DISCUSSION
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.