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 Table of Contents  
CLINICAL CHALLENGE
Year : 2019  |  Volume : 11  |  Issue : 5  |  Page : 223-225  

A painless, slow-growing ulcer on the scalp


1 Department of Dermatology, Valme University Hospital, Seville, Spain
2 Department of Pathology, Valme University Hospital, Seville, Spain

Date of Web Publication16-Oct-2019

Correspondence Address:
Dr Fernando Garcia-Souto
Department of Dermatology, Valme University Hospital, Seville
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijt.ijt_54_19

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How to cite this article:
Garcia-Souto F, Coronel-Perez IM, Sosa-Moreno F, Sanchez-Santos Y, Escudero-Ordoñez J. A painless, slow-growing ulcer on the scalp. Int J Trichol 2019;11:223-5

How to cite this URL:
Garcia-Souto F, Coronel-Perez IM, Sosa-Moreno F, Sanchez-Santos Y, Escudero-Ordoñez J. A painless, slow-growing ulcer on the scalp. Int J Trichol [serial online] 2019 [cited 2019 Nov 19];11:223-5. Available from: http://www.ijtrichology.com/text.asp?2019/11/5/223/269342



A 37-year-old male patient was referred to our department for a painless, slow-growing lesion on his scalp for 2 years. The patient denied any preceding trauma. Physical examination revealed a well-defined, round, 12-mm ulcer on the occipital area of the scalp. Interestingly, the edge of the ulcer exhibited a violaceous color [Figure 1]. Dermoscopy findings were unremarkable. Bacteriological and fungal cultures were negative. A punch skin biopsy exhibited large tumor nodules arising from the dermis of basaloid cells with scant cytoplasm and peripheral palisading [Figure 2].
Figure 1: A well-defined, round, 12-mm ulcer with a distinctive violaceous edge was observed on the occipital area of the scalp

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Figure 2: (a and b) Histopathology showed large tumor nodules arising from the dermis of basaloid cells with scant cytoplasm and peripheral palisading. Angulated narrow tumor nests growing in an infiltrative manner at the leading edge of the tumor were also seen (H and E, (a) ×10, (b) ×20)

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   Diagnosis Top


Scalp basal cell carcinoma (BCC).


   Answer Top


After histopathology confirmation, the lesion was excised surgically without recurrence after 1 year of follow-up.

BCC is the most frequent cancer worldwide. It is a locally destructive lesion with varied clinical and histological appearances. BCCs arising from the scalp are less frequently reported. BCCs have been classically described as arising from nevus sebaceous that often appears on the scalp. In addition, scalp BCCs have also been reported in patients who have received radiotherapy for brain tumors.[1] Although hair would be presumed to offer relative sun protection to the scalp, some reports suggested an increased incidence of scalp BCCs, mainly in younger women.[2]

An interesting retrospective study of 113,634 BCCs found that only 2952 (2.6%) of all histologically confirmed BCCs were on the scalp, showing a predominance of nodular subtype (55%) with the superficial subtype (8%).[3] This study also found that scalp BCCs are more common in men and in the elderly. These results are in line with most previous studies. Interestingly, incomplete excision was relatively common; thus, the authors suggested Mohs surgery, other margin control techniques, or wider surgical margins in the presence of high-risk factors, including aggressive histologic subtypes and perineural invasion.[3]

Dermoscopy features of scalp BCCs might also differ from other localizations. Some authors propose that scalp BCCs have significantly more pigmentation and melanocytic criteria than BCCs located elsewhere.[4] For this reason, scalp BCCs may represent the most challenging differential diagnosis between BCCs and both benign and malignant melanocytic lesions.

Diagnosis is often based on histopathologic examination together with dermoscopy findings. Histopathology typically shows a basaloid epithelial tumor arising from the epidermis that typically forms a palisade, with a cleft forming from the adjacent tumor stroma. On the other hand, treatment as in our patient relies mainly on surgical excision. Several reports suggest Mohs surgery or wider surgical margins for scalp BCCs due to high rates of incomplete excision.[3]

The differential diagnosis of slow-growing ulcers in the scalp is broad and may include infections (tuberculosis, leishmaniasis, and dermatophytosis), neoplasms (squamous cell carcinoma, angiosarcoma, lymphoma, and metastasis), and miscellaneous (pyoderma gangrenosum, sarcoidosis, lupus erythematous, and giant cell arteritis). In our particular case, given the distinctive violaceous edge, we strongly considered the possibility of a pyoderma gangrenosum of the scalp that we discard after the histopathology result.

Our case of BCC is unusual because of its distinctive violaceous edge that might create confusion with other entities. BCC should always be included in the differential diagnosis when evaluating a painless, slow-growing ulcer on the scalp.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chen F, Yang SF, Chen CH, Lieu AS, Cheng ST, Huang MY, et al. Secondary basal cell carcinoma of scalp after radiotherapy: A case report. Medicine (Baltimore) 2018;97:e12170.  Back to cited text no. 1
    
2.
Katz TM, Silapunt S, Goldberg LH, Jih MH, Kimyai-Asadi A. Analysis of 197 female scalp tumors treated with mohs micrographic surgery. J Am Acad Dermatol 2005;52:291-4.  Back to cited text no. 2
    
3.
Cho M, Lee J, James CL, Marshman G, Huilgol SC. Scalp basal cell carcinoma: Review of 2,202 cases. Dermatol Surg 2016;42:834-41.  Back to cited text no. 3
    
4.
Suppa M, Micantonio T, Di Stefani A, Soyer HP, Chimenti S, Fargnoli MC, et al. Dermoscopic variability of basal cell carcinoma according to clinical type and anatomic location. J Eur Acad Dermatol Venereol 2015;29:1732-41.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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