Updated guidelines on the management of basal cell carcinoma (BCC) in adults were published in November 2021 by the British Association of Dermatologists (BAD), in the British Journal of Dermatology.[1]
Surgical Therapy
Offer standard surgical excision as a first-line treatment to adults with low-risk BCC.
Offer standard surgical excision with immediate reconstruction as a first-line treatment option to adults with primary BCC with a high-risk factor, if the BCC has well-defined clinical margins under bright lighting and magnification or dermoscopy.
Offer standard surgical excision with delayed definitive reconstruction, or Mohs micrographic surgery, as the first-line treatment option to adults with high-risk BCC in a high-risk anatomical site if the BCC has poorly defined clinical margins under bright lighting and magnification or dermoscopy.
For excision, recommended peripheral clinical surgical margins are 4 mm for low-risk BCC and at least 5 mm for primary BCC with a high-risk factor.
Ensure adequate excision at the deep margin to a clear plane, including a fat layer where present, and other deeper structures if needed.
Consider Mohs micrographic surgery in adults with primary BCC with at least one high-risk factor, or with advanced BCC. Offer it as a first-line treatment to adults with recurrent BCC with at least one other high-risk factor, especially if the tumor is at a high-risk site.
In adults with recurrent BCC with at least one other high-risk factor, consider standard surgical excision with at least a 5 mm margin and delayed definitive reconstruction.
Systemic Therapy
Offer vismodegib, if available, to adults with advanced BCC who are unsuitable for Mohs micrographic surgery, standard surgical excision, or radiotherapy, including patients with Gorlin syndrome, following multidisciplinary team discussion.
Radiotherapy
Offer radiotherapy as an option to adults (suggested age ≥ 60 years) with low-risk or high-risk BCC who are unsuitable for or decline Mohs micrographic surgery or standard surgical excision and who express a preference for radiotherapy, and in whom the lesion is:
A nodular BCC
An infiltrative subtype of BCC, provided a sufficient planning margin is used
An excised BCC with involved margins
Do not offer radiotherapy for recurrent BCC following previous radiotherapy, or for lesions associated with certain genetic syndromes predisposing to skin cancers, for example Gorlin syndrome or xeroderma pigmentosum. Discuss treatment alternatives at a multidisciplinary team meeting.
Do not routinely offer radiotherapy for a BCC that is:
On an area of poor blood supply (eg, the lower limbs)
In a younger patient (suggested age < 60 years), in whom the late effects of radiotherapy could be an issue
Invading bone or cartilage
Other Treatment Options
Offer topical imiquimod, topical 5-fluorouracil, cryosurgery, or topical photodynamic therapy to adults with low-risk BCC who are unsuitable for or decline standard surgical excision.
Management Following Primary Treatment
In adults with excised high-risk BCC with an involved histological margin, offer further standard surgical re-excision, if not contraindicated, after multidisciplinary team discussion.
Refer all adults with excised high-risk BCC with a close histological margin (< 1 mm) for multidisciplinary team discussion of management options, which may include surgical re-excision, Mohs micrographic surgery, radiotherapy, or monitoring.
Do not routinely offer follow-up to patients with adequately treated isolated BCC, unless for a postoperative review.
Offer, if possible, at least yearly follow-up to adults with a history of multiple BCCs who are likely to develop further tumors or recurrence within 12 months.
For more information, please go to Basal Cell Carcinoma.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Basal Cell Carcinoma Clinical Practice Guidelines (BAD, 2021) - Medscape - Dec 06, 2021.
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