Skin Cancer of the Head and Neck: When You Need More Than a Dermatologist

Skin cancer is the most commonly diagnosed cancer in the United States, and the head and neck — the face, scalp, ears, and neck — are among the most frequently affected areas given their lifetime exposure to the sun. For most patients, a dermatologist manages skin cancer effectively: a quick biopsy confirms the diagnosis, an in-office procedure removes it, and the patient moves on. But for a meaningful subset of patients, skin cancer of the head and neck requires a level of surgical expertise and oncologic management that goes well beyond what a dermatologist can offer. Knowing when that threshold has been crossed — and getting to the right specialist before the disease progresses — can make an enormous difference in outcome.

The Landscape: What Types of Skin Cancer Affect the Head and Neck

The three most common skin cancers that affect the head and neck are basal cell carcinoma, squamous cell carcinoma, and melanoma. They behave differently and require different approaches.

Basal cell carcinoma is the most common skin cancer overall. It rarely spreads to lymph nodes or distant organs, but it can grow deeply — eroding into soft tissue, cartilage, bone, and even the skull base or orbit if neglected or repeatedly recurrent. When a basal cell carcinoma is small and superficial, a dermatologist handles it well. When it is large, deeply invasive, located near critical structures like the eye or ear, or has recurred after prior treatment, the reconstruction and the oncologic resection both require more specialized hands.

Cutaneous squamous cell carcinoma (cSCC) is a more aggressive beast. Unlike basal cell carcinoma, squamous cell carcinoma can metastasize — spreading first to regional lymph nodes in the neck, and in advanced cases to the lungs, liver, and bones. Most cases of cSCC are low-risk and handled straightforwardly, but certain features push a tumor into the high-risk category: size greater than 2 cm, invasion deeper than 6 mm, poor differentiation on pathology, perineural invasion (tumor tracking along nerve sheaths), location on the ear or lip, and immunosuppression in the patient. High-risk cSCC near the parotid gland or in the periauricular area (around the ear) is particularly prone to parotid lymph node involvement and requires careful neck and parotid assessment.

Melanoma is the most dangerous of the three. Even lesions that appear small can metastasize, and the biology of the disease can be aggressive. Melanoma of the head and neck has specific patterns of lymph node spread that are not always predictable based on tumor location, which is why sentinel lymph node biopsy — a surgical procedure to sample the first draining lymph node — is a standard part of staging for appropriate-thickness melanomas. Management of head and neck melanoma, particularly when lymph nodes are involved or when the primary tumor is in a complex anatomic location, falls squarely in the domain of head and neck surgery working alongside medical oncology.

When Dermatology Refers to a Head and Neck Surgeon

The referral I receive most often is a patient whose dermatologist has identified a skin cancer that requires more extensive surgery than can be performed in the office, involves lymph nodes or high-risk features suggesting node involvement, affects the parotid gland or its lymph nodes, or requires reconstruction beyond a simple closure.

Parotid involvement deserves special mention. The parotid gland — the large salivary gland in front of and below the ear — contains lymph nodes within its substance. These nodes are the first drainage station for skin cancers of the lateral face, scalp, and periauricular region. When a squamous cell carcinoma or melanoma in these locations spreads to lymph nodes, the parotid nodes are often the first place it goes. Removing the involved portion of the parotid gland while preserving the facial nerve — which runs through the gland and controls the muscles of facial expression — requires training in parotid surgery. Injuring the facial nerve during this operation produces a partial or complete facial paralysis that affects blinking, smiling, and eating, with significant functional and cosmetic consequences. This is not a procedure to be taken lightly or performed without specific experience.

Similarly, melanoma staging with sentinel lymph node biopsy requires a surgeon comfortable with the technique, a nuclear medicine team to perform the preoperative lymphoscintigraphy (the radiotracer injection that maps the draining lymph nodes), and pathology with expertise in analyzing melanoma sentinel nodes. When the sentinel node is positive — confirming lymph node spread — the subsequent decision about further surgery, systemic therapy with targeted agents or immunotherapy, and surveillance is made collaboratively with medical oncology.

The Reconstruction Question

Some of the most challenging aspects of head and neck skin cancer surgery involve reconstruction. Removing a large or deeply invasive tumor from the face, ear, scalp, or neck can create a significant defect — missing skin, underlying soft tissue, cartilage, or even bone. How that defect is reconstructed affects not just cosmetic appearance but also function: protecting the eye, preserving the ability to eat and speak normally, and maintaining the structural integrity of the face and neck.

Local and regional flaps — rearranging adjacent tissue to close a wound — can accomplish a great deal, and I use these routinely. For larger defects, free tissue transfer (microvascular free flap reconstruction) may be necessary, bringing vascularized tissue from a distant donor site — the forearm, thigh, or back — to fill a major defect. This is the same reconstructive approach I use for oral and throat cancer patients following major resections, and it requires microsurgical experience to execute reliably.

Multidisciplinary Management and Systemic Therapy

Advanced skin cancer, particularly metastatic squamous cell carcinoma and stage III or IV melanoma, is now treated with systemic therapy in addition to surgery. The landscape of systemic treatment has changed dramatically in the last decade. For melanoma, targeted therapy (BRAF/MEK inhibitors for BRAF-mutated disease) and immune checkpoint inhibitors (anti-PD-1 agents such as pembrolizumab and nivolumab) have transformed outcomes for patients with lymph node involvement or distant metastases. For advanced cSCC, cemiplimab (an anti-PD-1 antibody) and pembrolizumab have produced durable responses in patients with unresectable or metastatic disease.

These therapies are often given in the adjuvant setting — after surgery — to reduce the risk of recurrence. Understanding the interplay between surgery, radiation, and systemic therapy requires close coordination between head and neck surgery, radiation oncology, and medical oncology. At St. Luke's, these cases come through our weekly multidisciplinary tumor board, where a head and neck cancer case is reviewed by specialists across all relevant disciplines before a treatment plan is finalized.

Who Needs to See a Head and Neck Surgeon

A referral to a head and neck surgeon is appropriate when a skin cancer involves the parotid gland or periparotid lymph nodes, when there is clinical or radiographic evidence of cervical (neck) lymph node involvement, when the tumor is large, invasive, or has recurred after prior treatment, when melanoma staging requires sentinel lymph node biopsy, when the tumor is located in a complex anatomic site requiring sophisticated reconstruction, or when systemic therapy is part of the treatment plan and multidisciplinary coordination is needed.

A dermatologist is an excellent first-line physician and often the person who makes the diagnosis. But when the situation is complex — oncologically, surgically, or reconstructively — the right next step is a subspecialty consultation. I work closely with dermatologists in the Milwaukee area and welcome referrals for patients who need this level of care.

Taking the Next Step

If you or someone you care for has been diagnosed with a head and neck skin cancer that involves lymph nodes, the parotid region, or a site requiring significant reconstruction, I am glad to see you in consultation. You can reach my office at 414-649-3920 to schedule an appointment at Aurora St. Luke's Medical Center. Bringing any prior biopsy reports, imaging, and operative notes from previous procedures will allow us to make the most of our time together.

Dr. Steven Sperry is a fellowship-trained head and neck surgeon specializing in head and neck cancer surgery and microvascular free flap reconstruction at Aurora St. Luke's Medical Center in Milwaukee, Wisconsin.