What is the best course of action for a 65-year-old male patient with a non-healing lesion in the cervical area, a past medical history (PMH) of basal cell carcinoma, and evidence of excessive sun exposure?

From the Guidelines

The best course of action for this 65-year-old male patient with a non-healing cervical lesion, history of basal cell carcinoma (BCC), and excessive sun exposure is immediate referral to a dermatologist for evaluation and biopsy of the lesion, as the non-healing nature of the lesion combined with his history of BCC and sun exposure significantly increases the risk that this represents a recurrent or new skin cancer. The patient should be seen within 1-2 weeks given these concerning features. The dermatologist will likely perform a punch or excisional biopsy to determine if the lesion is malignant, as seen in patients with locally advanced BCC, where the objective response rate was 43% with vismodegib, a smoothened (SMO) inhibitor targeted at the hedgehog pathway 1. While awaiting the appointment, the patient should avoid irritating the area, keep it clean with gentle soap and water, and apply petroleum jelly to maintain a moist wound environment. No topical antibiotics or steroids should be applied without medical direction.

Some key points to consider in the management of this patient include:

• The importance of sun protection, as UV exposure increases the risk for skin cancer among people with all skin types, but especially fair-skinned people 1
• The use of sunscreens that block both ultraviolet A (UV-A) and ultraviolet B (UV-B) light, which may be more effective in preventing squamous cell cancer and its precursors than those that block only UV-B light 1
• The need for regular full-body skin examinations, as patients with previous skin cancers have a significantly higher risk of developing subsequent malignancies, with 30% to 50% of these patients developing another BCC within 5 years 1
• The potential benefits of strict sun protection measures, including daily broad-spectrum SPF 50+ sunscreen, wide-brimmed hats, and sun-protective clothing, in reducing the risk of skin cancer.

Given his history, the patient will likely need regular full-body skin examinations every 3-6 months following resolution of the current concern. Additionally, the patient should immediately implement strict sun protection measures to reduce the risk of further skin cancers.

From the FDA Drug Label

INDICATIONS AND USAGE Fluorouracil is recommended for the topical treatment of multiple actinic or solar keratoses. In the 5% strength, it is also useful in the treatment of superficial basal cell carcinomas when conventional methods are impractical, such as with multiple lesions or difficult treatment sites. The best course of action for this patient is to wait for the biopsy results to confirm the diagnosis of the non-healing lesion in the cervical area.

• If the biopsy results confirm a superficial basal cell carcinoma, treatment with 5-fluorouracil (5% strength) may be considered, especially if conventional methods such as surgery are impractical.
• However, if the lesion is isolated and easily accessible, surgery is the preferred treatment option due to its high success rate of almost 100% 2. It is also important to continue monitoring the skin on his back every three months due to the patient's history of excessive sun exposure and basal cell carcinoma.

From the Research

Patient Assessment and Diagnosis

• The patient's non-healing lesion in the cervical area, combined with a past medical history (PMH) of basal cell carcinoma, warrants further investigation 3.
• The presence of hyperpigmented skin on the patient's back due to excess sun exposure increases the risk of skin cancer, highlighting the importance of regular monitoring 4.

Treatment Options for Basal Cell Carcinoma

• Imiquimod 5% cream has been shown to be effective in treating superficial basal cell carcinoma, with studies demonstrating high histologic clearance rates 5, 6.
• However, the efficacy of imiquimod for other types of basal cell carcinoma, such as nodular BCC, may be limited, and alternative treatments like Mohs micrographic surgery may be necessary 4, 7.
• Photodynamic therapy, cryotherapy, and topical 5-fluorouracil are other treatment options for non-melanoma skin cancers, but their effectiveness and safety vary depending on the specific condition and patient characteristics 4.

Management and Follow-up

• Given the patient's history and physical examination, a biopsy of the lesion was a reasonable diagnostic step, and reviewing the lab results will help determine the best course of action 3.
• Scheduling regular follow-up appointments, such as every three months, to monitor the patient's skin, particularly in areas with excessive sun exposure, is crucial for early detection and treatment of potential skin cancers 4.