DESCRIPTION
Most common cutaneous malignancy. Locally invasive, slow-growing, rarely metastasizes (unless patient is immunocompromised). Neither life-threatening nor trivial.

HISTORY

• More common after age 40.
• Highest incidence in the fair-skinned.
• Cumulative sun exposure is primary risk factor. Occur mostly on sun-exposed skin of face, scalp, ears, neck
• Clinical variants include nodular, pigmented, superficial, sclerotic basal cell carcinoma (BCC).

PHYSICAL FINDINGS

1. Nodular BCC. Most common variant. A pearly white, almost translucent, dome-shaped papule with overlying telangiectasias. Papule or nodule enlarges slowly, may become flattened in center or may develop a raised, rolled, translucent border. Frequently ulcerates, bleeds, becomes crusted in center.
2. Pigmented BCC. Contains melanin, may therefore resemble melanoma.
3. Superficial BCC. Least aggressive form. More commonly on trunk, extremities. Circumscribed, round to oval, red, scaling plaque resembles eczema, psoriasis, extramammary Paget disease, or Bowen disease.
4. Sclerosing BCC. Most subtle and least common variant. Smooth, pale white to yellow papules. Resembles scar tissue. Borders may be difficult to discern.

TREATMENT
Without treatment, BCCs persist, enlarge, ulcerate, invade, destroy surrounding structures. Treatment determined by size and location of tumor, tumor variant, patient's concerns. Clinical aggressiveness correlates with histologic pattern.

• Electrosurgery involves electrodesiccation and curettage of obvious tumor. The 5-year cure rates approach 92%.
• Primary excision preferred for well-defined nodular, sclerotic, and recurrent BCC. The 5-year cure rates approach 90%.
• Mohs micrographic surgery is a highly specialized, tissue-sparing method of excision used for difficult tumors with contiguous growth, especially BCCs. Mohs micrographic surgery is used for recurrent BCC, histologically aggressive forms of BCC, and tumors in anatomically important locations such as around eyes, nasal ala, mouth, and ears. Also used for tumors with high risk of recurrence. Treatment of choice for sclerotic and recurrent BCC. The 5-year cure rates approach 99%. Non-surgical options are increasing. These include radiation therapy, photodynamic therapy, and topical immune modulators.
• Radiation therapy may be useful for difficult to treat tumors, such as on eyelids, and for patients unwilling or unable to tolerate surgery. The 5-year cure rates are roughly 90%.
• Photodynamic therapy is an evolving chemotherapeutic modality for superficial BCC that is not widely available today but may be useful in the future.
• Topical imiquimod 5% cream is an immune response modifier shown to be about 85% effective or better for superficial BCC.