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For further information, see CMDT Part 6-11: 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



  • Excision is the preferred treatment of SCC

  • Mohs micrographic surgery is recommended for

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

    • Recurrent tumors

    • Aggressive histologic subtypes (perineural or perivascular invasion)

    • Large lesions (> 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

Therapeutic Procedures

  • Electrodesiccation and curettage and x-ray radiation may be used for some lesions



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

  • In addition, palpation of the lips is essential to detect hard or indurated areas that represent early SCC; all such cases must be biopsied

  • Multiple SCCs are very common on the sun-exposed skin of organ transplant recipients because of their 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


  • 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

  • Nicotinamide 500 mg orally twice daily can decrease the rate of development of squamous cell carcinomas by 30% in high-risk groups

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