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Key Features

Essentials of Diagnosis

  • Pearly papule, erythematous patch > 6 mm, or nonhealing ulcer, in sun-exposed areas (face, trunk, lower legs)

  • History of bleeding

  • Fair-skinned person with a history of sun exposure (often intense, intermittent)

General Considerations

  • Most common form of cancer

  • Occur on sun-exposed skin in otherwise normal fair-skinned individuals; ultraviolet light is the cause

  • Can be divided into clinical and histologic subtypes, which determine both clinical behavior and treatment

    • Clinical subtypes: superficial, nodular, pigmented, and morpheaform

    • Histologic subtypes: superficial, nodular, micronodular, and infiltrative

  • Morpheaform, micronodular and infiltrative basal cell carcinomas

    • Not amenable to topical therapy or electrodesiccation and curettage

    • Typically require surgical excision or Mohs micrographic surgery

  • Clinicians should examine the whole skin routinely, looking for bumps, patches, and scabbed lesions

Clinical Findings

Symptoms and Signs

  • Most common presentation is a papule or nodule that may have a scab or erosion

  • Occasionally, the nodules have a brown-gray color or have stippled pigment (pigmented basal cell carcinoma)

  • Lesions grow slowly, attaining a size of 1–2 cm or more in diameter, usually only after years of growth

  • There is a waxy, "pearly" appearance, with telangiectatic vessels easily visible

  • Pearly or translucent quality of the lesions is most diagnostic, a feature best appreciated if the skin is stretched

  • On the back and chest and lower legs, basal cell carcinomas appear as reddish, somewhat shiny, scaly plaques

  • Morpheaform basal cell carcinomas are scar-like in appearance

  • When examining the face, look at the eyelid margins and medial canthi, the nose and alar folds, the lips, and then around and behind the ears

Differential Diagnosis

  • Squamous cell carcinoma

  • Actinic keratosis

  • Intradermal nevus

  • Fibrous papule of the nose

  • Seborrheic keratosis (unpigmented type)

  • Sebaceous (epidermal inclusion) cyst

  • Sebaceous hyperplasia

  • Keratoacanthoma

  • Molluscum contagiosum

  • Melanoma

  • Paget disease

Diagnosis

Diagnostic Procedures

  • Lesions suspected to be basal cell carcinomas should be biopsied, by shave or punch biopsy

  • Biopsy confirms the diagnosis

Treatment

Medications

  • Imiquimod (applied topically 5 nights per week for 6–10 weeks depending on host reaction) and 5-fluorouracil (applied topically twice daily for up to 12 weeks)

    • May be appropriate for select patients with superficial basal cell carcinomas

    • However, the treated area must be observed for evidence of complete cure

  • Hedgehog pathway inhibitors (vismodegib, sonidegib) are reserved for the treatment of advanced or metastatic basal cell carcinoma or in patients with extensive tumor burden (eg, basal cell nevus syndrome)

Surgery

  • Therapy is aimed at eradication with minimal cosmetic deformity, often by excision and suturing with recurrence rates of 5% or less

  • The technique of three cycles of curettage and electrodesiccation depends on the skill of the operator and is not recommended for head and ...

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