Patients are increasingly asking about Mohs vs image-guided radiation for the treatment of basal cell and squamous cell carcinoma. Both approaches can be used to treat skin cancer, but they differ in how the cancer is removed or treated, how margins are evaluated, and what the healing process looks like.

What is image-guided radiation therapy?

Image-guided superficial radiation therapy, sometimes called IGSRT, is a form of radiation treatment used for certain skin cancers. Unlike Mohs surgery, it does not require cutting or stitches. Radiation energy is directed at the area of the skin cancer over a series of treatments.

One of the main reasons patients may be interested in image-guided radiation is that it avoids surgery. However, unlike Mohs surgery, the tissue margins are not examined under a microscope during treatment to confirm that all of the cancer cells have been removed.

Does radiation really mean no scar?

Radiation is sometimes described as a scarless treatment because there is no surgical incision. However, radiation still causes injury to the skin as it treats the cancer.

Dr. Peter Boothman explains that skin must heal after radiation just as it must heal after other forms of trauma. Radiated skin can develop changes in texture and structure, including loss of hair follicles and increased firmness or stiffness. These changes may also make future surgery in the same area more difficult if another skin cancer develops or the original cancer returns.

How does Mohs confirm the cancer is gone?

During Mohs surgery, the skin cancer is removed and the margins are examined under a microscope while the patient waits. If cancer cells are still present at an edge, the surgeon can return specifically to that area and remove additional tissue.

This allows the surgeon to continue until the margins are clear while preserving as much healthy tissue as possible. The surgeons in the video describe the ability to leave the office knowing the margins are clear as one of the major benefits of Mohs surgery.

How Do Mohs Surgeons Plan the Repair?

Mohs surgery does not end when the cancer is removed. Once the margins are clear, the repair is planned just as thoughtfully as the cancer removal itself.

Our fellowship-trained Mohs surgeons take great pride in their patients’ results. They consider the natural movement of the skin, facial symmetry, skin tension, nearby structures, and how the repair will look and function over time. On areas such as the nose, eyelids, lips, ears and cheeks, even small decisions can make a meaningful difference.

The repair is also individualized to the patient. Does the patient grow a beard? How will the scar sit within natural lines of the face? Will the repair affect movement, expression or symmetry? These details are considered when planning the reconstruction.

The goal is not simply to close the wound. It is to remove the cancer completely, preserve as much healthy tissue as possible, and reconstruct the area with careful attention to both function and appearance.

See some of our patient experiences on Youtube with before and after photos:

• Mohs Surgery for Melanoma on the Nose
• Mohs Surgery for Basal Carcinoma on the Nose- at 27 years old  
• Minimal scars with Mohs surgery on the nose
• Nose flap before and after 

Mohs vs Image-Guided Radiation: How Are They Different?

Mohs surgery and image-guided radiation therapy treat skin cancer in very different ways. With Mohs surgery, the cancer is removed and the tissue margins are examined under a microscope during the procedure. If cancer cells are still present, the surgeon removes additional tissue only from the area where they remain.

Image-guided radiation therapy treats the cancer with targeted radiation over a series of visits rather than removing it surgically. One of the main differences is that the margins are not examined under a microscope during radiation treatment, so there is not the same immediate confirmation that the entire cancer has been removed.

The treatments also differ in timing and healing. Mohs is typically completed in one office visit, while image-guided radiation may require multiple treatments over several weeks. Radiation can also change the surrounding skin, which may make future surgery more difficult if the cancer recurs or another skin cancer develops in the same area.

How many treatments does radiation require?

In the discussion, Dr. Ryan Thorpe explains that image-guided radiation therapy may require approximately 15 to 20 treatments over several weeks.

Mohs surgery, by comparison, is typically performed in the office in a single visit. The cancer is removed, the tissue is examined, and reconstruction is usually completed the same day.

What happens if skin cancer comes back in a radiated area?

If a skin cancer recurs after radiation, surgery may still be necessary. However, the surgeons explain that operating in previously radiated skin can be more challenging because radiation can change the skin’s flexibility and ability to heal.

The physicians at Ada West Dermatology frequently treat recurrent skin cancers and note that some of the largest and more difficult cancers they encounter have occurred in previously radiated areas.

When is radiation actually a good option?

Radiation does have an important role in skin cancer treatment. The physicians explain that there are circumstances in which radiation may be the best option, particularly for certain aggressive cancers or situations where surgery may not be appropriate.

When radiation is needed, the surgeons discuss the value of involving a radiation oncologist, a physician who specializes specifically in radiation therapy and has access to a broader range of radiation techniques.

How do I decide between Mohs and radiation?

There is no single treatment decision that applies to every patient or every skin cancer. Treatment depends on factors such as the type and location of the cancer, how aggressive it is, the patient’s age and overall health, how much tissue would need to be removed, and whether treatment can be performed safely in the office.

Our Mohs physicians emphasize that treatment decisions should combine established medical guidelines with the circumstances of the individual patient. For many basal cell and squamous cell carcinomas, Mohs surgery remains the standard surgical approach because it allows the cancer margins to be examined during the procedure while minimizing the amount of healthy tissue removed.

Want to understand other nonsurgical treatments as well?

Dr. Winchester explains radiation, topical therapies and additional skin cancer treatment options.