Basal cell carcinoma (BCC) is the most common type of skin cancer, yet its recognition and management are crucial for preventing significant morbidity. This guide aims to equip primary care health providers in the UK with essential knowledge about BCC, its presentation, diagnosis, and management strategies.

What is Basal Cell Carcinoma?

Basal cell carcinoma originates from the basal cells in the epidermis. Unlike other skin cancers, BCC rarely metastasizes but can cause substantial local destruction if not treated promptly. It’s primarily caused by cumulative sun exposure and is more common in individuals with fair skin.

Risk Factors

• Sun Exposure: Chronic exposure to UV radiation is the leading cause.
• Skin Type: Fair-skinned individuals, especially those with a tendency to freckle or burn easily, are at higher risk.
• Age: Incidence increases with age.
• Gender: Slightly more common in men.
• History of Skin Cancer: Previous BCC increases the risk of recurrence.
• Genetic Conditions: Conditions like Gorlin syndrome can predispose individuals to multiple BCCs.

Clinical Presentation

BCCs often present as slow-growing lesions. Key clinical features include:

• Nodular BCC: Appears as a pearly or translucent nodule with visible blood vessels (telangiectasia). It may ulcerate, forming a central crater.
• Superficial BCC: Presents as a scaly, red patch that might be mistaken for eczema or psoriasis.
• Morphoeic (sclerosing) BCC: Looks like a scar or firm, pale, ill-defined lesion. It’s more aggressive and challenging to treat.
• Pigmented BCC: Contains melanin, making it look brown or black, often confused with melanoma.

Diagnostic Approach

Clinical Examination

• Visual Inspection: Pay attention to lesion characteristics such as size, color, border, and ulceration.
• Dermatoscopy: Enhances visualization of vascular patterns and pigmentation structures specific to BCC.

Biopsy

• Punch Biopsy: Useful for obtaining a full-thickness skin sample.
• Shave Biopsy: Effective for superficial lesions.
• Excisional Biopsy: Preferred for small lesions where complete removal is feasible.

Management Strategies

Treatment Options

Surgical Excision

• Standard Excision: Ensures clear margins, typically with a 3-4 mm margin of healthy tissue.
• Mohs Micrographic Surgery: Ideal for high-risk or recurrent BCCs, offering the highest cure rate by examining 100% of the margin during surgery.

Non-Surgical Treatments

• Cryotherapy: Suitable for small, superficial BCCs.
• Topical Therapies: Imiquimod and 5-fluorouracil are used for superficial BCCs.
• Photodynamic Therapy (PDT): Combines a photosensitizing agent with light exposure, effective for superficial lesions.

Radiotherapy

Reserved for patients who cannot undergo surgery or for lesions in difficult-to-treat locations.

Follow-Up and Prevention

• Regular Skin Examinations: Patients with a history of BCC should have routine skin checks to identify new or recurring lesions early.
• Sun Protection: Advise patients on the importance of sunscreen, protective clothing, and avoiding peak sun hours.
• Patient Education: Educate about self-examination and the early signs of BCC.

Conclusion

Early recognition and management of basal cell carcinoma are vital in primary care to prevent extensive tissue damage and preserve patient quality of life. By understanding the risk factors, clinical presentations, and appropriate treatment modalities, UK primary care providers can play a crucial role in managing this common but potentially destructive skin cancer.

For further reading and guidance on managing skin conditions in primary care, consider exploring the following Practitioner Development UK articles:

Eight Common Skin Conditions Seen in the Older Adult and 

Tips for Health Care Providers Caring for Patients with Skin Changes

References

Codd, M., Fry, A., & Verma, S. (2018). Basal cell carcinoma: diagnosis and treatment. BMJ, 361, k1607.

National Institute for Health and Care Excellence (NICE). (2021). Skin cancer prevention: Basal cell carcinoma. Retrieved from https://www.nice.org.uk/guidance/ng196