Basal Cell Carcinoma

From Heather Brannon, MD,

Your Guide to Skin Conditions / Acne.
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Basic Information About Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common type of skin cancer. It occurs more often
in men than in women. The incidence of this skin cancer among Caucasians in the US is .
19% per year, and the incidence is increasing worldwide. Most basal cell carcinoma is
seen after the age of 40, but those seen in patients who are younger than 35 tend to be
more aggressive.
What is Basal Cell Carcinoma?
Basal cell carcinoma arises in cells called basal keratinocytes in the deepest layer of the
epidermis, hair follicles, and sweat ducts. UVB radiation is important for the induction of
this skin cancer damaging DNA and its repair system, also causing mutations in tumorsuppressing genes. Basal cell carcinoma grows by direct extension and appears to rely on
the surrounding supportive tissue to grow. Therefore, it does not metastasize through
blood vessels or lymphatics. Its course is unpredictable. It may grow slowly for years,
then suddenly grow rapidly.
Basal Cell Carcinoma Risk Factors
Some common risk factors for basal cell carcinoma include:

Chronic sun exposure mainly to UVB radiation but also UVA

A history of repeated sunburns or childhood exposure to the sun
A suppressed immune system
HIV disease
Ionizing radiation used for acne in the 1940's
Fair skin and the propensity to freckle or burn rather than tan
Some rare risk factors for basal cell carcinoma include:

Exposure to arsenic
A condition called granuloma inguinale
Scarred or previously damaged skin, especially radiation damage
Rare genetic diseases such as xeroderma pigmentosa, nevoid basal cell carcinoma
syndrome, and albinism
Appearance of Basal Cell Carcinoma
The skin changes caused by this skin cancer depend on the type of basal cell carcinoma
involved. The most common appearance is of a raised pink or pearly white bump that

may have a translucent, rolled, pearly edge and small visible blood vessels. Some basal
cell carcinomas are pigmented and may look like a mole with a pearly border. Another
type is flat and scaly with a waxy appearance and an indistinct border. All of the basal
cell carcinoma types have a tendency to bleed with minimal to no trauma. If the lesion
has invaded the surrounding tissues, it may be fixated and difficult to move. 85% occur
on the face and neck since these areas are the most exposed to the sun.
Pictures of Basal Cell Carcinoma
The following pictures show various basal cell carcinoma lesions:

Basal cell carcinoma on the face

Basal cell carcinoma on the nose
Pigmented basal cell carcinoma
Spreading basal cell carcinoma on the back
Basal cell carcinoma behind the ear
Diagnosis of Basal Cell Carcinoma
The only way to diagnose basal cell carcinoma is to biopsy suspicious looking lesions.
The preferred type of biopsy is called a shave biopsy in which the lesion is shaved off
with a flexible razor. Depending on the extent of the skin cancer, another biopsy option is
to excise the lesion. Useful information such as whether the complete tumor was removed
and tumor depth can only be obtained by biopsy.

Options for Treating Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common type of skin cancer. It typically spreads
locally and does not metastisize. Basal cell carcinoma grows very slowly over a period of
years, then can expand rapidly. It is diagnosed by biopsy, and treatment options depend
on information gleaned from the biopsy. Find out more about risk factors for basal cell
carcinoma.
Pictures of Basal Cell Carcinoma
The following pictures show various basal cell carcinoma lesions:

Basal cell carcinoma on the face

Basal cell carcinoma on the nose
Pigmented basal cell carcinoma
Spreading basal cell carcinoma on the back
Basal cell carcinoma behind the ear
Treating Basal Cell Carcinoma with Electrodessication and Curettage
Electrodessication and curettage involves destroying the tumor with an electrocautery
device then scraping the area with a curette.

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Many times the diseased tissue can be differentiated from the normal tissue by the texture
felt while scraping. This process is repeated several times to ensure complete removal of
the tumor. This procedure is useful for small tumors less than 6 mm because it tends to
leave a scar.
Treating Basal Cell Carcinoma with Simple Excision
This procedure involves surgical excision of the lesion including a margin of normal skin.
This method is preferred for larger lesions (>2cm) on the cheek, forehead, trunk, and
legs. The advantage of this treatment is that it is quick and inexpensive. However, the
difference between normal and cancerous tissue must be judged with the naked eye.
Treating Basal Cell Carcinoma with Mohs' Micrographic Surgery
Mohs' micrographic surgery is a special type skin surgery that must be performed by an
experienced Mohs' surgeon. It involves excision of the tumor and immediate examination
of the tissue under the microscope to determine margins. If any residual tumor is left, it
can be mapped out and excised immediately. The process of excision and examination of
margins may have to be repeated several times. The advantage of this technique is that it
is usually definitive and has been reported to have a lower recurrence rate than other
treatment options. The disadvantage is the time and expense involved.
Treating Basal Cell Carcinoma with Radiation Therapy
This procedure involves a course of radiation therapy to the tumor area. It is used for
some primary tumors in patients who are not fit for surgery or have inoperable tumors. It
may also be used where tumors are difficult to excise or where it is important to preserve
surrounding tissue such as the lip. Its use is declining.
Treating Basal Cell Carcinoma with Cryotherapy
Cryotherapy involves destroying the tissue by freezing it with liquid nitrogen. This may
be effective for small, well-defined superficial tumors. It is also used effectively for the
treatment of actinic keratosis, a premalignant condition. This procedure is inexpensive
and time-efficient but can only be used in a small number of cases.
Prevention of Basal Cell Carcinoma

Avoid UVB radiation from sun exposure especially midday sun

Use protective clothing

Use sunscreen with an SPF of at least 15. This is especially important for
children.
Have suspicious lesions checked out - If you have a question, get it checked out.
Treating premalignant lesions prevents their transformation to potentially metastatic
cancers.

Effects of Sun on the Skin

From Heather Brannon, MD,
Your Guide to Skin Conditions / Acne.
FREE Newsletter. Sign Up Now!

Cellular Skin Changes Caused by UV Radiation

Sunlight has a profound effect on the skin causing premature skin aging, skin cancer, and
a host of skin changes. Exposure to ultraviolet light, UVA or UVB, from sunlight
accounts for 90% of the symptoms of premature skin aging. Many skin changes that were
commonly believed to be due to aging, such as easy bruising, are actually a result of
prolonged exposure to UV radiation.
What is UV Radiation?
The sun gives off ultraviolet radiation that we divide into categories based on the
wavelength.

UVC - 100 to 290 nm

UVB - 290 to 320 nm
UVA - 320 to 400 nm
UVC Radiation
UVC radiation is almost completely absorbed by the ozone layer and does not affect the
skin. UVC radiation can be found in artificial sources such as mercury arc lamps and
germicidal lamps.

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UVB Radiation
UVB affects the outer layer of skin, the epidermis, and is the primary agent responsible
for sunburns. It is the most intense between the hours of 10:00 am and 2:00 pm when the
sunlight is brightest. It is also more intense in the summer months accounting for 70% of
a person's yearly UVB dose. UVB does not penetrate glass.
UVA Radiation
UVA was once thought to have a minor effect on skin damage, but now studies are
showing that UVA is a major contributor to skin damage. UVA penetrates deeper into the
skin and works more efficiently. The intensity of UVA radiation is more constant than
UVB without the variations during the day and throughout the year. UVA is also not
filtered by glass.
Damaging Effects of UVA and UVB
Both UVA and UVB radiation can cause skin damage including wrinkles, lowered
immunity against infection, aging skin disorders, and cancer. However, we still do not
fully understand the process. Some of the possible mechanisms for UV skin damage are
collagen breakdown, the formation of free radicals, interfering with DNA repair, and
inhibiting the immune system.
Collagen Breakdown
In the dermis, UV radiation causes collagen to break down at a higher rate than with just
chronologic aging. Sunlight damages collagen fibers and causes the accumulation of
abnormal elastin. When this sun-induced elastin accumulates, enzymes called
metalloproteinases are produced in large quantities. Normally, metalloproteinases
remodel sun-injured skin by manufacturing and reforming collagen. However, this
process does not always work well and some of the metalloproteinases actually break
down collagen. This results in the formation of disorganized collagen fibers known as
solar scars. When the skin repeats this imperfect rebuilding process over and over
wrinkles develop.
Free Radicals
UV radiation is one of the major creators of free radicals. Free radicals are unstable
oxygen molecules that have only one electron instead of two. Because electrons are found
in pairs, the molecule must scavenge other molecules for another electron. When the
second molecule looses its electron to the first molecule, it must then find another
electron repeating the process. This process can damage cell function and alter genetic
material. Free radical damage causes wrinkles by activating the metalloproteinases that
break down collagen. They cause cancer by changing the genetic material, RNA and
DNA, of the cell.
DNA Repair
UV radiation can affect enzymes that help repair damaged DNA. Studies are being
conducted looking into the role a specific enzyme called T4 endonuclease 5 (T4N5) has
in repairing DNA.

Immune System Effects

The body has a defense system to attack developing cancer cells. These immune system
factors include white blood cells called T lymphocytes and specialized skin cells in the
dermis called Langerhans cells. When the skin is exposed to sunlight, certain chemicals
are released that suppress these immune factors.
Cell Death
The last line of defense of the immune system is a process called apoptosis. Apoptosis is
a process of cell-suicide that kills severely damaged cells so they cannot become
cancerous. This cell-suicide is seen when you peel after a sunburn. There are certain
factors, including UV exposure, that prevent this cell death allowing cells to continue to
divide and possibly become cancerous.

Effects of Sun on the Skin

From Heather Brannon, MD,
Your Guide to Skin Conditions / Acne.
FREE Newsletter. Sign Up Now!

Visible Skin Changes Caused by UV Radiation

Texture Changes Caused by the Sun
UV exposure causes thickening and thinning of the skin. Thick skin is found in coarse
wrinkles especially on the back of the neck that do not disappear when the skin is
stretched. A condition called solar elastosis is seen as thickened, coarse wrinkling and
yellow discoloration of the skin. A common effect of UV exposure is thinning of the skin
causing fine wrinkles, easy bruising, and skin tearing.

Picture of changes in facial skin with age

Blood Vessel Changes Caused by the Sun
UV radiation causes the walls of blood vessels to become thinner leading to bruising with
only minor trauma in sun-exposed areas. For example, most of the bruising that occurs on
sun-damaged skin occurs on the backs of the hands and forearms not on the inside of the
upper arm or even the inside of the forearm.

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The sun also causes the appearance of telangiectasias, tiny blood vessels, in the skin
especially on the face.
Picture of telangiectasias on the leg
Picture of telangiectasias on the arm
Pigment Changes Caused by the Sun
The most noticeable sun-induced pigment change is a freckle or solar lentigo. Lightskinned people tend to freckle more noticeably. A freckle is caused when the melaninproducing cell, or melanocyte, is damaged causing it to get bigger. Large freckles, also
known as age spots or liver spots, can be seen on the backs of the hands, chest, shoulders,
arms, and upper back. These are not actually age related but sun-damage related. UV
exposure can also cause white spots especially on the legs, but also on the backs of the
hands and arms, as melanocytes are destroyed.

Picture of solar lentigo on the back

Picture of solar lentigo on the arm
Skin Bumps Caused by the Sun
UV radiation causes an increased number of moles in sun-exposed areas. Sun exposure
also causes precancerous lesions called actinic keratoses that develop especially on the
face, ears, and backs of the hands. The are small crusty bumps that can often be felt better
than they can be seen. Actinic keratoses are felt to be premalignant lesions because 1 in
100 cases per year will develop into squamous cell carcinoma. UV exposure also causes
seborrheic keratoses, which are warty looking lesions that appear to be "stuck on" the
skin. In contrast to actinic keratoses, seborrheic keratoses do not become cancerous.

Picture of actinic keratoses - close up

Picture of actinic keratoses - scalp
Picture of actinic keratoses - arm
Picture of actinic keratoses - ear
Picture of seborrheic keratosis
Skin Cancer Caused by the Sun
The ability of the sun to cause skin cancer is a well-known fact. The 3 main skin cancers
are melanoma, basal cell carcinoma, and squamous cell carcinoma. Melanoma is the most
deadly skin cancer because it metastasizes more readily than the other skin cancers. It is
believed that the amount of exposure of the skin to the sun before the age of 20 is actually
the determining risk factor for melanoma. Basal cell carcinoma is the most common skin
cancer and tends to spread locally, not metastasize. Squamous cell carcinoma is the
second most common skin cancer, and it can metastasize although not as commonly as
melanoma. The risk of getting basal cell carcinoma or squamous cell carcinoma is
determined by a person's lifetime exposure to UV radiation and the person's pigment
protection.

Picture of basal cell carcinoma

Picture of squamous cell carcinoma
Picture of melanoma

Proper Use of Sunscreen

Exposure to ultraviolet light, UVA or UVB, from sunlight accounts for 90% of the
symptoms of premature skin aging such as wrinkles and skin cancers. The most
important skin-care product available to prevent wrinkles and skin cancer is
sunscreen, but most people do not use sunscreen correctly.
Important factors to consider with sunscreen use are the
spectrum of UV radiation absorbed, the amount of
sunscreen applied, and the frequency of application.
UV Radiation
The sun gives off ultraviolet (UV) radiation that we divide
into categories based on the wavelength. UVC radiation is
absorbed by the atmosphere and does not cause skin
damage. UVB radiation affects the outer layer of skin, the
epidermis, and is the primary agent responsible for
sunburns. UVB does not penetrate glass, and the intensity
of UVB radiation depends on the time of day and the
season. UVA radiation penetrates deeper into the skin and
works more efficiently. The intensity of UVA radiation is
more constant than UVB without the variations during the
day and throughout the year. UVA is also not filtered by
glass.
Sunscreen Ingredients
Sunscreens ingredients can be divided into compounds that
physically block radiation or compounds that absorb
radiation. The radiation blockers are very effective at
reducing the exposure of the skin to both UVA and UVB
radiation. Older formulations like zinc oxide are opaque and
may be cosmetically unacceptable. However, a newer
formulation of micronized titanium dioxide is not as opaque
and provides excellent protection. The radiation absorbing
ingredients are differentiated by the type of radiation they
absorb - UVA absorbers and UVB absorbers.

Join the Discussion

"Has anyone found a way to
make sunscreen use a part of
their daily skin care routine? If
so, how do you do it?"
Your Opinion

Related Resources

Effects of Sun on the Skin

UVB Absorbers
UVA Absorbers
What is SPF?
Aging Skin Links
Skin Cancer Links

From Other Guides

Sunscreen and Children
Safer Sunning

Elsewhere on the Web

Aging Skin Pictures
FDA Sunscreen Information
Sun Essentials

Picking the Proper Sunscreen

The SPF measures the amount of UVB absorption, but there is no method of
reporting the UVA absorption. The only way to determine if a sunscreen protects
against UVA and UVB radiation is to look at the ingredients. A good broad-spectrum
sunscreen should have an SPF of at least 15 and contain avobenzone, titanium
dioxide, or zinc oxide.
Applying Sunscreen Properly
Most people use sunscreen improperly by not applying enough. They apply only 25%

to 50% of the recommended amount. Sunscreen should be applied liberally enough

to all sun-exposed areas that it forms a film when initially applied. It takes 20-30
minutes for sunscreen to be absorbed by the skin, so it should be applied at least a
half an hour before going out in the sun. Sunscreen should also be the last product
applied especially on the face since some sunscreens can break down in the presence
of water contained in water-based foundations and moisturizers.
Reapplying Sunscreen
Most instructions on sunscreen labels recommend reapplying sunscreen "frequently",
but the definition of "frequently" is vague. A common instruction is to reapply
sunscreen after 2-4 hours in the sun. However, one study has shown that reapplying
sunscreen 20 to 30 minutes after being in the sun is more effective than waiting 2
hours. It is possible that this time period is more effective because most people do
not apply enough sunscreen initially, and this second application approximates the
actual amount needed. Sunscreen should also be reapplied after swimming,
excessive sweating, or toweling.
Daily Sunscreen
Sunscreen should be applied daily. The daily use of a low-SPF sunscreen (15) has
been shown to be more effective in preventing skin damage than the intermittent
use of a higher SPF sunscreen.
Sunscreen and Insect Repellents
Insect repellents reduce the sunscreen's SPF by up to one-third. When using
sunscreen and insect repellent together, a higher SPF should be used and reapplied
more often.

What is SPF?
From Heather Brannon, MD,
Your Guide to Skin Conditions / Acne.
FREE Newsletter. Sign Up Now!
SPF stands for Sun Protection Factor. The number is determined experimentally indoors
by exposing human subjects to a light spectrum meant to mimic noontime sun. Some
subjects wear sunscreen and others do not. The amount of light that induces redness in
sunscreen-protected skin, divided by the amount of light that induces redness in
unprotected skin is the SPF. It is mainly a measure of UVB protection and ranges from 1
to 45 or above.
A sunscreen with an SPF of 15 filters 92% of the UVB. Put another way, a sunscreen
with an SPF of 15 will delay the onset of a sunburn in a person who would otherwise
burn in 10 minutes to burn in 150 minutes. The SPF 15 sunscreen allows a person to stay
out in the sun 15 times longer.

There is currently no uniform measure of UVA absorption. There are broad-spectrum

sunscreens that protect against UVA and UVB radiation although it is important to
remember that the SPF does not predict UVA protection.

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The UV Index is a public health education tool reported by meteorologists in 58 U.S.
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The "protectiveness" of clothing can also be measured by SPF. The following are SPF's
of various types of clothing:

Nylon Stockings - SPF 2

Hats - SPF 3-6
Summer-weight clothing - SPF 6.5
Sun-protective clothing - up to SPF 30

Basal Cell Carcinoma Risk Factors

From Lisa Fayed,
Your Guide to Cancer.
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What Causes Basal Cell Carcinoma?

Basal cell carcinoma is the most commonly diagnosed type of skin cancer. It is estimated
that 75% of non-melanoma skin cancer cases are basal cell carcinomas. So, what exactly
causes it?
UV Rays
Ultraviolet rays from the sun and from tanning beds are the primary risk factors for
developing BCC. It is important to stay out of the sun during its peak times (10 a.m.-2
p.m.), as this is when the sun's rays are at their hottest. When outdoors, wear sunscreen,
even when it is shady!
Skin Tone

Fair skinned people have a higher risk factor for developing basal cell carcinoma. Keep
in mind that when exposed to UV rays, all skin tones are at risk!
Basal Cell Nevus Syndrome
This syndrome is a genetic disorder that causes tumors to develop at early ages.

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People with syndromes like basal cell nevus syndrome, are more sensitive to UV rays.
Other Factors
Other risk factors for development include radiation therapy treatment and immune
suppression therapy.
The bottom line is that the best defense for the average, healthy person against BCC is
the use of sun screen! Br sun smart- an ounce of prevention is really worth a pound of
cure when it comes to skin cancer!