The American Journal of Medicine
Volume 122, Issue 11 , Pages 1007-1009, November 2009

Not What She Had in Mind

Department of Dermatology, Army General Hospital, Athens, Greece

Article Outline

 

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Presentation 

Are you hoping to dissuade patients from body piercing? One odd case might fortify your argument. A 19-year-old female, who had been wearing a nose ring since she was 15 years old, presented with a 9-month history of a slow-growing, pearly plaque on her right nasal ala at the site of the nostril piercing (Figure 1). This did not cause pain or pruritus. She reported excellent general health and no significant past medical or family history. Her skin was Fitzpatrick phototype III—white- to olive; sometimes burns; slowly tans to light brown—and she had no previous episodes of sunburn or sun-bed exposure. Without seeking medical advice, she used a topical antibiotic on the affected area for 1 month, but she did not achieve any visible improvement.

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Assessment 

Upon examination, the lesion was a well-defined oval; waxy and colored dark brown and grey. It measured approximately 0.7 cm in diameter. The hole that had once held the patient's nose ring could still be seen inside the plaque's limits. No erosion or ulceration was evident within the lesion, and no inflammation was noted around it. A pearly, translucent border with thin superficial vessels was visible, rising above the plaque in a few areas.

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Diagnosis 

The clinical picture was compatible with basal cell carcinoma. To confirm the diagnosis, a 2-mm punch biopsy was performed, and a skin specimen was taken from the raised border of the lesion. Histological examination revealed a large number of uniform cells with large, hyperchromatic, oval nuclei, little cytoplasm, and a characteristic palisades arrangement (Figure 2). Increased mucin could be seen in the surrounding dermal stroma. These findings were diagnostic for nodular basal cell carcinoma.

Basal cell carcinoma is the most prevalent type of skin cancer in the white population and the most common malignancy in humans, occurring all over the world. It is more common among the elderly and is documented slightly more often in males than in females.1 The tumor grows slowly and rarely metastasizes, but it can cause clinically significant local destruction if neglected or inadequately treated.

These malignancies are considered rare in young populations, but limited epidemiologic data show a global increase in non-melanoma skin cancers of up to 10% per year and an increasing incidence in younger female populations.2, 3, 4, 5 It also appears to be arising more frequently in younger, immunosuppressed, patients.1 Tumors usually occur on the sun-exposed and sun-damaged skin of lighter-skinned individuals. An estimated 70% of cancerous growths occur on the face, with the nose being the most common site (20-30%).1, 6 Interestingly, the forearms and the backs of the hands, although also sun-exposed areas, are less common sites.

Patients might have a hereditary tendency to basal cell carcinoma, or the disease might develop sporadically. It is believed that ultraviolet radiation reaches the epidermal cell layer, is absorbed by the DNA of skin cells, and then induces DNA alterations in tumor suppressor genes within these cells.7 Major targets are the p53 gene and the patched gene, also known as PTCH. Inactivation of these genes leads to cell proliferation.

Other factors related to the development of basal cell carcinoma are ionizing radiation, exposure to arsenic, and trauma.6, 8 Burns, sharp and blunt trauma, varicella zoster virus lesions, and vaccine scars, are possible etiologic factors; a 7.3-13% incidence of basal cell cancer associated with trauma has been reported,6, 8, 9 No exact explanation of how trauma or the resulting scar tissue plays a role in tumor pathogenesis has been uncovered.8 It has been pointed out that continuous irritation is a predisposing factor. Slow initial healing, scar instability, and a lack of immunologic mechanisms in scars can result in recurrent ulceration and ultimately, neoplastic changes.10 Nonetheless, no animal model has demonstrated basal cell carcinoma induced by physical trauma.11

Body piercing, particularly the trend of piercing sites other than the earlobe, has increased in popularity and social acceptance during the last decade. However, complications, including local and systemic adverse reactions, have been reported.12 Our patient's lesion occurred on sun-exposed skin. However, trauma from nasal piercing seemed to represent the only predisposing factor for its development.

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Management 

To our knowledge, this is the first case of basal cell carcinoma associated with nasal piercing in a teenager.13 Our patient's tumor was surgically excised along with a 4-mm margin of skin that appeared to be clinically normal. The defect was repaired with a full-thickness skin graft. Histological examination of the lesion showed that the basal cell carcinoma had indeed been totally excised with negative margins. Three months later, the surgical site was healed with good cosmetic and functional results.

The choice for the appropriate treatment of basal cell carcinoma is based upon the location and size of the tumor, patient age and medical history, the histologic subtype of basal cell carcinoma, and cost. Surgical excision is probably the treatment of choice. Margins of at least 4 mm are needed to achieve 95% cure rates.14 If standard vertical (bread-loaf) tissue-sectioning is used, as in our patient's case, areas of margin involvement might be missed, so that the pathologist cannot be certain that every point on the periphery remains clear of malignant cells. However, a verdict on whether the depth of the surgery was sufficient can be attained.

Mohs micrographic surgery with control of excision margins is probably the best technique for recurrent or morphoeic basal cell carcinoma occurring at a site where maximal retention of normal tissue is desirable. Significant disadvantages of Mohs micrographic surgery are its increased expense and time requirement compared with other techniques, such as curettage.15

Topical imiquimod has been used successfully for the treatment of superficial basal cell carcinoma in recent years. Its exact mechanism of action remains unknown. Cure rates of 70-100% for superficial basal cell carcinoma have been reported after imiquimod has been applied 5 times a week over 6 weeks.13 The cure rates for nodular basal cell carcinoma are lower. Imiquimod is indicated for: biopsy-confirmed superficial basal cell carcinoma of the trunk, neck, or extremities in immunocompetent adults when surgical excision is considered less appropriate; it is not to be used on anogenital skin, the hands, or the feet. Other treatment options for basal cell carcinoma include curettage (usually with electrodesiccation), cryosurgery, radiation therapy, photodynamic therapy, topical application of 5-fluorouracil cream, and intralesional administration of interferon alfa-2b.

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References 

  1. Carucci JA, Leffell DJ. Basal cell carcinoma. In:  Wolff K,  Goldsmith LA,  Katz SI,  Gilchrest BA,  Paller A,  Leffell DJ editor. Fitzpatrick's Dermatology in General Medicine. 7th ed.. New York: McGraw-Hill; 2007;p. 1037–1042
  2. Ridky TW. Nonmelanoma skin cancer. J Am Acad Dermatol. 2007;57:484–501
  3. de Vries E, van de Poll-Franse LV, Louwman WJ, et al. Predictions of skin cancer incidence in the Netherlands up to 2015. Br J Dermatol. 2005;152:481–488
  4. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA. 2005;294:681–690
  5. Douglas HE, Agarwal R, Lam DG. Teenage BCC: to tan or not to tan?. J Plast Reconstr Aesthet Surg. 2008;61:1245–1246
  6. Noodleman FR, Pollack SV. Trauma as a possible etiologic factor in basal cell carcinoma. J Dermatol Surg Oncol. 1986;12:841–846
  7. Lacour JP. Carcinogenesis of basal cell carcinomas: genetics and molecular mechanisms. Br J Dermatol. 2002;146(suppl 61):17–19
  8. Ozyazgan I, Kontas O. Previous injuries or scars as risk factors for the development of basal cell carcinoma. Scand J Plast Reconstr Surg Hand Surg. 2004;38:11–15
  9. Dolan OM, Lowe L, Orringer MB, et al. Basal cell carcinoma arising in a sternotomy scar: a report of three cases. J Am Acad Dermatol. 1998;38:491–493
  10. Horton CE, Crawford HH, Love HG, Loeffler RA. The malignant potential of a burn scar. Plast Reconstr Surg Transplant Bull. 1958;22:348–353
  11. Goldberg LH. Basal cell carcinoma. Lancet. 1996;347:663–667
  12. Meltzer DI. Complications of body piercing. Am Fam Physician. 2005;72:2029–2034
  13. Khundkar R, Wilson PA. Basal cell carcinoma at the site of a nasal piercing [published online ahead of print October 30, 2008]. J Plast Reconstr Aesthet Surg. 2009;62:557–558doi:10.1016/j.bjps.2008.06.083
  14. Ramsey ML, Sewell LD. Basal cell carcinoma. eMedicine Web site http://emedicine.medscape.com/article/1100003-overviewUpdated January 8, 2008. Accessed March 8, 2009
  15. Bennett RG. Current concepts in Mohs micrographic surgery. Dermatol Clin. 1991;9:777–788

 Parwathi “Uma” Paniker, MD, Section Editor

 Funding: None.

 Conflict of Interest: None declared.

 Authorship: Both authors had access to the data and a role in writing the manuscript.

PII: S0002-9343(09)00686-X

doi:10.1016/j.amjmed.2009.08.003

The American Journal of Medicine
Volume 122, Issue 11 , Pages 1007-1009, November 2009

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