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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.6 Rio de Janeiro Nov./Dec. 2004
WHICH IS YOUR DIAGNOSIS?
Maurício ZaniniI; Carlos D'Apparecida Santos Machado FilhoII; Fábio TimonerIII; José Antônio TebcheraniIV
IEffective Member of the Brazilian Society
of Dermatology, resident in Dermatological Surgery of the ABC Faculty of Medicine
IIPh.D. in Medicine, Effective Member of Brazilian Society of Dermatology, Head Intern of the ABC Faculty of Medicine Dermatology Department
IIIEffective Member of the Brazilian Dermatology Society, Auxiliary Professor of Dermatological Surgery of the ABC Faculty of Medicine Dermatology Department
IVPathological M.D. of the ABC Faculty of Medicine and Padre Bento Hospital Complex
HISTORY OF THE DISEASE
A 46 year-old female patient, a housewife with Fitzpatrick phototype III, complained of a facial stain that had evolved over three years. She referred to slow growth with periods of improvement during the winter, and worsening in the summer. The use of a medicinal barrier balm led to partial improvement. The patient denied having other cutaneous lesions. As for morbidity and family background, nothing special was worth mentioning. The physical examination was normal. A slightly atrophic and erythematous lesion was observed in the left upper labial region. It was not infiltrated, had ordinary boundaries, was scarcely perceptible and was oval shaped, 2x1.5 cm (Figure 1).
The clinical hypotheses established for the case were seborrheic dermatitis, contact dermatitis, perioral dermatitis, erythematous lupus, Bowen's disease and basal cell carcinoma. The final diagnosis was obtained by histopathology, and confirmed superficial basal cell carcinoma (BCC). The patient was given topical 5-fluorouracil 5% cream (5FU) for daily application. The condition began showing resolution three months after treatment began. There was no recurrence of the disease after a year of follow up.
BCC is a malignant tumor that is most common in human beings. It was first described by Jacob in 1827.1,2 BCC is responsible for 70% of non melanoma cutaneous cancers.3 It usually emerges as of the 30th year of age. The most common locations for developing BCC display a high density of sebaceous glandules, and most particularly on the face. Eighty-five percent of cases arise on the head and throat, most commonly on the nasal pyramid (30%).1 In a recent retrospective Brazilian study, females had a higher incidence of the tumor (55.7%).2
While the origin of BCC is still debated, it is thought to start from the basal layer and/or outer edge of the pilosus follicle.1 Ultraviolet radiation is considered the main precipitating factor of the neoplasia. However other ionizing irradiations, ingestion of arsenic, chronic inflammation, thermal injury and coal-tar derivatives are also risk factors.1
BCC exists in various histologic and clinical forms. The nodular type is most common.1 According to Bandeira et al., of the 704 BCCs studied histologically, the superficial form was responsible for 14.1% of cases.2 Superficial or erythematous BCC is a histologic-clinical variant that usually manifests itself as an erythematous lesion. With or without scaling, it is round or oval in shape and has defined borders, though it is not always perceptible. Its most frequent localization is on the trunk.4 In histopathology, multiple collections of tumors were observed to stem from the epidermis, with peripheral palisading, and juxtatumoral stromal retraction.4
There are various approaches to treating superficial BCC, namely, curettage, surgical excision, photodynamic therapy, cryosurgery, radio-electrodissection, laser and topical chemotherapy.5,6 Due to the low age range of patients, esthetic localization and mildly aggressive clinical-histological pattern, 5 FU 5% cream was opted for.
The topical imiquimod, an immunomodulator, leads to cures in 87 to 100% of cases. However, it should not yet be used routinely, at least not until further and better controlled studies have taken place.4 Although some specialists have acclaimed radiation therapy, the authors of the present study consider it to be an excellent alternative, mainly for young patients, and especially when the condition bears a non negligible oncogenic potential.7
Use of 5-FU 5% cream is limited to superficial BCC and must be done over an average period of three months, with daily applications. Its cure index varies from 80 to 95%.5 Its occlusive use might make the effect of this chemotherapy potent. The greatest inconvenience of the latter is the process of local inflammation, which provokes pain, erythema and exudation, as well as prolonging treatment time.5
1. Barnhill RL. Textbook of dermatopathology. 1st ed. New York: McGraw-Hill; 1998. p. 512-4.
2. Bandeira AM, Bandeira V, Silva JF, Mazza E. Carcinomas basocelulares: estudo clínico e anatomopatológico de 704 tumores. An bras Dermatol. 2003; 78:23-34.
3. Festa Neto C. Tratamento tópico do carcinoma basocelular superficial e nodular pelo imiquimod creme a 5%: observação de 10 casos. An bras Dermatol. 2002; 77: 693-8.
4. Azulay RD, Azulay DR. Dermatologia. 2ª ed. Rio de Janeiro: Guanabara-Koogan; 1999. p. 333-6.
5. Gadelha AR, Costa IMC. Cirurgia dermatológica em consultório. 1a ed. São Paulo: Atheneu; 2002. p. 321-7.
6. Nouri K, Chang A, Trent JT, Jiménez GP. Ultrapulse CO2 used for the successful treatment of basal cell carcinomas found in patients with basal cell nevus syndrome. Dermatol Surg. 2002;28:287-290.
7. Ekmekçi P, Bostanci S, Anadolu R, Erdem C, Gürgey E. Multiple basal cell carcinomas developed after radiation therapy for tinea capitis: a case report. Dermatol Surg. 2001; 27:667-9.
Dr. Maurício Zanini
Rua Vicente de Carvalho, 198
09060-590 Santo André SP
Telefone: (11) 4992-7724
* Work done at ABC Foundation Faculty of Medicine, Santo André, Sao Paulo, Brazil (Dermatology Department).