Options and Insights on How to Treat Basal Cell Carcinoma

How to Treat Basal Cell Carcinoma—A Dermatologist’s Insights

A stubborn lesion on a sun-exposed body part, such as the face or neck, may raise concern for skin cancer. Basal cell carcinoma is a skin malignancy that may go unnoticed for a long time because of its slow growth and, in some cases, the lack of alarming symptoms like bleeding and abnormal pigmentation. Though typically less aggressive than melanoma, this tumor still requires attention, as its presence may indicate more serious health issues.

In this article, we focus on how to treat basal cell carcinoma and why swift action is crucial, as with any form of cancer. We also discuss the risk factors for this skin condition and the ways to prevent its development.

What Is Basal Cell Carcinoma?

The epidermis is the skin’s most superficial layer. Typical skin cells that make up most of the epidermis are called “keratinocytes,” which protect the body from severe water loss, infection, and various forms of injury.

At the lowest portion of the epidermis is the basal layer, which houses the youngest keratinocytes. These young cells actively divide before maturing, dying, and reaching the most superficial epidermal layer, the skin barrier. After reaching the surface, dead keratinocytes fulfill their primary role of shielding the body against environmental damage.

Basal cell carcinoma, occasionally referred to as “basal cell skin cancer” or “basal cell cancer,” is a type of skin malignancy affecting the young cells in the basal epidermal layer. This skin tumor may also arise from abnormal hair follicle cells growing within this layer. DNA mutations occur more frequently in cells that multiply rapidly. That’s why cells in the basal epidermal layer are cancer-prone.

The parts of the skin that get the most sun or UV exposure are at the greatest risk for basal cell carcinoma formation. This risk is even higher for men, as well as individuals with fair skin. Men typically spend more time outdoors than women, and fair skin is highly sensitive to UV-induced DNA damage.

Basal cell cancer can develop in non-exposed skin areas in people with the following risk factors:

• Poor immunity
• Chronic skin conditions like non-healing wounds.
• Inherited disorders that increase people’s skin cancer risk like basal cell nevus syndrome and xeroderma pigmentosum
• Significant exposure to arsenic, which often occurs in certain workplaces and polluted areas
• Advancing age
• High dietary fat intake

Basal cell skin cancer lesions usually grow slowly, often appearing as translucent or pearly white, dome-shaped bumps or rounded pits surrounded by broken capillaries or spider veins. Some may look like moles because of their dark color. The tumors can itch, bleed, and persist despite over-the-counter treatments.

Basal cell carcinoma rarely leads to lymph node involvement or distant spread. However, longstanding lesions can invade deeper tissues, resulting in disfigurement and pain or numbness. In some cases, excessive tumor growth can impair function. For example, eyelid lesions can restrict eyelid mobility, while basal cell cancer reaching the inside of the nose can compromise the sense of smell.

Unlike melanoma, cosmetic deformity from slow, progressive local spread is much more common than death due to basal cell carcinoma. However, this tumor may be a sign that a person is likely to develop more fatal cancers, including melanoma, later in life.

How Do Dermatologists Diagnose Basal Cell Carcinoma?

Your dermatologist will begin their evaluation by reviewing your skin condition’s history and asking about details, such as lifestyle and family history, that may increase your skin cancer risk. They will also perform a complete skin examination, noting the tumor’s characteristics and possible signs of distant spread. Lesions are typically examined with a handheld device called a “dermatoscope” (or “dermoscope”) to identify features that may indicate skin cancer.

Suspicious lesions may require further workup. Noninvasive imaging techniques like reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) may be employed alongside dermoscopy to assess superficial tumors. These tools provide high-resolution views of cancer cells without the need for a skin biopsy.

However, your dermatologist may recommend a biopsy if they suspect deep tissue involvement or a more aggressive cancer type like melanoma. This minor procedure, done under local anesthesia, entails taking a tiny sample from the lesion for microscopic examination. If basal cell carcinoma with deep tissue involvement is confirmed, the dermatologist may suggest using imaging tools like a CT scan or MRI to assess the extent of spread.

Signs that basal cell carcinoma is highly aggressive include the following:

• Size exceeding 2 centimeters
• Deep tissue extension
• Midfacial location
• Irregular shape
• Persistence or recurrence
• Major nerve or blood vessel involvement, which increases the risk of remote cancer spread

A history of chronic immune or inflammatory disorders further raises the likelihood that the tumor is aggressive. Identifying these risks is essential for determining your treatment options.

What Is Your Best Option for Basal Cell Carcinoma Treatment?

As with any type of skin cancer, the best treatment option for basal cell carcinoma is surgical excision. The dermatologist can approach this procedure by performing either a wide excision or the Mohs technique.

Wide excision involves removing the visible tumor along with a 4- to 6-millimeter margin. The surgeon doesn’t stop during the procedure to examine the excised tissue microscopically for complete clearance of cancerous cells. Instead, tumor clearance is determined after surgery.

While more affordable, wide excision doesn’t guarantee the elimination of microscopic cancer cells after the procedure. That’s why, without additional treatment, it has a significant risk of recurrence.

Meanwhile, Mohs surgery entails the stepwise removal of tumor tissue, with each thin layer examined under a microscope for cancer cells. Once the tumor is fully excised, a narrow margin of healthy skin is also taken out to ensure complete clearance. This method allows the surgeon to confirm the elimination of all tumor cells while preserving as much healthy tissue as possible, maintaining both cosmetic and functional integrity.

Mohs surgery has significantly higher cure rates and lower recurrence risk than wide excision. This procedure is widely regarded as the gold standard for treating nonmelanoma skin cancer types like basal cell carcinoma.

However, only dermatologists with specialized training and board certification can perform Mohs procedures. So, unlike in Glendale and Encino, where you can find certified Mohs surgeons at BHSkin Dermatology’s offices, this service isn’t available in all geographic locations.

To learn more, you may read our previous article comparing these excision methods. Other surgical skin cancer treatment options involve either scraping the tumor off and burning its blood supply (curettage with electrodesiccation), freezing it (cryosurgery), or destroying it with a laser (laser ablation).

However, like wide excision, these techniques do not ensure all cancer cells are removed during surgery. Additionally, they have even lower cure rates and greater cancer recurrence risk.

Can You Treat Basal Cell Carcinoma Without Surgery?

Since basal cell skin cancer typically grows slowly, non-surgical intervention is considered in some cases. Treatment options include radiation therapy, topical skin cancer medications, photodynamic therapy, immunotherapy injections, targeted therapy, and electrochemotherapy. The choice depends on various factors, including tumor type, aggressiveness, and location, patient tolerance and preference, potential benefits versus risks, and treatment availability.

Radiation therapy is often recommended if surgery is contraindicated, as in the following cases:

• Tumor growth in cosmetically or functionally sensitive areas, such as the fingers
• Involvement of vital structures, such as the major blood vessels and nerves of the neck
• Advanced age
• Presence of medical conditions that make surgery risky, such as severe heart disease
• Patient preference

Radiation therapy may also be used to clean up any remaining cancer cells after wide excision. However, this treatment should not be used for patients with inherited skin cancer syndromes, as they have a greater risk of developing another cancer from radiation than people without such conditions. It’s also not advised for tumors that grow back after a previous course of radiation treatment.

Topical chemotherapy medications may be considered for low-risk tumors, such as small, superficial basal cell carcinoma. They’re particularly useful for older adults and individuals with advanced medical conditions and lesions in cosmetically sensitive areas. However, these treatments aren’t recommended for tumors with aggressive features, such as widespread involvement and recurrence.

FDA-approved drugs that fall under this category include imiquimod and 5-fluorouracil. Some studies suggest that both agents are equally effective, but others favor imiquimod over 5-fluorouracil. For further information, you may read our previous article on chemotherapy creams.

Photodynamic therapy exposes skin cancer cells to enhanced blue or red light after the application of a light sensitizer. The success rate is between 70% and 90%. This treatment is recommended for superficial basal cell carcinoma occurring in multiples or growing near actinic keratosis lesions.

Immunotherapy injections deliver chemotherapy drugs like 5-fluorouracil, interferon, interleukin-2, and bleomycin into the lesion, strengthening the skin’s immune response against tumor cells. Common side effects include injection site soreness and flu-like symptoms. The effectiveness of these treatments is still debated, but interferon has been reported to work in up to 96% of cases.

Vismodegib and sonidegib are FDA-approved targeted therapies for basal cell carcinoma that may be considered if surgery and radiation aren’t viable options. Vismodegib may be used for metastatic (widespread) and locally advanced disease, while sonidegib is indicated only for locally invasive tumors. These medications can shrink basal cell cancer lesions but do not cure the disease.

Electrochemotherapy enhances cancer cell sensitivity to chemotherapy drugs, such as bleomycin, through electrical stimulation. This treatment may be considered for large, clustered lesions but, like targeted therapy, is only meant to ease symptoms and doesn’t provide a cure.

How Can You Prevent Basal Cell Carcinoma?

As with any skin cancer, avoiding excessive UV light exposure is the most effective way to prevent basal cell carcinoma. Staying off tanning beds, using sun protection, and limiting phototherapy to the recommended doses can help safeguard your skin. Higher nicotinamide intake can help counteract UV-induced immunosuppression, but more research is needed to confirm the role of this vitamin in skin cancer prevention.

For individuals diagnosed with basal cell carcinoma, the National Comprehensive Cancer Network recommends skin cancer screening every 6-12 months for the first two years, then annually for life. Everyone is encouraged to perform regular skin checks by self-examination, even without a skin cancer history.

Key Takeaways: Basal Cell Carcinoma Treatments

Basal cell cancer is a slow-growing skin tumor with numerous treatment options, including both surgical and non-surgical approaches. Mohs surgery provides the best cosmetic outcomes and the highest cure rates. However, non-surgical treatments such as radiotherapy and topical medications may be considered for individuals who cannot undergo or prefer to avoid surgery.

As with any type of cancer, prevention is always preferable over cure. However, when basal cell cancer does develop, prompt detection and treatment help reduce complications, maintain quality of life, and extend life expectancy.

Finally, skin cancer is a serious condition requiring expert care. This rule applies whether the tumor is slow-growing, like basal cell carcinoma, or aggressive, like invasive squamous cell skin cancer and melanoma. To get the best results from any skin cancer treatment, trust only a highly trained, board-certified dermatologist.

Not sure if it’s neck cancer? Ask LA’s top skin disease experts

Basal cell carcinoma is a tumor that develops gradually and may not cause symptoms at first. Many people mistake it for a harmless skin blemish and delay treatment until problems arise. If you have a persistent, suspicious skin lesion, seeing a skin expert is the safest course of action.

At BHSkin Dermatology, our skin cancer care specialists are some of the best in California. Our board-certified dermatologists have helped many patients regain their peace of mind, helping them navigate their treatment journey with skill and compassion. Visit our Glendale or Encino office or use our virtual portal for your first consultation.

Book your appointment today!

References:

1. Baba, P. U. F., Hassan, A. U., Khurshid, J., & Wani, A. H. (2024). Basal Cell Carcinoma: Diagnosis, Management and Prevention. Journal of Molecular Pathology. 5(2), 153-170. https://www.mdpi.com/2673-5261/5/2/10
2. Likhacheva, A., Awan, M., Barker, C. A., Bhatnagar, A., Bradfield, L., Brady, M. S., Buzurovic, I., Geiger, J. L., Parvathaneni, U., Zaky, S., & Devlin, P. M. (2020). Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline. Practical Radiation Oncology. 10(1), 8–20. https://www.sciencedirect.com/science/article/pii/S1879850019303236
3. Martel, J. L., Miao, J. H., Badri, T., & Fakoya, A. O. (2024). Anatomy, Hair Follicle. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470321/
4. Tang, J. Y., Epstein, Jr. E. H., & Oro, A. E. (2019). Chapter 111: Basal Cell Carcinoma and Basal Cell Nevus Syndrome. Fitzpatrick’s Dermatology, 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570&sectionid=210434418
5. Uchinomiya, K., & Tomita, M. (2023). A Mathematical Model for Cancer Risk and Accumulation of Mutations Caused by Replication Errors and External Factors. PLOS One. 18(6), e0286499. https://pmc.ncbi.nlm.nih.gov/articles/PMC10266611/

Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online