Basalioma in the practice of a dermatocosmetologist

Natalia Sachuk , chief physician of the Farmosa Medical Center, dermatovenerologist, trichologist, dermato-oncologist, cosmetologist, member of the All-Ukrainian Academy of Dermatovenerology, Association of Psoriasis, Association of Preventive and Anti-Aging Medicine, member of the Society of Trichologists of Ukraine, member of the All-Ukrainian Association of Dermatovenerologists and Cosmetologists of Ukraine (Ukraine)

Basal cell carcinoma: what is it?

Basal cell carcinoma is a malignant tumor, but with slow locally destructive growth and very little ability to metastasize, but untimely consultation with a doctor or incorrect treatment tactics can lead to fatal consequences. BCC arises from epidermal stem cells or precursor cells of the hair follicle. The main features of BCRC are:

• red spot or irritation in the face, neck, hands for more than 1 month;
• flat pink formation with elevation along the periphery;
• shiny pearl-colored knot;
• erosion or ulcer that does not heal for more than 1 month;
• scar zone with unclear contours and a shiny surface.

The main primary method for diagnosing BCC is dermatoscopy and diagnostic biopsy of the formation, as a result of which the histological picture will give the form of BCC. When dermatoscopy, a sign of BCC is a pronounced vascular pattern: tree-like vessels ⎼ in 95% of cases, linear - in 40%, polymorphic - in 20%, point vessels - in 10%.

BCC is divided into morphological forms, which differ in clinical presentation, localization, and degree of aggressiveness:

• superficial BCC - occurs in young patients on the upper body, often with multiple lesions. Externally, these are pink or red scaly spots, asymmetrical, often ulcerated and bleeding. The growth of this form is slow;
• nodular form of BCC - most often localized on the face, nose, ears, and back. Externally, it is a small, pink, shiny surface that rises above the skin like a knot, maybe with a crater in the central part. Bleeding occurs when it persists for more than six months, this is the reason to seek help from a specialist;
• sclerosing type of BCC - often found on the forehead, pale pink or waxy in color, there is a slight erosion in the central part, spreading along the nerves on the skin;
• pigmented type of BCC is a form in which the plaque is brown, gray-gray, with a cyanotic tint, may resemble melanoma, but upon histological examination it turns out that it is BCC;
• Basal squamous cell BCC is a combination of squamous cell and basal cell skin cancer, a very aggressive form with rapid growth.

Often this group of patients gets an appointment with a cosmetologist-esthetician, dermatocosmetologist, therefore, if the specialist does not have additional education in dermato-oncology, dermatoscopy, errors in diagnosis are possible. Clients often come for treatment of rosacea or to remove a “nodule”, and here it is important to understand that timely recognition of cancer will save lives and relieve negative consequences. The group of squamous cell and basal cell skin cancer is quite dangerous, and any manipulation in the area of the tumor can provoke active growth and progression of the disease. Such patients must be referred for treatment and follow-up to an oncologist.

Precancerous diseases of BCC

Basalioma very often appears at the site of precancerous skin diseases, which include: xeroderma pigmentosum, Bowen's disease, Paget's disease, Queyra's erythroplasia.

Xeroderma pigmentosum

This is a hereditary skin disease in which solar ultraviolet radiation causes irreversible changes in all layers of the epithelium. The cause of the disease is the congenital absence of an enzyme that destroys melanin released into the skin during tanning. In response to solar radiation, an inflammatory reaction appears, and subsequently atrophy with malignant tumor degeneration of individual foci.

Bowen's disease
It occurs due to the aggressive influence of solar insolation and aggressive chemicals on the skin. Clinically, the disease is manifested by the formation of a spot with uneven outlines, which over time transforms into a slowly growing plaque. The plaque has a smooth copper-colored surface, covered with scales, ulcers and cracks.

Paget's disease
It most often develops after 50 years in patients of both sexes. Its first manifestations include slight redness of the nipple or a certain area of the areola, with superficial peeling and increased sensitivity. Subsequently, burning, itching and pain occur, and serous-bloody discharge from the nipple appears. Classic symptoms are nipple retraction and the formation of an area on the areola and the skin around it that resembles an orange peel in appearance.

Erythroplasia Keira
An inflammatory skin disease of the glans penis and foreskin, often leading to the development of squamous cell or basal cell carcinoma. It develops more often in men aged 40 to 70 years. Clinically, it is a red shiny spot, a plaque on the mucous membrane of the head of the penis, often extending to the foreskin. The formation is painless to the touch and protrudes slightly above the surface of the skin. A disease with similar clinical manifestations that develops on the mucous membranes of the genital organs in women is described as Bowen's disease of the genital area.
There is another group of diseases that can be a precursor to basal cell carcinoma: keratoacanthoma, trophic ulcers, solar keratosis, seborrheic acanthoma, radiation ulcers, keloid scars, cutaneous horn, syphilitic gummas and granulomas.

Keratoacanthoma

A fairly common disease, which is a benign tumor of epithelial tissue, is located mainly in open areas of the body. Less commonly, it is found on the mucous membranes of the mouth, nose and genitals. It is characterized by rapid growth rates, despite the high degree of differentiation characteristic of benign tumors. Clinically, it manifests itself as a pink, red, sometimes bluish-colored node or plaque protruding above the surface of the skin, with an island of keratin in the center and raised crater-shaped edges. The typical size of this formation ranges from 1⎼5 cm.

Trophic ulcers

They are complications of metabolic diseases such as diabetes mellitus, obliterating atherosclerosis, and deep vein thrombosis of the lower extremities. In diabetes mellitus, ulcers occur more often on the feet. With arterial and venous insufficiency, ulcers develop on the legs and near the ankles. Visually, trophic ulcers are round, long-term non-healing skin defects. They are often painless to the touch, and their surface is constantly wet.

Solar keratosis
Its appearance is facilitated by a certain genetic predisposition and intense insolation. This type of keratosis consists of numerous foci of skin peeling, which become denser over time, rise above the surface of the skin and peel off.

Seborrheic acanthoma, or actinic keratosis

It develops mainly in elderly people and is a uniformly pigmented soft tumor covered with oily crusts. As the tumor grows, the crusts may crack and be rejected, being replaced by similar crusts located deeper. The growth of this formation is extremely slow, sometimes reaching several decades. Degeneration into basal cell carcinoma, according to various sources, occurs no more often than in 5–7% of cases.

Treatment

The most common mistake cosmetologists and dermatocosmetologists make is neglecting anamnestic data and the clinic. Specialists take on cryodestruction and electrocoagulation with a light hand, which leads to active growth of the tumor due to insufficient depth of removal, and the lack of observation in the post-rehabilitation period leads to a lack of timely treatment.

The choice of treatment method depends on the location of the tumor, morphological shape and age of the patient. The main methods are:

• radio wave, laser or surgical excision of the tumor and histological examination, cryosurgery;
• photodynamic therapy, immunotherapy, radiation, tergent therapy, which are mainly used when there are contraindications to surgical treatment methods.

Taking into account the appearance of tumors on exposed parts of the body, the importance of ultraviolet radiation is enormous for stimulating tumor growth, therefore it is very important to protect precancerous skin conditions from insolation and monitor them over time with dermatoscopy, especially if the patient has a hereditary predisposition to skin tumors.

Clinical case

Patient S., born in 1957, turned to a dermatocosmetologist, dermato-oncologist at the Farmosa Medical Center (Vinnitsa) in 2014 with complaints of a burst vessel under the eye, on the forehead, and chin. Examination with a dermatoscope revealed a marked vascular pattern with abnormal vessels, ulceration, and desquamation. From the anamnesis: they have existed for more than a year, have not been treated. Before this, there was the same spot on his nose, which he removed by cryodestruction in a beauty salon. After a while, new “burst vessels” appeared. The patient was sent for radio wave diagnostic biopsy using the Surgitron device, after which histological examination confirmed adenomatous type BCC with ulceration. With a diagnosis of BCRC, he was sent to oncologists for medical examination and subsequent treatment. Dermoscopic observation of facial skin is recommended 1⎼2 times a year.

This is an example where a primary mistake by a cosmetologist led to late diagnosis and progression of the disease.

First published: Les Nouvelles Esthetiques Ukraine 5 (99)/2016