What are the main treatments for BCC in the NHS? 

Basal cell carcinoma is the most common form of skin cancer in the United Kingdom and is generally slow-growing and highly treatable. Because these tumours rarely spread to distant parts of the body, the primary goal of medical intervention is to remove the growth completely while preserving the appearance and function of the skin. Most individuals diagnosed with this condition will receive a curative treatment that results in a positive long-term outcome. The choice of management depends on several clinical factors including the location, size, and specific subtype of the cancer identified during a biopsy. 

What We’ll Discuss in This Article 

• Standard surgical excision for low-risk and high-risk lesions 

• The precision of Mohs micrographic surgery for facial tumours 

• Non-surgical creams used for superficial variants of the disease 

• The application of radiotherapy for complex or inoperable cases 

• Minor procedures including curettage, cautery, and cryotherapy 

• The use of photodynamic therapy for superficial skin cancers 

Surgical excision as the primary treatment 

Surgical excision is the most common and effective treatment for the majority of basal cell carcinomas managed within the British healthcare system. This procedure involves removing the entire tumour along with a safety margin of healthy surrounding skin to ensure that no microscopic cancer cells are left behind. NHS clinical guidance specifies that surgical excision is the preferred treatment for most basal cell carcinomas because it allows for a complete histological examination of the tissue margins. The operation is typically performed under a local anaesthetic, meaning the area is numbed and the patient remains awake throughout the process. 

For standard low-risk tumours, a surgeon usually removes a four-millimetre margin of healthy skin around the visible growth. The resulting wound is typically closed with stitches, although larger or more complex lesions may require a skin graft or a skin flap to repair the area. A skin graft involves taking a thin layer of healthy skin from another part of the body, while a flap involves moving nearby skin to cover the defect. Once the tissue is removed, it is sent to a pathology laboratory for analysis to confirm that the edges are clear of cancer, a process that typically takes two to three weeks. 

Mohs micrographic surgery for complex facial sites 

Mohs micrographic surgery is a specialised surgical technique reserved for tumours in high-risk locations such as the eyelids, nose, ears, and lips. This method is particularly valued for its ability to save as much healthy tissue as possible while achieving the highest known cure rate for skin cancer. During the procedure, the surgeon removes the visible cancer and then takes thin layers of tissue from the margins to be examined under a microscope immediately. This cycle is repeated until the pathologist confirms that no cancer cells remain in the samples. 

By checking the tissue in real-time, the surgeon can be extremely precise, removing only the cancerous cells and a minimal amount of healthy tissue. This is especially important on the face, where preserving the natural contours and function of features is a clinical priority. While Mohs surgery is a more time-consuming process than standard excision, it significantly reduces the risk of the cancer returning in the future. In the United Kingdom, this specialised procedure is usually carried out in regional dermatology centres by consultants with specific training in Mohs techniques. 

Topical treatments and creams for superficial lesions 

Individuals with the superficial subtype of the disease may be offered non-surgical options such as medicinal creams that can be applied at home over several weeks. NICE guidelines support the use of topical treatments like imiquimod or 5-fluorouracil for low-risk superficial basal cell carcinomas when surgery is not desirable or appropriate. These medications work by stimulating the immune system to attack the abnormal cells or by directly interfering with the DNA of the cancer to prevent it from growing. 

Imiquimod, often sold under the brand name Aldara, is typically applied five times a week for six weeks. 5-fluorouracil, or Efudix, is usually applied twice daily for several weeks. While these treatments are effective and avoid the need for surgery and stitches, they often cause a significant skin reaction. The treatment area may become red, sore, and scaly, and it may even develop shallow ulcers or crusting during the process. This reaction is a sign that the medication is working, and the skin usually heals well with minimal scarring once the course of treatment is finished. 

The role of radiotherapy in skin cancer management 

Radiotherapy involves the use of high-energy rays to destroy cancer cells and is an alternative for patients who are not suitable for surgery. This might be due to the location of the tumour, the general health of the patient, or if a person prefers to avoid an operation. Radiotherapy is particularly effective for larger tumours on the face where surgical reconstruction would be difficult, or for older patients who may find an operation more physically taxing. 

The treatment is typically delivered in a series of small doses over several weeks in a hospital oncology department. Modern radiotherapy is highly targeted, aiming to deliver the radiation to the tumour while avoiding damage to the surrounding healthy structures. While it is a painless process, the skin in the treated area can become red and sore, similar to a sunburn, during the final stages of the treatment. Radiotherapy provides excellent local control of the disease and is a valuable tool for complex or inoperable cases. 

Minor procedures including curettage and cryotherapy 

Curettage and cautery are minor surgical procedures often used for small, well-defined basal cell carcinomas on the trunk or limbs. After the area is numbed with a local anaesthetic, the surgeon uses a sharp, spoon-shaped instrument called a curette to scrape the cancer cells away. The surface of the wound is then sealed using an electric needle in a process called cautery to stop any bleeding and destroy any remaining abnormal cells. This process may be repeated two or three times to ensure the area is clear. 

Cryotherapy is another option for very small or superficial lesions, involving the application of liquid nitrogen to freeze the cancer cells. The extreme cold causes the cells to die and eventually form a blister or a scab that falls away after a few weeks. While cryotherapy is quick and does not require stitches, it can sometimes leave a white or pale scar at the site of treatment. These minor procedures are generally reserved for lesions that are clinically assessed as being at very low risk of recurring or growing into deeper tissues. 

Photodynamic therapy as a non-invasive option 

Photodynamic therapy is a non-invasive technique that uses light-sensitive medication and a specific light source to target and destroy cancer cells. A specialised cream is applied to the lesion and left under a dressing for several hours to allow it to be absorbed by the abnormal cells. When the area is then exposed to a specific wavelength of light, a chemical reaction occurs within the cancer cells that leads to their destruction. 

This method is particularly useful for superficial basal cell carcinomas, especially when a patient has multiple lesions in one area or if the tumour is in a location where a surgical scar would be undesirable. Most patients require two sessions of photodynamic therapy, usually spaced one week apart. The treatment is well-tolerated, although some individuals may experience a stinging or burning sensation during the light exposure. One of the main benefits of this approach is the excellent cosmetic result, as it typically leaves very little scarring once the skin has healed. 

Conclusion 

The management of basal cell carcinoma in the NHS is highly successful, with surgical excision and Mohs surgery remaining the most common curative options. For superficial or lower-risk cases, non-invasive methods such as topical creams and photodynamic therapy offer effective alternatives with good cosmetic outcomes. Your specialist team will recommend the most appropriate clinical pathway based on the unique characteristics of your skin cancer and your overall health. If you experience severe, sudden, or worsening symptoms, call 999 immediately. 

Authority Snapshot (E-E-A-T) 

This article is designed to provide clear and factual information regarding skin health for the general public. The content is written by the Medical Content Team and has been reviewed by Dr. Stefan Petrov. He is a UK-trained physician with an MBBS and postgraduate certifications including Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and the UK Medical Licensing Assessment (PLAB 1 & 2). He has hands-on experience in general medicine, surgery, anaesthesia, ophthalmology, and emergency care. Dr. Petrov has worked in both hospital wards and intensive care units, performing diagnostic and therapeutic procedures, and has contributed to medical education by creating patient-focused health content and teaching clinical skills to junior doctors.