PracticalDermatology

Basal cell carcinoma (BCC) is the most common type of skin cancer worldwide and is increasing in incidence.^1-11 It occurs more commonly in patients with lighter skin; however, it can affect patient with skin of color as well. While the presentation of BCC in skin of color is rare, this atypical presentation may increase the time to detection, which may lead to worse outcomes.^3,4 Herein we report two cases of basal cell carcinoma in African American patients.

This is a retrospective clinical review of two African American patients with basal cell carcinoma. One patient was seen by otolaryngologists at Ochsner-LSU Health Shreveport, and one patient was seen by the dermatology service at Ochsner-LSU St. Mary’s Medical Center. Both patients were male. One patient was 67 years old, and the other patient was 68 years old. In both cases, the diagnosis of basal cell carcinoma was made by biopsy and histologic examination. Both patients presented with BCC on the vertex of the scalp and have a history of chronic obstructive pulmonary disorder. We performed this study with the intention of examining the presentation and analyzing the clinical characteristics of each case.

Case 1

A 67-year-old male with a past medical history of hypertension, bilateral hip replacements, and 0.75 pack-per-year smoking history presented with a lesion on the scalp vertex. Patient reports the lesion has been increasing in size and changing colors. Physical examination revealed a large multi-colored epidermal lesion to the parietal scalp (Fig 1). Shave biopsy was performed, which revealed underlying pigment within the dermis. Follow-up punch biopsy completed to obtain depth of the lesion as melanoma was then suspected. Punch biopsy revealed basal cell carcinoma (pigmented), nodular type (Fig 2).

Fig 1. Multi-colored epidermal lesion to the parietal area of the scalp.

Fig 2. Tumor composed of islands of basophilic cells in the dermis. The peripheral cell layer of the islands has a palisaded arrangement of the nuclei. Melanin pigment present.

Case 2

A 68-year-old male presented with a 2-year history of lesion to scalp. Patient has a past medical history of cystic-bullous lung disease status post right lobectomy, asthma, chronic obstructive pulmonary disorder, and extensive sun exposure from farming. Physical exam revealed a 3x3cm pedunculated lesion on the right parietal scalp (Fig 3). Biopsy revealed BCC with matrical differentiation (Fig 4).

Fig 3. Pedunculated lesion on the right parietal scalp.

Fig 4. Basaloid tumor cells with scant cytoplasm that are arranged in irregularly-shaped lobules/nests of various sizes and shapes with focal tumor necrosis.

DISCUSSION

Basal cell carcinoma arises from the basal layer of the epidermis and most commonly occurs on the head and neck region. Lifetime exposure to UV radiation is the predominant risk factor in the development of BCC. Additional risk factors include advanced age, male sex, immunosuppression, genetic disorders, and fair skin. The prognosis of BCC is very favorable, depending upon the subtype. Personal history of BCC is a risk factor for recurrence. Therefore, it is recommended that patients with a previous diagnosis of BCC are screened at least yearly for the development of new skin cancers.^1,5,6,10,11

BCC is diagnosed by a combination of clinical and histological examination. Clinically, they appear pearly and may have telangiectasias or a central ulceration. Dermoscopy can also aid in the clinical diagnosis, showing well-focused arborizing vessels. Biopsy is indicated to confirm the diagnosis and provide information on the subtype as management can change for the more aggressive histological variants. Histological findings diagnostic of BCC show nests of basal cells with peripheral palisading cells. The most common histological type of BCC is the nodular subtype, as seen in Case 1.^2,7

There are many therapies available in the treatment of BCC including surgical excision, radiation, and topical medications. Procedural treatment options consist of standard excision, Mohs micrographic surgery (MMS), cryosurgery, and electrodesiccation and curettage. Topical medications such as 5-fluorouracil and imiquimod are options for multiple superficial BCCs or with patients who are not surgical candidates.^2,7,11

More research is needed to expand upon the limited data regarding the incidence and risk of skin cancer in people of color. While BCC is rare in African Americans, it tends to have a delayed diagnosis and therefore can have a more serious course of disease.^3,4 The late presentation of skin cancer in patients with dark skin may be due to general disinformation or socioeconomic factors that disproportionately affect people of color. A multifaceted strategy involving educational outreach and nondiscriminatory skin cancer screenings for all races may aid in reduction of the disparity of skin cancer associated morbidity and mortality between different racial groups.

The authors have received no funding for this manuscript. They report no conflicts of interest.

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