Makindo Medical Notes.com

Related Subjects: |Nikolsky's sign |Koebner phenomenon |Erythema Multiforme |Pyoderma gangrenosum |Erythema Nodosum |Dermatitis Herpetiformis |Lichen Planus |Acanthosis Nigricans |Acne Rosacea |Acne Vulgaris |Alopecia |Vitiligo |Urticaria |Basal Cell Carcinoma |Malignant Melanoma |Squamous Cell Carcinoma |Mycosis Fungoides (Sezary Syndrome) |Xeroderma pigmentosum |Bullous Pemphigoid |Pemphigus Vulgaris |Seborrheic Dermatitis |Pityriasis/Tinea versicolor infections |Pityriasis rosea |Scabies |Dermatomyositis |Toxic Epidermal Necrolysis |Stevens-Johnson Syndrome |Atopic Eczema/Atopic Dermatitis |Psoriasis

About

• Slow growing tumour of the epidermal basal keratinocytes with 95% cure rate
• Metastases rare - local spread.
• Although it is a type of skin cancer it is almost never a danger to life.
• Commonest skin cancer in the UK forms a "rodent ulcer"

Pathology

• Basal cell carcinoma is the commonest skin malignancy
• Arises from basal keratinocytes of the epidermis and adnexal structures
• Gene defects on the sonic hedgehog signalling pathway are seen
• Lack of metastases may be related to "stromal dependency"
• Tumour cells existence depends on a specialised tumour stroma

Aetiology

• Relationship with ultraviolet (UV) radiation from the sun or from sunbeds.
• There are defects in the P53 tumour suppressor genes in about half
• Seen in those with an inability to tan
• Commonest in those over 40
• Not familial other than with Gorlin's syndrome,

Risks

• UV exposure from the sun or from sunbeds.
• Affects areas that are exposed to the sun: face, head, neck and ears.
• Exposure to the sun, outdoor hobbies or outdoor workers, sunny climates.
• People who have used sunbeds or have regularly sunbathed.
• Fair complexion with pale skin who burn easily and rarely tan
• Radiation exposure, Arsenic, Immunosuppression, Xeroderma pigmentosum

Clinical

• Face, head, neck, inner canthus, behind the ear - scab that bleeds and does not heal completely or a new lump on the skin. Some are superficial and look like a scaly red flat mark on the skin. Others form a lump and have a pearl-like rim surrounding a central crater and there may be small red blood vessels present across the surface. If left untreated, BCCs can eventually cause an ulcer; hence the name "rodent ulcer". Most BCCs are painless, although sometimes they can be itchy or bleed if caught.
• BCC advances by direct extension and destroys normal tissue. Very rarely spread to local lymph nodes. Tend to grow slowly and locally.

Clinical subtypes

• Nodular - pearly type edges, Ulcerative, Cystic
• Pigmented - resembles melanoma
• Morpheic - pale plaques scar like
• Superficial lesions

Investigations

• Skin biopsy with complete removal is the modality of choice.

Management

• Main treatment: Surgery with wide local excision using LA. Skin grafting may be needed.
• Mohs micrographic surgery: around nose, eyes, ears. The procedure involves excision of the affected skin and examination of the skin removed under the microscope straight away to see if all of the BCC has been removed. If any residual BCC is left at the edge of the excision further skin is excised from that area and examined under the microscope and this process is continued until all of the BCC is removed. Used to treat more complex BCCs such as those present at difficult anatomical sites or recurrent BCCs. The site is then often closed with a skin graft. This is a time-consuming process and is only undertaken when simple surgery may not be suitable.
• Superficial BCC: Curettage and cautery - the skin is numbed with local anaesthetic and the BCC has scraped away (curettage) and then the skin surface is sealed by heat (cautery). Cryotherapy - freezing the BCC with liquid nitrogen. Creams - these can be applied to the skin. The two most commonly used are 5-fluorouracil (5-FU) and imiquimod.
• Photodynamic therapy - a special cream is applied to the BCC which is taken up by the cells that are then destroyed by exposure to a specific wavelength of light. This treatment is only available in certain dermatology departments
• Local radiotherapy / cryotherapy
• Vismodegib: this is a type of chaemotherapy that has recently become available for the treatment of very complex BCCs, e.g. locally advanced BCCs or the very rare BCC that has spread to other parts of the body.
• Intralesional interferon
• Check your skin for changes once a month. A friend or family member can help you particularly with checking areas that you cannot easily inspect, such as your back.
• When choosing a sunscreen look for a high protection SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying. Keep babies and young children out of direct sunlight.