Combined sentinel lymphadenectomy and mohs micrographic surgery for high-risk cutaneous squamous cell carcinoma

BACKGROUND: There are subgroups of cutaneous squamous cell carcinoma (SCC) that have a higher risk for both regional and distant metastasis. When cutaneous SCC does metastasize, it typically spreads first to local nodal groups. Sentinel lymph node (SLN) localization has been successfully used to evaluate nodal metastasis in breast carcinoma, melanoma, and other select tumors. It may also be useful in certain high-risk cutaneous SCCs. Currently, Mohs micrographic surgery is the treatment of choice for these tumors. METHODS: A patient presented with a high-risk recurrent SCC on the forehead. The regional nodal groups were clinically negative and radiographically negative by computed tomographic scan. Sentinel lymphadenectomy was performed by means of technetium 99m-radiolabeled sulfur colloid. The main tumor was resected with Mohs micrographic surgery. RESULTS: A left preauricular SLN was localized by lymphoscintigraphy. The SLN was located intraoperatively by means of a gamma probe and excised. Subsequent pathologic evaluation of the SLN was negative for evidence of metastatic SCC by light microscopy with hematoxylin and eosin, and with immunohistochemical stains for cytokeratins AE1 and AE3. The day after SLN excision, the tumor was removed via Mohs micrographic surgery with clear surgical margins after a total of 8 stages. Aggressive subclinical spread by both subcutaneous "skating" and perineural invasion was noted. CONCLUSION: The combination of Mohs micrographic surgery and sentinel lymphadenectomy is feasible and has theoretical utility in the management of a subset of cutaneous SCCs at high risk for metastasis. The ability of sentinel lymphadenectomy to identify regionally metastatic cutaneous SCC as well as the additive benefit of SLN and Mohs micrographic extirpation in the treatment of high-risk cutaneous SCC remain to be further clarified.     

Topical imiquimod therapy for basal and squamous cell carcinomas: a clinical experience

Basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (SCCs) are the most common malignancies in humans. Together, they constitute approximately 95% of nonmelanoma skin cancers (NMSCs). Surgical excision remains the mainstay of therapy of low-risk NMSC, though Mohs micrographic surgery is the gold standard for high-risk NMSC. Both methods produce high cure rates, but they may not be appropriate treatments for elderly patients who are either not surgical candidates or refuse to undergo surgery for their skin cancers. Imiquimod cream 5% is a topical immune response modifier that targets the toll-like receptors 7 and 8 and up-regulates inflammatory pathways targeting diseased tissue. This noninvasive topical therapy may be more appropriate for some patients. Herein, we describe our 5-month clinical experience in mostly elderly subjects with BCC (n=21) or SCC (n= 19) who were not candidates for surgical excision and were treated with topical imiquimod. Most subjects had a history of skin cancer, and the median age of the subjects was 78 years and 79 years in the BCC and SCC groups, respectively. After biopsy alone or biopsy followed by curettage, subjects received imiquimod cream 5% once daily 5 times weekly for 6 weeks. Twenty-three BCC lesions and 22 SCC lesions were included in the analysis. Most of the 45 lesions treated were located on the head and most were in high-risk areas. Approximately 3 months after imiquimod therapy, repeat biopsies showed that only 3 (2 BCCs and 1 SCC) lesion sites had residual tumor. After a median follow-up of 26 months, there was only one additional SCC recurrence. We also present a selection of representative case studies. Imiquimod cream 5% as adjunctive therapy to curettage was safe and well-tolerated in this mostly elderly population. The improved residual tumor and recurrence rates compared with historical rates for electrodesiccation and curettage (ED&C) alone suggest that adjunctive imiquimod therapy may be an appropriate treatment option for patients who desire or require less invasive treatment for NMSCs.     

Mohs surgery for squamous cell carcinoma

Cutaneous squamous cell carcinoma (SCC) is the second most common human cancer and can behave aggressively. Mohs micrographic surgery offers the highest cure rates for high-risk SCCs and is particularly useful for SCCs on challenging anatomic sites.     

Residual skin cancer after preoperative biopsy: evaluation by Mohs micrographic surgery

BACKGROUND: Some patients are referred for Mohs surgery with no or minimal clinical evidence of skin cancer at the biopsy site. OBJECTIVE: To determine the incidence of residual skin cancer at biopsy sites during Mohs micrographic surgery. METHODS: We evaluated all patients that underwent Mohs surgery for basal cell and squamous cell carcinomata in one year. The study was carried out prospectively. Debulking was done using a no. 15 blade at the clinical borders of the tumor or biopsy site. All specimens were sectioned at the middle and cut to the periphery at 20- microm intervals. RESULTS: Seven hundred and forty-one patients underwent operations. In 390 patients, a biopsy was performed prior to surgery. A total of 351 patients were biopsied as prestaged (chemocheck) during surgery. Ninety-nine (25%) of the preoperatively biopsied patients showed no residual tumor in the debulking specimen or the first layer. Of these 99 patients, 84 had basal cell carcinoma and 15 had superficial or in situ squamous carcinoma. CONCLUSIONS: In this study, preoperative biopsy for diagnosis of skin cancer of the face was curative in 25% of patients, despite pathologic diagnosis of incompletely excised tumor. However, as the majority of preoperatively biopsied patients showed residual tumor, Mohs micrographic surgery is indicated in all patients with incomplete removal of skin cancer of the head and neck.     

The Majority of Cutaneous Squamous Cell Carcinomas Arise in Actinic Keratoses

Background: Retrospective studies have given conflicting results with respect to how many cutaneous squamous cell carcinomas (SCCs) arise in actinic keratoses (AK). Objective: This study was conducted to determine what percentage of SCCs arise in AKs and to obtain more information about two histological features of SCCs, namely, thickness and ulceration. Methods: A prospective study was done of all SCCs treated by the authors during one calendar year. Results: Two hundred eight patients with SCC were entered into the study. An AK was contiguous with an SCC in 72% of the cases. This was taken as evidence that the SCC arose in the AK. Men presented with thicker and more ulcerated SCCs than women, but these were not statistically significant: p = 0.06 for thickness and p = 0.07 for ulceration. Ulcerated SCCs were more likely to arise on the head and neck (p = 0.02), on patients who had multiple skin cancers (p = 0.005), and on patients who had a family history of skin cancer (p = 0.03). Conclusion: Actinic keratoses need to be removed before they turn into SCCs. The prognostic significance of ulceration of cutaneous SCCs needs to be determined.     

Mohs micrographic surgery for melanoma

The results of multiple investigators have confirmed the value of Mohs surgery in the treatment of melanoma. In addition, these studies have contributed to our understanding of the biologic behavior of melanoma. The success of Mohs surgery confirms that melanoma grows in a contiguous fashion before it spreads systemically. It is known that once tumor breaks away from the main mass, trying to improve survival by increasing the extent of conventional surgery is often fruitless. Therefore, the goal of surgery is to remove all of the tumor, including the silent contiguous foci. If melanoma did not grow in a contiguous fashion before metastasis, the results of Mohs surgery would be inferior to wide excision, and higher local recurrences would be expected. Instead, the excellent results support the concept of contiguous tumor growth. Satellites and in-transit metastases that appear later may be removed with the fixed-tissue technique. We have also learned that melanoma sends out silent contiguous extensions, necessitating excision of some normal-appearing skin. The width of those extensions is unrelated to the depth of the melanoma. The value of Mohs surgery is the ability to identify these extensions microscopically and to excise tumor-bearing tissue while sparing normal skin. In fact, Mohs surgery often spares a diameter of 1.8 cm or more when compared with standard surgery, a distinct advantage to patients whose melanomas are on the head, neck, hands, feet, or genitalia or in patients whose melanoma has indistinct clinical margins and would require an even wider margin of normal skin when using standard surgical techniques. We now have long-term results from large numbers of patients--confirmed by multiple investigators and data--to support the concept of Mohs surgery for melanoma. This information emphasizes the important role that Mohs micrographic surgery plays in the treatment of melanoma.     

Histological evaluation of residual basal cell carcinoma after shave biopsy prior to Mohs micrographic surgery

Background Patients who are referred for Mohs surgery after pre‐operative biopsy has been performed show in some cases no clinical or pathological evidence of tumour persistence. We have previously shown that 25% of these patients show no residual skin cancer either basal cell carcinoma or squamous cell carcinoma. The reasons for ‘disappearance’ of the tumour may be true non‐persistence or false non‐persistence because of wrong‐site Mohs surgery. Objective To determine the incidence of residual basal cell carcinoma after shave biopsy of primary nodular basal cell carcinoma prior to Mohs micrographic surgery. Methods A prospective unblinded study was performed on patients undergoing Mohs surgery for primary nodular basal cell carcinoma. The tumour was removed as a shaved excision using a No. 15 blade at the clinical borders like a shave biopsy (Mohs shave). The bases of the tumors were excised and then sectioned vertically at the middle and cut to the periphery at 10–15 μm intervals till the edge. Results Fifty‐one patients were evaluated. In 40 patients, residual basal cell carcinoma was found at the base of the shave excision site (78.4%). Conclusions Pre‐operative shave biopsy performed during Mohs surgery for primary nodular basal cell carcinoma is ‘curative’ in 22% of the patients.     

Mohs micrographic surgery: a review of indications,technique, outcomes,and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.     

[Translated article] Risk of a Second Skin Cancer in a Cohort of Patients With Nonmelanoma Skin Cancer – Basal Cell Carcinoma or Squamous Cell Carcinoma – Treated With Mohs Micrographic Surgery: A National Prospective Cohort Study

ObjectivePatients with nonmelanoma skin cancer (NMSC)—ie, basal cell carcinoma (BCC) or squamous cell carcinoma (SCC)—have an increased risk of developing a second skin cancer. The aim of this study was to describe the frequency, incidence per 1000 person-years, and predictors of a second skin cancer in a cohort of patients with NMSC treated with Mohs micrographic surgery (MMS).Material and methodsProspective study of a national cohort of patients with NMSC who underwent MMS at 22 Spanish hospitals between July 2013 and February 2020; case data were recorded in the REGESMOHS registry. The study variables included demographic characteristics, frequency and incidence per 1000 person-years of second skin cancers diagnosed during the study period, and risk factors identified using mixed-effects logistic regression.ResultsWe analyzed data for 4768 patients who underwent MMS; 4397 (92%) had BCC and 371 (8%) had SCC. Mean follow-up was 2.4 years. Overall, 1201 patients (25%) developed a second skin cancer during follow-up; 1013 of the tumors were BCCs (21%), 154 were SCCs (3%), and 20 were melanomas (0.4%). The incidence was 107 per 1000 person-years (95% CI, 101–113) for any cancer, 90 per 1000 person-years (95% CI, 85–96) for BCC, 14 (95% CI, 12–16) per 1000 person-years for SCC, and 2 (95% CI, 1–3) per 1000 person-years for melanoma. More men than women developed a subsequent skin cancer (738 [61%] vs 463 [39%]). The main risk factors were a history of multiple tumors before diagnosis (relative risk [RR], 4.6; 95% CI, 2.9–7.1), immunosuppression (RR, 2.1; 95% CI, 1.4–3.1), and male sex (RR, 1.6; 95% CI, 1.4–1.9).ConclusionPatients have an increased risk of developing a second tumor after MMS treatment of NMSC. Risk factors are a history of multiple tumors at diagnosis, immunosuppression, and male sex.     

Cancer of the forehead and temple regions

Several characteristics inherent in tumors of the forehead and temple provide therapeutic challenges for the physician. These include spread along anatomic structures, a propensity toward aggressive growth patterns, the risk of nerve damage, and the preservation of important cosmetic landmarks. As a result of these problems, Mohs micrographic surgery is often indicated in the treatment of skin cancer of the forehead and temple. The high cure rates afforded by micrographic surgery, even for aggressive tumors, and tissue conservation are benefits to the patient. Although most BCCs and SCCs in this region can be handled by a dermatologic surgeon, patients may present with aggressive or neglected tumors exhibiting extensive invasion. These patients may require a cooperative approach between the dermatologic and head and neck surgeon to achieve complete tumor extirpation or appropriate reconstruction. In this article, we have tried to indicate the rationale behind the use of Mohs micrographic surgery for tumors of the forehead and temple. In selected tumors, a team approach between the micrographic and other surgeons will maximize both tumor excision and functional and cosmetic repair for the patient.     

Riesgo de aparición de segundas neoplasias cutáneas en una cohorte de pacientes diagnosticados de carcinoma queratinocítico (carcinoma basocelular y carcinoma epidermoide) tratados con cirugía de Mohs. Estudio de cohortes prospectivo nacional

ObjectivePatients with nonmelanoma skin cancer (NMSC)—ie, basal cell carcinoma (BCC) or squamous cell carcinoma (SCC)—have an increased risk of developing a second skin cancer. The aim of this study was to describe the frequency, incidence per 1000 person-years, and predictors of a second skin cancer in a cohort of patients with NMSC treated with Mohs micrographic surgery (MMS).Material and methodsProspective study of a national cohort of patients with NMSC who underwent MMS at 22 Spanish hospitals between July 2013 and February 2020; case data were recorded in the REGESMOHS registry. The study variables included demographic characteristics, frequency and incidence per 1000 person-years of second skin cancers diagnosed during the study period, and risk factors identified using mixed-effects logistic regression.ResultsWe analyzed data for 4768 patients who underwent MMS; 4397 (92%) had BCC and 371 (8%) had SCC. Mean follow-up was 2.4 years. Overall, 1201 patients (25%) developed a second skin cancer during follow-up; 1013 of the tumors were BCCs (21%), 154 were SCCs (3%), and 20 were melanomas (0.4%). The incidence was 107 per 1000 person-years (95% CI, 101-113) for any cancer, 90 per 1000 person-years (95% CI, 85-96) for BCC, 14 (95% CI, 12-16) per 1000 person-years for SCC, and 2 (95% CI, 1-3) per 1000 person-years for melanoma. More men than women developed a subsequent skin cancer (738 [61%] vs 463 [39%]). The main risk factors were a history of multiple tumors before diagnosis (relative risk [RR], 4.6; 95% CI, 2.9-7.1), immunosuppression (RR, 2.1; 95% CI, 1.4-3.1), and male sex (RR, 1.6; 95% CI, 1.4-1.9).ConclusionPatients have an increased risk of developing a second tumor after MMS treatment of NMSC. Risk factors are a history of multiple tumors at diagnosis, immunosuppression, and male sex.     

Sebaceous carcinoma of the eyelid treated with Mohs micrographic surgery

BACKGROUND: Sebaceous carcinoma is an aggressive neoplasm that commonly arises from the meibomian glands of the eyelids and other sebaceous glands of the ocular adnexa. Historic data indicate a nearly 30% local recurrence rate with standard surgical excision. Excision by means of Mohs micrographic surgery may be more efficacious. However, reports documenting the effectiveness of this technique for the treatment of eyelid sebaceous carcinoma have been limited to a few cases. OBJECTIVE: We report our experience in the treatment of ocular sebaceous carcinoma with the Mohs fresh tissue technique. METHODS: Eighteen patients with a diagnosis of sebaceous carcinoma of the eyelid who underwent resection by means of the Mohs fresh tissue technique during the years 1988-1998 were reviewed. RESULTS: Sixteen of the 18 patients were free of disease after an average follow-up of 37 months (11.1% recurrence rate). One patient who experienced local recurrence also had metastatic disease of the parotid lymph nodes (5.6% metastatic rate). The recurrence and metastasis were noted 9 months after excision. The other patient experienced a local recurrence 19 months postoperatively. Both patients exhibited pagetoid spread and involvement of both the upper and lower eyelid at the time of Mohs excision. CONCLUSION: Mohs surgery offers excellent results when used as the primary treatment modality for sebaceous carcinoma of the eyelid. When compared with historic series of standard surgical excision, Mohs micrographic surgery has a significantly lower recurrence rate and metastatic rate.     

Squamous cell carcinoma of the skin: epidemiology,classification, management,and novel trends

Squamous cell carcinoma (SCC) is the second most common non‐melanoma skin cancer. It originates from epidermal keratinocytes or adnexal structures (such as eccrine glands or pilosebaceous units). We describe the salient features of cutaneous SCC. We also review novel classification schemes proposed during the last decade which attempt to stratify SCC lesions based on prognosis. Biopsy leads to definitive diagnosis. Treatment includes surgical excision; Mohs micrographic surgery produces excellent cure rates and spares the maximal amount of tissue. Other modalities include electrodessication and curettage, cryosurgery, radiotherapy, topical medications, photodynamic therapy, and systemic therapy. Management and follow‐up depend on the risk stratification of individual lesions.     

Quality-of-life outcomes of treatments for cutaneous basal cell carcinoma and squamous cell carcinoma

Quality of life is an important treatment outcome for conditions that are rarely fatal, such as cutaneous basal cell carcinoma and squamous cell carcinoma (typically called nonmelanoma skin cancer (NMSC)). The purpose of this study was to compare quality-of-life outcomes of treatments for NMSC. We performed a prospective cohort study of 633 consecutive patients with NMSC diagnosed in 1999 and 2000 and followed for 2 years after treatment at a university-based private practice or a Veterans Affairs clinic. The main outcome was tumor-related quality of life 1 to 2 years after therapy, measured with the 16-item version of Skindex, a validated measure. Skindex scores vary from 0 (best) to 100 (worst) in three domains: Symptoms, Emotions, and Function. Treatments were electrodessication and curettage (ED&C) in 21%, surgical excision in 40%, and Mohs surgery in 39%. Five hundred and eight patients (80%) responded after treatment. Patients treated with excision or Mohs surgery improved in all quality-of-life domains, but quality of life did not improve after ED&C. There was no difference in the amount of improvement after excision or Mohs surgery. For example, mean Skindex Symptom scores improved 9.7 (95% CI: 6.9, 12.5) after excision, 10.2 (7.4, 12.9) after Mohs surgery, and 3.4 (-0.9, 7.6) after ED&C. We conclude that, for NMSC, quality-of-life outcomes were similar after excision and Mohs surgery, and both therapies had better outcomes than ED&C.     

Kutanes Plattenepithelkarzinom

Squamous cell carcinoma (SCC) of the skin accounts for 20?% of non-melanoma skin cancer and is one of the most frequent types of cancer in Caucasian populations. Diagnosis is based on the clinical features and should be histopathologically confirmed to adequately address the prognosis and treatment. Complete surgical excision with histopathological control of excision margins is the gold standard in the treatment of primary SCC. Sentinel lymph node biopsies (SLNB) can be considered in SCC with a tumor thickness of >6 mm but there is currently no evidence concerning prognostic and therapeutic effects. Radiotherapy can be discussed as an alternative to surgery for inoperable tumors or as adjuvant therapy for a high risk of recurrence. In SCC with distant metastases various chemotherapeutic agents are used; however, there is no standard regimen. The epidermal growth factor receptor (EGFR) inhibitors and immune checkpoint blockers can be discussed as treatment options, preferentially in clinical trials. There is no standard follow-up schedule for patients with SCC. A risk-adapted follow-up is recommended based on the risk of metastatic spread or development of new lesions primarily by dermatological control and supplemented by ultrasound investigations in high risk patients.     

改良Mohs显微描记手术治疗Merkel细胞癌二例

【摘要】 Mohs显微描记手术是切除皮肤肿瘤的理想术式。本文2例Merkel细胞癌患者行改良Mohs显微描记手术切除肿瘤，随访1年余，肿瘤未复发。与传统扩大切除术相比，改良Mohs手术是Merkel 细胞癌患者更好的选择。     

Long-term follow-up of skin cancer in the PUVA-48 cooperative study

Five-hundred fifty-one psoriasis patients receiving therapy with psoralen plus UVA light in seven medical centers for up to 10 years were evaluated for the development of skin cancer. Basal cell carcinoma developed in 13 patients (2.4%), and squamous cell carcinoma (SCC) developed in 9 (1.6%), an incidence that is significantly elevated over that in the general population. The increase in basal cell carcinoma was found only in patients with exposure to other carcinogenic agents, whereas the increase in SCC was also seen in patients without such exposures. Cumulative UVA dosage was not correlated with the development of basal cell carcinoma, but there was a trend of increasing numbers of SCCs in patients with higher dosages. Five of 9 patients had SCCs on sites that were not sun exposed. All patients with tumors had them treated surgically, and, to date, none have recurred. This study confirms a previous report of an increase in the incidence of SCC in psoriatic patients treated with PUVA.     

Altered density,composition and microanatomical distribution of infiltrating immune cells in cutaneous squamous cell carcinoma of organ transplant recipients

Organ transplant recipients (OTR) who require the long‐term use of immunosuppressant medications to prevent organ rejection are more than 65 times more likely than the general population to develop squamous cell carcinoma of the skin (SCC), which is a type of skin cancer and the most frequent malignant tumor after organ transplantation. Allegedly, the immune system in the skin may influence the disease as SCCs tend to behave more aggressively in immunosuppressed patients. The aim of this study was to gain an insight into the distribution patterns of different immune cells in SCCs arising in immunosuppressed OTR and non‐transplant patients. The researchers from Heidelberg, Germany, stained different immune cell subsets in 20 SCCs from kidney transplant recipients and SCCs from thoroughly matched immunocompetent non‐transplant patients (IC). They compared quantities and tissue distribution of immune cells in tumors and surrounding skin in both groups by using a novel semi‐automatic technology and computerized microscopy. The investigators found that the density of immune cells in SCC and surrounding skin from OTR was overall reduced compared to IC, particularly at the tumor borders. In addition to reduced CD4+ immune cells at the tumor borders the density of CD8+ T cells (a subset of immune cells thought to help fight tumours), within the SCCs and tumor‐surrounding skin of OTR was significantly diminished. One possible explanation may be that immunosuppressants (drugs that suppress the immune system to stop the body rejecting the new, transplanted organ) influence the ability of immune cells to accumulate in the skin and position themselves at the site of a growing SCC in order to detect and defend against cancer. The authors note that additional studies must be done to learn more about the functional relevance of the particular immune cell subsets for the control of skin cancer.     

MMP‐10 (Stromelysin‐2) and MMP‐21 in human and murine squamous cell cancer

Abstract: The squamous cell cancers (SCC) of renal transplant recipients are more aggressive and metastasize earlier than those of the non‐immunocompromised population. Matrix metalloproteinases (MMPs) have a central role in tumor initiation, invasion and metastasis. Our aim was to compare the expression of MMPs‐10, ‐12 and ‐21 in SCCs from immunosuppressed (IS) and control patients and the contribution of MMPs‐10 and ‐21 to SCC development in the FVB/N‐Tg(KRT5‐Nfkbia)3Rto mouse line. Immunohistochemical analysis of 25 matched pairs of SCCs, nine of Bowen’s disease and timed back skin biopsies of mice with selective inhibition of Rel/NF‐κB signalling were performed. Semiquantitatively assessed stromal MMP‐10 expression was higher (P = 0.009) in the control group when compared with IS patients. Tumor cell‐derived MMP‐10, ‐12 and ‐21 expression did not differ between the groups but stromal fibroblasts of the control SCCs tended to express MMP‐21 more abundantly. MMP‐10 expression was observed already in Bowen’s disease while MMP‐21 was absent. MMP‐10 and ‐21 were present in inflammatory or stromal cells in ageing mice while dysplastic keratinocytes and invasive cancer were negative. Our results suggest that MMP‐10 may be important in the initial stages of SCC progression and induced in the stroma relating to the general host‐response reaction to skin cancer. MMP‐21 does not associate with invasion of SCC but may be involved in keratinocyte differentiation.     

Human papillomavirus in cutaneous squamous cell carcinoma and cervix of a patient with psoriasis and extensive ultraviolet radiation exposure

"High-risk" human papillomaviruses (HPVs) are associated with intraepithelial neoplasia and cancer of the uterine cervix. HPV has also been found in nonmelanoma skin cancer (NMSC), especially in squamous cell carcinomas (SCCs) of immunosuppressed patients. Recently, lesions of psoriasis have been shown to harbor HPV, and patients with psoriasis often have a history of extensive therapy with ultraviolet radiation (UVR). UVR is the major known risk factor in the occurrence of NMSC, in which HPV may be a cofactor for SCC. We report an otherwise healthy, nonimmunosuppressed patient with psoriasis who had a history of extensive exposure to UVR and experienced multiple SCCs on UV-exposed body sites. By the polymerase chain reaction method, we detected HPV in 5 of 9 SCCs. Automated sequencing showed HPV types 12 and 17. Only 1 of 3 normal skin specimens was HPV positive (HPV type 17). This positive specimen was from UV-exposed skin; one of the two HPV-negative, normal skin specimens was located on a body site not exposed to sun. In addition, HPV type 62 was found in a brush specimen of the uterine cervix. This case report suggests an association between psoriasis, HPV infection, and UVR exposure, in onset of SCC.