Natura Dermatology & Cosmetic’s Christine Zullo PA-C, Provides Insight On How A Pimple May Not Be A Pimple At All. It Could Be Skin Cancer.
Clinical Advisor “Slow growing pink pearly nasal papule.”
Case: A 73 year old man presented with a “pimple” for four months that was increasing in size and bled with scratching. He denied a known history of skin cancer, but did admit to history of sun exposure as a child. After examination, the patient was given a diagnosis of basal cell carcinoma.
Basal cell carcinoma (BCC) is the most common skin cancer in the United States. Incidence increases with advancing age and history of sun exposure, and both sexes are equally affected. BCC may appear anywhere on the body, although it is more commonly found on the sun exposed areas of the scalp, face, ears, upper chest, back, and legs.
The greatest risk factor for BCC appears to be intense sun exposure in childhood, particularly with a history of blistering sunburns. In addition, lighter-skin complexion, radiation therapy, a family history of BCC and immunosuppresion are all known contributing conditions.
BCCs are generally slow-growing and are typically detected when the lesion is still localized and it can be surgically removed. BCCs originate from the basal cells, which reside in the lower level of the epidermis where they typically affect. If left untreated they will continue to grow locally and at times aggressively, leading to considerable disfigurement. The term “rodent ulcer” refers to an ulcerating BCC that is likely the result of longstanding neglect. Very rarely do BCCs metastasize to regional lymph nodes or elsewhere, but once this occurs, the prognosis is poor.
BCCs can present in multiple ways. 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. There is also the pigmented BCC which is frequently mistaken for a melanocytic lesion, but has a shiny pearly characteristic and the absence of a pigment network. The morpheaform BCC appears as a white sclerotic plaque and often resembles a scar. 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. Finally, fibroepithelioma of Pinkus is a variant of BCC that appears as a flesh-colored sessile papule on the lower trunk and can be mistaken for a neuroma or a fibroepithelial polyp (skin tag).
A simple shave biopsy is usually sufficient to correctly diagnose a BCC.
There are several acceptable treatment options, but 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). Surigical excision and ED&C are most often treatment of choice in a young, low-risk patient. Higher-risk patients should undergo Mohs micrographic surgery, a staged removal of the tumor to reduce the risk of recurrence. Micronodular, infiltrative, and morpheaform BCCs have the highest incidence of positive tumor margins after excision and the highest recurrence rates, therefore these should be treated with Mohs surgery.
Alternate treatment options include topical chemotherapeutic and immune-modulating agents, radiation, and photodynamic therapy. Topical therapy is generally reserved for superficial BCC only. 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, but is considered “off-label” treatment.
Approximately 30%-50% of patients with a history of BCC will develop another nonmelanoma skin cancer within five years of their most recent diagnosis. That is why clinical yearly skin examinations and monthly self-examinations are strongly encouraged and will aid in early detection of any new or recurrent tumors.
Founded in 2006, Natura Dermatology & Cosmetics is wholly owned by Will Richardson, MD FAAD one of Fort Lauderdale’s premiere skin cancer detection and prevention specialists. We offer skin cancer screenings at both our Fort Lauderdale and Coconut Creek offices. For more information, please contact our office at 954.537.4106 and speak to one of our friendly appointment specialists.