History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors include ultraviolet (UV) radiation, sun exposure, x-ray exposure, arsenic exposure, xeroderma pigmentosum, nevoid basal cell carcinoma (Gorlin-Goltz syndrome), transplantation history.

papules with associated telangiectasias

Characteristic of basal cell carcinoma.[3][4][Figure caption and citation for the preceding image starts]: Nodular basal cell carcinoma on the cheek, on background of diffuse solar damage with marked solar elastosisFrom the collection of Prof. Robert A. Schwartz [Citation ends].com.bmj.content.model.Caption@7064e5da

plaques, nodules, and tumours with rolled borders

Characteristic of basal cell carcinoma.[3][4]

small crusts and non-healing wounds

Characteristic of basal cell carcinoma.[3][4]

non-healing scabs

Characteristic of basal cell carcinoma.[3][4]

pearly papules and/or plaques

Characteristic of basal cell carcinoma.[3][4]

Other diagnostic factors

uncommon

metastases associated with large or neglected BCC

Metastases are uncommon, but may occur in the lungs and bones, typically in association with a large long-standing neglected basal cell carcinoma (BCC).[11]

local destruction with advanced lesion

Several centimetres in diameter and deeply eroding into the surrounding tissue.

Risk factors

strong

Ultraviolet (UV) radiation

UV radiation induces DNA damage in keratinocytes. Damage to p53, a pro-apoptotic molecule, leads to resistance of the DNA-damaged cell to apoptosis.

It is believed that 290-320 nanometre wavelength UV-B (commonly referred to as sunburn wavelength) plays a greater role in the formation of basal cell carcinoma than 320-400 nanometre wavelength (so-called tanning wavelength) UV-A radiation.[18]

sun exposure

The aetiology of basal cell carcinoma is related to repetitive and frequent sun exposure.[1][2]

Ask about living in sunny or tropical countries, frequent sunny holidays, outdoor work and hobbies, and sunbed use.

x-ray exposure

Although no longer commonly encountered, there is a well-known association of x-ray surface therapy (in the past most commonly for acne) and basal cell carcinoma.[24] The same is true for other radiotherapy survivors.[25]

arsenic exposure

Arsenic exposure is a well-known factor in the pathogenesis of basal cell carcinoma.[26] It is most commonly found in contaminated well water.[27] Exposure may be cryptic.[28]

aberrant hedgehog signalling pathway

Sporadic basal cell carcinomas (BCCs) have key genetic defects in the hedgehog signalling pathway, including loss of function mutations in PTCH1 in 90% of BCC tumours and mutations in the G‐protein coupled receptor smoothened (SMO) in up to 20% of BCC.[29][30]

xeroderma pigmentosum

An inborn error of DNA-repair mechanisms that predisposes patients to develop early skin ageing, innumerable basal cell carcinomas, squamous cell carcinomas, and melanoma.[31]

nevoid basal cell carcinoma (Gorlin-Goltz) syndrome

An uncommon autosomal dominant condition caused by a mutation of PTCH1.[32] It may first be evident with a broad face, rib deformities, and possibly central nervous system abnormalities. It may also present with palmoplantar pits and odontogenic keratocysts. Other clinical manifestations include osteosarcoma, medulloblastoma, and ovarian fibroma.[33]

Although it was believed that initially patients presented with nevi (hamartomas) of the skin, it is evident that these are trichoepitheliomas or trichoblastomas that progress into infundibulocystic and other types of basal cell carcinoma.[34][35][36][37][38]

history of non-melanona skin cancer

A history of basal cell carcinoma (BCC) or squamous cell carcinoma is the most common predisposing factor for the development of BCC.[6]

childhood cancer survivors

One retrospective cohort study reported that the risk for basal cell carcinoma (BCC) in childhood survivors who received radiotherapy is 30 times greater than expected in the general population; multiple BCCs occurred in 47% of BCC patients, with 13% having 10 or more BCCs.[39]

The greatest risks for BCCs were observed when radiotherapy was combined with chemotherapy, when radiotherapy occurred in patients younger than 5 years, and in the areas receiving radiation, mostly in the head and neck.[39]

transplant recipient

Patients with transplantation history (particularly solid organ) may present with new-onset skin lesions that itch or ulcerate. Most often, the biopsied lesions are squamous cell carcinoma, but there is increase in incidence of basal cell carcinoma.[6][40]

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