not use enough suncream. Experts say an average-sized adult needs at least 6 to 8 teaspoons of lotion to give the SPF coverage it says on the bottle.

- Always wear sunglasses in strong sunlight.

- Do not let your skin go red or burn.

- Stay out of the sun during the hottest part of the day. This is usually between 11am and 3pm.

- Do not use a sunbed or sunlamp. If it is important for you to look tanned, use fake tan lotions or sprays.

- Check your skin regularly for any changes.

Protecting yourself from the sun is important. But regular exposure to a small amount of sunshine helps our bodies make vitamin D. Remember not to let your skin go red or burn.

Vitamin D is important for general health. It keeps our bones, teeth, muscles and immune system healthy. If you are not exposed to the sun often, you may want to ask your dermatologist or GP to check your vitamin D levels. It can get very low in people who avoid the sun completely. Your GP may prescribe some vitamin D supplements if you have low vitamin D levels.

Body image

Doctors will try to minimise the effects of skin cancer treatments on your appearance. Many people have only minor scarring after treatment. But if the skin cancer was larger or deeper, the effects of treatment may be more obvious.

If treatment has changed the way you look, you may feel differently about yourself and your body image. Body image is the picture in your mind of how your body looks and works. The effects will often improve with time, but you may feel more self-conscious about how you look.

Everyone’s reactions are different. You may feel more self-conscious about your body but find it manageable. Or you may find your concerns are on your mind a lot of the time, which may affect how you cope.

Talking with people you trust can help. This could be your family or close friends, or your cancer doctor or nurse. Talking to another person who has been through something similar can also help.

There are practical things that can help you to:

- feel better about your appearance

- manage changes to your body

- improve your confidence.

You may want to consider using camouflage make-up to cover a scar. The British Association of Skin Camouflage provides advice about camouflage make-up. Talk to your doctor or specialist nurse about camouflage make-up or about any concerns you have.

We have more information about body image and cancer treatment in our booklet Body image and cancer.

‘My anxiety has actually been ok. I thought it would maybe affect me more when I found out the scab was skin cancer. But somehow you just deal with it. I had a type of cancer that was very treatable.’ Dominic, diagnosed with skin cancer

Your feelings

Even though your skin cancer is likely to be cured, you may feel anxious or upset for a while after you have been diagnosed. It is important to remember there is no right or wrong way to feel. Everyone’s reactions are different, and you might have a mixture of emotions. We have more advice on coping with your feelings in our booklet How are you feeling? The emotional effects of cancer.

You may find it helpful to talk with family and friends, or your doctor or nurse. Talking about your feelings can be helpful. Sometimes it is easier to talk to someone who is not directly involved in your situation. If you are finding it difficult to cope, your cancer doctor or GP may be able to refer you to a counsellor who can help.

You can call the Macmillan Support Line on 0808 808 00 00 to speak to cancer support specialists about anything that is on your mind.

Further information

About our information

We provide expert, up-to-date information about cancer. And all our information is free for everyone.

Order what you need

You may want to order more booklets or leaflets, or download more eBooks like this one. Visit be.macmillan.org.uk or call us on 0808 808 00 00.

We have booklets on different cancer types, treatments and side effects. We also have information about work, financial issues, diet, life after cancer and information for carers, family and friends.

Online information

All of our information is also available online at macmillan.org.uk/information-and-support There you’ll also find videos featuring real-life stories from people affected by cancer, and information from health and social care professionals.

Other formats

We also provide information in different languages and formats, including:

- audiobooks

- Braille

- British Sign Language

- Easy Read booklets

- large print

- translations.

Find out more at macmillan.org.uk/otherformats If you’d like us to produce information in a different format for you, email us at cancerinformationteam@macmillan.org.uk or call us on 0808 808 00 00.

Help us improve our information

We know that the people who use our information are the real experts. That’s why we always involve them in our work. If you’ve been affected by cancer, you can help us improve our information.

We give you the chance to comment on a variety of information including booklets, leaflets and fact sheets.

If you’d like to hear more about becoming a reviewer, email reviewing@macmillan.org.uk You can get involved from home whenever you like, and we don’t ask for any special skills – just an interest in our cancer information.

Other ways we can help you

At Macmillan, we know how a cancer diagnosis can affect everything, and we are here to support you.

Talk to us

If you or someone you know is affected by cancer, talking about how you feel and sharing your concerns can really help.

Macmillan Support Line

Our free, confidential phone line is open 7 days a week, 8am–8pm. Our cancer support specialists can:

- help with any medical questions you have about your cancer or treatment

- help you access benefits and give you financial advice

- be there to listen if you need someone to talk to

- tell you about services that can help you in your area.

Call us on 0808 808 00 00 or email us via our website, macmillan.org.uk/talktous

Information centres

Our information and support centres are based in hospitals, libraries and mobile centres. There, you can speak with someone face to face.

Visit one to get the information you need, or if you’d like a private chat, most centres have a room where you can speak with someone alone and in confidence.

Find your nearest centre at macmillan.org.uk/informationcentres or call us on 0808 808 00 00.

Talk to others

No one knows more about the impact cancer can have on your life than those who have been through it themselves. That’s why we help to bring people together in their communities and online.

Support groups

Whether you are someone living with cancer or a carer, we can help you find support in your local area, so you can speak face to face with people who understand. Find out about support groups in your area by calling us or by visiting macmillan.org.uk/selfhelpandsupport

Online community

Thousands of people use our online community to make friends, blog about their experiences and join groups to meet other people going through the same things. You can access it any time of day or night. Share your experiences, ask questions, or just read through people’s posts at community.macmillan.org.uk

The Macmillan healthcare team

Our nurses, doctors and other health and social care professionals give expert care and support to individuals and their families. Call us or ask your GP, consultant, district nurse or hospital ward sister if there are any Macmillan professionals near you.

Help with money worries

Having cancer can bring extra costs such as hospital parking, travel fares and higher heating bills. If you’ve been affected in this way, we can help.

Financial guidance

Our financial guidance team can give you advice on mortgages, pensions, insurance, borrowing and savings.

Help accessing benefits

Our benefits advisers can offer advice and information on benefits, tax credits, grants and loans. They can help you work out what financial help you could be entitled to. They can also help you complete your forms and apply for benefits.

Macmillan Grants

Macmillan offers one-off payments to people with cancer. A grant can be for anything from heating bills or extra clothing to a much-needed break.

Call us on 0808 808 00 00 to speak to a financial guide or benefits adviser, or to find out more about Macmillan Grants. We can also tell you about benefits advisers in your area.

Visit macmillan.org.uk/financialsupport to find out more about how we can help you with your finances.

Help with work and cancer

Whether you’re an employee, a carer, an employer or are self-employed, we can provide support and information to help you manage cancer at work. Visit macmillan.org.uk/work

Other useful organisations

There are lots of other organisations that can give you information or support.

Skin cancer support organisations

British Association of Skin Camouflage

Tel 01254 703107

Email cform@skin-camouflage.net

www.skin-camouflage.net

Provides information about how to use make-up such as skin camouflage.

Changing Faces

Helpline 0300 012 0275 (10am to 4pm, Mon to Fri)

www.changingfaces.org.uk

Has a range of advice and information services about visual differences to the face or body. Offers support and information for children, young people and adults, and their families. Also works with healthcare professionals, schools and employers to promote awareness about visual differences to the face or body.

Let’s Face It

Email sandra.smith@lets-face-it.org.uk

www.lets-face-it.org.uk

An international network for people with facial disfigurement. Links patients, their families, friends and professionals forself help, information and mutual support.

Skinship UK

Helpline 01557 428 504 (9am to 5pm, Mon to Fri)

www.skinshipuk.org

Aims to improve current public perception of, and reaction to, skin diseases and disfigurement. Offers emotional support.

Skin support

www.skinsupport.org.uk

Developed by the British Association of Dermatologists to support people with skin conditions. Offers information about different skin conditions including skin cancer and Bowen’s disease.

General cancer support organisations

Cancer Focus Northern Ireland

Helpline 0800 783 3339 (Mon to Fri, 9am to 1pm)

Email nurseline@cancerfocusni.org

www.cancerfocusni.org

Offers a variety of services to people affected by cancer in Northern Ireland, including a free helpline, counselling and links to local support groups.

Cancer Support Scotland

Tel 0800 652 4531 (Mon to Fri, 9am to 5pm)

Email info@cancersupportscotland.org

www.cancersupportscotland.org

Runs cancer support groups throughout Scotland. Also offers free complementary therapies and counselling to anyone affected by cancer.

Maggie’s

Tel 0300 123 1801

Email enquiries@maggies.org

www.maggies.org

Has a network of centres in various locations throughout the UK. Provides free information about cancer and financial benefits. Also offers emotional and social support to people with cancer, their family, and friends.

Tenovus

Helpline 0808 808 1010 (Daily, 8am to 8pm)

Email info@tenovuscancercare.org.uk

www.tenovuscancercare.org.uk

Aims to help everyone in the UK get equal access to cancer treatment and support. Funds research and provides support such as mobile cancer support units, a free helpline, benefits advice and an online ‘Ask the nurse’ service.

LGBT-specific support

LGBT Foundation

Tel 0345 330 3030 (Mon to Fri, 10am to 6pm)

Email info@lgbt.foundation

www.lgbt.foundation

Provides a range of services to the LGBT community, including a helpline, email advice and counselling.

The website has information on various topics including sexual health, relationships, mental health, community groups and events.

Cancer registries

The cancer registry

A national database that collects information on cancer diagnoses and treatment. This information helps the NHS and other organisations plan and improve health and care services. There is one in each country in the UK:

National Cancer Registration and Analysis Service

Tel 0207 654 8000

Email enquiries@phe.gov.uk

www.ndrs.nhs.uk

Tel (Ireland) 0214 318 014

www.ncri.ie (Ireland)

Northern Ireland Cancer Registry

Tel 0289 097 6028

Email nicr@qub.ac.uk

www.qub.ac.uk/nicr

Scottish Cancer Registry

www.ndrs.nhs.uk/cancer-registration-your-rights-and-privacy

Welsh Cancer Intelligence and Surveillance Unit (WCISU)

Tel 02920 104278

phw.nhs.wales/services-and-teams/welsh-cancer-intelligence-and-surveillance-unit-wcisu/

Disclaimer, thanks and sources

Disclaimer

We make every effort to ensure that the information we provide is accurate and up to date, but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or third-party information or websites included or referred to in it. Some photos are of models.

Thanks

This eBook has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been approved by our Senior Medical Editor, Dr Samra Turajlic, Consultant Medical Oncologist.

With thanks to: Maggie Curtis, Macmillan Skin Cancer Nurse Specialist; Dr Ophelia Dadzie, Consultant Dermatologist; R Mallipeddi, Consultant Dermatological Surgeon and Lead for Skin Cancer; and Dr Agata Rembielak, Consultant Clinical Oncologist.

Thanks also to the people affected by cancer who reviewed this edition, and those who shared their stories.

We welcome feedback on our information. If you have any, please contact cancerinformationteam@macmillan.org.uk

Sources

Below is a sample of the sources used in our skin cancer information. If you would like further information about the sources we use, please contact us at cancerinformationteam@macmillan.org.uk

Best Practice. Overview of skin cancer. Last reviewed, 24 Jan 2021. Last updated, 14 Jun 2019. Available from www.bestpractice.bmj.com/topics/en-gb/267 [accessed February 2021].

National Institute for Health and Care Excellence (NICE). NICE pathway: Skin cancer treatment overview. Last updated, November 2020. Available from pathways.nice.org.uk/pathways/skin-cancer [accessed February 2021].

National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral NICE guideline [NG12]. Published 23 June 2015. Last updated, 29 January 2021. www.nice.org.uk/guidance/ng12 [accessed February 2021].

National Institute for Health and Care Excellence (NICE). Sun exposure: risks and benefits overview. Last updated, November 2020. Available from pathways.nice.org.uk/pathways/sunlight-exposure-risks-and-benefits [accessed February 2021].

Scottish Intercollegiate Guidelines Network (SIGN) 140. Management of primary cutaneous squamous cell carcinoma. First issued, 2014. Revalidated, June 2017. Available from www.sign.ac.uk/our-guidelines/management-of-primary-cutaneous-squamous-cell-carcinoma/ [accessed February 2021].

Can you do something to help?

We hope this eBook has been useful to you. It’s just one of our many publications that are available free to anyone affected by cancer. They’re produced by our cancer information specialists who, along with our nurses, benefits advisers, campaigners and volunteers, are part of the Macmillan team. When people are facing the toughest fight of their lives, we’re there to support them every step of the way.

We want to make sure no one has to go through cancer alone, so we need more people to help us. When the time is right for you, here are some ways in which you can become a part of our team.

5 ways you can help someone with cancer

Share your cancer experience

Support people living with cancer by telling your story, online, in the media or face to face.

Campaign for change

We need your help to make sure everyone gets the right support. Take an action, big or small, for better cancer care.

Help someone in your community

A lift to an appointment. Help with the shopping. Or just a cup of tea and a chat. Could you lend a hand?

Raise money

Whatever you like doing you can raise money to help. Take part in one of our events or create your own.

Give money

Big or small, every penny helps.

Call us to find out more 0300 1000 200

macmillan.org.uk/getinvolved