Basal Cell Carcinoma

Low risk BCCs management: Patient (>24 years) has a BCC less than or equal to 1cm below the clavicle, and is of the superficial or nodulocystic histology, and is not overlying important anatomical structures (e.g. major vessels), and the patient is not immunosuppressed, and does not have Gorlin’s syndrome. 

Lesions should be biopsied if there is uncertainty regarding the diagnosis, if not, they must be closely followed-up and referred if not improved by treatment. 

For superficial BCCs (sBCC) 

Prescribe: 

• Topical fluorouracil 5% cream (Efudix) 

1 cm margin around the lesion twice daily, for 4 weeks.   

Alternatively; 

Prescribe: 

• Imiquimod (Aldara 5% cream) once daily, 5 times a week, for 6 weeks. 

Consider surgery for sBCC and some nodular BCCs at low risk sites

Low/ intermediate risk BCCs management: Patient (>24 years) has a BCC less than 1 cm above the clavicle and is of the Superficial or nodulocystic histology; Patient has a BCC greater than or equal to 2cm below the clavicle and is of the Superficial or nodulocystic histology; Patient is not immunosuppressed, does not have Gorlin’s syndrome. 

Nodulocystic BCCs of greater than 1cm above the clavicle and greater than 2cm below it should be treated with a complete excision by an accredited skin surgeon, with 4mm surgical margins.  

Nodulocystic BCCs ≤1 cm at low-risk sites can be treated with curettage and cautery (with sufficient passes).  If the histopathology shows any high-risk features, then a formal excision by an accredited skin surgeon in an approved site is advised.  

High risk BCCs management: Patient (>24 years) has a BCC greater than or equal to 1cm on their facial areas (nose, lips, periorbital) and is of a high-risk (Infiltrative, micronodular, basosquamous) Histological type; Patient is immunocompromised or has a genetic predisposition e.g. Gorlin’s syndrome. 

High risk BCCs as mentioned above regardless of size should be referred as an urgent referral 

Note that infiltrative BCCs can be difficult to diagnose. To aid diagnosis, stretching out the lesion or using an alcohol wipe may reveal the typical pearly features. 

Dermoscopy can show the sharply focused telangiectasia. Consider a shave biopsy to confirm.   

Low risk BCCs management: Patient (>24 years) has a BCC less than or equal to 1cm below the clavicle, and is of the superficial or nodulocystic histology, and is not overlying important anatomical structures (e.g. major vessels), and the patient is not immunosuppressed, and does not have Gorlin’s syndrome. 

Manage in secondary care. Surgery can be considered by GPs with available skills in some low-risk situations. 

• A simple guide is ≤1 cm below clavicle [but excluding hands, nail units, genitals, pretibial, ankles and feet] 
• For further detail on low risk sites see BAD guidelines for management of BCCs 

Low/ intermediate risk BCCs management: Patient (>24 years) has a BCC less than 1 cm above the clavicle and is of the Superficial or nodulocystic histology; Patient has a BCC greater than or equal to 2cm below the clavicle and is of the Superficial or nodulocystic histology; Patient is not immunosuppressed, does not have Gorlin’s syndrome. 

Manage in secondary care. 

• ≥ 2 cm Below clavicle [but excluding hands, nail units, genitals, pretibia, ankles and feet] 
• <1 cm on the face, excluding nasolabial sites (central face, eyebrows, periorbital, nose, lips (cutaneous and vermilion), chin, mandible, preauricular, postauricular, temple, ears nose, forehead, ears, neck) 

High risk BCCs management: Patient (>24 years) has a BCC greater than or equal to 1cm on their facial areas (nose, lips, periorbital) and is of a high-risk (Infiltrative, micronodular, basosquamous) Histological type; Patient is immunocompromised or has a genetic predisposition e.g. Gorlin’s syndrome. 

Manage in secondary care.  

• All basal cell lesions ≥1 cm on face and ≥2 cm below clavicle.  
• Cases with high-risk histopathology may need discussion within a skin cancer MDT  

BAD clinical guidelines 

DermnetNZ basal cell carcinoma 

NICE CKS Skin Cancers, see also NICE – Improving Outcomes for People with Skin Tumours including Melanoma 

PCDS - Basal Cell Carcinoma 

• Suspect BCC in lesions which have intermittent spontaneous bleeding. 
• If topical treatment provokes excess inflammation consider moderate potency steroid for up to 10 days. 
• Patients prescribed Efudix or Imiquimod should be followed up (3-6 months) after completion of treatment.   
• All non-face to face consultations or requests for advice should have an accompanying photograph and ideally a dermoscopy image if possible. 
• BCCs occur in all skin types. Patients who have had a BCC are prone to developing further skin cancer (estimated clinical risk of 50% over 5 years)  
• Incomplete excisions at high-risk sites can lead to complex and high morbidity recurrence.  
• Once a person develops basal cell carcinoma, they have commenced a chronic disposition to UV-pathology and should consider sun protection and self-examination for potential skin cancers.  

1. BAD Patient Information Leaflet – Basal Cell Carcinoma 
2. Patient.Info Basal Cell Carcinoma 
3. BAD Patient Information Leaflet – 5-Fluorouracil cream (Efudix) 
4. BAD Patient Information Leaflet - Imiquimod cream 
5. Patient.info Skin Cancer Types 

Malignant 

ICD11 code - 2C32