derm.actinic-keratosis-nmsc.core.v1PRODUCTION

derm.actinic-keratosis-nmsc.core.v1

Actinic keratosis & keratinocyte carcinoma (BCC + cSCC, dermatology lens)

dermatologysubacutechronicadultgeriatric

Hard-required inputs

0 / 9

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a UV-driven keratinocyte dysplasia → carcinoma continuum on a field-cancerised canvas: AK (precursor with a measurable progression risk) → SCC in situ (Bowen) → invasive cSCC, alongside BCC (the most common human cancer — locally destructive, rarely metastatic). The dermatology engine owns recognition → biopsy → lesion-vs-field therapy → risk-stratified surgery → surveillance, and ROUTES advanced systemic disease to oncology by engine_id while co-managing checkpoint-inhibitor cutaneous toxicity. The failure modes are missing an invasive cSCC under an "AK", under-treating the field, and under-recognising the aggressive transplant cSCC (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386).

Inputs

Actions

Advance rule

Set

Advance when

continuum + field-cancerisation framing set; advanced-systemic + melanoma + irAE routes noted by engine_id

Patient inputs (15)

photodamage_and_risk_factors*history • CONTEXT

not present

Cumulative UV, fair skin (Fitzpatrick I–II), age, outdoor exposure, prior radiation, chronic wound/scar, voriconazole, HPV and field cancerisation set the pre-test prior and the field-vs-lesion strategy (AAD 2018 cSCC PMID 29331386)

immunosuppression_status*history • CONTEXT

Solid-organ transplant (cSCC ~65–100× general population, more aggressive, multiple), CLL, HIV, chronic immunosuppression escalate aggressiveness, surveillance cadence and chemoprevention/immunosuppression-modulation decisions (AAD 2018 cSCC PMID 29331386; transplant cohort PMID 28615224)

prior_nmsc_count_and_sites*history • CONTEXT

not present

Number/site of prior keratinocyte carcinomas and AK burden drives field-therapy choice, surveillance interval and chemoprevention (prior NMSC ≈ strongest predictor of the next) (AAD 2018 BCC PMID 29331385)

lesion_morphology_and_dermoscopy*symptom • ENTRY

Morphology + dermoscopy is the primary discriminator: pearly/arborising-vessel/leaf-like → BCC; hyperkeratotic/white-circle/looped-vessel/ulcerated → cSCC; rough strawberry-pattern macule → AK; pigmented → route melanoma engine (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386)

invasion_features_induration_tenderness_growth_ulceration*symptom • RED_FLAGS

Induration, tenderness, rapid growth, ulceration or failure of field therapy is the AK-vs-invasive-cSCC pivot that lowers the biopsy threshold (AAD 2018 cSCC PMID 29331386)

locally_advanced_or_metastatic_signs*symptom • RED_FLAGS

Deep fixation, bone/orbit/parotid involvement, perineural symptoms, regional nodes or distant disease route to urgent staging + MDT and gate advanced-systemic therapy (AAD 2018 cSCC PMID 29331386)

high_risk_cscc_features*history • RISK_STRATIFICATION

not present

BWH/AJCC8 high-risk cSCC features (≥2 cm, >6 mm/beyond subcutaneous-fat depth, perineural invasion ≥0.1 mm, poor differentiation, ear/lip/temple, recurrent, immunosuppressed) gate Mohs/MDT + staging (AAD 2018 cSCC PMID 29331386)

tumor_site_size_recurrence_status*history • RISK_STRATIFICATION

Mask/H-zone facial site, size, ill-defined borders, aggressive histologic subtype and recurrent-at-prior-site status select Mohs vs standard excision vs C&E vs RT (AAD 2018 BCC PMID 29331385; Mohs RCT PMID 19010733)

age*demographic • TREATMENT

Elderly/frail status favours non-surgical or watchful-waiting options for low-risk BCC and modifies aggressiveness of intervention vs life expectancy (AAD 2018 BCC PMID 29331385)

genetic_photosensitive_syndromehistory • CONTEXT

not present

Basal cell nevus (Gorlin) syndrome, xeroderma pigmentosum, oculocutaneous albinism cause early, multiple, aggressive NMSC and change surveillance + Hedgehog-inhibitor relevance (AAD 2018 BCC PMID 29331385)

cbc_with_differentiallab • INITIAL_WORKUP

Baseline before advanced systemic therapy; CLL/lymphoproliferative immunosuppression context for aggressive cSCC (AAD 2018 cSCC PMID 29331386)

lftlab • INITIAL_WORKUP

Baseline hepatic function before Hedgehog inhibitor / checkpoint inhibitor; checkpoint-inhibitor hepatitis irAE surveillance (cemiplimab EMPOWER PMID 29863979)

inflammatory_markerslab • MONITORING

Adjunct in suspected locally advanced/infected ulcerated tumour and as a checkpoint-inhibitor irAE surveillance adjunct (cemiplimab EMPOWER PMID 29863979)

pregnancy_statusdemographic • TREATMENT

Hedgehog inhibitors are absolute teratogens — excision/Mohs are safe in pregnancy but systemic therapy is deferred and contraception/MDT coordination is mandatory (AAD 2018 BCC PMID 29331385)

creatininelab • TREATMENT

Race-free eGFR (CKD-EPI 2021) for contrast-staging-imaging risk and renal context in transplant recipients on calcineurin/mTOR immunosuppression (AAD 2018 cSCC PMID 29331386; Inker NEJM 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement

informationallife_threateningmetastatic_or_locally_advanced_nmsc
Regional-nodal or distant metastatic, or unresectable locally advanced (deep fixation, bone/orbit/parotid, extensive perineural) BCC or cSCC
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehigh_risk_cscc_features
cSCC with BWH/AJCC8 high-risk features: ≥2 cm, >6 mm or beyond-subcutaneous-fat depth, perineural invasion ≥0.1 mm, poor differentiation, ear/lip/temple, recurrent, or immunosuppressed
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevererapidly_growing_ulcerated_or_bleeding_lesion
Indurated, tender, rapidly growing, hyperkeratotic, ulcerated or bleeding lesion (incl. crateriform keratoacanthoma) — invasion pivot
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveretransplant_recipient_new_or_aggressive_nmsc
Solid-organ transplant recipient with a new, aggressive, or multiple keratinocyte carcinoma (cSCC ≈65–100× general-population risk)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterecurrent_tumour_at_prior_site
Keratinocyte carcinoma recurring at a previously treated site
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatecheckpoint_inhibitor_irAE_on_routed_systemic
Patient on routed cemiplimab/pembrolizumab develops a cutaneous (or systemic) immune-related adverse event
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatehedgehog_inhibitor_teratogen_gating
Pregnant/conceiving patient or inadequate contraception with a Hedgehog-inhibitor-eligible advanced BCC
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment

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Recommended regimen

AK & keratinocyte carcinoma — continuum-directed ladder (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386; advanced systemic routed to oncology)

axis: ak_nmsc_continuum_directed_ladderstep 1 - Step 1 — Actinic keratosis: lesion-directed + FIELD-directed therapy (on a cancerised field)

Selected step "Step 1 — Actinic keratosis: lesion-directed + FIELD-directed therapy (on a cancerised field)" — Biopsy-consistent or clinically typical AK / SCC in situ without invasion features; discrete lesions → lesion-directed, multiple/field cancerisation → field therapy

cryotherapy_liquid_nitrogen_lesion_directed
first line
cryosurgery
triggers: discrete_isolated_aks, few_lesions_no_field
AAD 2018 cSCC (PMID 29331386) — lesion-directed cryotherapy is highly effective for discrete AKs; does not treat the surrounding cancerised field, so combine with field therapy when field cancerisation is present.
fluorouracil
first line
topical_antimetabolite_field_therapy
5% (or 4%/0.5%) cream • topical • once–twice daily ×2–4 wk per regimen (max: per labeling; cyclic courses)
triggers: field_cancerisation, multiple_aks, highest_sustained_field_clearance_preferred
AAD 2018 cSCC (PMID 29331386); four-treatment AK RCT (Jansen NEJM 2019 PMID 30855743) — topical 5-FU had the highest sustained efficacy of the four field treatments; brisk inflammatory reaction is expected and therapeutic.
rxcui 4492
imiquimod
first line
topical_immune_response_modifier_field_therapy
5% (or 3.75%) cream • topical • per regimen (e.g., 5% 2–3×/wk ×4 wk cycles; 3.75% daily ×2-wk cycles) (max: per labeling)
triggers: field_cancerisation, superficial_bcc_nonsurgical, immune_priming_field
AAD 2018 BCC (PMID 29331385) + cSCC (PMID 29331386) — TLR7 agonist field therapy for AK and an option for low-risk superficial BCC where surgery is undesirable; expect a robust local inflammatory response.
rxcui 59943
tirbanibulin
second line
topical_microtubule_inhibitor_field_therapy
1% ointment • topical • once daily ×5 consecutive days (max: one 5-day course per field area)
triggers: short_course_field_therapy_preferred, face_or_scalp_ak_field
AAD-era newer agent — short 5-day field course for AK of the face/scalp with a favourable tolerability profile; recurrence may necessitate retreatment.
rxcui 2471078
diclofenac
second line
topical_nsaid_field_therapy
3% gel (in hyaluronic acid) • topical • BID ×60–90 days (max: per labeling)
triggers: low_irritation_field_therapy_preferred, extended_course_tolerated
AAD 2018 cSCC (PMID 29331386) — topical diclofenac is a lower-irritation field option with slower onset and a longer course; modest clearance vs 5-FU.
rxcui 3355
calcipotriol
add on
vitamin_d_analog_immune_priming_adjunct
compounded with 5-FU (calcipotriol 0.005% + 5-FU 5%) • topical • BID ×4 days (immune-priming combination) (max: per regimen)
triggers: combination_5fu_calcipotriol_immune_priming, enhanced_short_course_field_clearance
Short-course calcipotriol+5-FU drives a TSLP-mediated T-cell immune priming of the field with high short-course AK clearance and possible cSCC-protective immunity; combination field-immunotherapy adjunct.
rxcui 29365
photodynamic_therapy_field_directed
first line
photodynamic_therapy
triggers: field_cancerisation, cosmetically_sensitive_field, superficial_bcc_or_bowen_nonsurgical
AAD 2018 cSCC (PMID 29331386) + BCC (PMID 29331385) — aminolevulinate/methyl-aminolevulinate photodynamic therapy gives excellent field clearance and cosmesis for AK, Bowen disease and superficial BCC where surgery is undesirable.

outpatient playbook — drug actions (4)

1. AK field therapy — topical 5-FU (highest sustained clearance) ± lesion-directed cryotherapy
rxcui 4492
5% cream • topical • per regimen ×2–4 wk
trigger: Actinic keratosis with field cancerisation, no invasion features (four-treatment AK RCT PMID 30855743)
5-FU had the highest sustained efficacy of the four field treatments; cryotherapy for discrete lesions
2. Low-risk BCC/cSCC — standard excision with guideline margins (or C&E / topical for selected superficial BCC)
4 mm BCC / 4–6 mm cSCC margin • surgical • single procedure
trigger: Biopsy-proven low-risk keratinocyte carcinoma (AAD 2018 BCC PMID 29331385)
Excision with margin assessment is curative for low-risk tumours; C&E/topical for selected superficial BCC
3. High-risk / facial H-zone / recurrent / aggressive — Mohs micrographic surgery + MDT
complete margin control • micrographic surgical • staged single setting
trigger: High-risk cSCC (BWH/AJCC8) or facial/recurrent/aggressive BCC (Mohs RCT PMID 19010733)
Lowest recurrence with tissue sparing; adjuvant RT for perineural/positive-margin/nodal disease
4. Locally advanced/metastatic — vismodegib (BCC) / cemiplimab (cSCC; BCC if HHI-failed) — ROUTED to oncology
rxcui 2058826
cemiplimab 350 mg q3wk • IV • q3wk
trigger: Unresectable/metastatic NMSC (EMPOWER PMID 29863979; ERIVANCE PMID 22670903)
Hedgehog inhibitor (advanced BCC) / anti-PD-1 (advanced cSCC); oncology shared-care, derm co-manages cutaneous irAE

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Rough, scaly, sandpapery erythematous macules/papules on chronically photodamaged skin (face/scalp/ears/dorsal hands/forearms) — actinic keratosis on a cancerised field (AAD 2018 cSCC PMID 29331386); Pearly, rolled-border telangiectatic papule or a non-healing/bleeding sore — basal cell carcinoma (AAD 2018 BCC PMID 29331385); Indurated, tender, rapidly growing, hyperkeratotic or ulcerated lesion → biopsy pivot for invasive cSCC (AAD 2018 cSCC PMID 29331386).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Actinic keratosis & keratinocyte carcinoma (BCC + cSCC, dermatology lens)** (derm.actinic-keratosis-nmsc.core.v1).
Phenotype framing: Terminal lesion differential with named pivots: AK (rough strawberry-pattern macule) vs SCC in situ/Bowen (well-demarcated scaly plaque) vs invasive cSCC (indurated/tender/ulcerated — biopsy pivot) vs BCC (pearly, rolled border, arborising vessels — basal vs squamous) vs melanoma (pigmented → route derm.melanoma.core.v1) vs seborrheic keratosis (stuck-on, milia-like cysts) vs keratoacanthoma (rapid crateriform — cSCC variant, treat as cSCC) vs benign lichenoid keratosis vs amelanotic/hypertrophic mimics vs porokeratosis (raised keratotic rim) vs hypertrophic actinic vs psoriasis/eczema patch. Dermoscopy pivots: BCC arborising vessels / leaf-like / blue-grey ovoid nests / spoke-wheel; cSCC white circles / keratin / looped & hairpin vessels; AK red pseudonetwork / strawberry pattern.
Scope: Frame as a UV-driven keratinocyte dysplasia → carcinoma continuum on a field-cancerised canvas: AK (precursor with a measurable progression risk) → SCC in situ (Bowen) → invasive cSCC, alongside BCC (the most common human cancer — locally destructive, rarely metastatic). The dermatology engine owns recognition → biopsy → lesion-vs-field therapy → risk-stratified surgery → surveillance, and ROUTES advanced systemic disease to oncology by engine_id while co-managing checkpoint-inhibitor cutaneous toxicity. The failure modes are missing an invasive cSCC under an "AK", under-treating the field, and under-recognising the aggressive transplant cSCC (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386).

No severity triggers fired against current inputs.

Plan

Regimen axis: **AK & keratinocyte carcinoma — continuum-directed ladder (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386; advanced systemic routed to oncology)** — step "Step 1 — Actinic keratosis: lesion-directed + FIELD-directed therapy (on a cancerised field)".
1. cryotherapy_liquid_nitrogen_lesion_directed (cryosurgery, first line) — AAD 2018 cSCC (PMID 29331386) — lesion-directed cryotherapy is highly effective for discrete AKs; does not treat the surrounding cancerised field, so combine with field therapy when field cancerisation is present.
2. fluorouracil 5% (or 4%/0.5%) cream topical once–twice daily ×2–4 wk per regimen (topical_antimetabolite_field_therapy, first line) — AAD 2018 cSCC (PMID 29331386); four-treatment AK RCT (Jansen NEJM 2019 PMID 30855743) — topical 5-FU had the highest sustained efficacy of the four field treatments; brisk inflammatory reaction is expected and therapeutic.
3. imiquimod 5% (or 3.75%) cream topical per regimen (e.g., 5% 2–3×/wk ×4 wk cycles; 3.75% daily ×2-wk cycles) (topical_immune_response_modifier_field_therapy, first line) — AAD 2018 BCC (PMID 29331385) + cSCC (PMID 29331386) — TLR7 agonist field therapy for AK and an option for low-risk superficial BCC where surgery is undesirable; expect a robust local inflammatory response.
4. tirbanibulin 1% ointment topical once daily ×5 consecutive days (topical_microtubule_inhibitor_field_therapy, second line) — AAD-era newer agent — short 5-day field course for AK of the face/scalp with a favourable tolerability profile; recurrence may necessitate retreatment.
5. diclofenac 3% gel (in hyaluronic acid) topical BID ×60–90 days (topical_nsaid_field_therapy, second line) — AAD 2018 cSCC (PMID 29331386) — topical diclofenac is a lower-irritation field option with slower onset and a longer course; modest clearance vs 5-FU.
6. calcipotriol compounded with 5-FU (calcipotriol 0.005% + 5-FU 5%) topical BID ×4 days (immune-priming combination) (vitamin_d_analog_immune_priming_adjunct, add on) — Short-course calcipotriol+5-FU drives a TSLP-mediated T-cell immune priming of the field with high short-course AK clearance and possible cSCC-protective immunity; combination field-immunotherapy adjunct.
7. photodynamic_therapy_field_directed (photodynamic_therapy, first line) — AAD 2018 cSCC (PMID 29331386) + BCC (PMID 29331385) — aminolevulinate/methyl-aminolevulinate photodynamic therapy gives excellent field clearance and cosmesis for AK, Bowen disease and superficial BCC where surgery is undesirable.

Setting playbook (outpatient) — Recognise the AK→cSCC continuum and BCC, biopsy any invasion-suspicious or uncertain lesion, deliver lesion- vs field-directed AK therapy and risk-stratified surgery (Mohs for high-risk/facial/recurrent), route locally advanced/metastatic disease to oncology, and establish risk-based recurrence + new-primary surveillance with photoprotection/chemoprevention — intensified in transplant recipients (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386)
8. AK field therapy — topical 5-FU (highest sustained clearance) ± lesion-directed cryotherapy 5% cream topical per regimen ×2–4 wk — Actinic keratosis with field cancerisation, no invasion features (four-treatment AK RCT PMID 30855743) (5-FU had the highest sustained efficacy of the four field treatments; cryotherapy for discrete lesions)
9. Low-risk BCC/cSCC — standard excision with guideline margins (or C&E / topical for selected superficial BCC) 4 mm BCC / 4–6 mm cSCC margin surgical single procedure — Biopsy-proven low-risk keratinocyte carcinoma (AAD 2018 BCC PMID 29331385) (Excision with margin assessment is curative for low-risk tumours; C&E/topical for selected superficial BCC)
10. High-risk / facial H-zone / recurrent / aggressive — Mohs micrographic surgery + MDT complete margin control micrographic surgical staged single setting — High-risk cSCC (BWH/AJCC8) or facial/recurrent/aggressive BCC (Mohs RCT PMID 19010733) (Lowest recurrence with tissue sparing; adjuvant RT for perineural/positive-margin/nodal disease)
11. Locally advanced/metastatic — vismodegib (BCC) / cemiplimab (cSCC; BCC if HHI-failed) — ROUTED to oncology cemiplimab 350 mg q3wk IV q3wk — Unresectable/metastatic NMSC (EMPOWER PMID 29863979; ERIVANCE PMID 22670903) (Hedgehog inhibitor (advanced BCC) / anti-PD-1 (advanced cSCC); oncology shared-care, derm co-manages cutaneous irAE)

Non-pharmacologic actions:
- Rigorous photoprotection counselling for every patient (broad-spectrum sunscreen, sun avoidance, protective clothing) (AAD 2018 cSCC PMID 29331386)
- Oral nicotinamide 500 mg BID for high-risk/recurrent NMSC (continue indefinitely — ONTRAC PMID 26488693)
- Acitretin chemoprevention + transplant-team immunosuppression reduction / mTOR switch for transplant recipients with recurrent cSCC (PMID 28615224; PMID 27163483)
- Structured skin self-examination education + scheduled lifelong total-body skin exams
- Biopsy any non-resolving or recurrent lesion — never re-treat empirically (AAD 2018 cSCC PMID 29331386)

AVOID / contraindication checks:
- Hedgehog inhibitor absolute teratogen (vismodegib/sonidegib — pregnancy absolute contraindication; mandatory contraception during and after therapy; pregnancy testing; ERIVANCE PMID 22670903)
- Checkpoint inhibitor allograft rejection risk in solid organ transplant (cemiplimab/pembrolizumab in transplant recipients carry high allograft rejection risk — multidisciplinary transplant/oncology decision, not initiated here; EMPOWER PMID 29863979)
- Checkpoint inhibitor severe irAE is an emergency (Grade 3–4 colitis/hepatitis/pneumonitis/myocarditis/endocrinopathy → emergent oncology hold + systemic corticosteroids; cutaneous irAE routed to derm.drug eruption.core.v1)
- Topical 5fu pregnancy and dpd deficiency caution (5 fluorouracil avoided in pregnancy; dihydropyrimidine dehydrogenase deficiency increases systemic absorption toxicity risk)
- Imiquimod and 5fu brisk inflammatory reaction is expected and therapeutic (set patient expectations; do not mistake the field reaction for infection or treatment failure)
- Acitretin teratogen with prolonged post treatment conception bar and rebound on cessation (systemic retinoid chemoprevention — pregnancy contraindicated; long washout; AK/NMSC rebound if stopped)
- Do not empirically field treat or monitor an undiagnosed indurated or ulcerated lesion (biopsy first — masks invasive cSCC; AAD 2018 cSCC PMID 29331386)
- Radiotherapy avoided in genetic photosensitive syndromes (xeroderma pigmentosum / basal cell nevus syndrome — radiation induces further tumours)

Monitoring

Regimen monitoring:
- risk based recurrence and new primary surveillance: low-risk BCC/cSCC q6–12mo, high-risk cSCC q3–6mo ×2y then extend, lifelong total-body skin exam (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386)
- transplant recipients intensified surveillance q3–6mo (monthly with heavy burden) + transplant-team immunosuppression-modulation coordination (transplant cohort PMID 28615224; azathioprine meta-analysis PMID 27163483)
- hedgehog inhibitor AEs: muscle spasm, dysgeusia, alopecia, weight loss, fatigue; adherence and dose-interruption strategy (ERIVANCE PMID 22670903)
- checkpoint inhibitor irAE surveillance (skin, thyroid, hepatitis, colitis, pneumonitis, hypophysitis, myocarditis) — derm co-monitors skin, escalates severe irAE to oncology (EMPOWER PMID 29863979)
- field therapy response and adherence: reassess clearance after the expected inflammatory course; biopsy any non-resolving or recurrent lesion (four-treatment AK RCT PMID 30855743)
- chemoprevention adherence: nicotinamide indefinitely (benefit not sustained if stopped — ONTRAC PMID 26488693); acitretin tolerance/lipids/LFTs in high-risk/transplant

Setting (outpatient) monitoring:
- Risk-based recurrence + new-primary surveillance (low-risk q6–12mo; high-risk cSCC q3–6mo ×2y; transplant intensified) (AAD 2018 cSCC PMID 29331386)
- Hedgehog-inhibitor AEs and checkpoint-inhibitor irAE co-monitoring for routed-systemic patients (ERIVANCE PMID 22670903; EMPOWER PMID 29863979)

Follow-up plan: Lifelong derm continuity: scheduled total-body skin exams (prior NMSC ≈ strongest predictor of the next; substantial cumulative new-primary risk), structured skin self-examination, rigorous photoprotection counselling, chemoprevention adherence (nicotinamide, acitretin for high-risk/transplant), field-cancerisation re-treatment as needed, transplant-team immunosuppression-modulation continuity, and Gorlin/xeroderma-pigmentosum familial/genetic counselling. Re-stage and re-route to oncology on recurrence/locally-advanced progression; reconcile any checkpoint-inhibitor cutaneous irAE with derm.drug-eruption.core.v1.
- Close-out criterion: lifelong surveillance + self-exam + photoprotection + chemoprevention + transplant + familial counselling documented; recurrence/advanced re-entry path defined

Monitoring phase: Post-treatment recurrence + new-primary surveillance at a risk-based cadence (AAD 2018: low-risk BCC/cSCC every 6–12 mo; high-risk cSCC every 3–6 mo for the first 2 years then extend; lifelong total-body skin exam). Transplant recipients intensified (every 3–6 mo, sometimes monthly with heavy burden). On routed advanced systemic therapy: Hedgehog inhibitor AEs (muscle spasm, dysgeusia, alopecia, weight loss) and checkpoint-inhibitor irAE — severe cutaneous irAE routed to derm.drug-eruption.core.v1, severe systemic irAE emergent oncology hold. Field-therapy response and adherence reassessed; biopsy any non-resolving or recurrent lesion.

Disposition

Current setting: outpatient — Recognise the AK→cSCC continuum and BCC, biopsy any invasion-suspicious or uncertain lesion, deliver lesion- vs field-directed AK therapy and risk-stratified surgery (Mohs for high-risk/facial/recurrent), route locally advanced/metastatic disease to oncology, and establish risk-based recurrence + new-primary surveillance with photoprotection/chemoprevention — intensified in transplant recipients (AAD 2018 BCC PMID 29331385 + cSCC PMID 29331386)

Disposition criteria:
- Continue lesion/field/surgical plan + chemoprevention + risk-based surveillance in derm clinic if low/intermediate risk (AAD 2018 BCC PMID 29331385)
- MDT/oncology referral for high-risk cSCC, perineural invasion, locally advanced or metastatic disease (AAD 2018 cSCC PMID 29331386)
- Transplant co-management with the transplant team for immunosuppression modulation; advanced systemic therapy delegated to oncology by engine_id

Escalation triggers (move to higher acuity):
- Indurated/tender/rapidly growing/ulcerated lesion or field-therapy non-response → urgent diagnostic biopsy (AAD 2018 cSCC PMID 29331386)
- Locally advanced (deep fixation, bone/orbit/parotid, perineural symptoms) or regional-nodal/metastatic disease → urgent staging + MDT/oncology (AAD 2018 cSCC PMID 29331386)
- Transplant recipient with a new/aggressive/multiple cSCC → accelerated dermatology + transplant-team coordination (transplant cohort PMID 28615224)
- Recurrent tumour at a prior treatment site → Mohs micrographic surgery (Mohs RCT PMID 19010733)
- Checkpoint-inhibitor severe (Grade 3–4) irAE on routed systemic therapy → emergent oncology hold + route cutaneous irAE to derm.drug-eruption.core.v1 (EMPOWER PMID 29863979)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Regional-nodal or distant metastatic, or unresectable locally advanced (deep fixation, bone/orbit/parotid, extensive perineural) BCC or cSCC
- [SEVERE] cSCC with BWH/AJCC8 high-risk features: ≥2 cm, >6 mm or beyond-subcutaneous-fat depth, perineural invasion ≥0.1 mm, poor differentiation, ear/lip/temple, recurrent, or immunosuppressed
- [SEVERE] Indurated, tender, rapidly growing, hyperkeratotic, ulcerated or bleeding lesion (incl. crateriform keratoacanthoma) — invasion pivot

Citations

- AAD 2018 Guidelines of care for the management of basal cell carcinoma (Kim et al, JAAD; PMID 29331385, DOI 10.1016/j.jaad.2017.10.006) + AAD 2018 Guidelines of care for the management of cutaneous squamous cell carcinoma (Kim et al, JAAD; PMID 29331386, DOI 10.1016/j.jaad.2017.10.007) + comparative AAD/NCCN/ASTRO US-guideline analysis (Mittal & Mittal, J Skin Cancer 2024; PMID 38370137, DOI 10.1155/2024/3859066); trial anchors cemiplimab EMPOWER-CSCC (Migden NEJM 2018 PMID 29863979), vismodegib ERIVANCE (Sekulic NEJM 2012 PMID 22670903), nicotinamide ONTRAC (Chen NEJM 2015 PMID 26488693), four-treatment AK RCT (Jansen NEJM 2019 PMID 30855743), Mohs vs excision 5-yr RCT (Mosterd Lancet Oncol 2008 PMID 19010733), transplant keratinocyte-cancer cohort (PMID 28615224) [PMID:29331385](https://pubmed.ncbi.nlm.nih.gov/29331385/)
- Cited evidence (PMID 29331386) [PMID:29331386](https://pubmed.ncbi.nlm.nih.gov/29331386/)
- Cited evidence (PMID 38370137) [PMID:38370137](https://pubmed.ncbi.nlm.nih.gov/38370137/)
- Cited evidence (PMID 29863979) [PMID:29863979](https://pubmed.ncbi.nlm.nih.gov/29863979/)
- Cited evidence (PMID 32306208) [PMID:32306208](https://pubmed.ncbi.nlm.nih.gov/32306208/)

Last reconciled with current guidelines: 2026-05-22.

References

AAD 2018 Guidelines of care for the management of basal cell carcinoma (Kim et al, JAAD; PMID 29331385, DOI 10.1016/j.jaad.2017.10.006) + AAD 2018 Guidelines of care for the management of cutaneous squamous cell carcinoma (Kim et al, JAAD; PMID 29331386, DOI 10.1016/j.jaad.2017.10.007) + comparative AAD/NCCN/ASTRO US-guideline analysis (Mittal & Mittal, J Skin Cancer 2024; PMID 38370137, DOI 10.1155/2024/3859066); trial anchors cemiplimab EMPOWER-CSCC (Migden NEJM 2018 PMID 29863979), vismodegib ERIVANCE (Sekulic NEJM 2012 PMID 22670903), nicotinamide ONTRAC (Chen NEJM 2015 PMID 26488693), four-treatment AK RCT (Jansen NEJM 2019 PMID 30855743), Mohs vs excision 5-yr RCT (Mosterd Lancet Oncol 2008 PMID 19010733), transplant keratinocyte-cancer cohort (PMID 28615224) — PMID:29331385
Cited evidence (PMID 29331386) — PMID:29331386
Cited evidence (PMID 38370137) — PMID:38370137
Cited evidence (PMID 29863979) — PMID:29863979
Cited evidence (PMID 32306208) — PMID:32306208