Pictorial case study - Basal cell carcinoma

Dr Jean Watkins discusses the presentation and treatment of this common skin cancer.

Presentation

A 72-year-old man presented with a slightly raised, scaly lesion with telangiectasia, on the tip of his nose. He was otherwise fit and healthy, and having enjoyed an outdoor life on a farm was now spending a lot of his time tending his garden. On examination, a raised border was elicited, suggesting extensive basal cell carcinoma (BCC).

Discussion

The head and neck are the most common sites for BCC. Sun exposure or sunbeds and radiation are related to its development, especially in those with fair hair, blue eyes and fair skin that burns easily. The nose is particularly vulnerable and a recent study found that 40% of BCC on the head and neck were adjacent to the nose.1

Although BCC rarely spreads to other parts of the body, early recognition is still important, as larger lesions may be more difficult to treat and there is a risk of local spread. Any skin lesion that fails to heal, oozes, crusts, or bleeds easily, especially if associated with telangiectasia, or a depressed area that resembles a scar, should arouse suspicion.

Management

All vulnerable areas that may have sun damage should be checked to exclude other lesions. Referral to a dermatologist or dermatological surgeon should be made. If the diagnosis is in doubt, a biopsy may be required. Excision of the lesion, with histology of the tissue to confirm the diagnosis and complete removal, is the best treatment. However, the decision on treatment depends on the site, size and depth of the lesion, as well as the patient's health and acceptance of this approach.

A superficial BCC may respond to topical 5-fluorouracil and in some cases, curettage and cautery, cryotherapy or phototherapy may suffice. Mohs surgery is sometimes used for difficult sites. Where none of these is possible or acceptable, radiotherapy may be offered.

Patients should be advised of the risk of recurrence and should check their skin regularly. They should avoid exposure to sunlight between 10am and 4pm, and protect their skin with clothing, a broad-brimmed hat, and a topical sunscreen of at least SPF 30.

Differential Diagnoses

  • Actinic keratosis
  • Molluscum contagiosum
  • Bowen's disease
  • Melanocytic naevus
  • Squamous cell carcinoma
  • Psoriasis
  • Malignant melanoma
  • Sebaceous hyperplasia
  • Fibrous papule of the face

Dr Watkins is a retired GP in Hampshire

Reference

1. Levy R, Hanke W. The nose: a high-risk area for cancer. www.skincancer.org/skin-cancer-information/ basal-cell-carcinoma/the-nose.

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