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Nonmelanoma skin cancers (NMSCs) are the most common neoplasms worldwide, and their incidence continues to rise. The 2 most common NMSCs are squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). Both types can be locally aggressive and lead to cartilage and bone destruction. These cancers are most commonly found in sun-exposed areas, with 80% of lesions occurring on the face, a cosmetically sensitive area.[1] Given their propensity to involve cosmetically sensitive areas such as the head and neck, treatment options should prioritize the most effective cure rates while also emphasizing optimal cosmetic outcomes. Therapeutic options include surgery, radiotherapy, topical agents, and systemic therapy. Surgery is the gold standard for treatment, with Mohs surgery having superior 5- and 10-year recurrence rates compared with standard excisions.[1] Although surgical excision has long been considered the gold standard for treatment, patients may not be ideal surgical candidates due to age, comorbidities, or inferior functional or cosmetic outcomes, especially in sites such as the lip, eye, and nose. As such, other treatment modalities may be considered in such circumstances, including radiotherapy. Indications for radiotherapy include tumors in anatomical sites where surgical excisions might have a poor cosmetic outcome, adjuvant treatment in the case of positive surgical margins, or those that are at high risk for recurrence.

Although surgical excision has long been considered the gold standard for treatment, patients may not be ideal surgical candidates due to age, comorbidities, or inferior functional or cosmetic outcomes, especially in sites such as the lip, eye, and nose. As such, other treatment modalities may be considered in such circumstances, including radiotherapy. Indications for radiotherapy include tumors in anatomical sites where surgical excisions might have a poor cosmetic outcome, adjuvant treatment in the case of positive surgical margins, or those that are at high risk for recurrence. With the emergence of precise surgical methods like Mohs micrographic surgery, which allows for the removal of tumors while preserving surrounding tissue, the utilization of radiation therapy for NMSCs has diminished.[2]  In the United States, the primary method of radiation treatment for skin cancer is through teletherapy, also known as external beam radiation. This technique involves directing a beam of radiation, typically composed of photons or electrons, from an external source toward the targeted lesion. Teletherapy has undergone significant improvements and adaptations over time, becoming a versatile technology capable of effectively treating numerous types of skin cancers. Advancements in teletherapy led to a decline in the popularity of another radiation therapy approach, brachytherapy, nearly 2 decades ago. However, there has been a resurgence of interest in brachytherapy, particularly in Europe and, to some extent, in the United States.[2] Brachytherapy is a treatment delivery technique in which radioactive sources are placed directly within or next to the tumor, delivering a targeted dose of radiation while minimizing exposure to surrounding healthy tissue. This treatment modality allows for precise delivery of radiation to the cancerous tissue while minimizing exposure to surrounding healthy tissue. Brachytherapy can be used to treat various types of cancer, including prostate, cervical, breast, and head and neck cancers, but its use for skin cancer is gradually increasing worldwide. Technically, in modern brachytherapy, radioactive sources can be positioned in various ways: within a body cavity (intracavity), across a tissue boundary into a confined space (transluminal), within body tissues (interstitial), or on the body surface (surface-mold technique).

Brachytherapy is generally considered a safe and effective treatment for skin cancer, but like any medical procedure, it can carry certain risks and complications. Complications of brachytherapy can be categorized as either acute or late toxicity. Dermatitis is a common complication in patients undergoing brachytherapy, particularly in the head and neck. Most commonly, these were reported as being either grade 1 or grade 2.[14] The occurrence of grade 3 dermatitis or ulceration represents the second most commonly reported skin toxicity, affecting as many as 50% of patients undergoing brachytherapy in the head, neck, and facial regions.[15][16][17] Changes in skin pigmentation are often cited as the most prevalent late toxicity, with occurrences of grade 1 to 2 hypopigmentation ranging from 5% to 100%. Telangiectasia ranks as the second most frequently reported late toxicity, with its occurrence varying between 5% and 31.4%.[13][15][18][19][20]

Overall, brachytherapy offers a valuable treatment option for skin cancer, providing excellent tumor control while preserving cosmesis and minimizing adverse effects. However, treatment decisions should be made in consultation with an interprofessional team of oncologists and surgeons to determine the most appropriate approach for each case. Enhancing patient-centered care, outcomes, safety, and team performance in brachytherapy requires a collaborative effort among various healthcare professionals, including physicians, advanced practitioners, nurses, pharmacists, and others. Physicians and advanced practitioners need expertise in treatment planning, radiation dosimetry, and patient assessment. Nurses require proficiency in patient education, symptom management, and monitoring for treatment-related adverse effects. Developing a comprehensive treatment strategy is essential for successful brachytherapy. This involves interprofessional collaboration to tailor the treatment plan to the individual patient's needs, considering factors such as tumor characteristics, patient comorbidities, and treatment goals. Regular team meetings and case conferences can facilitate strategic planning and ensure alignment among team members. Ethical considerations in brachytherapy include informed consent, patient autonomy, and respect for patient confidentiality. Healthcare professionals must uphold ethical principles in all aspects of care delivery, ensuring that patients are fully informed about the risks, benefits, and alternatives to brachytherapy. Ethical dilemmas, such as balancing treatment efficacy with potential adverse effects, should be addressed through open communication and shared decision-making. Coordinating care across various healthcare settings and disciplines is critical in brachytherapy. This involves seamless transitions between outpatient clinics, radiation oncology departments, and other healthcare facilities. Care coordination ensures continuity of care, minimizes treatment delays, and optimizes patient outcomes. As a result, dermatologists must work closely with oncologists and radiation oncologists to provide effective, safe brachytherapy for patients with NMSC who are amenable to this treatment modality.