Management of Basal Cell Carcinoma

Publication Date: March 1, 2018
Last Updated: March 14, 2022

Recommendations

Grading and staging, biopsy, clinical information, and pathology report for the treatment of BCC

Stratification of localized BCC using the NCCN guideline framework is recommended for clinical practice. (C)
323935
The recommended biopsy techniques for BCC are punch biopsy, shave biopsy, and excisional biopsy. The biopsy technique used will depend on the characteristics of the suspected malignancy (morphology, location, etc) and the judgment of the physician. (B)
323935
The biopsy size and depth should be adequate to provide the recommended clinical information and pathology report elements to permit accurate diagnosis and guide therapy. (A)
323935
Repeat biopsy may be considered if initial biopsy specimen is inadequate for accurate diagnosis. (B)
323935

Clinical information provided to pathologist

  • Age
(A)
323935
  • Sex
(B)
323935
  • Anatomic location
(B)
323935
  • Recurrent lesion
(A)
323935
  • Size of lesion
(A)
323935
  • Immunosuppression
(B)
323935
  • History, especially radiation, burn, organ transplant
(B)
323935

Pathology report elements

  • Histologic subtype
(B)
323935
  • Invasion beyond reticular dermis
(B)
323935
  • Perineural involvement
(C)
323935

SURGICAL TREATMENT

A treatment plan that considers recurrence rate, preservation of function, patient expectations, and potential adverse effects is recommended. (A)
323935
C&E may be considered for low-risk tumors in none terminal hairebearing locations. (B)
323935
For low-risk primary BCC, surgical excision with 4-mm clinical margins and histologic margin assessment is recommended. (B)
323935
Standard excision may be considered for select high-risk tumors. However, strong caution is advised when selecting a treatment modality without complete margin assessment for high-risk tumors.
  • Low-risk BCC
(A)
323935
  • High-risk BCC
(C)
323935
Mohs micrographic surgery is recommended for high-risk BCC. (A)
323935

NONSURGICAL TREATMENT

Cryosurgery may be considered for low-risk BCC when more effective therapies are contraindicated or impractical. (A)
323935
If surgical therapy is not feasible or preferred, topical therapy (eg, imiquimod or 5-FU), MAL- or ALA-PDT, and radiation therapy (eg, superficial radiation therapy, brachytherapy, external electron beam, and other traditional radiotherapy forms for BCC) can be considered when tumors are low risk, with the understanding that the cure rate may be lower.
  • Imiquimod
(A)
323935
  • 5-FU
(B)
323935
  • Adjustment of topical therapy dosing regimen on the basis of side effect tolerance is recommended.
(A)
323935
There is insufficient evidence to recommend the routine use of laser or electronic surface brachytherapy in the treatment of BCC. (-)
323935

Photodynamic therapy

  • aminolevulinic acid
(A)
323935
  • methylaminolevulinate
(A)
323935

Radiation therapy

  • Traditional radiotherapies and modern superficial radiation therapy
(B)
323935
  • Electronic surface brachytherapy
(C)
323935
Laser therapy (C)
323935

MANAGING PATIENTS WITH METASTATIC AND ADVANCED BASAL CELL CARCINOMA

Multidisciplinary consultation and smoothened inhibitors are recommended for patients with metastatic BCC. (A)
323935
If treatment of metastatic BCC with smoothened inhibitors is not feasible, platinum-based chemotherapy or best supportive care is recommended. (C)
323935
If surgery and radiation therapy are contraindicated or inappropriate for the treatment of locally advanced BCC, or if residual tumor persists following surgery and/or radiation therapy and further surgery and radiation therapy are contraindicated or inappropriate, systemic therapy with a smoothened inhibitor should be considered. (A)
323935
Patients with advanced disease should be provided with or referred for best supportive and palliative care, to optimize symptom management and maximize quality of life. (C)
323935

Treatment with SMO inhibitors

Metastatic and Locally advanced BCC (A)
323935
Gorlin syndrome (B)
323935

FOLLOW-UP AND REDUCING RISK FOR FUTURE SKIN CANCERS

After diagnosis of a first BCC, skin cancer screening for new keratinocyte cancers (BCC or cSCC) and for melanoma should be performed on at least an annual basis. (A)
323935
Patients with a history of BCC should be counseled on skin self-examination and sun protection. (A)
323935
The use of topical and oral retinoids (eg, tretinoin, retinol, acitretin, and isotretinoin) is not recommended to reduce the incidence of future keratinocyte cancers in those with a history of BCC.
  • Tretinoin
(A)
323935
  • Acitretin
(B)
323935
  • Isotretinoin
(A)
323935
  • Oral retinol
(A)
323935
Dietary supplementation of selenium and b-carotene is not recommended to reduce the incidence of future keratinocyte cancers in those with a history of BCC.
  • Selenium
(A)
323935
  • β-Carotene
(A)
323935
There is insufficient evidence to make a recommendation on the use of oral nicotinamide, DFMO, or celecoxib in the chemoprevention of BCC.
  • Celecoxib
(B)
323935
  • DFMO
(A)
323935
  • Oral nicotinamide
(B)
323935

Recommendation Grading

Disclaimer

Overview

Title

Management of Basal Cell Carcinoma

Authoring Organization

Publication Month/Year

March 1, 2018

Last Updated Month/Year

August 7, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline addresses the management of patients with basal cell carcinoma (BCC) from the perspective of a US dermatologist. The main focus of the guideline is on the most commonly considered and utilized approaches for the surgical and medical treatment of primary BCC, but it also includes recommendations on the treatment of recurrent tumors when applicable, appropriate biopsy techniques, staging, follow-up, and prevention of BCC.

Target Patient Population

Patients with basal cell carcinoma

Target Provider Population

Providers who treat patients with basal cell carcinoma

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D002280 - Carcinoma, Basal Cell

Keywords

skin cancer, basal cell carcinoma