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Referral and warning signs
When to refer
Refer ALL suspected SCC lesions to Dermatologist/Surgeon for biopsy and management. Refer confirmed high-risk or advanced/metastatic cases to multidisciplinary oncology team.
Red flags
- Rapidly growing lesion
- Ulceration or bleeding
- Induration (firmness)
- Symptoms like pain or numbness (suggests perineural invasion)
- Lesion arising in chronic wound or scar
- Palpable regional lymph nodes
- Immunosuppressed patient
Signs and symptoms
- Persistent, firm, red nodule.
- Flat sore with a scaly, crusted surface.
- New sore or raised area on an old scar or ulcer.
- Rough, scaly patch on the lip that may evolve into an open sore.
- Red sore or rough patch inside the mouth.
- Lesion may grow relatively quickly, ulcerate, or bleed easily.
- Often occurs on sun-exposed areas (face, ears, scalp, lips, back of hands), but can occur anywhere, including chronic wounds/scars (Marjolin's ulcer) or genitals.
Risk factors
- Chronic sun exposure / UV radiation damage.
- Fair skin, light hair/eyes.
- Actinic keratoses (precursor lesions).
- History of previous skin cancer.
- Immunosuppression (organ transplant recipients, HIV).
- Exposure to arsenic or industrial carcinogens.
- Chronic non-healing wounds, burns, scars (Marjolin's ulcer).
- Certain genetic syndromes (e.g., Xeroderma Pigmentosum).
- HPV infection (associated with SCC in genital/periungual areas).
Diagnosis
Clinical assessment
Suspect based on appearance of persistent, indurated, scaling, crusted, or ulcerated lesion, especially on sun-exposed skin or in chronic wound. Differentiate from Basal Cell Carcinoma, Actinic Keratosis, Keratoacanthoma, Melanoma, Warts, Dermatitis.
Investigations
- Skin Biopsy: Essential for diagnosis. Shave, punch, or excisional biopsy. Histopathology confirms SCC, determines differentiation, depth, perineural invasion.
- Assessment for Metastasis (if high-risk features present): Palpation of regional lymph nodes, Imaging (Ultrasound, CT, MRI) depending on location/suspicion.
Diagnostic criteria
Histopathological confirmation from skin biopsy.
Management
Non-pharmacological management
- Referral to Dermatologist/Surgeon/Oncologist depending on complexity/stage.
- Surgical Excision: Standard treatment. Complete removal with adequate margins. Mohs micrographic surgery for sensitive areas.
- Curettage and Electrodessication: Option for small, low-risk SCCs.
- Cryotherapy: Option for small, superficial SCCs.
- Radiotherapy: Primary treatment if surgery not feasible, or adjuvant for high-risk features, or for nodal/distant mets.
Pharmacological treatment
- Topical Therapies (SCC in situ/Bowen's): 5-Fluorouracil (5-FU) cream, Imiquimod cream.
- Systemic Therapy (advanced/metastatic SCC): Chemotherapy (limited role), EGFR inhibitors (Cetuximab), Immunotherapy (PD-1 inhibitors - Cemiplimab, Pembrolizumab).
Monitoring
Regular skin checks (self and clinical). Monitor regional lymph nodes. Follow-up frequency depends on risk factors.
Complications
- Local recurrence
- Metastasis (lymph nodes, distant organs)
- Tissue destruction / Cosmetic disfigurement
- Perineural invasion -> Pain, numbness, motor deficit
Prevention
- Sun protection (avoid peak sun, shade, clothing, sunscreen).
- Avoid tanning beds.
- Early detection and treatment of actinic keratoses.
- Regular skin checks (especially high-risk individuals).
Patient education
- Explain SCC diagnosis.
- Importance of complete excision/treatment.
- Sun protection measures lifelong.
- How to perform skin self-exams.
- Need for regular follow-up skin checks.
- Signs of recurrence or new skin cancers to report.
Uganda-specific notes
Occurs particularly in Persons with Albinism (high risk) and on lower extremities in areas of chronic ulcers/scars (Marjolin's ulcer). Access to pathology, specialized surgery (Mohs), radiotherapy, and systemic therapies limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 12, Section 12.3.2 (Listed under Adult Cancers)