Basal cell carcinoma (BCC) (periocular)

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Contents

Aetiology

Commonest (80-90%) malignant tumour of the skin of white-skinned populations
Commonest periocular malignancy
Incidence of BCC shows marked geographic variation; the reported age-standardised incidence rate of any BCC in the UK is 285 per 100,000 people and 4.5 per 100,000 for periocular BCC
Arises from the basal layer of the epidermis
Main clinical sub-types include: nodular, nodular-ulcerative and morphoeic. 
Typical clinical presentation of periocular BCC is a single lesion with ulceration
Further classified into high and low risk subtypes according to tumour factors (high-risk histological subtype), patient factors (e.g. immunosuppression) and tumour location (involving the medial canthus)
Rarely metastasises (incidence <0.1%) and so rarely fatal
Slow growing, locally invasive

Predisposing factors

Older patients (median age at diagnosis 67 years; rare under 40 years)
M:F = approximately 3:2
History of ultraviolet light (UVB) exposure (particularly during childhood and adolescence) e.g. from sunlight and indoor tanning
Outdoor workers are at significantly increased risk
Fair complexion
History of previous BCC or other non-melanoma skin cancer
Family history
Immune compromise (e.g. HIV infection, or on immunosuppression drugs)

Symptoms of basal cell carcinoma

Slow developing, non-resolving lesion of eyelid skin
usually painless, may bleed

Signs of basal cell carcinoma

Location in order of prevalence (commonest first):

  • lower lid (40-50%)
  • medial canthus (27%) - deeper tissue penetration more likely with possible invasion of orbit or paranasal sinuses (may be hidden by spectacle nose pad)
  • upper lid (25%)

Clinical presentations

  • nodular (hard nodule, pearly appearance, abnormal (telangiectatic) vessels)
  • nodulo-ulcerative (as nodular but with raised rolled border surrounding central ulcer, may bleed)
  • morphoeic or sclerosing (flat hardened plaque of thickened skin, without surface vascularisation nor ulceration, ill-defined border making it difficult to determine area of involvement)

Occasional secondary infection or inflammation

  • overlying purulent discharge or crusting

Change in lid contour/redirection or loss of eyelashes
Loss of texture of surrounding skin
May involve palpebral conjunctiva, evert eyelids to evaluate any extension
Later cases sometimes pigmented (more prominent in dark skinned races)

Differential diagnosis

  • Squamous cell carcinoma, sebaceous carcinoma, chalazion, keratoacanthoma, actinic keratosis, molluscum contagiosum, papilloma
  • Anterior marginal blepharitis can resemble sclerosing BCC
  • BCC diagnosis is suspected clinically but is usually confirmed by histology which can also help to define the clinical subtype

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere.

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological 

Document with photography if possible
Refer with details of location, appearance, size and history (to aid assessment of urgency)
Advise patient of possible diagnosis
Reassure that this is a low risk skin cancer
Advise on sun protection measures
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Pharmacological 

None

Management category

B1: no treatment by optometrist; routine referral
This slow growing neoplasia rarely metastasises but if left untreated could threaten sight (or life if BCC invades beyond orbit)

Possible management by ophthalmologist

Biopsy for histopathology analysis to confirm diagnosis

Surgery remains the most effective treatment modality for BCC in terms of cure rate. Mohs micrographic surgery is considered the gold standard treatment of periocular BCC because it has the highest chance of curing the disease and minimises the size of the defect that needs to be repaired. It has been reported to have the lowest recurrence rate of any treatment modality (approx 3% over four years).

Other treatment modalities that are sometimes used include cryotherapy, photodynamic therapy, carbon dioxide laser ablation, and chemotherapy including topical 5-fluorouracil, Imiquimod (topical immune response modulator) and Hedgehog Pathway Inhibitors such as Vismodegib

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation. (www.gradeworkinggroup.org)
 

Sources of evidence

Ashraf DC, Vagefi MR Hedgehog pathway inhibitors for periocular basal cell carcinoma. Int Ophthalmol Clin. 2020;60(2):13-30

Juniat V, Shah P, Vonica O, Daniel CS, Murta F. Periocular basal cell carcinoma recurrence following surgical treatment: Safe surveillance time. Eye (Lond). 2023;37(5):971-976.

Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database, part I: periocular basal cell carcinoma experience over 7 years. Ophthalmology 2004; 111(4):624–30

Moran JM, Phelps PO. Periocularskin cancer: Diagnosis and management. Dis Mon. 2020;66(10):101046

Narayanan K, Hadid OH, Barnes EA. Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma. Cochrane Database Syst Rev. 2014;12:CD007041

Phan K, Oh LJ, Goyal S, Rutherford T, Yazdabadi A. Recurrence rates following surgical excision of periocular basal cell carcinomas: systematic review and meta-analysis. J Dermatolog Treat. 2020;31(6):597-601

Saleh GM, Desai P, Collin JR, Ives A, Jones T, Hussain B. Incidence of eyelid basal cell carcinoma in England: 2000-2010. Br J Ophthalmol. 2017;101(2):209-212

Thomson J, Hogan S, Leonardi-Bee J, Williams HC, Bath-Hextall FJ. Interventions for basal cell carcinoma of the skin. Cochrane Database Syst Rev. 2020;11(11):CD003412

Trakatelli M, Morton C, Nagore E, Ulrich C, Del Marmol V, Peris K, Basset-Seguin N; BCC subcommittee of the Guidelines Committee of the European Dermatology Forum. Update of the European guidelines for basal cell carcinoma management. Eur J Dermatol. 2014;24(3):312-29

Zhang Z, Behshad S, Sethi-Patel P, Valenzuela AA. Glasses: Hiding or causing skin cancer? Orbit. 2016;35(5):262-6

Summary

What is Basal Cell Carcinoma?

Basal Cell Carcinoma (BCC) is a low-risk cancer that is the most common malignant tumour of the skin in white people. BCC rarely spreads to other parts of the body. Instead, it slowly enlarges, causing no pain, though bleeding may occur from the surface. Around the eye (periocular), the most usual form and location is a small hard whitish nodule that appears on the lower eyelid.

In the UK BCC around the eyes affects 4-5 people per 100,000 of the population per year. In other parts of the world, especially where ultra-violet (UV) exposure is higher, more people are affected; for example, the figure may be three to four times higher in Australia. People who work outdoors are more likely to develop BCC.

It is very important to distinguish BCC from other growths that sometimes appear on the eyelids. It is usual to take a small sample of the tumour (known as a biopsy) for examination in the laboratory, so that the diagnosis can be confirmed and a treatment plan developed.

How is Basal Cell Carcinoma managed?

The usual treatment is either radiotherapy or surgery to remove the tumour. A special kind of surgery, known as Mohs micrographic surgery, is sometimes recommended. In this procedure, thin slices of the tumour are removed one after another and examined under the microscope until the surgeon is satisfied that all of the tumour has been removed. The result is complete removal of the tumour with the smallest possible wound.

Basal cell carcinoma
Version 9
Date of search 10.12.23
Date of revision 29.03.24
Date of publication 09.04.24
Date for review 09.12.25
© College of Optometrists