Basal cell carcinoma is the most common form of cancer worldwide In the United States it accounts for approximately 80 percent of all skin cancers The majority of basal cell carcinomas are successfully treated with current therapies ETIOLOGY PATHOGENESIS The first sign of basal cell carcinoma is an unusual growth on skin may be a waxy lump or a small smooth shiny or pale growth or a flat spot that looks slightly different from normal skin Some basal cell carcinomas develop so slowly that you only notice them after they ve been there for a while Rarely painful may bleed and then heal Rarely spreads to other parts of body but often on face which may cause cosmetic and or functional damage PERTINENT HISTORICAL FINDINGS CLINICAL SYMPTOMS Clinicopathologic types of BCC each of which has a distinct biologic behavior include the following Nodular Cystic pigmented or keratotic is the most common type of BCC usually presents as a round pearly flesh colored papule with telangiectases Infiltrative Tumor infiltrates the dermis in thin strands between collagen fibers making tumor margins less clinically apparent Micronodular

Not prone to ulceration may appear yellow white when stretched is firm to the touch and may have a seemingly well defined border Morpheaform Appears as a white or yellow waxy sclerotic plaque that rarely ulcerates usually flat or slightly depressed fibrotic and firm Superficial Seen mostly on the upper trunk or shoulders usually erythematous well circumscribed patch or plaque often with a whitish scale PERTINENT PHYSICAL EXAM FINDINGS Approximately 85 of BCCs occur on the face head scalp included and neck others appear on the trunk or extremities rarely they may occur on the hands Other characteristic features of BCC tumors include the following Waxy papules with central depression Pearly appearance Erosion or ulceration Bleeding especially when traumatized Oozing or crusted areas in large BCCs Raised border Translucency Telangiectases over the surface Slow growing 0 5 cm in 1 2 years Black blue or brown areas Periocular tumors most commonly involve the following Lower eyelid 48 72 Medial canthus 25 30 Upper eyelid 15 Lateral canthus 5 DIFFERENTIAL DIAGNOSIS Actinic Keratosis Malignant Melanoma Melanocytic Nevi Molluscum Contagiosum Psoriasis Sebaceous Hyperplasia Squamous Cell Carcinoma DIAGNOSTIC EVALUATIONS Clinical Skin biopsy

MEDICAL MANAGEMENT Cryotherapy is a nonsurgical treatment for basal cell carcinoma Liquid nitrogen is applied to skin and frozen skin sloughs off as skin underneath heals Curettage and Electrodessication Cancerous tissue scraped away with a curette 

The wound usually heals within a few weeks Radiation therapy usually done over 3 4 weeks a treatment that involves x rays or high energy particles can be useful for tumors in areas that are hard to treat surgically or for patients who are at a higher risk of having complications from surgery Radiation is also sometimes used after surgery to destroy any cancerous cells that remain or to treat tumors with a higher risk of recurrence Topical Chemotherapy fluorouracil lotion applied at home for 3 6 weeks or imiquimod lotion that causes immune cells to attack abnormal tissue Reconstruction Surgery including skin grafts and flaps SURGICAL MANAGEMENT when applicable Laser Surgery tumor is vaporized with a highly focused light beam Laser surgery only kills tumor cells on the surface of the skin and doesn t go deeper so its use is limited and close follow up is essential Mohs Surgery for tumors with high risk of recurrence In this procedure the surgeon removes the tumor tissue layer by layer mapping and freezing each layer Each layer is examined under a microscope for tumor cells before proceeding to the next This is a precise complex and time consuming process but Mohs surgery makes sure that the whole tumor is removed It also limits the amount of scarring by keeping as much normal skin as possible 

Mohs surgery has the highest cure rate of all therapies and is especially effective for high risk basal cell carcinomas such as large tumors tumors that have recurred after other treatments and tumors in areas such as the face Standard surgical excision or removal removes the tumor from skin A portion of tissue around the tumor a safety margin is also taken off to make sure that all the cancer cells have been removed The wound is then closed with sutures stitches Surgery is most effective for tumors with well defined borders One advantage to this procedure is that the tissue can be sent to a laboratory so a pathologist can verify if the whole tumor has been removed EMERGENCY MANAGEMENT when applicable Not applicable PATIENT EDUCATION MAINTENANCE AND PREVENTION The best way to prevent skin cancer is to avoid excessive exposure to the sun Skin cancer prevention includes staying in the shade avoiding the midday sun wearing protective hats and clothing using broad spectrum sunscreens with a minimum of 30 sun protection factor SPF not using tanning beds Broad spectrum sunscreens protect against both kinds of the sun's ultraviolet UV radiation UVA and UVB rays Apply two thin coats and reapply every 2 hours It's also important to use sunscreen on cloudy days The UVA and UVB rays can pass through the clouds and damage your skin

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