A man with a pigmented growth on his chest
Differential diagnosis for pigmented BCC
- Malignant melanoma
- Melanocytic nevus
- Spitz nevus
- Pigmented seborrheic keratosis
- Pigmented dermatofibroma
- Squamous cell carcinoma
- Pigmented Bowen’s disease (squamous cell carcinoma in situ)
- Keratoacanthoma
- Trichoepithelioma
- Sebaceous hyperplasia
- Fibrous papule of the nose
Treatment: Local destruction, photodynamic therapy, immune modulators
Treatment options available for BCC depend on characteristics of the tumor type, location, individual patient, and economic resources.
Cryosurgery, electrodessication and curettage, CO2 laser destruction, surgical excision, Mohs micrographic surgery, radiation therapy, topical therapy such as 5-fluorouracil (5-FU) and imiquimod (Aldara), intralesional interferon, and photodynamic therapy are used to treat BCC.
Older treatments for low-risk BCCs in cosmetically less significant areas
Cryosurgery induces cytotoxicity by production of extracellular and intracellular ice crystals. It is rapid and cost-effective, and demonstrates high cure rates.
Electrosurgery can be used for superficial and nodular BCC on the trunk and extremities.
Surgical excision is an effective method for BCCs located on low-risk areas without aggressive histologic features.
Radiation therapy is an option for the treatment of both primary and recurrent BCCs.
Topical chemotherapeutic agent 5-fluorouracil (Efudex, Carac, Fluoroplex) is also effective against BCC.
Interferon (interferon alpha 2b) has also been used as intralesional injections to treat superficial and nodular BCCs.
Treatment for high-risk tumors
Mohs micrographic surgery is currently the standard of treatment for high-risk BCCs and BCCs located in cosmetically sensitive locations such as the nasolabial fold and periorbital areas. It has a higher cure rate than other modalities.
Relatively new methods
Imiquimod is used for primary superficial BCC (not on head or neck) in adults with normal immune systems. It is used for tumors 2 cm or smaller in diameter on certain areas of the body. Imiquimod treatment is indicated only when surgical methods are not appropriate.7
Photodynamic therapy includes the use of various intravenous and topical photosensitizers—ie, intravenous verteporfin, topical 5-aminolevulinic acid (ALA), topical methyl aminolevulinate (mALA)—combined with different sources of visible light. Photodynamic therapy is being used for some BCCs but is not recommended for pigmented BCC.8
Given the ill-defined nature of this lesion, and its size, we recommended surgical excision using either regular excision with staining or marking of margins, or Mohs micrographic surgery. Unfortunately, the patient was lost to follow-up.
Acknowledgments
The author wants to thank Dr. Shahbaz A. Janjua with his assistance in the preparation of this manuscript.
CORRESPONDING AUTHOR
Amor Khachemoune, MD, CWS, SUNY Downstate Medical Center, Department of Dermatology Box 46, 450 Clarkson Ave, Brooklyn, NY 11203. E-mail: amorkh@pol.net
