I Got Skin Cancer — My Crohn’s Meds May Have Played a Part

Certain immunosuppressive medications used in IBD may increase our risk for basal and squamous cell cancers. However, early detection usually results in successful treatment.

Those of us who live with ulcerative colitis or Crohn’s disease (two types of inflammatory bowel disease, or IBD) are used to things not going according to plan with our digestive tract.

Many of us also experience symptoms that go beyond our gut. As if living with one lifelong health problem wasn’t enough, people with IBD also are more likely to have other chronic diseases, such as arthritis and heart disease, than people without IBD.

Skin complications are common too: For example, anywhere between 3–10% of people with ulcerative colitis and 4–15% of us with Crohn’s develop erythema nodosum, which causes warm, painful bumps under the skin, usually on the arms, knees, and legs. And, it’s not the only skin condition we need to be aware of.

An increased risk of skin cancer is one of the many possible health complications that can arise when living with IBD.

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Exploring the link between IBD and skin cancer

Why would IBD increase a person’s risk for skin cancer?

Well, IBD medications seem to be at least partly responsible. A recent review of studies found that people with IBD who took immunosuppressive medications known as thiopurines — such as azathioprine (brand names include Imuran and Azapress) — had significantly higher risk for nonmelanoma skin cancer (NMSC) while their risk for melanoma was no different than the general population.

Nonmelanoma skin cancer includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

While this sounds super scary, it’s worth noting that both of these types of cancers typically do not spread to other parts of the body and are highly treatable, at least in the general population. However, in immunosuppressed people, SCC can be more aggressive, making early diagnosis and treatment especially important.

An 2022 study, however, found that those who took thiopurines had an increased risk for melanoma as well as BCC and SCC, while those who took anti-TNF medications (such as Remicade and Humira) only had an elevated risk for BCC and melanoma.

Medication alone doesn’t fully explain the link, however. Another study suggests that IBD itself may predispose people to skin cancer, noting that those who were diagnosed with Crohn’s disease as children were more likely to develop skin malignancies later in life regardless of medication.

In addition, people with ulcerative colitis are more likely to develop BCC before being diagnosed with UC, although the reasons for this remain unclear.

A personal journey

Unfortunately, I discovered this link between IBD and non-melanoma skin cancer in my own life.

It started when I noticed a small red spot, around 1 centimeter in diameter, on my hairline about 18 months ago.

The spot didn’t go away but it didn’t look particularly scary either. However, according to the Skin Cancer Foundation, BCC doesn’t look like a typical mole — instead, it often presents as a red patch or shiny bump. Uh-oh.

Between that and the fact that I kept catching it whenever I brushed my hair, I decided to go to my primary care doctor so he could have a look.

My doctor echoed my sentiment that it was probably nothing serious, and we first tried different creams, which helped it look less angry and even fade, but not disappear.

Here in the UK, if your primary care doctor suspects cancer, you can be referred to a specialist for an urgent appointment within 2 weeks, so when I returned to the doctor a month later reporting it hadn’t disappeared, I was quickly booked with a dermatologist, who asked me to send further photos.

He also didn’t think it was anything to worry about initially, but when he heard my medical history and my family history (my father had 20 basal cell carcinomas removed in the past and I had been on azathioprine for 10+ years for my Crohn’s disease), he recommended that we biopsy it to be safe.

The biopsy was straightforward. A nurse made a small and superficial incision, cutting away a tiny piece of the lesion on my scalp that she would send to the lab. Then 6 weeks later I received the diagnosis of a superficial basal cell carcinoma.

Treating my skin cancer

Naturally, I was worried, but my doctor reassured me that the prognosis was good and that treatment was simple enough.

He prescribed a cream called imiquimod (brand names include Aldara and Zyclara); this treatment is used for BCCs that are superficial in the skin and therefore don’t require invasive surgery. I was told to apply this ointment twice a day for 6 weeks and I’d see the doctor in 3 months for a checkup.

What he didn’t tell me was that this cream would cause things to get much worse before they got better. What was a nondistinguishable, hardly noticeable red patch multiplied in size overnight, forming a red, sore, scaly patch that grew along my hairline.

I panicked and called the dermatology office and the doctor told me this wasn’t my cancer spreading as I’d feared but the cream bringing the damage to the surface, just like it was supposed to.

By the time I finished the treatment, the area had faded to a pink circle. Thankfully, my dermatologist was confident that the cream had done all that was needed, although we’d need to keep a close eye in case it returned.

Lowering our risk

If you live with IBD, your doctor may advise taking certain precautions to lower your risk of developing skin cancer. These may include wearing sunblock, covering up in the sun with protective clothing and hats, and scheduling more regular dermatology appointments.

The US-based Crohn’s and Colitis Foundation recommends yearly skin checks for all people with IBD who take immunosuppressive medications. This is not offered in England where I live, so instead I have to go through the process of going back to my primary care doctor each time I find a spot or patch.

I’ve had two more dermatology referrals since that first one and have spotted one more precancerous spot (called an actinic keratosis), which has now been removed. I am also waiting for another of these to be removed.

However, after these referrals, my dermatologist felt that the thiopurine medication I had taken for such a long time was the likely cause of my cancer, especially given my age. In the general population, BCCs occur most commonly in people over 50, and I’m only 38.

My dermatologist recommended that my IBD team stop my treatment with azathioprine to prevent any further recurrences after the basal cell carcinoma was treated.

This was scary, as I haven’t been med-free in a long time, although my doctors have offered me a drug called vedolizumab (or Entyvio) as an alternative, should I flare. Unlike other biologics, this medication only targets the gut rather than the whole immune system. A review of studies suggests this has fewer side effects than traditional biologics.

Living with skin cancer

The diagnosis also meant I would have to change many habits. While I never used sunbeds or even spent time sunbathing (I’ve always avoided the heat as I find it gives me stomach cramps), I now make sure I use SPF 50 sunscreen on my face each day — even in British cloudy weather and even if I’m only leaving the house to take my son to school!

I recently went on my first post-skin cancer beach holiday, and I knew I had to be prepared. I invested in sun-protective clothing with a UPF 50+ rating (which helps block UV radiation); and opted for swim T-shirts rather than bikinis, as well as long-sleeved cover-ups when I was out of the water. I also wore a wide-brimmed UPF 50 hat and used SPF 100 sunscreen.

My cancer diagnosis also made me reflect on my habits in general. Stopping my medication meant I really had to look at my diet and lifestyle as a whole.

I’m now trying to incorporate more fruits and vegetables into my diet. I’ve also started exercising more and generally just trying to commit to a healthier lifestyle.

These efforts may not prevent a flare-up entirely but they help me feel that I’m doing all I can. I know I can always try the vedolizumab if I have a bad flare, but I’d like to prevent that in the first place.

I’ve also struggled with more negative, anxious thoughts about my body since my cancer diagnosis, so I’ve been introducing some simple practices to help me overcome this. For example, I’ve invested in some really good sunscreen products, so I now enjoy applying my SPF 50 each day and feel more positive about protecting my skin.

The takeaway

If you take immunosuppressant medications for your IBD, it can increase your risk of skin cancer.

Of course, any decisions about discontinuing or changing medications should be made with your physician and other members of your IBD team. Together, you’ll need to weigh the risks of uncontrolled IBD with the potential side effects of IBD medications.

No matter what you decide, being vigilant and having regular skin checks is always important.