Palo Alto Dermatology Institute dermatologists have one of the largest skin cancer treatment experiences in the history of Northern California. Our founder, Dr. Morganroth, is one of the most experienced skin cancer surgeons in the US and has personally performed over 37,400 Mohs surgeries on non-melanoma skin cancers and countless excisions of melanoma and melanoma in situ (as of January 2025).
Our treatment decision tree for non-melanoma skin cancer including basal cell carcinoma, squamous cell carcinoma, squamous cell carcinoma in situ, and other non-melanoma skin cancers is complex and based on our multi-decade skin cancer treatment experience. We choose the treatment with the highest cure rate, minimal sacrifice of normal skin, and smallest scar for the best cosmetic outcome based on a number of factors including the histologic subtype (cell pattern observed with a microscope) of the skin cancer, size, location, whether the tumor is new or recurrent after a prior treatment, the patient’s experience with prior treatments, and whether the patient has a genetic disorder that impacts the treatment outcome or increases the risk of recurrence.
Mohs micrographic surgery (Mohs) is the gold standard treatment for skin cancer and has the highest cure rate. Mohs is the preferred treatment for skin cancers of the head, neck, hands and shins for our patients. The indications for Mohs surgery are dictated by a treatment algorithm developed in 2012 by all of the American dermatology professional organizations. The Mohs Appropriate Use Criteria (Mohs AUC) is a formula that takes tumor type, size, location and history of prior treatment to create a numerical score from 3 to 9. Palo Alto Dermatology Institute offers Mohs on skin cancers with a Mohs AUC rating of 7 to 9. For the skin cancers that are not candidates for Mohs surgery with a Mohs AUC of 3-6, Palo Alto Dermatology Institute offers two additional excision techniques with immediate frozen section histologic examination that provide a near Mohs surgery cure rate and outcome. The advantages of these techniques over standard excision performed elsewhere are: 1. histologic confirmation within minutes that the tumor has been removed completely; 2. the skin is repaired after the tumor is confirmed clear eliminating the need for surgery later; and 3. the highest cure rate possible.
In contrast, standard excision performed in the vast majority of dermatology and plastic surgery offices involves removing the skin cancer and repairing the skin immediately without immediate confirmation of clear margins. The excision specimen is sent by courier to an outside laboratory that produces a pathology result in 3 to 10 days. If the pathology report indicates tumor is present on the margin, a repeat surgery is required to remove the residual skin cancer.
Palo Alto Dermatology Institute’s state-of-the-art facility in downtown Palo Alto is uniquely equipped in the San Francisco Bay Area to provide three different and highly effective “on demand” skin cancer excision techniques. “On demand” means that the results of whether the tumor is completely excised occurs in minutes instead of days or weeks and is available anytime the office is open and our surgeons are present. The skin is not repaired until the margins are confirmed clear and the need for additional surgery one or two weeks later is virtually eliminated. We offer Mohs surgery, excision with traditional frozen sections, and excision with en face frozen sections that provide the highest cure rates for all skin cancers, regardless of size, location or subtype.
Skin cancer treatment options offered by Palo Alto Dermatology Institute for basal cell carcinoma, squamous cell carcinoma, and squamous cell carcinoma in situ.
Cure rate 97.6-99%
Mohs surgery offers the highest cure rate for skin cancer by checking 100% of the excision specimen margin (or edges) with frozen tissue histology while you wait. In addition to the highest cure rate, this technique creates the smallest defect to preserve normal skin and function and minimize the size of the reconstruction scar. Please click here for more information and a slide presentation of Mohs.
Cure rate 87.9-95.2%
Excision is the skin cancer treatment most commonly employed by surgeons, primary care doctors, dermatologists who do not perform Mohs surgery, and other physicians to treat skin cancer. Excisions involve surgical removal of the skin cancer with a margin of normal skin to ensure complete removal.
The differences between Mohs surgery and excision is primarily in the manner in which the excised tissue is processed and examined to determine if the skin cancer is completely removed. Excision specimen are submitted to a pathology lab for permanent tissue processing so that the margins can be evaluated by a pathologist. Unlike Mohs surgery where 100% of the skin margin is examined microscopically by the Mohs surgeon within an hour of removal, excision specimen are submitted for permanent sections to an outside laboratory and are processed and examined over a 2 to 7 day or more waiting period.
The majority of skin excision specimen are examined in a manner where less than 1% of the actual margin is examined by the pathologist. If the less than !% of the margin is clear, it is assumed that the other 99% of the margin is also clear. In contrast, Mohs surgery examines 100% of the margin and is a more accurate representation of whether the margins are actually clear. Please visit the Mohs surgery presentation to see and illustration of the differences between excisions and Mohs.
If the excision procedure is performed in hospital or surgery center, a pathologist may be available on site to assess the excision margin with frozen sections in less than an hour. At Palo Alto Dermatology Institute, a dermatologic surgeon skilled in reading slides is always on site. While the vast majority of the excision specimen margin is still not examined with frozen sections (unlike Mohs surgery), the frozen tissue examination while you wait enables the surgeon to preserve normal skin, minimize the need for a repeat surgery, and provided the highest cure rate for all skin cancers.
A variation of the frozen tissue examination is called en face sectioning. This technique provides a superior analysis of the excision specimen edges vs. standard excision by checking the excision skin edges, however it does not approach the higher cure rate of Mohs surgery because the small percentage of the base of the excision.
At Palo Alto Dermatology Institute, we are a private practice uniquely equipped to offer standard excision for the skin cancers that do not qualify for Mohs surgery in four different manners.
- Standard excision (formalin fixed tissue) – pathology report in days
- *Standard excision (frozen tissue) – pathology report in minutes
- Standard excision with en face** sections (formalin fixed) – pathology report in days
- *Standard excision with en face** sections (frozen tissue) – pathology report in minutes
* these two frozen tissue pathology techniques are performed at Palo Alto Dermatology Institute
** excision specimen have entire peripheral margin examined
Cure rate 73.0-92.3%
Electrodessication and curettage is also known as “scrape and burn” and is most commonly used for basal cell carcinoma. This technique involves local anesthesia of the skin cancer site, scraping of the area with a circular scalpel (curette) and then using electric current to gently burn the scraped area. This is repeated up to two additional times. This treatment leaves a scraped area that will be allowed to heal in on its own over a period of weeks. The debris from the scraping may be sent to pathology but it will not provide any indication of the margins. The cure rate is dependent on the skill and experience of the dermatologist. Scarring is variable based on the size and location.
This treatment is best for superficial basal cell carcinoma and small nodular basal cell carcinomas on the trunk and extremities (except tumors located on the breast).
Cure rate 89.0-97.0%
Radiation treatment uses ionizing radiation over a series of treatments (up to 20 sessions) to destroy the cancer cells. Despite the plethora of advertisements promoting radiation for all skin cancers, Palo Alto Dermatology Institute does not recommend radiation treatment for skin cancers that can be easily managed by Mohs surgery or excision in patients without any major contraindications for surgery. Prior to agreeing to radiation, the patient should be counseled regarding the other skin cancer treatment options, limitations for radiation, the lower cure rate and short and long-term complications of radiation treatment of the skin. Palo Alto Dermatology Institute may recommend radiation treatment under a limited number of circumstances including:
- Non-surgical candidates due to health issues or blood thinners
- Tumors with nerve involvement
- Incompletely removed tumors with excision
- Adjuvant treatment for aggressive skin cancers that have a risk of recurrence or local spread
68.6% recurrence at 5 years
This therapy is most useful for actinic keratoses (pre-cancers) and is not recommended for skin cancer treatment due to the high recurrence rate.
30% recurrence for superficial BCC
This treatment utilizes a topical chemotherapy agent and is primarily used for actinic keratoses (pre-cancers). The cure rate is 70% at best for superficial basal cell carcinoma.
Melanoma and melanoma in situ are potentially serious skin cancers and are primarily managed with surgical excision. Invasive melanomas may require additional procedures to examine lymph nodes and imaging studies based on the details of the pathology report. Advanced melanoma may require systemic medications to minimize spread and/or treat tumors that have spread to other areas of the body. Palo Alto Dermatology Institute can provide the surgical excision for uncomplicated melanoma and will coordinate care with oncologic surgeons, oncologists and melanoma centers for more complicated tumors.
Melanoma
Wide local excision with 0.5 to 2cm margins based on Breslow depth of tumor (reported on the pathology report). The excision specimen is sent for permanent tissue histology at an outside dermatopathology laboratory with results in 3 to 7 days,
Melanoma in situ
Wide local excision with 0.5 to 0.8cm margin sent for permanent tissue histology at an outside laboratory.
Mohs micrographic surgery for head and neck melanoma in situ if the tumor characteristics meet the Mohs Appropriate Use Criteria.
