68-year-old woman presents with a many month history of squamous cell in situ of left hand. This large 2.5 cm lesion on the hand poses a unique challenge to ensuring hand function post-operatively. Treatment options include C&D (curettage and desiccation), curettage only with post-treatment imiquimod, Mohs excision with a skin graft closure, or superficial radiotherapy (SRT).
Although this is a non-invasive superficial lesion, SCC in situ cells can course deep into the dermis following the basement membrane of adnexal elements such as sebaceous glands, hair follicles, and eccrine glands. So curettage alone can leave a few cells deep within the deep adnexal elements. This is reason electrodessication or imiquimod is employed to “clean up” the remaining cells.
SRT (Superficial Radiotherapy) is not an optimal treatment in this location of thin skin over the tendons and the metacarpophalangeal joint. Radiation penetration of even a 50 KVP beam extends to 5 mm. Inflammatory and scarring effects of radiation can cause functional impairment.
Mohs and reconstruction offers a single stage procedure with rapid recovery. Although hand movement restriction is necessary for skin graft healing, the splinting or a bolster would be limited to 3 – 5 days.