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For further information, see CMDT Part 6-40: Squamous Cell Carcinoma

Key Features

Essentials of Diagnosis

  • Nonhealing ulcer or warty nodule

  • Skin damage due to long-term sun exposure

  • Common in fair-skinned individuals and in organ transplant recipients and other immunosuppressed patients

General Considerations

  • Squamous cell carcinoma (SCC) usually occurs subsequent to prolonged sun exposure on exposed parts in fair-skinned individuals who sunburn easily and tan poorly

  • It may arise from an actinic keratosis

Clinical Findings

  • The lesions appear as small red, conical, hard nodules that occasionally ulcerate


  • Diagnosis is made by biopsy


  • Can be treated in situ with

    • Imiquimod

    • 5-fluorouracil (in similar dosing as for superficial BCC)

    • Curettage

    • Electrodessication

  • Preferred treatment for invasive SCC is excision or Mohs micrographic surgery

  • Mohs micrographic surgery is recommended for

    • High-risk lesions (lips, temples, ears, nose)

    • Recurrent tumors

    • Aggressive histologic subtypes (perineural or perivascular invasion)

    • Large lesions (greater than 1.0 cm face, > 2.0 cm trunk or extremities)

    • Immunosuppressed patients

    • Lesions developing within a scar

    • Tumors arising in the setting of genetic diseases



  • Follow-up for squamous cell carcinoma must be more frequent and thorough than for basal cell carcinoma, starting at every 3 months, with careful examination of lymph nodes for 1 year, then twice yearly thereafter

  • Multiple SCCs are very common on the sun-exposed skin of organ transplant patients because of the patient's immunosuppressed state; the tumors begin to appear after 5 years of immunosuppression

  • Other forms of immunosuppression that may also increase skin cancer risk and be associated with more aggressive skin cancer behavior

    • Allogeneic hematopoietic stem cell transplants

    • Chronic lymphocytic leukemia (and small lymphocyte lymphoma)

    • HIV/AIDS

    • Chronic iatrogenic immunosuppression

  • Voriconazole appears to increase the risk of development of SCC, especially in lung transplant patients


  • In actinically induced SCCs, rates of metastasis are estimated from retrospective studies to be 3–7%

  • SCCs of the ear, temple, lip, oral cavity, tongue, and genitalia have much higher rates of recurrence or metastasis and require special management

  • Patients with multiple squamous cell carcinomas (especially > 10) have higher rates of local recurrence and nodal metastases


  • Tumor aggressiveness correlates with lesion size, duration, location, origin, and degree of anaplasia

  • Tumors of the scalp, eyelids, nose, ears, and lips invade subcutaneous tissues and have a greater risk of subclinical tumor extension


  • Sun protection and avoidance

When to Refer

  • There is a question about the diagnosis

  • Recommended therapy is ineffective

  • Specialized treatment is necessary


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