From the Guidelines
Basal cell carcinoma (BCC) in primary care requires prompt recognition and appropriate management, with primary care providers maintaining a high index of suspicion for BCC when patients present with slow-growing, pearly or translucent papules or nodules, often with telangiectasias, rolled borders, or central ulceration, particularly on sun-exposed areas 1.
Key Considerations
- Initial management involves a thorough skin examination and biopsy of suspicious lesions.
- Definitive treatment typically requires referral to dermatology or surgery, with primary care providers prioritizing referrals based on lesion characteristics, such as facial lesions, rapidly growing tumors, or those with aggressive histologic features.
- Treatment options include:
- Surgical excision
- Mohs micrographic surgery
- Electrodessication and curettage (C&E)
- Cryotherapy
- Topical therapies (imiquimod 5% cream or 5-fluorouracil)
- Photodynamic therapy
- Radiation therapy
Treatment Selection
- For low-risk primary BCC, surgical excision with 4-mm clinical margins and histologic margin assessment is recommended 1.
- Mohs micrographic surgery is recommended for high-risk BCC.
- C&E may be considered for low-risk tumors in non-terminal hair-bearing locations, but is less effective for lesions on terminal hair-bearing skin and may be associated with a longer healing time and inferior cosmetic outcome compared with standard excision 1.
Follow-up and Prevention
- Patients require regular skin examinations every 6-12 months due to the 30-50% risk of developing additional BCCs within 5 years.
- Prevention counseling should emphasize daily sunscreen use (SPF 30+), protective clothing, avoiding peak sun hours (10am-4pm), and regular self-examination.
- Risk factors include fair skin, significant sun exposure, older age, immunosuppression, arsenic exposure, and genetic syndromes like nevoid basal cell carcinoma syndrome, which should prompt more vigilant surveillance 1.
From the FDA Drug Label
1.2 Superficial Basal Cell Carcinoma Imiquimod Cream is indicated for the topical treatment of biopsy-confirmed, primary superficial basal cell carcinoma (sBCC) in immunocompetent adults, with a maximum tumor diameter of 2.0 cm, located on the trunk (excluding anogenital skin), neck, or extremities (excluding hands and feet), only when surgical methods are medically less appropriate and patient follow-up can be reasonably assured 14.2 Superficial Basal Cell Carcinoma In two double-blind, vehicle-controlled clinical studies, 364 subjects with primary sBCC were treated with imiquimod cream or vehicle cream 5 times per week for 6 weeks. Table 12: Composite Clearance Rates at 12 Weeks Post-Treatment for Superficial Basal Cell Carcinoma Study Imiquimod Cream Vehicle Cream Study sBCC1 70% (66/94) 2% (2/89) Study sBCC2 80% (73/91) 1% (1/90) Total 75% (139/185) 2% (3/179)
Imiquimod cream is indicated for the treatment of primary superficial basal cell carcinoma (sBCC) in immunocompetent adults. The cream should be applied 5 times a week for 6 weeks.
- Key considerations:
- Biopsy-confirmed primary sBCC
- Maximum tumor diameter of 2.0 cm
- Located on the trunk, neck, or extremities (excluding hands and feet)
- Surgical methods are medically less appropriate
- Patient follow-up can be reasonably assured
- Efficacy: 75% composite clearance rate at 12 weeks post-treatment 2
From the Research
Diagnosis and Treatment of Basal Cell Carcinoma
- Basal cell carcinoma (BCC) is the most common skin cancer, and its treatment can be managed through various methods, including surgical excision, Mohs micrographic surgery, cryosurgery, electrodesiccation and curettage, topical application of imiquimod or fluorouracil, photodynamic therapy, or radiation therapy 3.
- The choice of treatment depends on the patient's condition, tumor location, and risk of recurrence, with surgical excision and Mohs surgery being the most commonly used due to their low recurrence rate and ability to confirm residual tumor pathologically 3.
Surgical Treatment
- Surgical margins of 4mm seem to be suitable for small, primary, well-defined basal cell carcinomas, although some good results can be achieved with smaller margins and the use of margin control surgical techniques 4.
- For treatment of high-risk and recurrent tumors, margins of 5-6 mm or margin control of the surgical excision is required, considering factors such as previous treatment, histological subtype, site, and size of the lesion 4.
- The rate of incomplete excisions was higher for facial tumors and among tumors with an aggressive histological subtype, with morpheiform BCC on the nose or ear having the highest rate of incomplete excision 5.
Alternative Treatment Options
- Imiquimod is a topical, noninvasive, nonsurgical therapeutic option for the treatment of BCC, with a clinical cure rate of 80-85% at 12 months 6.
- Photodynamic therapy (PDT), cryotherapy, topical imiquimod, and 5-FU are suitable alternate treatment options for appropriately selected primary low-risk lesions 7.
- Radiotherapy is a suitable alternate for surgical methods for treatment in older patient populations 7.