Nonmelanoma skin cancer is the most common type of skin cancer in the United States and includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Individuals with light skin phototypes are at highest risk and account for most cases, but nonmelanoma skin cancer has been reported in individuals of all skin phototypes.
Patients who are unhoused may be at increased risk for skin cancer due to sun exposure and lack of access to healthcare professionals and skin care education.
Actinic keratoses are precancerous lesions that may arise on chronically sun-exposed skin. Because patients with actinic keratoses are at higher risk of developing nonmelanoma skin cancer, it is important to note their development and encourage sun protection.
Close examination of the skin to identify signs of potential skin cancer can lead to early diagnosis and treatment.
Education of patients on sun protection and skin self-exams increases awareness and can assist in prevention and early diagnosis.
Actinic keratosis
Actinic keratoses (AKs) present as rough, scaly macules or patches arising on chronically sun-exposed skin. Patients with AKs are at higher risk for developing nonmelanoma skin cancer. AKs may decrease and sometimes resolve with sunscreen use.
- AKs are very common in individuals with lighter skin colors and virtually unseen in people with darker skin colors.
- AKs are most often seen on sun-exposed areas of skin such as the face, scalp (if balding), ears, neck, forearms, and backs of the hands, although any skin area frequently exposed to sun can be affected.
- AKs can vary in size, usually beginning as “rough” localized skin lesions that the patient feels but are difficult to see.
Nodular BCC
Pigmented BCC
Superficial BCC
Infiltrating BCC
Basal cell carcinoma
Cutaneous BCC is the most common skin cancer. It can occur anywhere on the body (except the palms and soles), but most lesions appear on chronically sun-damaged skin of the face, head and ears, neck, chest, and upper back. Subtypes include:
- Nodular BCC – “Pearly” in appearance, lesions are usually skin-colored or pink papules or nodules, often with telangiectasias on the surface.
- Pigmented BCC – Lesions appear as brown, blue, gray, or black papules or nodules. Sometimes they will have more than one color and telangiectasias.
- Superficial BCC – May appear as a pink or red dry, scaly patch. They slowly enlarge and may develop a raised edge. Often mistaken for a dry patch of skin or a chronic rash.
- Infiltrating BCC – May appear as scar-like plaques on the skin that are slightly shiny, with possible scale, crust, erosion, and overlying telangiectasias. Lesions may be skin-colored, white, yellow, or pink.
Squamous cell carcinoma
Cutaneous SCC can occur anywhere on the body, but most lesions appear on chronically sun-damaged skin of the head, neck, forearms, and dorsal hands.
- Clinical presentation is highly variable, and lesions may grow slowly or evolve rapidly.
- In dark skin phototypes, SCC more commonly appears in sites of scars and chronic nonhealing ulcers.
- Some consider keratoacanthomas to be a variant of SCC, but others do not.
Skin exam
- Ensure there is adequate light in the room.
- Patient should be in a gown.
- Examine the entire skin surface (including scalp, mouth, eyes, nails, and genitals).
- You may find lesions related to a presenting complaint or discover unrelated but important findings.
Patient education
- Wear broad-spectrum sunscreen with sun protection factor (SPF) 30 or higher.
- Wide-brimmed hats, sunglasses, and long-sleeved shirts can help avoid some sun exposure.
- Stay out of the sun when it is the strongest (between 10:00 AM and 3:00 PM).
- Observe your skin for changes or problems (self-exam).
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