Topical Creams

1. 5-fluorouracil (Efudex, Carac) often abbreviated as 5-FU, is a topical chemotherapy cream that is used on the skin. It is taken up preferentially by "precancerous" and cancerous cells in the skin. It causes these areas of the skin to turn bright red as if suffering a severe sunburn. It causes the "precancerous" and cancerous cells to scale or scab up and fall off, leaving healthy skin behind. This treatment can last from ~2-6 weeks. This is a good treatment for numerous actinic keratoses. Sometimes 5-FU is combined with a vitamin D derived cream during treatment.
2. Imiquimod (Aldara) is a topical immunomodulator cream. It causes an increase in the level of signals from the immune system in the skin (not in the body as a whole) to fight off the presence of "precancerous" or cancerous cells. It causes these areas of the skin to appear red and somewhat crusted during the treatment of ~4-6 weeks. This is used for the treatment of numerous actinic keratoses as well as superficial skin cancers.
3. Retinoids are a class of medicated topical creams used potentially for the treatment of sun-damaged skin. They are not as good as 5-fluorouracil or imiquimod for treatment of actinic keratoses, but do have a role in the treatment in some cases.
4. Diclofenac (Solaraze) is a non-steroidal anti-inflammatory gel that is used on the skin. It affects inflammation in the skin and can help clear away sun damaged cells. The treatment lasts around 2-3 months. This can be used to treat actinic keratoses.

Photodynamic Therapy

This is performed by the topical application of a light sensitizing solution to the skin, followed by exposure of the treated skin to red or blue light in a doctor's office. This causes damage to the "precancerous" and cancerous cells resulting in their death. The light sensitizing solution is applied and allowed to set on the skin for ~16 hours, and then the patient is exposed to light for 12-20 minutes. There is a burning sensation during the actual light exposure. The treated area will appear red and scaly to scabby after the treatment. The skin will heal in ~10 days. This is an accepted treatment for actinic keratoses.

Curettage and Electrodesiccation

Commonly referred to as scraping and burning of the skin cancer. The area of skin where the skin cancer is located is numbed with local anesthetic. Skin cancer cells do not have the regular cell-to-cell attachments of healthy skin cells. This allows them to be removed by scraping the skin where the cancer is with a curette (scraping device), leaving the surrounding non-cancerous skin intact. The area is then treated with an electrical current to seal over blood vessels and destroy any remaining cancer cells. The area may be treated with liquid nitrogen instead of the electrical current. This is generally used for early skin cancers, especially superficial basal cell carcinoma and superficial squamous cell carcinoma. Melanoma would never be treated this way.

Excision

The skin cancer is treated by numbing the area with a local anesthetic and then removing the skin cancer with a surgical knife (referred to as a scalpel). After the cancer is removed, the area is often closed with stitches. The cancer specimen is then sent for pathologic evaluation. This is commonly used for basal cell carcinomas and for squamous cell carcinomas that cannot be treated by curettage and electrodesiccation. This is the main treatment for early melanomas.

Mohs Micrographic Surgery

Mohs surgery offers the highest cure rates for difficult skin cancers, particularly those on the head and neck. The area of skin where the skin cancer is located is numbed with local anesthetic. While sparing as much normal skin as possible, the cancer is removed with a surgical knife (scalpel). The tissue is examined completely under the microscope while the patient waits, to be certain all cancer roots are removed. If the entire cancer was not removed, the surgeon then goes back and removes more in the area with persistent skin cancer. Again, this is then looked at under the microscope. This process is then repeated until the skin cancer has been completely removed. Mohs surgery is the most precise way to remove skin cancer while also sparing as much normal skin as possible. After complete removal of the tumor, the area is often closed with stitches. Mohs surgery is primarily used to treat difficult basal cell carcinomas and squamous cell carcinomas on the face.

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Special Situations and Alterations in Your Immunosuppressive Medications

• In special situations your dermatologist may recommend imaging, radiation therapy or lymph node operations.
• Alterations in your immunosuppressive medications may be considered if the development of numerous and aggressive skin cancers begins. This should only be considered with the extensive input of your complete transplant team as this may increase the risk of organ rejection and death in some cases.
• Oral retinoids, such as acitretin and isotretinoin, are medications that may be recommended by your physician in an attempt to prevent or slow down the development of new squamous cell carcinomas and basal cell carcinomas. These drugs often work well, but are only effective in suppressing skin cancers while one is taking the medicine. The effect rapidly diminishes if the medication is stopped. Many patients tolerate the medicine very well, but some have difficulties with side effects such as dry skin, dry lips, dry eyes, or hair loss. Cholesterol, triglycerides and liver enzymes must also be monitored by regular blood tests. Women who are pregnant or likely to become pregnant in the future should not take oral retinoids. The benefit of oral retinoids can be significant if a transplant recipient is developing numerous or aggressive squamous cell carcinomas and there are no other factors which would prevent the taking of this type of medicine.