Pain and skin cancer

I discussed this with a few people last year and came across this article during the holidays.  I do not believe their pain figures for BCC and SCC as they seem far too high. It’s probably because it is a hospital setting and they see more advanced cases.




Pain and Skin Cancer

Pain is a significant predictor of squamous cell carcinoma compared to basal cell carcinoma, according to results of a recent study.

Investigators with Wake Forest University Baptist Medical Center conducted an institutional review board-approved study, analyzing data on 576 nonmelanoma skin cancers (NMSC) from 478 patients with a mean age of 68.8, . Of those patients, 353 had basal cell carcinoma (BCC) and 223 had squamous cell carcinoma (SCC). The patients used a visual analogue scale to rate the pain and itch they experienced.

For both types of NMSC, itch was the most reported symptom, at 43.5% in SCC and 33.4 % in BCC. The pain prevalence was 39.8 % for patients with SCC, compared to 17.7 % of patients with BCC.

With each one-point increment in visual analogue scale for pain, the odds of having SCC rather than BCC increased by 30 %, according to the study. There was nearly a fourfold increase in the likelihood of a patient having SCC versus BCC when the score for pain was greater than two (odds ratio=3.94; 95 % confidence interval, 2.49-6.23).

“With an increasingly aging population, patients often present with numerous BCCs and SCCs, and it is often difficult for the clinician to prioritize lesion biopsy and removal,” the study authors wrote. “Thus, there is a need for better clinical tools to aid the physician in selecting lesions most likely to be SCCs.”

The study was published in the December issue of JAMA Dermatology, formerly Archives of Dermatology.


  1. #1 by hein2cv on January 10, 2013 - 2:51 am

    Thank you, Ian. In my experience, pain certainly seems to presage the change from AK to SCC, and for me, associated with surrounding erythema, esp if elevated, is an indication to not treat with liq N2 but to excise. As to pain with BCC – nah, itch more likely for sure. But most are found on totally unsuspecting patients. Maybe the change from AK to SCC has more inflammation associated with it: hence the erythema and thus the pain? You don’t see that inflammation with BCC.

  2. #2 by garypellizzari on January 10, 2013 - 11:17 am

    Hi Ian,
    I would suggest that skin practitioners with good skill level pick up most BCCs so early that symptoms are rarely present. BCCs and pain is a rarity in my practice. I agree with Hein, it seems to be more valid in SCC, particularly the more nodular they are.

  3. #3 by Tony Dicker on January 10, 2013 - 10:39 pm

    I use pain as a clue for diagnosing SCC. As Hein suggests, for the change from AK to SCC this is often the only clue.
    I don’t see painful BCC either, but agree that this probably relates to the patient population and the different stage of diagnosis. It probably depends on how they asked the question during the study

  4. #4 by Alan Cameron on January 11, 2013 - 3:14 am

    Same here, painful BCCs a rarity.

    …“Thus, there is a need for better clinical tools to aid the physician in selecting lesions most likely to be SCCs.”
    Cliff’s done some stuff on this and it’s pretty good….
    Rosendahl C et al. Dermoscopy of Squamous Cell Carcinoma and Keratoacanthoma. Arch Dermatol. 2012:1–7.

  5. #5 by Keith Van Den Heever on January 14, 2013 - 8:28 am

    Hi Ian, Hope you and your family have a great year ! I don’t believe their figures either. I find that patients complain more about symptoms from Seb-ks, than from SCCs and BCCs.I often see older men, in particular, with flagrant SCCs or BCCs,who refuse to have them removed because “they’re not bothering them”,in other words,completely asymptomatic.Their is a belief ( in regional Queensland,anyway),that if the lesions are asymptomatic,then they’re harmless.Patients complain very occasionally that BCCs are a bit itchy,and they notice SCCs if they’re small, indurated and spiky, so that they’re a bit tender if they press on them ( P=F/A ).I think there might also be a large supratentorial influence wrt clinical symptomology vs appearance.This may explain why seb-ks are so often “symptomatic”,as they are often very unsightly and scary looking.When I explain to patients that Medicare doesn’t cover treatment of seb-ks, their associated symptomatology rapidly disappears. It appears that it is just wishful thinking on the authors’ part to develop a clinical tool to grade the severity of lesions.I simply use the level of induration as a priority guide in IECs/SCCs .Severe BCCs are obvious. Kind regards, Keith ‘ rom: Skin Cancer Doctors [] Sent: Thursday, 10 January 2013 9:42 AM To: Subject: [New post] Pain and skin cancer

    Dr Ian Katz posted: “I discussed this with a few people last year and came across this article during the holidays. I do not believe their pain figures for BCC and SCC as they seem far too high. It’s probably because it is a hospital setting and they see more advanced cas”

  6. #6 by Hein Vandenbergh on January 14, 2013 - 11:43 am

    Yes, Keith – supratentoriality and appearance are intimately linked. But – I fail to see where Medicare comes into the equation. We do well enough to be able to remove a seb K for a consultation fee if the lesion bothers the patient. Health is not only physical. It is also emotional. They go to the club to try and meet a sheila, likely a lonely widow, and neither is long bereaved – thus craving for affection – but they do feel very self-conscious about that ugly raised ‘wart’ on their Rt temple. Freeze it, for kraissakes, and bill ’em a 23!

    As to the older men with flagrant SCCs ‘which do not bother them’, I firmly tell them [if I think it is an SCC, not a mere AK] that the bastard will kill them horribly. And then remove them as ‘silently’ as I can: serial curettage and diathermy as a 1st option [not acral/H&N], 2nd choice, depending on total numbers, X/C. Both pay well on M/care-the-(.)unt, and both dr and pt benefit.

    Be ruled by professionalism and compassion, not the effen bureaucracy – we are well-off cfr to most battlers. I do NOT think that symptomatology disappears if we tell them ‘no rebate’ – they just shut-up and mull on the lack of fairness in this world. Biopathology is nature, Medicare a Dr-control construct emanating from Attlee-esque England. He was no intellectual giant – and knew diddly-zip about psychology or market-forces if things were ‘free’. A Putin in reverse. I know: his nephew is a mate of mine, brilliant engineer. Uncle thought he was a brilliant SOCIAL engineer. Sorry, non-congruente!

    Fawk – who kicked the soap-box out from under me?!!

  7. #7 by Tom Crawford on February 5, 2013 - 11:48 pm

    I hardly ever place great significance on either pain or itch since there are plenty of benign lesions about which the same assertions are made.If such observations are to be proffered as having any value rather than empirical data then a similar comparative study comparing reports of these symptoms on lesions which are benign would seem necessary.Since this observation does not provide any discriminatory value.
    If pain and itch are significant symptoms then it would be interesting to establish what factors associated with the lesions mediate these symptoms

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