Core Dermatology Diagnoses / CategoriesNeoplastic Benign and Malignant

Basal cell carcinoma

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Publish date: Posted on
Last updated: February 2, 2022

Keywords #

basal cell carcinoma
keratinocyte carcinoma
non-melanoma skin cancer
sun damage

Diagnosis #

Basal cell carcinoma (BCC) is a malignant tumor arising from the basal layer of the epidermis. The characteristic presentation is a persistent, pink, pearly papule that often bleeds. While BCC has a very low metastatic potential, treatment is indicated because it can cause significant local tissue destruction. The most prevalent risk factor for developing BCC is sun exposure. Ultraviolet-induced (UV) carcinogenesis along both the hedgehog and TP53 pathways is common in the development of BCC.[1] There are rare genetic syndromes in which patients are predisposed to developing multiple BCCs beginning at a young age. These include basal cell nevus syndrome, Bazex syndrome, and xeroderma pigmentosum.

Key Concepts #
  • BCC is the most common type of skin cancer. 
  • BCC commonly presents as a pink, pearly, telangiectatic papule. 
  • BCC is very unlikely to metastasize but is treated because of its potential for local tissue destruction. 
  • UV radiation is the most important risk factor for BCC development. 
  • While mainstay therapy is excision of the lesion, electrodessication and curettage, imiquimod, and cryosurgery are also options for treatment. 
Epidemiology #

BCC is a disease that is predominantly present in Caucasians with a lifetime 30% risk of developing one.[2] In the United States, states closer to the equator and at higher altitude have much higher incidences of BCC than more northern states.[3,4] Men are at a higher risk of developing BCC than women, and the incidence of BCC dramatically increases with age.[5,6] It is estimated that more than 4 million BCCs are diagnosed and treated each year in the US, although this is likely an underestimation as reporting is not mandatory for BCC.

Clinical Features #
  • BCC presents on the face about 70% of the time, consistent with its sun exposure-related pathogenesis.[7]  
  • The most common subtype, nodular BCC, has the characteristic presentation of a pink, pearly, papule with telangiectasias.  
  • Central ulceration and a “rolled” border are also common characteristics.  
  • BCCs that occur on the trunk are commonly superficial BCCs, which can be scaly macules, patches, or plaques that are pink to red in color.  
Differential Diagnoses #
Diagnostic Workup #

BCC is commonly a clinical diagnosis; however, a skin biopsy is performed to better characterize the tumor and aid in guiding the proper therapy. Histopathology reveals atypical basaloid cells with peripheral palisading and tumor clefting.  

Dermoscopy can be very helpful in identifying BCCs as well. Common features seen on dermoscopy include arborizing (branch-like) telangiectasias, leaf-like areas on the periphery of the lesion, and large blue-grey ovoid nests or blotches. 

Treatment #

As with all skin cancers, the best treatment is prevention with UV protective clothing and sunscreen with a sun protection factor (SPF) of at least 30. Mohs surgery is the most effective method of therapy for BCC, but it is typically reserved for tumors on the head and neck, tumors >2 cm on the trunk and extremities, aggressive histologic features (infiltrative, micronodular), or recurrent/incompletely excised tumors. For tumors on the trunk and extremities, a standard surgical excision with 4 mm margins is the mainstay of therapy. For superficial BCCs on the trunk and extremities, electrodessication and curettage is an effective method of treatment.  

Other treatment modalities include topical imiquimod or 5-fluorouracil cream, chemotherapy, radiation therapy, and cryosurgery. 

References #
  1. Epstein EH. Basal cell carcinomas: attack of the hedgehog. Nat Rev Cancer 2008; 8:743.
  2. American Skin Association, www.americanskin.org,  Accessed 10/24/2019 
  3. Chuang TY, Popescu A, Su WP, Chute CG. Basal cell carcinoma. A population-based incidence study in Rochester, Minnesota. J Am Acad Dermatol 1990; 22:413.
  4. Reizner GT, Chuang TY, Elpern DJ, et al. Basal cell carcinoma in Kauai, Hawaii: the highest documented incidence in the United States. J Am Acad Dermatol 1993; 29:184. 
  5. Hannuksela-Svahn A, Pukkala E, Karvonen J. Basal cell skin carcinoma and other nonmelanoma skin cancers in Finland from 1956 through 1995. Arch Dermatol 1999; 135:781. 
  6. Scotto J, Fears TR, Fraumeni JF Jr, et al. Incidence of nonmelanoma skin cancer in the United States in collaboration with Fred Hutchinson Cancer Research Center. NIH publication No. 83-2433, U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Bethesda, MD 1983:xv. P.113 
  7. Wang YJ, Tang TY, Wang JY, et al. Genital basal cell carcinoma, a different pathogenesis from sun-exposed basal cell carcinoma? A case-control study of 30 cases. J Cutan Pathol 2018. 
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