Are squamous cell ulcers typically painful?

Pain Characteristics of Squamous Cell Carcinomas

Squamous cell carcinomas (SCCs) are typically painful, particularly when ulcerated, though early lesions may be painless which can delay diagnosis and lead to worse outcomes.

Pain as a Clinical Feature of SCC

Squamous cell carcinoma commonly presents with pain, especially when the lesion has progressed to ulceration. However, there are important clinical considerations regarding pain in SCC:

• Pain is often present in ulcerated SCCs, making it a key symptom that prompts patients to seek medical attention 1
• An important exception is early-stage oral squamous cell carcinoma, which is frequently painless in its initial stages, potentially delaying diagnosis 2
• The absence of pain in early lesions can lead to delayed presentation and worse outcomes

Factors Affecting Pain in SCC

Several factors influence whether an SCC lesion will be painful:

Stage and Progression

• Early, non-ulcerated SCCs may be asymptomatic
• Advanced SCCs with deeper invasion typically cause more pain
• SCCs that have invaded nerves (perineural invasion) are particularly painful 1

Anatomical Location

• SCCs in highly innervated areas (face, genitals, fingertips) tend to be more painful
• SCCs developing in areas with reduced sensation (chronic wounds, radiation-damaged skin) may be less painful initially

Special Clinical Scenarios

• SCCs arising in chronic wounds (Marjolin's ulcers) may initially be masked by the underlying wound pain 3, 4
• SCCs developing in venous leg ulcers may be particularly aggressive and painful as they progress 5

Clinical Implications

The pain characteristics of SCC have important clinical implications:

1. Diagnostic Vigilance: Any change in pain pattern in a chronic wound or ulcer should prompt immediate biopsy to rule out malignant transformation 4

2. Pain Management: Patients with advanced SCC often require significant pain management, including opioid analgesics 1

   • For palliative cases, topical morphine gel can be applied directly to painful malignant wounds
   • Subcutaneous opioids via syringe driver or opioid patches may be necessary

3. Warning Signs: For patients with epidermolysis bullosa (who are at high risk for SCC), altered sensation in a wound (tingling or increased pain) compared to normal wounds is a warning sign requiring evaluation 1

Diagnostic Considerations

Pain characteristics should be considered alongside other clinical features when evaluating for SCC:

• Non-healing wounds lasting longer than 4 weeks
• Rapidly growing, exuberant granulation-like tissue
• Deep, punched-out ulcers with raised or rolled edges
• Areas of hyperkeratosis with raised skin borders
• Wounds with altered sensation relative to normal wounds 1

Conclusion

While pain is a common feature of squamous cell carcinomas, particularly when ulcerated, clinicians should be aware that early lesions may be painless. This painless presentation, especially in oral SCCs, can delay diagnosis and lead to worse outcomes. Any chronic ulcer or wound that changes in appearance or pain characteristics should be biopsied promptly to rule out malignant transformation.