Most Likely Diagnosis: Basal Cell Carcinoma
Based on the clinical presentation of a 1.5 cm erythematous nodule with raised borders, central ulceration and crusting on a sun-exposed area (cheek) in a patient who enjoys the outdoors, the most likely diagnosis is basal cell carcinoma (BCC). 1
Key Diagnostic Features Supporting BCC
The clinical presentation demonstrates classic hallmarks of BCC:
Nodular morphology with raised, rolled borders - This is the characteristic appearance of nodulo-ulcerative BCC, the most common subtype, which typically presents as a pearly or flesh-colored papule with a smooth surface and rolled borders 1, 2
Central ulceration with crusting - Central ulceration is a defining feature of nodulo-ulcerative BCC as the tumor outgrows its blood supply 2
Location on sun-exposed area (cheek) - BCC predominantly occurs on sun-exposed areas like the face, with the nose and cheeks being the most common sites 1, 3
Bleeding with minor trauma (shaving) - While BCC rarely bleeds spontaneously, it characteristically bleeds when traumatized, exactly as described in this case 1
Outdoor exposure history - Solar UV radiation is the predominant risk factor for BCC, and this patient's enjoyment of the outdoors provides significant exposure 3, 4
Slow progressive growth over 5 months - BCC typically demonstrates slow, indolent growth over months to years 2
Features That Argue Against Alternative Diagnoses
Squamous cell carcinoma (SCC) is less likely because:
- SCC more commonly presents as a firm, hyperkeratotic plaque rather than a nodule with rolled borders 4
- The 5-month duration and lack of rapid growth make aggressive SCC less probable 5
- While SCC can occur on the cheek (area M - moderate risk), the morphology is more consistent with BCC 5
Melanoma is highly unlikely because:
- No pigmentation is described, and melanoma would be expected to show pigmentation and meet ABCDE criteria (asymmetry, border irregularity, color variability, diameter >6mm, evolution) 6
- The nodular appearance with central ulceration and crusting is not typical of melanoma 6
Recommended Diagnostic Approach
Complete excisional biopsy with 2 mm margins using a scalpel is the standard practice for any suspected malignant cutaneous lesion - not a partial or punch biopsy, as complete histologic assessment is necessary for accurate diagnosis and margin evaluation 1. The British Journal of Cancer emphasizes that surgical knife excision (rather than laser or electrocoagulation) prevents tissue destruction that could interfere with histopathological diagnosis 6.
Critical Pathology Elements Required
All excised tissue must be sent for histopathological examination to: 1
- Confirm BCC diagnosis and determine histologic subtype
- Assess margin clearance to determine if re-excision is necessary
- Identify high-risk features (infiltrative pattern, perineural invasion, depth of invasion) 5, 4
Important Clinical Caveats
Do not perform shave biopsy for this lesion - While shave technique is acceptable for raised lesions in general, a 1.5 cm nodule with ulceration requires complete excision for accurate staging and treatment 4
Negative family history does not exclude BCC - BCC is primarily related to UV exposure rather than genetic predisposition, unlike melanoma 3, 7
The firm consistency on palpation suggests deeper dermal involvement, which may indicate a more aggressive subtype requiring wider margins or Mohs micrographic surgery 5, 4
Post-Diagnosis Management
Following histopathological confirmation, the NCCN recommends: 1
- Physical examinations every 3-6 months for 2 years, then every 6-12 months thereafter
- Total body skin examination at each visit to detect new lesions
- Patient education about sun protection and self-examination, as the 5-year risk of subsequent skin cancer after one BCC diagnosis is 41% 4