Cutaneous Squamous Cell Carcinoma (cSCC)

British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma 2020

NICE guideline [NG12] Suspected cancer: recognition and referral. 1.7 Skin cancers. Last updated: Apr 2026.

PCDS Clinical guidance Squamous cell carcinoma – cutaneous. Last updated: May 2026.

Article Last Updated:09/06/2026

Cutaneous Squamous Cell Carcinoma (cSCC)

Cutaneous squamous cell carcinoma (cSCC) is the 2nd common type of skin cancer, arising from keratinocytes of the epidermis.

This updated UKMLA guide to cutaneous squamous cell carcinoma (cSCC) is based on BAD, NICE, and PCDS guidance, which covers risk factors, clinical features, referral criteria, diagnosis and management.

Causes and Risk Factors

Key risk factors:

Cumulative lifetime UV exposure – major risk factor
- Sunlight
- Sunbeds
- Artificial UV exposure (e.g. psoriasis management)
Fair-skin type (type 1-2)
Advancing age
Males

Importantly, individuals who are immunosuppressed (esp. those after organ transplantation) are at a much higher risk of developing cSCC.

Clinical Features

Location

Most common on sun-exposed sites:

Dorsum of the hand
Posterior forearm
Upper part of the face
Lower lip
Pinna

Appearance

Often raised (may be nodular, plaque-like, or verrucous)
Scaly, crusted, or hyperkeratotic surface
Central ulceration / induration
Friable surface (bleeds easily after minor trauma)
Poorly defined, irregular margins (an important feature that differentiates from BCC)

cSCC variants:

Keratoacanthoma: a low-grade variant of SCC, covered in the Pre-Malignant Skin Lesions article
Marjolin ulcer: aggressive SCC arising from a scar or inflammation

Symptoms

The presence of pain or tenderness should raise suspicion for SCC.
SCC is more frequently painful than BCC or melanoma (SCC > BCC > melanoma), which are typically asymptomatic.^[Ref]

Click to See Clinical Images

Squamous cell carcinoma
Source: https://dermnetnz.org/topics/cutaneous-squamous-cell-carcinoma

Complications

cSCC carries the risk of metastasis; the risk is higher in immunosuppressed individuals

Most common location: lymph nodes

Red Flags and When to Refer

Consider a suspected cancer pathway referral if there is a suspected squamous cell carcinoma skin lesion.

Investigation and Diagnosis

Gold standard: skin biopsy for histology

Preferred: full-thickness incisional biopsy (containing both peripheral and deep margins)
Large / anatomically challenging area → incisional (punch) biopsy

Management

1st line: standard surgical excision (in resectable primary disease)

Consider Mohs micrographic surgery if:

Tumour margins are not clearly visible / well-defined
At sites where tissue conservation is important (e.g. eyelid, lips, ears, fingers, genitalia)
At cosmetically sensitive areas (e.g face)

If surgery is not appropriate: primary radiotherapy is an option

Surgical Margins

Peripheral surgical margins (determined under magnification / dermoscopy):

Low risk tumour → ≥4 mm margin
High risk tumour → ≥6 mm margin
Very high risk tumour → ≥ 10mm margin

Also ensure at least 1 mm histological clearance at all margins.

Tumour risk definitions:

Low Risk	High Risk	Very High Risk
ALL the following must be met	ANY of the following	ANY of the following
Diameter ≤20mm (pT1) Thickness ≤4mm Invasion to dermis only No perineural invasion No lymphovascular invasion Histology: well or moderately differentiated	Diameter: 20-40mm (pT2) Thickness 4-6mm Invasion to subcutaneous fat Perineural invasion (dermal only) Histology: poorly differentiated Lymphovascular invasion Tumour at ear or lip Tumour arising within scar or area of chronic inflammation (i.e. Marjolin’s ulcer)	Diameter >40mm (pT3) Thickness >6mm Invasion beyond subcutaneous fat Any bone invasion Nerve invasion Histology: high-grade subtype (adenosquamous, desmoplastic, spindle / sarcomatoid / metaplastic) In-transit metastasis

Low Risk

High Risk

Very High Risk

ALL the following must be met

ANY of the following

Diameter ≤20mm (pT1)
Thickness ≤4mm

Invasion to dermis only
No perineural invasion
No lymphovascular invasion
Histology: well or moderately differentiated

Diameter: 20-40mm (pT2)
Thickness 4-6mm

Invasion to subcutaneous fat
Perineural invasion (dermal only)
Histology: poorly differentiated
Lymphovascular invasion
Tumour at ear or lip
Tumour arising within scar or area of chronic inflammation (i.e. Marjolin’s ulcer)

Diameter >40mm (pT3)
Thickness >6mm

Invasion beyond subcutaneous fat
Any bone invasion
Nerve invasion
Histology: high-grade subtype (adenosquamous, desmoplastic, spindle / sarcomatoid / metaplastic)
In-transit metastasis