Non-surgical treatments for skin cancers

Most skin cancers start by affecting just the top part of the skin

These early skin cancers are usually called superficial or in situ and because they are thin, they can be treated from the surface by cryotherapy (freezing) or applying a cream or ointment, as well as by excision (cutting out). The best treatment depends on a combination of factors:

• How well the treatment works.
• Side effects (including scarring and discomfort).
• Cost.
• Convenience.

The following information summarises these factors for the most common treatments for superficial basal cell carcinoma and superficial squamous cell carcinoma (Bowen’s disease). Note that photodynamic therapy can also be used effectively for thicker (nodular) basal cell carcinoma.

Comparison of treatments for skin cancers 

How well does it work? 

Surgical excision

98.6% cure rate (Liebovitch 2005) 

Cryotherapy

97-98% cure rate (Holt 1988, Kuflik 1991)  

Topical therapies:

• Imiquimod: Up to 82% cure rate for superficial basal cell carcinoma (Geisse 2004). 
• Fluorouracil: Up to 92% cure rate for Bowen’s disease (superficial squamous cell carcinoma) (Moreno 2007). 
• Combination fluorouracil/calcipotriol: Treatment has been shown to reduce the risk of squamous cell carcinoma in the treated area for up to three years (Rosenberg 2019). This benefit has not been shown with other treatments for superficial skin cancers. 

Photodynamic therapy 

Photodynamic therapy is known for its excellent cosmetic result, leaving less scarring than other treatment methods for skin cancer (DermNetNZ 2007).  

Studies have demonstrated higher cure rates for photodynamic therapy when compared with topical treatments or cryotherapy. (Morton 2006, Basset-Seguin 2008). However, in these studies, success rates for cryotherapy treatment were generally less than in trials where cryotherapy was not compared with PDT. 

What are the side effects? 

Surgical excision 

• Short term: Bleeding, bruising, swelling, pain, infection.
• Long term: Scarring in almost all cases, wound breakdown, nerve damage. 

Cryotherapy 

• Short term: Pain, blistering (including blood-filled blisters), swelling. 
• Long term: Changes in skin pigmentation. The treated area is commonly lighter or darker than the surrounding skin. 

Topical therapy 

• Short term: Irritation of the treated area: redness, pain, blistering, crusts and pustules. 
• Long-term: Side effects are uncommon. Scarring sometimes occurs after severe reactions during treatment. 

Photodynamic therapy 

• Short term: Pain during and soon after treatment. irritation , redness, blistering and crusts of the the treated area. People with a history of cold sores may experience an outbreak.  
• Long term: Side effects are uncommon. Scarring sometimes occurs after severe skin reactions. Side effects are less common, and the long term cosmetic outcome is superior to treatment with cryotherapy or topical treatments (Morton 2006). 

How much does it cost? 

Surgical excision 

The cost of excision varies, according to the size and the anatomical location of the skin cancer.  

Spot Check Clinic generally charges at least $150 out of pocket (i.e. above the amount paid by Medicare) for surgical excision of a skin cancer. The fee varies according to the size of the skin cancer and the location on the body. This fee is usually discounted for pensioners and Health Care Card holders.  

If the procedure is performed by a plastic surgeon and/or more complicated techniques such as Moh’s surgery or skin flaps or grafts are used, the cost can be thousands of dollars. 

Cryotherapy  

Approximately $50. In many cases, the cost is completely covered by Medicare, but only if the diagnosis has previously been confirmed by a biopsy. 

Topical therapy 

In biopsy-proven cases of superficial basal cell carcinoma, the Pharmaceutical Benefits Scheme subsidises the cost of imiquimod. In these cases, the out-of-pocket expense is about $40-80 (less for pensioners and Health Care Card holders).  

In cases where the PBS does not subsidise imiquimod, the typical cost is $120 or more.  

The PBS subsidises the cost of fluorouracil only for Department of Veterans’ Affairs cardholders. For others, the out-of-pocket expense is about $80 per prescription. It’s common to require a repeat prescription to complete the course of treatment. 

Combination fluorouracil/calcipotriol is not commercially available at pharmacies and is not covered by the PBS. It must be prepared by a compounding pharmacy. Typically, a course of treatment costs about $120. 

Photodynamic therapy 

Treatment costs are variable and are influenced by:  

• Whether skin preparation treatment (e.g. microneedling, curettage or laser-assisted drg delivery) is performed on the day of treatment.
• Amount of ALA cream used. 
• Type of light used to activate the ALA (i.e. LED red light phototherapy vs intense pulsed light).

Costs generally vary between $500 to $1,000 for treatment of a single skin cancer. No Medicare rebate is payable. 

How convenient is it? 

Surgical excision 

Surgical removal must be performed by a doctor. it usually takes 30-60 minutes. After the procedure, there is a period of aftercare lasting several weeks. Activities and exercise may be restricted during this period. 

Cryotherapy  

Cryotherapy is performed by a doctor and takes a few minutes. Aftercare is relatively simple; the wound usually heals in about three weeks. 

Topical therapy 

Imiquimod cream must be applied to the affected area and surrounding region five days a week for six weeks.  

Fluorouracil cream must be applied twice daily to the affected area and the surrounding region for four weeks.  

Combination 5-FU/calcipotriol cream is applied to the cancer twice daily for 6 days, followed by a break of 14 days and a further course of 6 days. In some cases, a further 6-day course must be applied 2 weeks later (Bricknell 2021). 

During treatment, the area usually becomes red, irritated and painful. Direct sunlight must be avoided during this period. 

Photodynamic therapy 

Treatment can usually be completed in a single visit to the skin cancer clinic, lasting several hours.  

Due to inflammation and pain and the appearance after treatment, limiting work and other activities for a week or more may be necessary. 

Direct sunlight must be avoided for about a week. 

A second visit to the clinic is necessary about 4-5 weeks later to check that treatment has worked. If there is evidence that the cancer is still present, a second application of PDT may be required.