When most patients hear the phrase "skin cancer," the first thing they think of is an operation. And for the majority of cases, surgery is indeed the gold standard — it offers the highest cure rate and reliable histological confirmation that the cancer has been completely removed. But not every skin cancer needs a scalpel. For certain lesions, certain patients and certain anatomical sites, a range of non-surgical treatments is available.
This article explains what those treatments are, when they work well, and — just as importantly — when surgery remains the better choice.
Accurate diagnosis comes first
Before any treatment — surgical or non-surgical — an accurate diagnosis is essential. This usually means a small skin biopsy to confirm the tumour type, its depth and any high-risk features. Non-surgical treatments work well for certain kinds of skin cancer (superficial Basal Cell Carcinoma [BCC], Actinic Keratosis [AK] and Bowen's disease) and poorly for others (nodular or infiltrative BCCs, most squamous cell carcinomas, and any suspected melanoma). Getting the diagnosis right guides everything that follows.
Topical creams
Two prescription creams have a well-established role in the treatment of superficial skin cancers and precancerous lesions. They can be applied at home, with monitoring in clinic.
Imiquimod (Aldara)
Imiquimod is an immunotherapy cream: it recruits the body's own immune system to recognise and destroy abnormal cells. It is licensed for superficial BCC and actinic keratoses, and is typically applied several times a week for four to twelve weeks. It usually causes redness, crusting and soreness as it works — the skin reaction is part of the treatment effect, not a side effect.
5-Fluorouracil (5-FU, brand name Efudix)
5-FU is a chemotherapy cream. It targets rapidly dividing abnormal cells. It is used for actinic keratoses, Bowen's disease (squamous cell carcinoma in situ) and some superficial BCCs. It is usually applied once or twice daily for around two to four weeks. As with imiquimod, the inflammatory skin reaction — redness, tenderness, crusting — is how you know the treatment is taking effect.
Topical creams have two real advantages: no scar, and the ability to treat "field change" (wide areas of sun-damaged skin containing multiple lesions) rather than just a single spot. The limitation is that they are reliable only for superficial disease, and cure rates are generally lower than surgery for invasive cancers.
Photodynamic therapy (PDT)
Photodynamic Therapy (PDT) is a two-stage treatment. First, a photosensitising cream (such as methyl aminolevulinate) is applied to the lesion and the surrounding skin and left to absorb for a few hours. The treated area is then exposed to a specific wavelength of red light, which activates the cream and selectively destroys the abnormal cells beneath.
PDT is a good option for superficial BCCs, Bowen's disease and widespread actinic keratoses — particularly on the face and scalp, where cosmetic outcome matters. Two sessions, usually a week apart, is the standard course. The treatment is generally well tolerated, though the light exposure itself can feel uncomfortable for the duration of the session.
Cryotherapy (liquid nitrogen)
Cryotherapy is a long-established clinic-based treatment in which liquid nitrogen is applied briefly to the lesion, freezing the abnormal tissue. The treated area blisters, crusts and slowly falls away over a few weeks. The application itself takes only a minute or two and is mildly stinging rather than painful; no local anaesthetic is needed.
Cryotherapy is best suited to actinic keratoses and selected small, superficial skin cancers. It is less suitable for thicker BCCs, pigmented lesions, or anything where a histological specimen is needed — because the tissue is destroyed rather than excised, there is nothing to send to the laboratory for analysis.
Radiotherapy
For some skin cancers, radiotherapy can deliver excellent cure rates without the need for an operation. It is typically used in three distinct settings:
- Primary treatment for patients who are unfit for surgery, or for tumours at anatomical sites where surgery would produce a less acceptable cosmetic or functional outcome — for example selected cancers on the nose, lip or ear.
- Adjuvant treatment after surgery, when the final histology shows close margins or features such as perineural invasion that raise the risk of recurrence.
- Palliative treatment for locally advanced disease that cannot be cured surgically, where the aim is to control the cancer and reduce symptoms.
A typical curative course is delivered over several visits as an outpatient, usually spread across two to four weeks. Modern techniques used at UK specialist centres are highly targeted, sparing surrounding healthy tissue.
Systemic therapy for advanced disease
For locally advanced or metastatic skin cancer, dedicated drug therapies have transformed outcomes over the last decade:
- Immunotherapy (cemiplimab) for advanced or metastatic squamous cell carcinoma.
- Hedgehog pathway inhibitors (vismodegib, sonidegib) for advanced or multiple basal cell carcinomas where surgery and radiotherapy are not suitable.
- Immunotherapy and targeted therapies for advanced melanoma, prescribed by a medical oncologist within a specialist skin cancer team.
These treatments are always specialist oncology-led, prescribed after full multidisciplinary discussion.
When non-surgical isn't enough
It is important to be honest: for most skin cancers, surgery remains the most reliable cure. Non-surgical treatments are carefully selected for lesions most likely to respond, for patients best suited to them, and for situations where they offer a genuine advantage. In other circumstances — a deep or infiltrative tumour, a high-risk histological subtype, a recurrent cancer, or any suspected melanoma — surgical excision still gives the clearest margins, the best cure rate and the most reliable long-term information.
"A good skin cancer plan is not about avoiding surgery; it is about choosing the right treatment for the right lesion in the right patient. Sometimes that is a cream, sometimes a light, and often a scalpel."
The role of the Multidisciplinary Team (MDT)
Every higher-risk skin cancer case in the UK is discussed at the Specialist Skin Cancer Multi-Disciplinary Team (MDT) meeting. This brings together dermatologists, plastic surgeons, pathologists, radiation and medical oncologists and specialist skin cancer nurses. The team reviews the clinical presentation, the histology and any imaging, and agrees the best treatment pathway — which may well be non-surgical.
Conclusion
Non-surgical treatments are not alternatives for everyone, but for the right patient with the right lesion they can deliver excellent results with less disruption than surgery. If you have been diagnosed with a skin cancer or a precancerous lesion and would like to understand whether a non-surgical option is appropriate for you, a specialist consultation is the best place to start. You can arrange an assessment through our Skin Cancer Centre. For a broader overview of early detection, our article on the early signs of skin cancer is a useful companion.
