At a Glance - Epidermoid cyst vs nodular BCC

Contributed by Dr Nigel Stollery, GP, Kibworth, Leicestershire and clinical assistant in dermatology at the Leicester Royal Infirmary.

Epidermoid cyst 







  • Slow growing nodules with normal skin overlying.
  • Punctum may be visible on closer inspection.
  • May increase or decrease in size.
  • Sebum can often be expressed if the nodule is squeezed which has a distinctive cheesy smell.
  • Not usually painful unless they become infected.


  • Cyst with a wall of keratinised squamous epithelium with abundant keratin lamellae.
  • Leakage from the cyst is common, often giving rise to a localised foreign body reaction.


  • Diagnosis can usually be made from the history and examination, especially if contents can be expressed.
  • If in doubt, excise and send for histology.


  • Smaller cysts may be left.
  • If required, they can be excised under local anaesthesia.
  • Patients need to be advised that recurrence may occur.
  • No malignant potential.

Nodular basal cell carcinoma







  • Slow growing lesion, more common on sun-exposed areas.
  • Roll edge may be apparent, with central ulceration.
  • Surface telangiectasia usually present, especially when viewed with a dermoscope.
  • Not initially painful or inflamed.
  • No discharge unless the centre ulcerates.
  • Low grade malignant tumour arising from the deep basal cell layer of the epidermis.


  • Incisional biopsy will confirm the diagnosis.


  • NICE guidance advises treatment in secondary care except for small BCCs in low-risk areas on the body.
  • Excision with a 5mm margin is the usual treatment of choice.
  • In cases of very large lesions radiotherapy is an option.
  • Photodynamic therapy may be appropriate and avoids the need for surgery.

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