Basal cell and squamous cell carcinoma - recognise and refer

BCC · basal cell carcinoma · rodent ulcer · SCC · squamous cell carcinoma · non-melanoma skin cancer · keratinocyte carcinoma

Recognise and refer - not a diagnostic tool. The urgencies differ: SCC is a suspected cancer referral, BCC is non-urgent - unless its site or size means delay would matter.

ROUTINE DERMBand D

Red flags

Any skin lesion raising suspicion of squamous cell carcinoma - NICE says consider a suspected cancer pathway referral
A non-healing ulcer in a chronic wound, burn or scar - consider SCC, and note this pattern is relatively more common in darker skin
Rapid growth, ulceration, bleeding, or a large lesion. Diameter and depth thresholds are high-risk features in cutaneous SCC staging, not NG12 referral criteria - no figure is quoted here because the UK guideline that carries them has not been read in full. Take the thresholds from it rather than from this page
Immunosuppression or a transplant recipient with any new or changing lesion - refer promptly
Perineural symptoms - numbness, tingling or facial weakness near a lesion - suggesting perineural invasion. Like the size thresholds, this is a recognised high-risk feature in SCC staging rather than an NG12 criterion, and it should raise urgency within whichever pathway applies

Recognise

On light skin

BCC: a pearly or waxy nodule, or an ulcer with a raised rolled edge, with prominent fine blood vessels. SCC: a firm, tender, keratotic or ulcerated nodule that grows over weeks to months.

On brown and black skin

The pearly translucency and the visible fine telangiectasia that define basal cell carcinoma in pale skin are frequently absent; BCC in brown and black skin is often pigmented, appearing as a dark brown or black nodule or plaque that is readily mistaken for a benign mole or for seborrhoeic keratosis. The raised rolled edge and the central ulceration are structural and remain useful. The more important difference is squamous cell carcinoma, which in Black patients is widely described as arising disproportionately in chronic scars, burns, long-standing ulcers and areas of chronic inflammation rather than in sun-exposed skin. No figure is given for that here because none could be traced to a source read in full, but the practical consequence stands on its own: a non-healing lesion within an old scar or a chronic leg ulcer deserves the same suspicion a sun-exposed lesion would attract in a pale-skinned patient. What is well supported is the outcome - an international expert consensus records that skin cancer in skin of colour often presents at an advanced stage with poorer outcomes, through lower awareness and unfamiliar clinical appearances leading to delayed diagnosis.

In any skin tone

A lesion that does not heal - the most useful single question is how long it has been there
BCC: NICE describes the typical features as an ulcer with a raised rolled edge, prominent fine blood vessels around a lesion, or a nodule, particularly a pearly or waxy one
SCC: firmer, faster-growing over weeks to months, often tender, keratotic or ulcerated
Ask about a non-healing ulcer within a scar, burn or chronic wound
Immunosuppression, particularly in transplant recipients, greatly increases SCC risk and aggressiveness

Distribution

Sun-exposed sites in most patients - face, ears, scalp, neck, forearms and hands. In brown and black skin, squamous cell carcinoma arises more often at sites of chronic scarring, ulceration or inflammation rather than on sun-exposed skin.

Photographs

Nodular basal cell carcinoma on the tip of the nose. A pearly, translucent nodule with a rolled edge, fine telangiectatic vessels crossing i — Nodular basal cell carcinoma on the tip of the nose. A **pearly, translucent nodule with a rolled edge, fine telangiectatic vessels crossing its surface, and a central crusted dip** where it has begun to erode. Slow-growing, on a sun-exposed site, and it never heals - that history plus this surface is the picture. Refer routinely; this is not an emergency. The only openly licensed photograph found for this entry shows light skin. **That is a limitation of this page, not of the disease** - a darker-skin photograph is still being sought.
Fitzpatrick II (Fitzpatrick type estimated from the photograph, not stated by the source) · Sand M, Sand D, Thrandorf C, Paech V, Altmeyer P, Bechara FG · Wikimedia Commons - BCC Nodular type.jpg · CC BY 2.0

A neglected squamous cell carcinoma of the cheek, shown from two angles in the published figure. A large ulcerated crater with a raised, eve — A neglected squamous cell carcinoma of the cheek, shown from two angles in the published figure. A large **ulcerated crater with a raised, everted, heaped-up edge** and adherent crust, with satellite nodules around it. Compare the edge with the basal cell carcinoma above: BCC rolls and pearls, SCC heaps up and keratinises. A lesion of this size needs urgent referral, not a routine one.
Fitzpatrick IV (Fitzpatrick type estimated from the photograph, not stated by the source) · Zemmez Y et al., Pan African Medical Journal · Wikimedia Commons - Giant squamous cell carcinoma of the cheek.jpg · CC BY 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Melanoma - recognise and refer — A pigmented BCC can be mistaken for melanoma and vice versa - both are referred, but on different pathways
Venous eczema, lipodermatosclerosis and venous leg ulcers — A leg ulcer that is not healing as expected may harbour SCC and warrants biopsy rather than more dressings
Psoriasis, including guttate — A solitary persistent scaly plaque that does not respond to treatment should be reconsidered, not re-treated

What to do in the ED

Recognise and refer only. Do not attempt to diagnose, exclude, excise, cauterise or biopsy these lesions in the ED.
Refer suspected squamous cell carcinoma on a suspected cancer pathway (NG12 1.7.4), and suspected basal cell carcinoma non-urgently (1.7.5) - NICE distinguishes the two explicitly, and conflating them either delays an SCC or floods the pathway
But NG12 1.7.6 provides the exception, and it matters more than the rule it qualifies: consider a suspected cancer pathway referral for a suspected BCC where there is particular concern that a delay may have a significant impact because of factors such as lesion site or size - a periocular, nasal, auricular or large lesion, for instance. A BCC near the eye is not a non-urgent BCC
Examine and document the site, size, duration and appearance
Ask about chronic wounds, scars and burns, and about immunosuppression
Refer promptly and with a lower threshold in transplant recipients and other immunosuppressed patients
Do not reassure a patient that a non-healing lesion is benign
Advise on sun protection without implying that darker skin does not need it

Disposition

ROUTINE DERM

Suspected cancer pathway referral for suspected SCC (NG12 1.7.4); non-urgent dermatology referral for suspected BCC (1.7.5) - but use the suspected cancer pathway for a BCC where site or size means a delay would have a significant impact (1.7.6). Lower the threshold and raise the urgency for immunosuppressed patients.

Safety-netting

This needs a specialist to examine it properly - we are not able to tell you what it is today. Do not pick at it or try to treat it yourself. Contact us or your GP if you do not hear about an appointment, if the lesion grows quickly, bleeds or becomes painful, or if a new one appears. Use sun protection - this applies whatever your skin tone.

Local variation

Some areas run teledermatology or photo-triage pathways for skin lesions, which change how and where the referral is made.

Sources

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