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## Complete Summary

#### GUIDELINE TITLE

Skin cancer.

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Skin cancer. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2005 May 25 \[Various\].

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Skin cancer. In: EBM Guidelines. Evidence-Based Medicine
\[CD-ROM\]. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2004
Aug 18 \[Various\].

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Skin cancer, including:

-   Melanoma

-   Basiloma (basalioma, carcinoma basocellulare, basal cell carcinoma
    \[BCC\])

-   Epidermoid carcinoma (c. epidermoides, c. spinocellulare, c.
    squamocellulare, spinalioma)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Dermatology\
Family Practice\
Internal Medicine

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the
core clinical knowledge essential in general practice. The guidelines
also describe the scientific evidence underlying the given
recommendations.

#### TARGET POPULATION

Patients with known or suspected skin cancer (melanoma, basiloma,
epidermoid carcinoma)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Evaluation of moles (naevi) for clinical features suspicious of
    malignancy

2.  Referral to a specialist for evaluation of large lesions, strong
    suspicion of melanoma, and lesions on the eyelids or in the vicinity
    of the nostrils or ear canal

3.  Dermatoscopy

4.  Biopsy

**Treatment/Management**

1.  Surgical excision

2.  Liquid nitrogen cryotherapy

3.  Photodynamic treatment

4.  Local treatment with imiquimod

5.  Referral of confirmed melanoma for further surgical treatment

6.  Follow-up examinations, as indicated, depending on type of
    malignancy. For melanoma, follow-up includes assessment of general
    condition, investigation of symptoms, assessment of site of
    excision, palpation of local lymph nodes; further evaluation (chest
    radiograph, blood count, liver function tests, liver
    ultrasonography) may be required if clinical examination indicates
    need.

**Prevention**

1.  Sunscreens, in the prevention of solar keratoses

**Note**: Measures to prevent skin cancer, including beta carotene and
isotretinoin were considered but not recommended.

#### MAJOR OUTCOMES CONSIDERED

-   Specificity and sensitivity of diagnostic measures

-   Recurrence rates after treatment

-   Incidence of melanoma and other skin cancers or keratoses

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of
systematic reviews and the Database of Abstracts of Reviews of
Effectiveness (DARE). In addition, the Cochrane Library and medical
journals were searched specifically for original publications.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

A.  Strong research-based evidence. Multiple relevant, high-quality
    scientific studies with homogenic results.

B.  Moderate research-based evidence. At least one relevant,
    high-quality study or multiple adequate studies.

C.  Limited research-based evidence. At least one adequate scientific
    study.

D.  No research-based evidence. Expert panel evaluation of other
    information.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence \[A-D\] supporting the recommendations are
defined at the end of the \"Major Recommendations\" field.

**Basic Rules**

-   The most important indication for excision of a naevus is suspicion
    of malignancy. Other indications include aesthetic considerations or
    the location of the naevus in an area exposed to friction. If naevi
    are excised for cosmetic reasons, always estimate the eventual
    consequences of a scar and the tendency of the patient to develop
    keloids.

-   A general practitioner can excise any naevus using local
    anaesthesia. Very large lesions and strong suspicion of melanoma
    should be referred to a specialist.

**Naevi, Melanoma**

-   The incidence of melanoma is increasing. Suspect a melanoma if a
    naevus starts to grow, change its colour, develop satellites, bleed,
    or discharge. A melanoma cannot be ruled out on clinical grounds
    (see picture 1\*), and it may develop on previously intact skin.

1.  **\"Ordinary-looking\" naevus**

    -   The need for excision depends on the history given by the
        patient concerning changes, and aesthetic considerations or
        annoying location. Requests for the removal of solitary naevi
        should generally be granted even if the doctor considers the
        lesion benign.

    -   The naevus is removed totally, but the margin of intact skin can
        be small.

    -   Benign lesions that may concern the patient include long-haired
        intradermal naevus, dermatofibroma (see pictures 2 and 3\*),
        fibroma molle (see picture 4\*), and cherry angioma (see picture
        5\*).

    -   The general practitioner often sees patients who require the
        removal of a large number of naevi, either one at a time or at
        the same consultation. Usually a reassuring conversation and the
        removal of a few large naevi calm the patient, unless the
        patient suffers from conversion, in which case the same problems
        occur again later.

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2.  **\"Slightly suspect\" naevus**

    -   For example, a naevus that looks benign but that has grown or
        changed colour (darker) or has bled or discharged according to
        the patient (Whited & Grichnik, 1998; DARE-988293, 1999)
        \[**C**\]

    -   Such a naevus should always be removed, and the excisional
        margin is determined by the appearance and location of the
        naevus.

    -   Granuloma pyogenicum is a benign growth that usually develops at
        the site of disrupted skin (see picture 6\*).

    -   The following lesions may be difficult to differentiate from
        melanoma:

        -   \"Blue naevus\" (see picture 7\*)

        -   Lentigo (see picture 8\*)

        -   Naevus spilus (see picture 9\*)

        -   Spitz naevus (see picture 10\*)

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3.  **Strong suspicion of a melanoma**

    -   See pictures 11, 12, 13\*

    -   Refer the patient to a plastic surgeon, a surgeon, or a
        specialist in otorhinolaryngology or ophthalmology if a naevus
        has

        -   Markedly grown and changed its colour (see picture 14\*)

        -   Become exceptionally large (see picture 13\*)

        -   Developed satellites

        -   Appeared on the site of a melanoma that has been excised
            before

    -   Make sure that the patient has reserved an appointment and that
        the naevus was removed.

**Treatment and Follow-up of a Melanoma**

-   In cases of melanoma, the patient should be referred for further
    surgical treatment, and the referring physician should make sure
    that the patient is treated without delay.

-   A larger excision of the skin and subcutaneous tissue is performed
    around the tumour. The extent of the excision is determined by the
    location, thickness (Breslow classification), and depth of
    infiltration (Clark classification) of the tumour.

-   Very superficial melanomas (Clark I-II, Breslow \<1 mm) should be
    excised with a 1-cm margin of intact tissue (see picture 15\*).
    Deeper melanomas should be removed with a 2- to 5-cm margin. The
    site of excision is reconstructed with a pedicle flap or free graft.
    Prophylactic evacuation of lymph nodes is performed in some cases of
    melanoma.

**Follow-up of a Melanoma**

-   Patients with a melanoma are followed-up every 3 months until 2
    years have passed from the diagnosis. Thereafter, follow-up is
    continued every 6 months for 5 years. The unit responsible for
    follow-up (hospital or primary care) can be decided on locally. It
    is important that the same doctor always sees the patient.

-   If the patient has numerous naevi or the syndrome of hereditary
    dysplastic naevi, follow-up of a melanoma should take place in a
    dermatological unit. High-quality photographs facilitate follow-up.
    These patients should be followed-up throughout their life.

-   At follow-up visits the general condition and symptoms are
    investigated, and the site of excision and local lymph nodes are
    palpated. Satellites of melanoma are usually felt as subcutaneous
    nodules, and they are visible under the skin as dark spots.

-   A melanoma first metastasizes into regional lymph nodes, which
    should be followed-up carefully by palpation. If the clinical
    examination suggests the spread of a melanoma, a chest x-ray, blood
    count, liver function tests, and liver ultrasonography should be
    performed.

-   If a melanoma has infiltrated the regional lymph nodes, they are
    removed surgically. A metastasized melanoma is treated by an
    oncologist. Cytostatics and interferon have been moderately
    effective in the treatment of metastasized melanoma.

**Basiloma (Basalioma, Carcinoma Basocellulare, Basal Cell Carcinoma
\[BCC\])**

-   See pictures 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26\*

-   Basiloma or basal cell carcinoma is the most common malignant skin
    tumour.

-   Basilomas are most commonly located in the face of persons who are
    elderly, light-skinned, or who have been heavily exposed to sunlight
    (see pictures 27 and 28\*).

-   A typical basiloma is a glittering tumour with elevated margins.
    Often ulceration develops in the centre. A so-called morphoid
    basiloma is difficult to recognize and its borders are difficult to
    determine.

-   A superficial basiloma usually occurs on the trunk (see picture
    29\*). Differentiation from psoriasis or eczema may sometimes be
    difficult. Slow growth lasting many years is typical for the
    clinical picture.

-   Solar ultraviolet B (UVB)-radiation is the most important
    predisposing factor.

**Treatment and Follow-up**

-   The general practitioner can excise (Thissen, Neumann, & Schouten,
    1999; DARE-992074, 2001; \"Interventions for basal cell carcinoma of
    the skin\", 2003) \[**C**\] a small, typical basiloma if he/she is
    familiar with the operative techniques in the area. Patients with a
    suspected basiloma on the eyelids or in the vicinity of the nostrils
    or ear canal should be referred to a specialist.

-   The treatment of choice is surgery. The tumour is excised under
    local anaesthesia with a 5-mm margin of intact tissue, and
    reconstruction is performed if necessary by pedicle flap or free
    graft.

-   A superficial basiloma, and some common basilomas, particularly in
    the elderly, can be treated with liquid nitrogen cryotherapy in a
    unit familiar with the technique (see picture 30\*). New methods for
    the treatment of basilomas include photodynamic treatment and local
    treatment with imiquimod.

-   A basiloma metastasizes rarely. Because local spread is common,
    special care should be taken in the treatment and follow-up of
    basilomas near the eyelids, nostrils, or ear canal.

-   Small basilomas in non-risk areas can be excised by the general
    practitioner who is also responsible for follow-up yearly.

-   Consider referring a young patient with basiloma to a dermatologist.
    Basiloma may be a manifestation of some rare inherited diseases (see
    picture 31\*).

**Epidermoid Carcinoma (c. epidermoides, c. spinocellulare, c.
squamocellulare, spinalioma)**

-   Epidermoid carcinoma most commonly occurs on the face and hands. The
    usual form is an ulcerating prominence or scaling plaque.

-   Epidermoid carcinoma may develop directly on previously
    healthy-looking skin, but more commonly it develops on some
    precancerous change (solar keratosis, leukoplakia, Bowen\'s
    disease).

-   Clinically it is often difficult to distinguish from solar keratosis
    (see picture 32\*), (see also, the Finnish Medical Society Duodecim
    guideline \"Solar Keratosis\"). Diagnosis must be confirmed by
    biopsy.

-   An epidermoid carcinoma should be treated by surgical excision. In
    the face, the margin must be at least 5 mm; in other parts of the
    body, preferably more.

-   Keratoacanthoma is a rapidly growing benign tumor (see picture
    33\*).

-   Bowen\'s disease is a superficial, \"incipient\" (in situ) carcinoma
    (see picture 34\*). It can be removed either surgically or by liquid
    nitrogen cryotherapy. The operation is usually performed by a
    surgeon, plastic surgeon, otologist, ophthalmologist, or
    dermatologist specialized in cryotherapy. The treating unit
    estimates the risk of relapse and determines the need for follow-up.

**Lip Carcinoma**

-   Lip carcinoma (epidermoid carcinoma of the lip) is usually situated
    in the lower lip (see picture 35\*). It presents first as an erosion
    or ulceration that can be preceded by leukoplakia.

-   A lip carcinoma is treated surgically by excising the lip at the
    site of the tumour with a margin and by performing reconstruction.

-   A lip carcinoma easily metastasizes in the lymph nodes under the
    skin, which should be palpated at follow-up examinations.

**Prevention of Skin Cancer**

There is little evidence of interventions to prevent skin cancer.
Sunscreens may be effective in the prevention of solar keratoses
(\"Prevention of skin cancer,\" 1995; DARE-950349, 1999) \[**C**\]

**Related Evidence**

Dermatoscopy may have a potential to improve the diagnostics of
malignant melanoma, but this has to be verified with higher quality
studies in primary care (Mayer, 1997; DARE- 978307, 1999) \[**D**\].

\*Note: All pictures identified in this summary can be found in the
original guideline document.

**Definitions**:

**Levels of Evidence**

A.  Strong research-based evidence. Multiple relevant, high-quality
    scientific studies with homogeneous results.

B.  Moderate research-based evidence. At least one relevant,
    high-quality study or multiple adequate studies.

C.  Limited research-based evidence. At least one adequate scientific
    study.

D.  No research-based evidence. Expert panel evaluation of other
    information.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=8262)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual
guidelines are the unique feature of the Evidence-Based Medicine
Guidelines. The evidence summaries allow the clinician to judge how
well-founded the treatment recommendations are. The type of supporting
evidence is identified and graded for select recommendations (see the
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Effective diagnosis and treatment of skin cancer

#### POTENTIAL HARMS

Excision of naevi can result in scarring and the tendency of the patient
to develop keloids.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Skin cancer. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2005 May 25 \[Various\].

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 Apr 30 (revised 2005 May 25)

#### GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

#### SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

#### GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Heli Majamaa

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Skin cancer. In: EBM Guidelines. Evidence-Based Medicine
\[CD-ROM\]. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2004
Aug 18 \[Various\].

#### GUIDELINE AVAILABILITY

This guideline is included in \"EBM Guidelines. Evidence-Based
Medicine\" available from Duodecim Medical Publications, Ltd, PO Box
713, 00101 Helsinki, Finland; e-mail: <info@ebm-guidelines.com>; Web
site: [www.ebm-guidelines.com](http://www.ebm-guidelines.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on December 17, 2002. The information
was verified by the guideline developer as of February 7, 2003. This
summary was updated on December 29, 2003, on October 4, 2004, on
February 18, 2005, and most recently on November 14, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008