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SKIN CANCER INFORMATION - FAQ

This is a patient education site that provides in-depth knowledge of skin cancer medicine.

Information in this website is not meant to replace the doctor-patient clinical consultation, but a mere attempt to answer some of the common questions arising from skin cancer clinical consultations.

If you have any questions about any of skin spots, please seek medical advice.

WHAT HAPPENS IF YOU DO NOTHING?

If you do nothing with skin cancers - simply put - could be fatal. This is rather very straight forward but commonly asked question.

May be because some of the skin cancers looks deceptively "normal" or "not-dangerous" that patients are asking this question.

I urge no one to "do nothing". Although some skin cancers may appear benign, it is still a CANCER.

AUSTRALIAN SKIN CANCER STATISTICS

Australia has the highest rate of skin cancer in the world, with over 380,000 people diagnosed every year.

Over 1,600 Australians die from skin cancer each year.

Skin cancer is the most common form of cancer in Australia.

Skin cancers account for over 80% of all new cancers diagnosed each year in Australia.

One in 24 males and one in 33 females will develop melanoma of skin by the age of 75.

Melanoma is the third most common life threatening cancer in Australian men after prostate and bowel cancer.

Melanoma is the third most common life threatening cancer in Australian women after breast and bowel cancer.

The number of melanoma cases diagnosed in Australia:

1997 – 8,366

2004 – 9,722

The number of people diagnosed with non-melanoma skin cancers (squamous cell carcinoma and basal cell carcinoma) in Australia:

1995 – 270,000

2002 – 374,000

The number of deaths in Australia from skin:

1993: - melanoma: 85
- non-melanoma skin cancer: 379
2005: - melanoma: 1,273
- non-melanoma skin cancer: 405

Men are 1.5 times more likely to develop melanoma of the skin than women and 3.3 times more likely to die from it.

WHAT IS CANCER?

Cancer is a disease of the body's cells. Our bodies are always making new cells: so we can grow, to replace worn out cells, or to heal damaged cells after injury. This process is controlled by certain genes. All cancers are caused by changes to these genes. Changes usually happen during our lifetime, although a small number of people inherit a changed gene from a parent.

WHAT IS SKIN CANCER?

The epidermis or top layer of skin contains three common types of cells: squamous cells, basal cells and melanocytes. Skin cancer is a disease of the these skin cells abused mainly by overexposure to ultraviolet (UV) radiation.

UV radiation disrupts the cells' genes and can cause them to grow abnormally. If these abnormal cells are not destroyed by the body's natural defense systems they can develop into skin cancers.

There are three main types of skin cancer named after the type of cells they start from. These are:

Basal Cell Carcinoma (BCC)

Squamous Cell Carcinoma (SCC)

Melanoma

BCC & SCC are also referred to as Non melanoma skin cancer, and Melanoma referred to as melanoma skin cancer. Distinction is clinically important as Melanoma has a much worse prognosis; an imminent life threat. BCC and SCC are less dangerous than Melanoma but we are still losing about 400 lives per year as a direct result of these “less dangerous” skin cancers.

Within each of these skin cancers, there are numerous different sub-types, each carrying different prognosis and treatment options. e.g. Basal cell carcinoma can be superficial BCC, multi-focal BCC, infiltrative BCC, sclerosing BCC, morphoeic BCC, etc.

WHAT CAUSES SKIN CANCERS?

Skin cancer is mainly caused by too much ultraviolet (UV) radiation from the sun (solar UV radiation). There are numerous other causative factors for skin cancers. Some causative factors tend to produce more of one type of skin cancer than the others.

UV radiation

Sun exposure is the cause of around 99% of non-melanoma skin cancers and 95% of melanoma in Australia, so it is important to adopt sun protection measures to prevent skin cancer.

The most important years for sun protection are during childhood and adolescence. Exposure to UV radiation during these years greatly increases the chance of skin cancer later in life.

There are three types of solar ultraviolet (UV) radiation: UVA, UVB and UVC. UVC does not reach the earth's surface. Both UVA and UVB radiation can cause skin cancer but UVB appear to be more a more potent instigator. UV radiation varies according to a number of factors such as time of year, latitude and altitude. UV radiation cannot be seen or felt. It can pass through light cloud so sunburn can occur even on cool or cloudy days.

Solariums

Solariums or sunbeds can emit ultraviolet (UV) radiation up to five times as strong as the midday sun. Solariums emit both UVA and UVB radiation - both are known causes of skin damage and skin cancer. Skin Cancer Authorities does not recommend the use of solariums or sunbeds for cosmetic purposes as all forms of UV radiation contribute to skin cancer burden in Australia.

Skin tanning

A tan is a sign of skin damage. Deliberate exposure to all forms of ultraviolet (UV) radiation will increase your risk of skin damage and skin cancer. Tanning without burning can still cause irreversible skin damage, premature ageing and skin cancer. Skin Cancer Authorities does not recommend any deliberate form of tanning as it will increase the risk of developing skin cancer.

Fake tanning products

Fake tanning products contain synthetic or vegetable dyes that temporarily paint the skin brown. These bind to the skin and come off when dead skin cells flake off. Fake tanning products do not provide adequate sun protection. Some brands include a sunscreen, which will provide only short-term protection for two hours from the time of application. The protection does not last as long as the 'tan' lasts.

Skin cancer and family history

Less than 5% of cases of melanoma are due to inherited genes (familial cancer). Risk factors include a family history of multiple cases of melanoma on the same side of the family; melanoma occurring at an early age; ocular (eye) melanoma; and pancreatic cancer in more than one family member. But having said that, if you have a first degree relative who had a melanoma, your risk of getting melanoma doubles. So be sure to alert your immediate family to have regular skin checks, if you have had a history of melanoma.

WHO IS AT RISK?

Most people living in Australia are at risk of skin cancer, but some groups are more at risk.

These are people who are :

Middle age or above

are fair skinned and burn quickly (very fair skin, blue eyes, blonde or red hair)

have freckles and/or moles

were exposed to the Australian sun as children, especially living near the tropics (Townsville residents have higher risk of skin cancer than those from Tasmania)

suntan intentionally

have a family history of skin cancer

have a past history of skin cancer

work outdoors for lengthy periods of time

use solariums, sunlamps and sunbeds.

History of arsenic poisoning, exposure to ionising radiation or polycyclic aromatic hydrocarbons, immune suppression, organ transplantation, tobacco, chronic ulcers and scars.

Genetic familial disease such as Gorlin’s syndrome, xeroderma pigmentosum

CLINICAL FEATURES OF SKIN CANCERS

There are three main types of skin cancers. They are broadly classified as Melanoma Skin Cancers and Non Melanoma Skin Cancers (BCC & SCC). Distinction is clinically important as Melanoma has a much worse prognosis; an imminent life threat. BCC and SCC are less dangerous than Melanoma but we are still losing about 400 lives per year as a direct result of these “less dangerous” skin cancers.

Basal Cell Carcinoma (BCC)

most common and least dangerous form of skin cancer

appears as a round or flattened lump or scaly area

red, pale or pearly in colour

grows slowly, usually on the head, neck and upper torso

as it grows it may form an ulcer (rodent’s ulcer)

may present as a non healing ulcer

There are numerous different subtypes: superficial BCC, Multifocal BCC, nodular BCC, Nodulocystic BCC, morphoic BCC, Sclerosing BCC, infiltrative BCC, and more.Click here to skin cancer gallery

Squamous Cell Carcinoma (SCC):

less common, but more dangerous than basal cell carcinoma

not as dangerous as melanoma

appears as a thickened, red, scaly spot that may bleed easily, crust or ulcerate

appears on skin most often exposed to the sun

grows over weeks to months and may spread to other parts of the body if not treated promptly.

Precursor skin condition is called Solar Keratosis (AKA Actinic Keratosis, Sunspots).

There are few different subtypes: bowen’s disease, invasive SCC, baso-squamous cell Carcinoma, keratoacanthoma, bowenoid solar keratosis. Click here to skin cancer gallery

Melanoma

Melanoma is cancer of the skin's melanocytes (pigment cells) and the most deadly form of skin cancer.

the least common but most serious form of skin cancer

appears as a new spot or an existing spot, freckle or mole that changes colour, size or shape. It grows quickly.

usually has an irregular or smudgy outline and is more than one colour. It may be red or pink; some are brown or black

only rarely causes pain, bleeds or itches, but sometimes it can bleed and crust

grows over weeks and months anywhere on the body (not just in places that get a lot of sun)

if untreated, cancer cells can spread to other parts of the body.

is usually flat but may be firm to touch and dome-shaped

there are few subtypes: superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, mucosal melanoma, acral lentiginous melanoma, subungual melanoma, desmoplastic melanoma. Click here to skin cancer gallery

WHAT DOES SKIN CANCERS LOOK LIKE?

This question along with "what should I look out for?" are one of the most commonly asked questions during the consultations. It is very difficult to teach patients what skin cancers look like and what they should be looking out for.

The best solution is to familiarise yourself with numerous real photos of skin cancers.

And the safest course of action is to seek medical oppinion early if you are unsure.

Please visit our Skin Cancer Gallery section to see thousands of photos of real skin cancers that I manage on daily basis.

WHY CHECK YOUR SKIN ?

“Skin cancer is almost totally preventable and
it can almost always be cured if found early enough”

Any new or unusual freckles, moles, sores or sunspots that are changing on your skin could potentially be cancerous. Early detection of all forms of skin cancer leads to a cure in 95% of cases.

People of all ages, but particularly those at high risk category should have a regular self skin examination.

It is important that you see your doctor as soon as you notice anything new or unusual. Remember, early detection can save lives.

HOW TO EXAMINE THE SKIN?

Skin cancer diagnosis requires skin check, whether it is self examination or a medical examination.

Self-examination

All adults should check their skin for changes at least every three months. By regularly checking your skin you will recognize:

what spots are normal, as well as

notice any changes.

Unlike many other cancers, skin cancers are often visible, making it easier to detect any changes. Early detection is crucial if skin cancer is to be cured. Use a hand-held mirror, in a good lighting condition, to check the skin on your back and the back of your neck or ask someone else to have a look for you. Don’t forget to check your armpits, inner legs, ears, eyelids, hands and feet. Use a comb to move sections of hair aside and inspect your scalp.

There are no simple rules or machines that can accurately diagnose skin cancers. But ABCD rule of early detection is a simple guide that can help you to objectively analyse the lesion.

A: Asymmetry – One half of the spot doesn’t match the other
B: Border – The edges are irregular, ragged, notched, or blurred
C: Colour – The colour is not the same all over and may include shades of brown or black, red, white or blue
D: Diameter – The spot is larger than 6 mm across (about 1/4 inch) or is getting bigger

Also be aware of any mole or freckle which:

changes over a period of months

grows in size

changes shape

becomes mottled in colour

Photographs of any suspicious areas can be useful to record any changes. People worried about changes that might indicate skin cancer should talk to their doctor.

One thing I want to emphasize is that the aim of self examination is not to teach the patients how to make the diagnosis, but to simply be able to note any odd lesions or to notice any new changes in them, so that you can seek medical advice early. A large majority of the lesions that the patient’s thought they were cancerous are actually benign. But some are indeed true skin cancers. In turn, this leads to an early detection and saved lives.

Medical Examination

Medical examination involves a routine annual visit to a doctor’s surgery, to have full body examination by a doctor. It generally takes approximately 10-15 minutes, it is easy and painless.

Routine medical examination is particular useful for those:

At higher risk:

Of the Age of 40 and above

Areas that are difficult to self examine such as back

There is added advantage of being able to accurately diagnose, monitor, and offer treatment if there is a need. You will also receive a peace of mind, by taking away the guess work, and self worries about not recognising a potentially dangerous spot.

HOW IS SKIN CANCER DIAGNOSED?

Skin cancer is diagnosed by clinical examination and biopsy.

Clinical Examination

Your doctor will first examine the suspicious spot and check other parts of your skin using a standard examination tool called Maggy Lamp (magnifying glass with a bright white light source). This instrument allows a better general visualisation of the skin and improves spotting of suspicious lesion. This is the instrument that is recommended by the skin cancer council.

Your doctor may also examine you with a manual or a digital surface microscope (dermatoscope). This is particularly useful if the doctor is suspecting a melanoma, as this instrument allows better visualization of the pigments within the pigmented skin spots.

Digital photography (both a normal and dermatoscopic view) should be taken if the lesion needs to be monitored. This allows an easy detection of any or no changes within the suspicious lesion.

There are other types of instruments called “blue light” or “wood’s lamp”, but their use in skin cancer examination is not as useful as the white light magnification instrument. Sometime though, it can assist in the skin cancer diagnosis.

There are no instruments, computer programs or digital instruments that will be able to give an automatic accurate diagnosis. All these instruments are used to assist the doctor in making the diagnosis.

At the end of the day, it is the doctor’s knowledge, training, and experience in the field of skin cancer medicine that determines the accuracy of the diagnosis. The positive thing about skin cancer is that it is visible, so it can be detected in the early stages and it can almost always be cured if found early enough.

Biopsy

If your doctor suspects that you have a skin cancer, to confirm it, they will suggest that you have a biopsy.

There are commonly three types of biopsies;

punch biopsy,

shave biopsy or

excisional biopsy.

Punch & shave biopsy takes a sample or a portion of the lesion while the excisional biopsy takes the whole lesion for a definitive histological examination (look under microscope at the pathology laboratory).

For more information, photos and videos of skin biopsies - click here for more biopsy info.

IMPORTANT FACTORS IN CHOOSING THE CORRECT TREATMENT?

The treatment of skin cancer has a high (95%) success rate, provided that the skin cancer is detected at an early stage, before there is a chance of the cancer spreading.

Some patients may need additional tests, such as X-rays, blood tests, scans and/or lymph node biopsy, to check whether there has been any spread of skin cancer to other parts of the body.

When planning the treatment, the doctor will take a number of factors into account, including:

the type and size of the cancer

where it is situated

whether it has spread to other parts of the body

your age

general health

your preference

When your doctor knows to what type of skin cancer, what stage of skin cancer progression, and the location of the skin cancer, they can make a decision on the type of treatment required.

TREATMENT OPTIONS FOR SKIN CANCERS?

In general sense, these are the treatment options for skin cancers:

Surgical excision

Cryotherapy

Cautery

Curettage

Topical ointments

Laser therapy

Photodynamic therapy

Radiation therapy

As you can see there are numerous skin cancer treatment modalities. It is essential that patient is aware that there are numerous options other than traditional surgery for a less aggressive skin cancer (such as BCC or early SCC), that are more patient friendly and cosmetically acceptable. For more advanced skin cancers (such as invasive BCC, invasive SCC, all Melanomas) excisional surgery is still the only option.

TREATMENT OPTIONS EXPLAINED

Surgery

Surgery is the oldest and most common form of skin cancer treatment used today. It is still the best option for treatment of more aggressive skin cancers such as invasive BCC or SCC.

It is a two step process. First step is to excise the skin cancer along with a margin of normal skin around it. Although margin excision means sacrificing healthy skin and possibly harder to reconstruct the skin, it is important to ensure the completeness of the skin cancer excision. The extent of margin excision depends on the type of the cancer and it is also proportional to the invasiveness of the skin cancer. It may be 2-3 mm in BCC to 3-5mm in SCC to a wider 10-20mm for Melanomas.

In most cases the wound can be stitched together and the resulting scar will be a straight line. But in situations where the wound edges cannot be closed, after excising a large skin cancer, a more advanced wound closure techniques such as skin flaps and skin graft is required. Again emphasis is that this is not a regular event, and it is used only if there is a difficulty in closing the wound after the skin cancer excision.

For the graft, the surgeon will take a layer of skin from another part of your body, where there is plenty of skin such as thigh or buttock, and place it over the wound.

The other possibility is to do a 'flap', where the surgeon will close the wound using a nearby flap of skin.

To view photos, videos and more information, please click here.

Moh Micrographic Surgery

In a standard skin cancer surgery, skin cancer along with a margin of normal skin is excised to ensure the completeness of the skin cancer removal. In certain situations it is important to ensure that the minimal extra skin is excised. Skin cancers in the face is one of such example. More skin removal means less chance of looking normal.

To minimise sacrificing the healthy and normal skin, Moh Micrographic Surgery was invented. This technique allows skin cancer margins to be histologically analysed immediately. So we only excise skin cancers and not the healthy skin.

Advantages of Moh Surgery are:

Immediate feedback on skin cancer clearance (eliminates second excision)

Minimise the healthy skin excision

Maximises the chance of cosmetic restoration

Dr Peter Kim regularly performs Moh Micrographic Surgery. To view photos, videos and more information, please click here.

Cryotherapy

This technique uses extreme cold to treat pre-cancerous skin conditions and some small skin cancers. Liquid nitrogen is applied to the skin lesion to freeze and kill abnormal cells.

A special technique called Repeat Freeze Thaw Cycle where the treated area is allowed to thaw after freezing, and the freeze-thaw cycle may be repeated several times, over a few minutes to treat the smaller non melanoma skin cancers.

Some pain, redness, and a blister may develop but the wound usually heals well within 1-2 weeks. A small white scar may remain over the treated area, especially after the repeat freeze thaw cycles.

Cautery (also known as diathermy)

This is another form of treatment where the doctor will numb the area with local anaesthetic and using a diathermy instrument to burn the cancers and pre-cancerous cells.

Some pain, redness, and a blister may develop but the wound usually heals well within 1-2 weeks. This technique often leaves a flat or depressed, light-colored scar.

Curettage

This is another form of surgery where the doctor will numb the area with local anaesthetic and, using a small, sharp, spoon-shaped instrument called curette, scoop out the treating lesion.

This technique usually leaves a flat or depressed and light-coloured scar and takes longer to heal than cryotherapy or cautery.

Radiotherapy or radiation therapy

This technique is generally used for cancers that may be hard to treat with surgery (for example, on the eyes, nose, or forehead), or if the person is medically unfit for any other type of surgery. The treatment uses high-energy X-rays to destroy cancer cells. Several treatments over several weeks are often needed to destroy the cells completely. This type of treatment can make the treating area red and sore, and can produce changes in skin colour and/or texture in the long term. Radiation therapy produces results comparable to skin surgeries, but it is only available in major hospital centers and it requires multiple treatment sessions over few weeks, which are not patient friendly.

Laser therapy

This is now being used more in the treatment of skin cancers. Principle is that a beam of light (laser) when shine on the skin cancer it destroys the cancer cells.

The strength of the beam can be controlled so that a precise removal of the cancer is possible without excessively damaging the surrounding normal skin. It is usually reserved for less dangerous skin cancers such as BCC. It is not an acceptable treatment for invasive SCC or Melanoma.

Laser therapy is usually performed under local anaesthesia. It is a non surgical treatment and takes only minutes. Due to the cost of the instrument and the expertise required for this treatment, it is not a widely available treatment option, but it can a very satisfactory treatment option. Advantages are that it is a much easier and cosmetically more satisfying skin cancer treatment option especially in the areas such as face, and a potentially complex and scarring surgeries such as flaps or skin grafts can be avoided by using Laser therapy.

To view photos, videos and more information on Laser Therapy, please click here.

Photodynamic Therapy

Photodynamic laser therapy utilizes a combined use of laser light and medicated ointment. This is a two step treatment process where the ointment is applied to the treating area to photosensitise the skin cancer. After 3 hours of incubation, laser light is illuminated over the area applied with the cream. The photosensitised skin cancer cells are selectively destroyed due to the illumination with laser light.

Advantages are that it is a much easier and cosmetically more satisfying skin cancer treatment option especially in the areas such as face, and a potentially complex and scarring surgeries such as flaps or skin grafts can be avoided by using photodynamic therapy.

To view photos, videos and more information on Laser Therapy, please click here.

Chemotherapy/Immunotherapy (topical)

In this technique, a drug is applied directly on the skin cancer or sunspots in the form of a cream, for example, Efudix (5-fluorouracil) or Aldara (Imiquimod). These medicated creams destroy the skin cancers when it is constantly applied. These creams are applied every day for 2-6 weeks and the treating area becomes red, followed by blistering, peeling or cracking skin. This reaction is only temporary, and the treated skin will flake away along with the skin cancer.

This treatment options is usually reserved for a less dangerous skin cancer such as BCC. It is not an acceptable treatment for invasive SCC or Melanoma.

Disadvantage of this treatment is that it is patient controlled treatment modality that runs over few weeks. Unlike other treatments where the outcome is doctor controlled, in this treatment modality, the outcome is controlled by the patient’s response to the cream and on how it is applied. Another words, if the patient does not apply it properly, failure will ensure. But the thought of applying cream on the skin to kill skin cancer is an attractive idea and it does work in certain cases.

Chemotherapy

This is the treatment of cancer with anti-cancer drugs. The aim is to kill all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from growing and reproducing themselves. Chemotherapy can be given before or after surgery and is usually given by injecting the drugs into a vein (intravenous treatment).There are other ways of having chemotherapy, including tablets. Chemotherapy is generally used as palliative treatment for melanoma that cannot be treated by other methods. Chemotherapy usually does not cure melanoma.

Lymph node biopsy and dissection

This is the operation that may be performed in melanoma. If there are signs that the melanoma might have spread to your lymph nodes, your doctor may recommend that you have a fine needle aspiration biopsy or a sentinel node biopsy.

In fine needle aspiration biopsy, the doctor inserts a needle into the node suspicious of metastasized melanoma, and sucks tissue into the syringe. This tissue is then examined under a microscope to see if it contains cancer cells. Occasionally, a node is removed surgically ('open biopsy') so that the whole lymph node can be examined under the microscope.

A sentinel node biopsy is a two step process of locating the lymph nodes that drain fluid from the area where the melanoma developed and removing that lymph node to have it histologically analysed. A harmless dye or radioactive chemical is injected into the site of the melanoma. After about an hour, the surgeon passes a hand-held machine called a 'counter' over the area, and the sentinel nodes are revealed by the dye or chemical. Once identified, the sentinel nodes are removed and checked for cancer cells.

If cancer cells are found in the lymph nodes, the surrounding nodes may then be removed to try to stop the spread of cancer beyond the lymph nodes into other parts of the body. This process is called lymph node dissection or removal.

FOLLOW UP - REASONS

Most people treated for early BCC or SCC does not have any further trouble with the disease but still a regular follow up regime is important in skin cancer medicine due to these reasons:

Even after a complete skin cancer excision, there is 2-3% chance that there could be a recurrent cancer in the same site. So it is prudent to check in 3 months to exclude this.

If non surgical treatment option was taken, then there is a need to review the treated area to either clinically or histologically ensure the complete resolution of the skin cancer.

If the invasive SCC was excised, it is important to ensure that it has not spread to other parts of your body.

Since you had a skin cancer, your chances of developing another cancer is high.

Most people treated for early melanoma do not have any further trouble with the disease. However, when there is a chance that the melanoma may have spread to other parts of your body, it is especially important that you have regular check-ups.

HOW OFTEN SHOULD I FOLLOW UP?

Your doctor will decide how often you will need check-ups, as everyone is different.

General guidelines are:

The interval of check ups of at least a yearly examination by a doctor is recommended, as there is an increased risk of another skin cancer in the future.

A more frequent follow up may be required depending on the condition of your skin. If so, the follow up interval should become less frequent if you have no further problems.

They will gradually become less frequent if you have no further problems.

HOW TO PREVENT SKIN CANCERS?

UV radiation is the single most important causative factor for skin cancers. By limiting the UV exposure alone, skin cancer incidence can be greatly reduced.

Other than that, there are no definite tablets or special creams that can prevent skin cancers.

Measure you can take to minimise skin cancers

Avoid outdoor activities between 10am-2pm (60% of the day’s harmful UV occurs between these hours.

Wide brimmed hat and closely woven fabric clothes.

Enjoy shades rather than sun-shine.

Sun creams (SPF 30+, apply 20 minutes before going outdoor, and regularly through the day).

Sun glasses.

Avoid solariums.

REFERENCES

National Cancer Control Initiative (NCCI). The 2002 national non-melanoma skin cancer survey. A report by the NCCI Non-Melanoma Skin Cancer Working Group. Edited by MP Staples, Melbourne: NCCI, 2003.

Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR). Cancer in Australia: and overview, 2006. Cancer Series Number 37. Canberra: AIHW, 2007.

Australian Institute of Health and Welfare (AIHW). State & territories GRIM (General Record of Incidence of Mortality) Books. Canberra: AIHW, 2005.

Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR). Cancer in Australia 2001. Cancer Series Number 28.

Cancer Council of Australia. Screening and early detection of skin cancers.

Bath-Hextall F, Leonardi-Bee J, Somchand N, Webster A, Delitt J, Perkins W. Interventions for preventing non-melanoma skin cancers in high risk groups. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.:CD005414. DOI: 0.1002/14651858.CD005414.pub2

National Health & Medical Research Council (NHMRC), 2002. Non-melanoma skin cancer: Guidelines for treatment and management in Australia.

National Health & Medical Research Council (NHMRC), 2002. Melanoma skin cancer: Guidelines for treatment and management in Australia.