Slow-growing pink, pearly nasal papule

Occurring with an estimated frequency of 0.3%-1% in the general population, basal cell carcinoma (BCC) — a non-melanoma skin cancer — is the most common malignancy in the United States and in countries with a fair-skinned population. Incidence increases greatly...

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Occurring with an estimated frequency of 0.3%-1% in the general population, basal cell carcinoma (BCC) — a non-melanoma skin cancer — is the most common malignancy in the United States and in countries with a fair-skinned population. Incidence increases greatly with advancing age, particularly after the fifth decade of life.Although it is most commonly found on sun-exposed areas — including the scalp, face, ears, upper chest, back, and legs — BCC may appear anywhere on the body. Both sexes are equally affected, but incidence on the anterior shins is greater in women, and incidence on the bald scalp is greater in men.

The greatest risk factor for BCC appears to be intermittent intense sun exposure in childhood, particularly with a history of blistering sunburns. In addition, lighter-skin complexion, radiation therapy, a family history of BCC¹ and immunosuppresion are all known contributing conditions. The role of smoking² and trauma with subsequent scar formation is debated.

Because BCCs are generally slow-growing, they are usually detected when still localized and amenable to surgical removal. Left untreated, however, they tend to grow locally, and at times aggressively, leading to considerable disfigurement. Very rarely, BCC may metastasize to regional lymph nodes or elsewhere; once this occurs, the prognosis is poor.

Although several variants exist, the classic presentation is that of the nodular BCC that presents as a shiny waxed semi-translucent nodule with spreading telangiectases and a characteristic rolled border. Crusting, bleeding and ulceration may occur. The pigmented variant is frequently mistaken for a melanocytic lesion, but the shiny pearliness and absence of pigment network can differentiate it.

The morpheaform BCC, often mistaken for a scar, appears as a white sclerotic plaque. Superficial BCC, appearing mostly on the trunk and extremities, may resemble an eczematous or psoriasiform pink, scaly plaque. Infiltrative BCCs are poorly circumscribed, have an irregular spiky appearance at the edges, and tend to penetrate deeper. The term “rodent ulcer” refers to an ulcerating BCC that is likely the result of longstanding neglect. Finally, fibroepithelioma of Pinkus is a variant of BCC that appears as a flesh-colored sessile papule on the lower trunk and resembles a neuroma.

BCCs originate from the basal cells, which reside in the lower level of the epidermis. Ultraviolet radiation is believed to induce mutation in the cells’ DNA, promoting the growth of carcinogens. Genetic inheritance may also be a factor.

Shave biopsy is usually sufficient to correctly diagnose a BCC. Further imaging is reserved for select cases in which deep invasion is suspected.

Histologically, BCC presents distinctively based on subtype, although most growths exhibit cohesive nests or islands of basaloid tumor cells and palisading of nuclei at the periphery of cell nests. There may be variable inflammatory infiltrate and ulceration. Immunohistochemical stains may be used to highlight the tumor cells.

Several acceptable treatment modalities exist, and the ultimate goal is complete cure with maximal function and cosmetic outcome. Factors that must be considered to determine the most appropriate treatment include patient age, location and size of the tumor, and clinical and histopathologic subtype.

Standard treatment options include Mohs micrographic surgery, excisional surgery and electrodesiccation and curettage (ED&C). The most recent National Comprehensive Cancer Network guidelines recommend ED&C for BCC in a non-hair-bearing area in a young, low-risk patient or excision with confirmation of negative margins.³ Higher-risk patients should undergo Mohs micrographic surgery, a staged removal of the tumor, which has the lowest recurrence rate. Micronodular, infiltrative, and morpheaform BCCs have the highest incidence of positive tumor margins after excision — as well as the highest recurrence rates — and these should be treated with Mohs surgery.

Alternate treatment options include topical chemotherapeutic and immune-modulating agents, radiation, and photodynamic therapy, among others. Topical therapy is generally reserved for superficial BCC only. Although imiquimod 5% cream (Aldara) is FDA-approved for use five times a week for six to eight weeks, many studies conclude that more frequent use may be more effective.⁴

Similarly, 5-fluorouracil (Efudex) interferes with DNA synthesis and cell proliferation. Radiation therapy is generally reserved for individuals who cannot undergo surgical procedures or for use in cases of recurrence. Photodynamic therapy appears to be somewhat effective for areas of extensive and diffuse BCC,⁵ but its use for this purpose is not FDA-approved. Interferon-alfa and topical tazarotene (Tazorac) are considered experimental treatments.

All patients should be warned regarding the dangers of sun and artificial ultraviolet radiation exposure. In addition, 30%-50% of patients with a history of BCC will develop another nonmelanoma skin cancer within the subsequent five years.³ Clinical yearly skin examinations and monthly self-examinations will aid in the early detection of any new or recurrent tumors.

This patient was treated with Mohs micrographic surgery, and the tumor was completely excised in two stages. The defect was closed with a full-thickness skin graft, providing excellent cosmetic results.

Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. The author has no relationships to disclose relating to the content of this article.

References

1. Corona R, Dogliotti E, D’Errico M, et al. “Risk factors for basal cell carcinoma in a Mediterranean population: role of recreational sun exposure early in life.” Arch Dermatol. 2001;137:1162-1168.

2. Boyd AS, Shyr Y, King LE Jr. “Basal cell carcinoma in young women: an evaluation of the association of tanning bed use and smoking.” J Am Acad Dermatol. 2002;46:706-709.

3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Basal cell and squamous cell carcinoma.

4. Geisse JK, Rich P, Pandya A et al. Imiquimod 5% cream for the treatment of superficial basal cell carcinoma: A double-blind, randomized, vehicle-controlled study. J Am Acad Dermatol. 2002;47:390-398.

5. Oseroff AR, Shieh S, Frawley NP et al. “Treatment of diffuse basal cell carcinomas and basaloid follicular hamartomas in nevoid basal cell carcinoma syndrome by wide-area 5-aminolevulinic acid photodynamic therapy.” Arch Dermatol. 2005;141:60-67.

All electronic documents accessed January 9, 2011.