Dermoscopy of basal cell carcinoma

Learning objectives
Introduction
Pigmented basal cell carcinoma
Non-pigmented basal cell carcinoma
Activity

Learning objectives

• Describe dermoscopic features of basal cell carcinoma

Introduction

Dermoscopy is useful to distinguish pigmented basal cell carcinoma from other pigmented lesions. There are specific features that help to distinguish these. Pigment may be grey, brown, blue or black. They are rarely completely pigmented in white-skinned individuals.

Pigmented basal cell carcinoma

The dermoscopic features of pigmented basal cell carcinoma include:

• Absence of pigment network
• Linear and arborising (branch-like) telangiectasia
• Structureless or leaf-like areas on the periphery of the lesion
• Large blue-grey ovoid nests or blotches
• Multiple blue-grey globules
• Specks of brown and grey pigment
• Spoke wheel areas (radial projections from a well circumscribed dark central hub)
• Focal ulceration

Pigmented basal cell carcinoma

Blue ovoid nests and structureless areas	Arborising blood vessels, structureless areas flecks of pigment and blue-grey globules	Focal ulceration structureless areas and flecks of pigment	Ulceration telangiectasia leaf-like areas and flecks of pigment
Spoke-wheel pigmentation and structureless areas	Flecks of pigment in structureless areas	Arborising telangiectasia and specks of brown pigment in structureless areas	Flecks of pigment and blue ovoid masses in structureless areas
Flecks of pigment and telangiectasia within pink nodule	Deeply pigmented border resembling melanoma	Multicoloured lesion resembling melanoma	Large nodule resembling melanoma

In some cases, it may be difficult to distinguish deeply pigmented or even non-pigmented basal cell carcinoma from melanoma.

Non-pigmented basal cell carcinoma

Non-pigmented basal cell carcinomas are much more common than pigmented basal cell carcinoma. It's surprising how often they contain flecks of colour however.

Experienced dermoscopists can often diagnose superficial basal cell carcinomas by their typical bluish-pink colour, asymmetrical arborising vessels and focal ulceration. Slight scaling and white areas of regression may also be present.

Nodular basal cell carcinomas lose the blue hue and instead have a white rim around central ulceration. Milia may be present.

Non-pigmented basal cell carcinoma

Bluish, scale, ulceration, regression	Subtle blue colour	Milia formation	Prominent vasculature
Vascular bcc	Crusting, telangiectasia	White nodule, telangiectasia, ulceration	Tiny ulcers

Activity

Imiquimod cream has restricted subsidy by PHARMAC for treating certain superficial basal cell carcinomas (New Zealand, September 2008). Observe the inflammatory response to treatment using dermoscopy.

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