HNY Central Digital Repository - York

Basal cell carcinoma is a locally invasive, slow growing type of skin cancer predominantly seen in Caucasians and individuals with excessive sun exposure. It is the most common skin cancer in England and Wales. Associated with very low mortality and rarely metastasises. It is important to be aware that patients diagnosed with one BCC are at increased risk of having further BCCs diagnosed at the same time, or of developing them subsequently (up to 44% in 3 years).

Exclude melanoma and SCC.

• Early diagnosis and typing (here is a very good resource with images).
• Discuss all management options (conservative, medical and surgical).
• Aim for cosmetically acceptable results.
• A thorough skin inspection should be undertaken once a BCC confirmed for other lesions.

Management

High Risk BCCs - high risk factors include:

• Size >1cm,
• patients aged under 24 or immunocompromised ,
• patients with genetic conditions predisposing to BCC such as Gorlin’s syndrome,
• morphoeic (scar like) BCCs or recurrent BCC
• Refer to Head and Neck if above the clavicle
• Refer to Oculoplastic Clinic if around the eye
• Refer to Dermatology as an urgent referral (not 2 week wait) if >1cm, surgical complexity (e.g. on shin, in close proximity to important anatomical structures etc) or diagnostic uncertainty

Low Risk BCCs (<1cm, below clavicle)

• Remove by accredited GP Minor Surgeon (either in-house or through Practice-to-Practice referral via LES scheme).
• Remove with 4mm margins, send for histology.

Superficial BCCs

• Tumours less than 1mm in thickness should be offered a full range of medical therapies (photodynamic therapy, imiquimod etc) but this requires referral to dermatology first. The dermatologist can then make a recommendation for the GP to prescribe in primary care. Imiquimod is ‘amber specialist recommendation’ and the CCG would not want GPs initiating this treatment without input from a specialist.

Please click here for the Practice to Practice referral summary flowchart.

None

Information to include in referral letter

• Size of lesion
• Location of lesion (e.g. above clavicle)
• Description of lesion
• Past medical history
• Drug History
• 3 photographs are required (field, close up and dermatoscopic image) 

Investigations prior to referral

• Low risk lesions should be managed as per the local guideline BCC pathway
• Incomplete excisions should be referred to dermatology or discussed via the local Skin MDT (as advice and guidance).

Patient information leaflets/ PDAs

Patient information leaflet - BCC

References

• NICE guidance: Improving Outcomes for People with Skin Tumours (2010)
• NICE CKS Skin cancers recognition and referral Nov 2016
• GPs managing low risk basal cell carcinoma here
• Gorlin’s Syndrome: here

Responsible Dermatologist: Dr Caroline Love