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Basal cell carcinoma (BCC) is the most common cutaneous malignancy in humans. These tumors typically appear on sun-exposed skin, are slow growing, and rarely metastasize. Neglected tumors can lead to significant local destruction and even disfigurement.

Although the exact etiology of BCC is unknown, a well-established relationship exists between BCC and the pilosebaceous unit, as tumors are most often discovered on hair-bearing areas. Tumors are currently believed to arise from pluripotent cells (which have the capacity to form hair), sebaceous glands, and apocrine glands. Tumors usually arise from the epidermis or the outer root sheath of a hair follicle.

Patients often complain of a slowly enlarging lesion that does not heal and that bleeds when traumatized. As tumors most commonly occur on the face, patients often give a history of an acne bump that occasionally bleeds.

• Patients often have a history of chronic sun exposure.

• Recreational sun exposure (eg, sunbathing, outdoor sports, fishing, boating)

• Occupational sun exposure (eg, farming, construction)

• Occasionally, patients have a history of exposure to ionizing radiation. X-ray therapy for acne was commonly used until 1950.

• Occasionally, patients have a history of arsenic intake; arsenic is found in well water in some parts of the United States.

Medical Care: In nearly all cases, the recommended treatment modality for BCC is surgery. While newer, nonsurgical therapeutic modalities are future possibilities, currently available medical modalities are considered to be experimental, with cure rates less than that of surgical modalities.

• 5-fluorouracil applied twice daily for 2-12 weeks of treatment can be effective in treating superficial BCC, with a reported cure rate as high as 93%. The use of 5-fluorouracil for other types of BCC is generally not recommended because it may not penetrate deeply enough into the dermis to eradicate all tumor cells. Irritation and crusting is common and expected, although significant irritation and discomfort are not uncommon.

• In a small study by Greenway et al, 1.5 million IU interferon alfa-2b injected intralesionally 3 times per week for 3 weeks resulted in clearing 3 cases of primary nonrecurrent BCC and 5 cases of primary superficial BCC. Because larger studies are needed, most practitioners consider this an experimental therapeutic modality. Acetaminophen can be administered to patients who experience the flulike symptoms associated with this therapy.

• Imiquimod cream has been used recently for the treatment of BCC. Small studies have shown cure rates of up to 88% for superficial BCC and nodular BCC. Studies for other histologic types of BCC are currently underway. Imiquimod is only FDA approved for the treatment of superficial BCC. Treatment is usually initiated 3 times per week and advanced as tolerated to once daily and even twice daily if tolerated to maintain mild-to-moderate skin irritation.

Surgical Care: The goal of therapy for patients with BCC is removal of the tumor with the best possible cosmetic result. By far, surgical modalities are the most studied, most effective, and most used treatments for BCC. The effectiveness of surgical modalities depends heavily on the surgeon's skills; considerable differences in cure rates have been observed among surgeons. Modalities used include electrodesiccation and curettage, excisional surgery, Mohs micrographically controlled surgery, and cryosurgery. Ionizing radiation, although a nonsurgical modality, should be considered in select patients and is discussed below

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