Solid Basal Cell Carcinoma on the Nasal Edge: Clinical Approach, Diagnosis, and Treatment
Basal cell carcinoma (BCC), which occurs in the facial region, especially in cosmetically and functionally critical areas such as the nasal edge and under the eyes, is the most common skin cancer.
A 50-year-old female patient presented with a progressively growing, black, irregularly bordered, nearly round lesion of 5 mm in diameter, located just below the right eye on the nasal edge, which had been present for approximately 3 months. An episcopic biopsy was performed under local anesthesia. The histopathological result was solid type basal cell carcinoma (BCC).
What is basal cell carcinoma?
Basal cell carcinoma is a slow-growing malignancy originating from basal cells in the deepest layer of the epidermis, but it has a high potential for local invasion. While the likelihood of metastasis is quite low, it can cause significant destruction of surrounding tissues if left untreated. Its local aggressiveness and the difficulty in achieving a clear surgical margin in facial areas can make treatment challenging. It can sometimes be confused with simple nevi.
It most commonly occurs in sun-exposed areas:
- Nose
- Around the eyes
- Forehead
- Ears
Therefore, BCCs in the facial area are of particular importance both functionally and aesthetically.
What are the subtypes of basal cell carcinoma?
Basal cell carcinoma (BCC) has different histopathological subtypes:
- Nodular (solid) type → The most common type
- Superficial type
- Infiltrative type
- Morfeiform (sclerosing) type
- Pigmented type
- Micronodular type
The solid type is generally better defined and surgically removed completely more easily than other aggressive types.
What are the signs of basal cell carcinoma?
The clinical presentation of BCC can be variable. The most common signs are:
- Pearly-colored raised area
- Slow-growing nodule
- Ulceration (“rodent ulcer”)
- Crusting and bleeding
- Irregular edges
- Pigmented (black/brown) appearance
As in this case:
- 5 mm in diameter
- Black color
- Irregular edges
- Lesion with a tendency to grow
This is quite typical of BCC.
What are the causes of basal cell carcinoma?
The main risk factors are:
- UV exposure (the most important cause)
- Fair skin
- Advanced age
- Male gender (also common in women)
- Immunosuppression
- History of radiation
- Genetic syndromes (e.g., Gorlin syndrome)
Location in the facial area, especially associated with chronic sun damage.
Is there a relationship between basal cell carcinoma and smoking?
The relationship between smoking and BCC is not clear. Some studies show:
A stronger association between smoking and squamous cell carcinoma, and a weaker or more indirect association with BCC.
However, smoking:
- Impairs tissue healing
- Increases the risk of postoperative complications
- Therefore, quitting smoking is recommended in BCC patients.
How is basal cell carcinoma diagnosed?
The diagnostic process consists of the following steps:
- Clinical examination
- Dermoscopic examination
- Biopsy (gold standard)
In this case:
- Excisional biopsy performed under local anesthesia
- Lesion completely removed
- Histopathology result: Solid type BCC
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| An excisional biopsy was performed from the nasal margin under local anesthesia. The lesion was marked above and below using long and short sutures. The surgical specimen was sent for histopathological examination. |
Microscopic examination results: Examination of the sections reveals a neoplastic lesion consisting of atypical basaloid cells with slightly pleomorphic, hyperchromatic nuclei and narrow basophilic cytoplasm, developing as solid islands in the dermis connected to the basal layer of the epidermis. Numerous mitotic figures are seen intermittently, and the cells around the tumor islands exhibit a palisade arrangement.
DIAGNOSIS: RIGHT EYE AREA, SKIN; EXCISIONAL BIOPSY - BASAL CELL CARCINOMA, SOLID TYPE - SURGICAL MARGINS ARE INTEGRATED
Differential diagnosis for basal cell carcinoma
The differential diagnosis is quite broad when evaluating pigmented, irregularly bordered, and growing lesions located in the facial region, especially around the nasal margins and infraorbital area. While basal cell carcinoma (especially pigmented or solid type) is clinically considered, other malignant and benign lesions exhibiting similar appearances must be considered.Firstly, one of the most critical differential diagnoses is malignant melanoma. Melanoma usually presents as asymmetric, irregularly bordered lesions showing color variation (black, brown, blue tones) and a tendency to grow rapidly. The ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolution) are guiding in clinical evaluation. In this case, the black color and irregular borders of the lesion may suggest melanoma; however, the diagnosis is clarified by histopathological examination.
Another important differential diagnosis is squamous cell carcinoma (SCC). SCC generally grows faster and presents as hyperkeratotic, ulcerative, and crusted lesions. The fact that it appears in sun-exposed areas and is sometimes accompanied by symptoms such as pain and tenderness is helpful in differential diagnosis. Pigmentation is less pronounced, but some variants can be clinically confused with BCC.
Among benign lesions, one of the most frequently confused is Seborrheic Keratosis. It is usually benign, appearing as brown-black plaques with an "adherent" appearance. Its verrucous surface and sudden onset provide clues in differential diagnosis. However, it can be clinically confused, especially with pigmented BCC.
Lesions such as Melanocytic Nevus (mole) and Actinic Keratosis should also be included in the evaluation. Nevi are generally stable and have been present for a long time; subsequent changes raise suspicion of malignancy. Actinic keratosis, on the other hand, is a precursor lesion, mostly seen as erythematous, scaly areas, and has the potential to transform into SCC.
In conclusion, clinical evaluation alone may not be sufficient for the differential diagnosis of pigmented and irregular lesions in the facial region. Although dermoscopy is helpful, biopsy and histopathological examination are the gold standard for definitive diagnosis. In this case, clarifying the diagnosis with excisional biopsy represents the most appropriate approach for proper management.
This approach is suitable for both diagnosis and treatment (especially in small lesions).
How is basal cell carcinoma treated?
Treatment selection is made considering the tumor's:
- Size
- Localization
- Subtype
- Risk status
Main treatment options:
- Surgical excision (most frequently preferred)
- Mohs micrographic surgery
- Curettage and electrocauterization
- Cryotherapy
- Topical treatments (imiquimod, 5-FU)
- Radiotherapy (in selected cases)
For facial areas, surgical excision or Mohs surgery is usually preferred.
What should the clear surgical margin be in the facial region during basal cell carcinoma surgery?
The surgical margin is critically important in preventing recurrence.
📌 Low-risk solid BCC:
3–4 mm clear surgical margin is sufficient.
⚠️ High-risk areas (nose, eye area):
5 mm or wider margin is recommended.
Alternative: Mohs surgery.
In this case:
Location: nasal margin – infraorbital region
👉 high-risk anatomical area
Therefore:
Careful margin control in standard excision
Re-excision or Mohs should be considered if necessary
Mohs micrographic surgery in basal cell carcinoma
Mohs micrographic surgery is the gold standard, especially for BCCs in the facial region.
Advantages:
- The entire tumor is evaluated under a microscope
- Maximum tissue is preserved
- Lowest recurrence rate is achieved
Indications:
- H-zone of the face (nose, around the eyes)
- Recurrent tumors
- Aggressive histological types
- Lesions with ill-defined borders
How is Mohs Surgery Performed in Basal Cell Carcinoma?
Mohs micrographic surgery is a tissue-sparing surgical technique that provides the highest cure rate, especially for Basal Cell Carcinoma (BCC) located in the facial region. The main goal of this method is to remove the entire tumor while minimizing the loss of healthy tissue.
The procedure is usually performed under local anesthesia and proceeds in stages (layer by layer). In the first stage, the surgeon removes the clinically visible tumor tissue along with a thin layer of tissue. The removed tissue is specially marked (mapped) and immediately sent to the laboratory. Here, the tissue is prepared in horizontal sections and all surgical margins (including peripheral and deep margins) are examined in detail under a microscope. This provides 100% margin assessment, unlike classical histopathology.
If tumor cells are detected in any area during microscopic examination, this area is precisely identified on the map, and additional tissue is removed only from that area. This process is repeated until all margins become tumor-free (negative). Therefore, Mohs surgery is the most precise method, providing both maximum tumor removal and maximum tissue preservation.
In the final stage, after the tumor is completely removed, the resulting defect is reconstructed. This can be done with primary closure, a local flap, or a graft. Mohs surgery is preferred, especially in aesthetically critical areas such as the nose and around the eyes, due to its low recurrence rate and better cosmetic results.
What are the high-risk and low-risk criteria for basal cell carcinoma?
✅ Low risk:
- <2 cm diameter
- Trunk/extremity location
- Nodular (solid) type
- Primary tumor
⚠️ High risk:
H-zone of the face
- > 2 cm
- Recurrent tumor
- Infiltrative/morpheform type
- Perineural invasion
- Poorly defined lesion
In this case:
Small size → low risk
However, facial location → falls into the high-risk category
What are the post-excision care recommendations for basal cell carcinoma?
Post-surgical care is crucial for healing and scar quality:
🩹 Early stage:
Keep the wound clean
Antibiotic ointment can be used
Sun protection is essential
☀️ Late stage:
SPF 50+ sunscreen
Scar massage
Use of silicone gel/patch
🔍 Follow-up:
Check-up every 3-6 months during the first year
Full skin examination for new lesions
Solid type basal cell carcinoma (BCC) developing in critical areas such as the sides of the nose and under the eyes can be treated with a high success rate with early diagnosis and appropriate surgery. However, considering the risk of recurrence and cosmetic results in these areas, surgical margin planning and, if necessary, Mohs surgery are of great importance.
You can click here to read previously prepared articles on Basal Cell Carcinoma by Dr. Murat Enoz on this website, and also click on the search results page link (you can access other articles and patient images by clicking on "more posts" at the bottom of the page) >> https://www.ent-istanbul.com/search?q=Basal+Cell+Carcinoma
Source links >>
Basal cell carcinoma: histological classification and body‐site distribution - Raasch - 2006 - British Journal of Dermatology - Wiley Online LibraryMurat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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