1) Disease Description (Causes and Symptoms)
- Definition summary: A malignant tumor originating from non-keratinizing cells of the epidermis and its appendages (basal layer); a skin cancer (non-melanoma) that locally invades but very rarely metastasizes.
- Main causes and pathophysiology:
- Long-term exposure to ultraviolet light (especially UVB) is a major risk factor. Intermittent, intense short-term exposure (sunburn) may be more dangerous.
- Mutations in tumor suppressor genes and abnormalities in the Hedgehog signaling pathway are involved in the carcinogenic mechanism.
- The risk of occurrence increases in immunosuppressed states (after organ transplantation, HIV, etc.).
- Main symptoms (including clinical types):
- Nodular type (most common): Small, translucent, shiny nodule with dilated superficial capillaries and central ulceration (a “rodent ulcer” appearance).
- Pigmented type: Brown/black lesion due to melanin → requires differentiation from melanoma.
- Sclerosing type (morpheaform): Smooth, hard plaque-like lesion with indistinct margins and a high recurrence rate.
- Superficial type: Multiple erythematous, scaly lesions, mainly on the trunk and limbs.
- Commonly occurs on the face (nose, around the eyes, forehead, etc.) and sun-exposed areas. It grows slowly but can destroy local tissue.
- Diagnosis: Confirmed by a skin biopsy (tissue sampling followed by histopathological examination).
2) Treatment Methods and Precautions
- Standard treatment
- Surgical excision (standard excision): After securing an appropriate excision margin according to the size and location of the lesion, reconstruction is performed (primary closure, flap, or graft).
- Mohs micrographic surgery: Strongly recommended as the first choice for high-risk recurrent lesions, when tissue preservation is important such as on the face, or when the margins are unclear. The recurrence rate is low (provided data: approximately 5.3% after conventional excision and approximately 1.3% after Mohs surgery).
- Nonsurgical options (such as low-risk superficial lesions)
- Topical treatment: 5% 5-fluorouracil (topical), imiquimod, etc.
- Photodynamic therapy (PDT)
- Curettage and electrodessication (small, low-risk lesions)
- Cryotherapy (some small superficial lesions)
- Radiation therapy: When surgery is difficult or as adjuvant therapy after surgery (especially for elderly patients or patients unable to undergo surgery).
- Systemic treatment (advanced/metastatic BCC)
- Hedgehog pathway inhibitors (e.g., vismodegib, sonidegib) — used for locally advanced or metastatic BCC. Monitoring is necessary because of adverse effects (muscle spasms, decreased sense of taste/loss of appetite, hair loss, weight loss, etc.).
- Considerations when selecting treatment: Location of the lesion, histologic type (sclerosing, recurrent, etc.), patient age and overall health, and cosmetic and functional outcomes.
- Complications and precautions (including self-care)
- Possibility of local tissue destruction, scarring, and reconstruction failure.
- Infection, bleeding, and nerve damage (depending on the location).
- Possibility of recurrence (especially with sclerosing, poorly demarcated, or recurrent lesions).
- Metastasis is possible, although rare (metastatic rate in the provided data: 0.0028–0.55%). Prognosis is poor after metastasis (provided data: average survival of approximately 8–10 months).
- Patients who are immunosuppressed should undergo follow-up more frequently.
- Prevention and lifestyle management
- Routine protection from ultraviolet light (use sunscreen with SPF, wear hats and protective clothing, and avoid periods of intense sunlight).
- Observe existing lesions and perform skin self-examinations (monitor for new lesions and changes in existing lesions).
- Although recommendations related to smoking and alcohol have a weak direct association with lesion progression, management is recommended considering overall wound healing and surgical risks.
3) Checklist Before an Outpatient Visit (Including Examples of Items and Records to Prepare)
- Items/materials to bring
- A list of currently used medications (including prescription and nonprescription drugs and supplements) and allergy information.
- History of previous skin cancer, prior surgery, and biopsy results (if available, the pathology report).
- Inform the doctor in advance about anticoagulants and antiplatelet agents being taken (e.g., warfarin, aspirin, DOACs, etc.).
- Photographs of the lesion (photographs showing changes over time are useful).
- Symptom records
- When the lesion first appeared and changes in its size (when it began and how quickly it has grown).
- Changes in symptoms such as pain, bleeding, ulceration, and itching.
- Previous treatments (medication, cryotherapy, curettage, etc.) and whether they were effective.
- Other points to confirm
- Whether the patient is immunosuppressed (transplantation, steroid or anticancer drug use, etc.), family history (skin cancer), and frequency of occupational or recreational sun exposure.
Example list of questions (to check for yourself during the outpatient visit)
- Has the size of the lesion changed during the past 6 months?
- Do any of the medications currently being taken include anticoagulants or immunosuppressants?
- Have you previously received treatment on the same area?
4) Examples of General Questions to Ask the Doctor
- What is the exact histologic type of this lesion (nodular, sclerosing, superficial, etc.)?
- What treatment options do you recommend, and what are the advantages and disadvantages of each?
- If I undergo surgery, what will the extent of excision and the scar be like? Will reconstruction be necessary?
- Is Mohs surgery necessary in this situation? What are the advantages and limitations of Mohs surgery?
- What is the risk of recurrence, and what is the recommended follow-up schedule?
- If systemic treatment (a Hedgehog inhibitor) is needed, what are the adverse effects and how are they managed?
- Are there any medications (e.g., anticoagulants) that I should stop taking before or after surgery?
5) Examples of Disease-Specific Questions
- Is Mohs surgery appropriate for treating this lesion, or would standard excision be sufficient? (A decision based on the location, size, and histologic type is necessary.)
- If the lesion recurs or has extensive local invasion, are systemic examinations (CT/MRI/lymph node evaluation) necessary? If so, which tests do you recommend?
Additional guidance: If you have a suspicious lesion or have already undergone a biopsy, bring the pathology report and a list of your current medications and consult a dermatologist or plastic surgeon.