Clinical Challenge: Asymptomatic Plaque on the Jaw - MPR

Clinical Challenge: Asymptomatic Plaque on the Jaw

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An 88-year old, fair-skinned woman is referred to the dermatology clinic from an extended care facility for evaluation of a skin lesion on her left jaw. According to her caretaker, the lesion has been present for months, and the patient has not experienced any discomfort or bleeding. Medical history includes treatment for a basal cell carcinoma on her temple as well as cryosurgical destruction of actinic keratoses on her arms. Physical examination reveals a 2cm erythematous, indurated plaque.

Basal cell carcinoma (BCC) is the most common form of skin cancer, with the risk steadily increasing with age.1 More than 80% of lesions are located on sun-exposed areas, and people with fair skin are at increased risk; genetic predisposition is...

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Basal cell carcinoma (BCC) is the most common form of skin cancer, with the risk steadily increasing with age.1 More than 80% of lesions are located on sun-exposed areas, and people with fair skin are at increased risk; genetic predisposition is a major contributing factor to the development of BCC.2 

BCC is commonly found in association with facial telangiectasias, lentigines, and actinic keratoses.2 Approximately 78% of BCCs are classified as nodular; other variants include pigmented and superficial (15%) and morpheaform (<7%).3

Morpheaform, or sclerosing, BCC presents as a solitary, pink-to-white indurated plaque or depression with a poorly defined border. The surface can be shiny or scar-like and lacks telangiectasias and pearliness − 2 characteristics of the more common nodular variant.

Histopathologic examination reveals strands of basaloid cells interspersed with dense collagen. Because of the atypical presentation and aggressive nature, morpheaform BCC is often treated with Mohs micrographic surgery to prevent recurrence.4,5

Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

References

1. Lomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer.  Br J Dermatol. 2012;166(5):1069-1080.

2. Kasumagic-Halilovic E, Hasic M, Ovcina-Kurtovic N. A clinical study of basal cell carcinomaMed Arch. 2019;73(6):394-398.

3. Scrivener Y, Grosshans E, Cribier B. Variations of basal cell carcinomas according to gender, age, location, and histopathological subtypeBr J Dermatol. 2002;147(1):41-47.

4. Kim JYS, Kozlow JH, Mittal B, et al; Work Group. Guidelines of care for the management of basal cell carcinomaJ Am Acad Dermatol. 2018;78(3):540-559.  

5. Zloty D, Guenther LC, Sapijaszko M, et al; Canadian Non-melanoma Skin Cancer Guidelines Committee. Non-melanoma skin cancer in Canada chapter 4: management of basal cell carcinomaJ Cutan Med Surg. 2015;19(3):239-248.