What are the treatment options for skin cancer on the hands?

Treatment Options for Skin Cancer on the Hands

Surgical excision is the treatment of choice for the majority of skin cancers on the hands, with specific margin requirements based on tumor type and risk stratification. 1

Primary Treatment Approach by Cancer Type

Squamous Cell Carcinoma (Most Common on Hands)

For well-defined, low-risk squamous cell carcinomas less than 2 cm in diameter, surgical excision with a minimum 4-mm margin is appropriate and achieves complete removal in 95% of cases. 1

• Larger tumors, high-risk tumors (Broders' grade 2-4), tumors extending into subcutaneous tissue, or those in high-risk locations (dorsum of hand, web spaces, proximal phalanges) require wider margins of 6 mm or more with histological examination of tissue margins. 1, 2

• For patients with multiple adjacent tumors on the dorsal hands and forearms, en bloc excision with split-thickness skin grafting can be used, though healing is prolonged and morbidity is significant 1

• Curettage and electrodesiccation is effective for low-risk tumors but should NOT be used on hair-bearing sites or if the subcutaneous layer is reached during surgery 1

• Mohs micrographic surgery provides the highest cure rates for high-risk squamous cell carcinomas and allows tissue-sparing excision, which is particularly valuable for hand preservation 1, 3

Basal Cell Carcinoma

• Surgical excision remains the primary treatment with similar margin principles as squamous cell carcinoma 1

• Curettage and electrodesiccation is acceptable for low-risk basal cell carcinomas with the same caveats regarding hair-bearing sites and subcutaneous involvement 1

Melanoma

For melanoma on the hands, wide excision with margins based on Breslow thickness is mandatory: 0.5 cm for in situ melanoma, 1 cm for tumors 1-2 mm thick, and 2-3 cm for thicker tumors, with modifications needed for preservation of function in melanomas of the fingers. 1

• Sentinel lymph node biopsy should be performed for melanomas >1 mm thickness before wide excision 1, 4

• Acral lentiginous melanoma (occurring on palms, soles, or under nails) requires the same surgical principles 1

Alternative Treatment Modalities

Radiation Therapy

• Radiation therapy is an acceptable alternative when surgery would compromise function or cosmesis, though surgical outcomes are superior based on evidence-based literature review 1

• RT is used more frequently as adjuvant therapy for perineural disease in high-risk patients 1

Topical Therapies (Limited Role)

• Topical 5-fluorouracil cream (5% strength) can be applied twice daily for superficial basal cell carcinomas, continuing for 3-6 weeks and potentially up to 10-12 weeks until lesions are obliterated. 5

• Topical treatments including 5-fluorouracil, imiquimod, and photodynamic therapy are options primarily for precancerous actinic keratoses rather than invasive cancers 1, 6

Critical Management Principles

Biopsy Requirements

• Full-thickness biopsy including deep reticular dermis is essential, as superficial biopsies frequently miss infiltrative histology present at deeper margins 1

• Shave biopsies may compromise pathologic diagnosis and complete assessment of Breslow thickness for melanoma 7

High-Risk Patient Considerations

• Patients with multiple tumors may benefit from destructive therapies (curettage and electrodesiccation, cryotherapy) for clinically low-risk tumors due to ability to treat multiple lesions in a single visit 1

• Immunosuppressed patients (organ transplant recipients) develop more aggressive tumors and may require consideration of reducing immunosuppressive therapy in cases of life-threatening skin cancer 1

Reconstruction Needs

• Most hand skin cancer defects require soft-tissue reconstruction due to the limited tissue availability and functional requirements 2, 3

• "Preservative surgery" emphasizes optimal reconstruction while maintaining function and cosmesis of the involved finger, hand dorsum, or palm 3

Common Pitfalls to Avoid

• Do not use curettage and electrodesiccation on hair-bearing sites, as tumor extension down follicular structures will not be adequately removed 1

• Do not perform superficial biopsies on suspected invasive lesions, as this will miss deeper infiltrative components 1

• Web space and dorsal proximal phalangeal squamous cell carcinomas are more sinister malignancies with greater propensity for metastatic spread and require aggressive management 2

• Patients with one skin cancer on the hand often have concurrent precancers or cancers at other sun-exposed sites and are at increased risk for melanoma, requiring full skin examination 1

Follow-Up Requirements

• Patients with hand skin cancers frequently develop additional hand skin cancers (almost one in five in large cohorts), necessitating ongoing surveillance 2

• Follow-up schedules should be titrated to the frequency of tumor development 1