Malignant Wounds - Basal Cell Carcinoma
Basal cell carcinoma is the most common skin cancer that affects one in every six Americans. Early detection and treatment are the key elements to prevention of extensive disfiguring surgery, risk of infection, or complications of a non-healing wound.
Most malignant dermal wounds are caused by over-exposure to ultraviolet light or by metastatic spread from a remote neoplasm to the skin; however, some systemic malignancies can cause dermal lesions. Some chronic wounds and cutaneous scars, especially from burns, can transition into neoplastic lesions (termed Marjolin’s ulcer)[i] and require a totally different plan of care in order to achieve full wound closure. Some of the signs that a wound may be a neoplasm, either benign or malignant, are the following:
- Unusual appearance
- Easy bleeding
- Rapid growth
- Failure to respond to standard care
- Repeated reoccurrence after apparent closure
- Unusual odor
Along with these physical symptoms come emotional stress, functional compromise, social concerns, and complications such as infection.[ii] Any wound that is even suspicious of being malignant requires immediate confirmation or negation by tissue biopsy.
Basal cell carcinoma (BCC) is the most common skin cancer, as well as the most frequently occurring cancer overall, affecting one in every six Americans. The benign neoplasm arises from damaged undifferentiated basal cells as a result of prolonged exposure to ultraviolet light, either from the sun or tanning beds. The UV exposure leads to the formation of thymine dimers, a form of DNA damage, and the longer the exposure the more thymine dimers are formed. SCC results when the DNA damage if greater than what the cells can naturally repair.[iii]
Risk factors for developing SCC include the following:
- Prolonged ultraviolet exposure in the sun or tanning beds
- Fair skin, red or blond hair, or light-colored eyes
- Radiation therapy for other skin conditions
- Family history of skin cancer
- Immunosuppression, including anti-rejection medication
- Exposure to arsenic in water or industry
- Certain inherited genetic disorders (e.g. Gorlin-Goltz syndrome, xeroderma pigmentosum)[iv]
BCC most commonly occurs on the head, face, neck, or extremities where skin is exposed to sun, but can occur anywhere on the body. It usually begins as a small pearly-white, scaly lesion that outgrows its blood supply, erodes, and eventually ulcerates. BCC also form as a non-healing or expanding chronic rash. The lesion may bleed easily with any scraping or friction, sometimes the first sign that the individual notices as being of concern. There may also be prominent telangiectatic surface vessels, rolled edges, or slightly raised dome shape. BCC is painless and slow growing.[v] As previously mentioned, sometimes a BCC will develop in the base of a non-healing traumatic or surgical wound.
BCC presents as the following three types:
- Nodular – appears as shiny, pearly skin
- Superficial – appears as a red patch, may be mistaken for eczema
- Infiltrative – (also called morpheaform) – appears as thickened skin or scar tissue; penetrates deeper and is harder to treat; is more aggressive[vi]
Medical management of BCC begins with a biopsy of any suspicious lesion with anesthetic and surgical shaving technique. It is essential that the biopsy is not too shallow and obtains a depth to the dermis. Treatment options include the following procedures:
- Surgical excision or Mohs procedure until there are 4mm (excision) or 2mm (Mohs) clean margins
- Cryosurgery (Sufficient enough to treat the lesion as well as have a margin of normal skin and acceptable depth)
- Electrodessication and curettage (Sufficient enough to treat the lesion as well as have a margin of normal skin and acceptable depth)
- Topical 5% imiquimod cream daily, 6 weeks for superficial BCC or 12 weeks for nodular BCC;[vii] 5-Fluorourcil;[viii] or vismodegib[ix]
- Radiotherapy for elder patients or for areas where excision would be disfiguring
- Photodynamic therapy for primary superficial BCCs only
- Recommendation of avoiding sun and tanning beds; use at least 30 SPF sunscreen
- Follow-up full-body skin inspection by a dermatologist to detect recurrence or new lesions
Wound management of any post-surgical lesions should follow the principle of moist wound therapy with special care to avoid the use of any cytotoxic agents (e.g. hydrogen peroxide, Dakin’s solution, acetic acid) that may impede the normal healing process by destroying essential fibroblasts. Silicone-backed foam dressings are suggested for absorbing any drainage, protecting the periwound skin, and facilitating re-epithelialization.
In summary, basal cell carcinoma the most common skin cancer that requires early detection and treatment in order to have the best aesthetic outcome and minimal risk of complications.
[i] Day D, Chakari W, Matzen SH. Malignant transformation of a non-healing wound on the lower extremity: A case report. Int J Surg Case Reports. 2018;53:468-470.
[ii] Maida V, Ennis M, Kuziemsky C, Trozzolo L. Symptoms associated with malignant wounds: A prospective case series. J Pain & Symptom Management. 2009;37(2):206-211.
[iii] Kyrgidis A, Tzellos TG, Vahtsevanos K, Triadidis S. New concepts for basal cell carcinoma. Demographic, clinical, histological risk factors, and biomarkers: A systematic review of evidence regarding risk for tumor development, susceptibility for second primary and recurrence. J Surg Res. 2010;159(1):545-556.
[iv] Basal cell carcinoma. Available at https://www.mayoclinic.org/diseases-conditions/basal-cell-carcinoma/symptoms-causes/syc-20354187. Accessed April 26, 2020.
[v] Firnhaber JM. Diagnosis and treatment of basal cell and squamous cell carcinoma. Am Fam Physician. 2012;86(2):161-168.
[vi] Basal Cell carcinoma. Available at https://en.wikipedia.org/wiki/Basal-cell_carcinoma. Accessed April 27, 2020.
[vii] Williams HC, Bath-Hextall F, Ozolins M, Armstrong S, Colver GB, Perkins W, et al. Surgery versus 5% imiquimod for nodular and superficial basal cell carcinoma: 5 year results of the SINS random control trial. J Investigative Dermat. 2017;137(3):614-619.
[viii] Jansen MHE, Mosterd K, Arits A, et al. Five-year results of a randomized controlled trial comparing effectiveness of photodynamic therapy, topical imiquimod, and topical 5-fluorouracil in patients with superficial basal cell carcinoma. J Invest Dermatol. 2018;138(3):527-533.
[ix] Glen P, Farrugia D, Farrier J. Complete remission of advanced, locally invasive basal cell carcinoma with vismodegib (Erivedge, Roche Pharmaceuticals). Head and Neck Oncology. Available at https://doi.org/10.1016/j.ijom.2020.03.006. Accessed April 24, 2020.