The appearance of BCCs can be subtle. It is recommended that you ask patients the following questions: “Do you have anything new on your skin? Do you have any new lumps or bumps? Do you have anything that bleeds?” Patients often know their own bodies very well, and with a subtle BCC, you may need the patient’s help to flag the area (Figure 5).
Figure 5. Subtle basal cell carcinomas, such as this, may require help from the patient to flag the area.
BCC is typically diagnosed by shave biopsy, and most BCCs are treated surgically. It is within the standard of care to treat BCCs with electrodessication and curettage, excision, Mohs surgery, or in some instances, topical prescription chemotherapy. The definitive surgical treatment of BCCs can leave significant scars that may interfere with the functioning of adjacent structures. BCCs frequently develop on the face, where scarring can have a substantially negative impact. The surgical removal of lesions near the eyes and lips can create functional problems; for example, downward pulling on an eyelid can result in chronic ectropion (Figure 6). Long-term ectropion can lead to dry eye, corneal problems, and blindness.
Figure 6. Basal cell carcinomas near the eyes and lips that are surgically removed can result in functional issues.
The best way to minimize the potential for the negative side effects of BCC treatment is to detect BCCs early. The treatment of choice may be Mohs surgery if a BCC develops in a cosmetically sensitive area or an area where repair could cause anatomic malfunction, is aggressive, occurs in a patient with immune suppression, is in an area where the recurrence rate is known to be high, or is recurrent. Mohs surgery involves the stepwise surgical removal of a lesion together with the performance of in-office histology during the procedure before closure. After each section of skin is removed, it is fixed and analyzed to detect remaining tumor and check for clear margins. This process allows the clinician to be sure that the margins are clear but no more tissue is taken than necessary. The repair is then done on site, typically on the same or next day.
Squamous cell carcinoma
Squamous cell carcinoma (SCC) is more aggressive than BCC, with a much higher rate of metastasis. SCC can present clinically in many different ways. It can appear as a shallow ulcer with built-up edges covered by a plaque or scab (Figure 7), as a cutaneous horn (Figure 8), or as a scaly, erythematous plaque that is unresponsive to topical steroids. Because the incidence of SCC is highest in fair-skinned individuals with sun exposure, the areas where SCC occurs most often in white patients are the head and neck, dorsal surfaces of the hands and forearms, and the legs.8,9 SCC on the ears or preauricular surfaces or at mucocutaneous interfaces (ie, the lips, genitalia, and perianal area) can be more aggressive, with rates of metastasis of up to 30% in some studies.10-12 SCC that occurs in a genital or perianal area is most likely associated with exposure to human papillomavirus.13 Patients with a history of organ transplant and subsequent immunosuppressive medication are at increased risk for the development of multiple SCCs.
Figure 7. Squamous cell carcinoma can present as a shallow ulcer with built-up edges covered by a plaque or scab.
A shave or punch biopsy can be performed to diagnose SCC. Treatment depends on the level of risk, location of the lesion, cosmesis, and patient comorbidities. Surgery—either excision, Mohs surgery, or electrodessication and curettage—is the gold standard treatment for most SCCs. For high-risk cases of SCC, surgical excision or Mohs surgery is preferred. In one study, in which 260 patients with high-risk SCCs underwent Mohs surgery, the recurrence rate after almost 4 years was only 1%.14 Radiation therapy can be used when the concern for metastasis or recurrence is high or complete surgical treatment is not possible. Once metastasis has developed, a multidisciplinary team can determine the potential benefits of chemotherapy and radiation, and if any surgical resection is possible.
Figure 8. Squamous cell carcinoma can clinically present as a cutaneous horn, seen here.