Basal Cell Carcinoma Clinical Practice Guidelines (2019)

European Dermatology Forum, European Association of Dermato-Oncology, European Organization for Research and Treatment of Cancer

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 04, 2019

The guidelines on diagnosis and treatment of basal cell carcinoma (BCC) were released in September 2019 by the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization for Research and Treatment of Cancer.[1]

Classification and Diagnosis

The guidelines propose a new classification of BCC into two categories: easy to treat and difficult to treat.

For easy-to-treat BCCs, diagnosis is based on clinical and dermatoscopic features. Diagnosis by clinical examination confirmed on dermatoscopy, without histopathological examination, is acceptable for the following:

  • Small nodular subtype on typical locations such as the head/neck or trunk

  • Multiple BCCs in nevoid basal cell carcinoma syndrome (NBCCS)

  • Superficial subtype located on the trunk and extremities

Dermatoscopic criteria for BCC are as follows:

  • Absence of brown reticular lines (pigment network)

  • Branching and linear vessels (arborizing and superficial telangiectasias)

  • Multiple erosions

  • Ulceration

  • Bluish-gray clods of variable size (ovoid nests and globules and focused dots)

  • Radial lines connected to a common base (leaf-like areas)

  • Radial lines converging to a central dot or clod (spoke-wheel areas)

  • Clods within a clod (concentric structure)

Histological diagnosis may not be required in superficial and small nodular (<1 cm) BCCs in low-risk areas, if clearly diagnosed clinically and/or with noninvasive techniques.

Aided noninvasive diagnosis with dermatoscopy, reflectance confocal microscopy, and/or optical coherence tomography can improve the diagnostic accuracy in difficult-to-recognize BCCs. Histopathological confirmation is mandatory in ambiguous lesions and in BCCs located in high-risk areas.

Difficult-to-treat BCCs include all locally advanced BCCs and also common BCCs that pose specific management problems, for reasons such as the following:

  • Technical difficulty of maintaining function and aesthetics due to the size or location (eyes, nose, lips and ears) of the tumor

  • The poorly defined borders often associated with morpheaform subtype or prior recurrence

  • Multiple prior recurrences on the face (often requiring much larger excision)

  • Prior radiotherapy

  • Patient reluctance to accept the consequences of surgery

  • Patient comorbidities interfering with surgery


The first-line treatment of easy-to-treat BCC is complete surgery.

In low-risk BCCs, a safety margin of 3-4 mm is recommended for standard excisions with 2D histology.

Microscopically controlled surgery should be offered for high-risk BCC, recurrent BCC, and BCC in critical anatomical sites. In high-risk BCCs for which micrographic surgery is not accessible, a variable safety margin of 5-15 mm should be chosen, based on individual tumor characteristics.

If narrow but histologically free margins are reported, re-excision may not be required. Lesions that have been incompletely excised—especially high-risk BCCs and those incompletely removed at the deep margin—require re-excision.

Topical agents (5% imiquimod, 5% fluorouracil) should be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial BCC and thin nodular BCC.

Destructive  therapies with curettage, electrocautery (electrodesiccation), cryotherapy, and laser ablation are therapeutic options for small, low-risk BCC on the trunk and extremities and for multiple small BCCs.

Topical or destructive (blind) treatments should be avoided in BCCs that are at risk for recurrence.

Photodynamic therapy with 5-aminolevulinic acid (5-ALA) or methyl-5-amino-4-oxopentanoate (MAL) in combination with red light is an effective treatment for superficial and thin nodular BCC.

 The therapy for a 'difficult-to-treat' BCC should preferentially be discussed by a multidisciplinary tumor board.

Hedgehog inhibitors (vismodegib or sonidegib) should be offered to patients with locally advanced and metastatic BCCs. Immunotherapy with anti-programmed cell death 1 (PD-1) antibodies is a promising therapeutic option, currently being investigated in clinical trials.

Radiotherapy represents a valid alternative to surgery for BCC on the face, especially in elderly patients.

In patients with NBCCS, close surveillance and regular skin examinations are required to diagnose and treat BCCs at early stage.


Follow-up for patients with BCC should be at 3-, 6-, or 12-month intervals, according to the risk category.

Long-term follow-up is recommended in patients with high-risk BCC subtypes, high-risk sites, multiple BCCs, and NBCCS.

For more information, see Basal Cell Carcinoma. For more Clinical Practice Guidelines, please go to Guidelines


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