# Basal Cell Carcinoma - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Basal Cell Carcinoma - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK539824/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class SD25.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Basal cell carcinoma - disease-level clinical article (basal-cell-carcinoma-full.txt) · Aldara 5% Cream (imiquimod) SmPC sections 4.1, 4.2 and 4.4 (eMC product 823, emc-aldara-5pct-imiquimod.txt) · Efudix 5% cream (fluorouracil) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 9260, emc-efudix-5pct-fluorouracil.txt) - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care - Basal cell carcinoma - disease-level clinical article (basal-cell-carcinoma-full.txt) - Aldara 5% Cream (imiquimod) SmPC sections 4.1, 4.2 and 4.4 (eMC product 823, emc-aldara-5pct-imiquimod.txt) - Efudix 5% cream (fluorouracil) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 9260, emc-efudix-5pct-fluorouracil.txt) ## Treatment metadata - Recognise, biopsy and refer (Referral & Advice) - Imiquimod — topical - Fluorouracil — topical ## Complete treatment card ```text BASAL CELL CARCINOMA Sources: Basal Cell Carcinoma - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK539824/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class SD25.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Basal cell carcinoma - disease-level clinical article (basal-cell-carcinoma-full.txt) · Aldara 5% Cream (imiquimod) SmPC sections 4.1, 4.2 and 4.4 (eMC product 823, emc-aldara-5pct-imiquimod.txt) · Efudix 5% cream (fluorouracil) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 9260, emc- efudix-5pct-fluorouracil.txt) Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (1) - A history of crusting and repeated bleeding from the spot is a common reason patients seek care [bleeding · crusting] SIGNS - what you find (9) - Nodular BCC often looks like a shiny, flesh-toned or pink bump with fine surface blood vessels - As it grows the surface can break down, leaving a raised, rolled edge around a central ulcer - Nodular BCC has a preference for facial sites - the nose, cheeks, forehead, and eyelids - Patients with darker skin more often show a pigmented variant of the nodular form - The superficial type shows up as pink to red scaly patches, sometimes with visible tiny vessels [scaling] - Superficial lesions tend to favor the shoulders, chest, or back and can be multiple - Because it can mimic eczema or psoriasis, a persistent scaly red patch deserves suspicion [scaling] - The morpheaform type looks pale or skin-colored, firm, and poorly outlined, like a scar [pallor · scarring] - The morpheaform variant behaves more aggressively, spreading widely into nearby tissue TESTS (5) - A biopsy - shave, punch, or excisional - is needed to confirm the diagnosis - Punch and shave samples correctly identify the subtype roughly 80% of the time - Well-focused branching vessels seen on dermoscopy are the classic clue - Other dermoscopic clues include blue-gray globules, leaf-shaped areas, and spoke-wheel patterns - Imaging beforehand may be warranted if deep, bony, or nerve involvement is a concern IF NOT THIS - what else fits (5) - Adnexal tumors arising from hair follicle, sweat gland, or sebaceous tissue - Certain subtypes of squamous cell carcinoma - Trichoblastoma or trichoepithelioma can be confused with the nodular form - Eczema or psoriasis can be mistaken for the superficial form - A scar or plaque of morphea can look like the morpheaform form Source StatPearls "Basal Cell Carcinoma" - disease-level clinical article Status traced to the source above Rx: Main treatment | Small SUPERFICIAL BCC only - the non-surgical option, after biopsy, dermatology-directed | Superficial BCC only - topical cytotoxic, after biopsy, dermatology- directed MAIN TREATMENT 1. RECOGNISE, BIOPSY AND REFER (REFERRAL & ADVICE) [1st line] Adult The most common skin malignancy, arising on sun-exposed skin as a slowly enlarging pearly papule that may ulcerate; locally invasive but rarely spreads to other organs. Biopsy confirms it and surgery cures it - Mohs micrographic surgery has the best long- term cure rate of any modality and is the standard for high-risk and recurrent lesions. Refer for biopsy and definitive treatment. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why The most common skin malignancy, arising on sun-exposed skin as a slowly enlarging pearly papule that may ulcerate; locally invasive but rarely spreads to other organs. Biopsy confirms it and surgery cures it - Mohs micrographic surgery has the best long- term cure rate of any modality and is the standard for high-risk and recurrent lesions. Refer for biopsy and definitive treatment. Caution RED FLAG - Lesions in high-risk facial locations (periorbital, nasolabial fold, external auditory canal): assess urgently and refer. Definitive treatment is SURGICAL and is not done here. Managing a BCC usually means an operation, though some cases can be handled with medical or radiation therapy instead. (Basal Cell Carcinoma - StatPearls - NCBI Bookshelf, NBK482439) The two drug rows below are the licensed topical options for a small, biopsy-proven SUPERFICIAL BCC - they are not alternatives to referral, and neither is for a lesion that has not been biopsied. RED FLAG - Rapid growth, bleeding, or ulceration of a chronic skin lesion: refer. For a lesion near the eye, nose or ear, delay risks more extensive surgery. SMALL SUPERFICIAL BCC ONLY - THE NON-SURGICAL OPTION, AFTER BIOPSY, DERMATOLOGY-DIRECTED 2. IMIQUIMOD [2nd line] Adult 5% cream, applied 5 times a week (for example Monday to Friday) for 6 weeks, at bedtime, left on the skin for about 8 hours and then washed off with mild soap and water. Enough cream to cover the tumour PLUS one centimetre of surrounding skin, rubbed in until it vanishes. Assess the response 12 weeks after the end of treatment; if clearance is incomplete, use a different therapy. x 6 weeks, with the response assessed 12 weeks after the last application Peds Not a paediatric treatment. SmPC verbatim: "Use in the paediatric patient population is not recommended. There are no data available on the use of imiquimod in children and adolescents in the approved indications." Source Aldara 5% Cream (imiquimod) SmPC sections 4.1, 4.2 and 4.4 (eMC product 823, emc- aldara-5pct-imiquimod.txt) Why Surgery is the gold standard for basal cell carcinoma and this does not displace it - Mohs micrographic surgery has the best long-term cure rate of any modality. What this adds is the licensed non-surgical option for a small superficial lesion, after biopsy and under dermatology direction. Article verbatim: "Topical 5-fluorouracil (5-FU) and imiquimod 5% cream are approved by the Food and Drug Administration (FDA) to manage superficial BCC. especially when the lesion is <2 cm, well-demarcated, and confined to the superficial dermis". The product label's own indication is "Small superficial basal cell carcinomas (sBCCs) in adults." and it prints the regimen. One Egyptian product: ALDARA 5% cream, 12 sachets, 879 EGP. Caution BIOPSY FIRST, ALWAYS. Every suspected lesion goes for histology: that is what confirms what it is and what directs the management. This cream is for a histologically confirmed SUPERFICIAL BCC, not for a lesion that looks like one. SURGERY REMAINS THE GOLD STANDARD. Of every treatment available, Mohs surgery cures the highest proportion over the long run, and it spares the most tissue; for a BCC that is high-risk, or one that has come back, it is the standard against which the rest are judged. Recurrence after Mohs is 1.0%; after standard excision 10.1%. The trade-off: treating from the outside leaves you without proof - neither that the tumour has gone entirely, nor histology to show it. In the licensing trials histological clearance was 82%, so roughly one in five treated tumours was not cleared - which is why the 12-week check matters. NOT NEAR THE EYE, NOSE, LIP OR HAIRLINE. The SmPC states that no evaluation was done in a basal cell carcinoma sitting closer than 1 cm to the eyelid, the nose, the lips or the hairline. Those are exactly the sites the article calls high-risk and sends for Mohs. Expect a severe-looking local reaction - in the trials severe erythema occurred in 31%, severe erosion in 13% and severe scabbing and crusting in 19%. The SmPC's own warning is that from the start of treatment until the skin has healed, the treated area will probably look markedly unlike the skin around it. Warn the patient before the first application, or they will stop. Avoid contact with the eyes, lips and nostrils; use with caution in autoimmune disease and in immunocompromised patients; wash hands before and after; do not re-use an opened sachet. SYSTEMIC THERAPY IS PRESCRIBED BY ONCOLOGY, NOT HERE. Where BCC is advanced or has metastasised and the conventional treatments no longer suit it, the article's answer is a hedgehog pathway inhibitor (HHI): vismodegib, which the FDA approved in 2012, and sonidegib behind it, for the locally advanced lesion that cannot be handled by surgery or by radiation. No dose for either is printed here. The other licensed topical option is fluorouracil 5% cream, which now has a row of its own. The article puts the two in one sentence and ranks neither: topical 5-fluorouracil and imiquimod 5% cream both carry Food and Drug Administration approval for managing superficial BCC. Imiquimod is printed first because ALDARA is stocked in Egypt and the only Egyptian 5-FU cream is currently marked not available. Egypt ALDARA 5% CREAM 12 SACHETS MEDA AB > ONE... 879.00 EGP SUPERFICIAL BCC ONLY - TOPICAL CYTOTOXIC, AFTER BIOPSY, DERMATOLOGY-DIRECTED 3. FLUOROURACIL [2nd line] Adult 5% cream. SmPC verbatim for a malignant lesion: "The cream should be applied once or twice daily under an occlusive dressing where this is practicable." "Treatment should be continued until there is marked inflammatory response from the treated area, preferably with some erosion in the case of pre-malignant conditions." "The usual duration of treatment for an initial course of therapy is three to four weeks, but this may be prolonged." Never treat a large area at once: "The total area of skin being treated with this medicine at any one time should not exceed 500 cm 2 (approximately 23 x 23 cm). Larger areas should be treated a section at a time." "The hands should be washed carefully after applying this medicine. Also care should be taken to avoid contact with mucous membranes or the eyes when applying the cream." Healing lags behind the course: "Lesions on the face usually respond more quickly than those on the trunk or lower limbs whilst lesions on the hands and forearms respond more slowly. Healing may not be complete until one or two months after therapy is stopped." - Three to four weeks for an initial course; may be prolonged Peds Not a paediatric treatment. SmPC verbatim: "In view of the lack of clinical data available, fluorouracil is not recommended for use in children." Basal cell carcinoma is in any case a disease of sun-damaged adult skin. Source Efudix 5% cream (fluorouracil) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 9260, emc-efudix-5pct-fluorouracil.txt) Why Added under the August 2026 ruling that the no-cytotoxic policy targets systemic chemotherapy, not a topical dermatology cream for a lesion already confirmed on biopsy; the earlier refusal had rested on a rule aimed at intravenous oncology. StatPearls lists topical 5-fluorouracil beside imiquimod 5% cream, both carrying FDA approval for superficial BCC. The cream's licensed uses go beyond this one diagnosis: the label also covers Bowen's disease, keratoacanthoma, and senile, actinic or arsenical keratoses, alongside superficial basal cell carcinoma itself, and it sets out how to apply it. Surgery stays the definitive treatment and remains first line. Egypt's single topical 5-FU product, EZADEX 5% cream 20 g, is currently marked not available; intravenous fluorouracil vials and ampoules are excluded by name so that a skin cream can never offer a chemotherapy infusion. Caution BIOPSY FIRST, ALWAYS, and only for a SUPERFICIAL lesion. Every suspected lesion goes for histology first, to confirm what it is and to direct the treatment. The label is explicit that the deeper tumours do not respond: a basal cell or squamous cell carcinoma that is nodular, or that penetrates deeply, will generally not answer to fluorouracil at all, and using it there is palliation only - reserved for a patient for whom nothing else can be done. CONTRAINDICATED IN PREGNANCY AND BREASTFEEDING. The SmPC bars fluorouracil outright for a woman who is pregnant and for one who is breastfeeding. CONTRAINDICATED WITH BRIVUDINE AND ITS ANALOGUES, and the interval is four weeks either way. Giving fluorouracil alongside an antiviral nucleoside - brivudine and the drugs like it - can push its plasma concentration up sharply, with the toxicity that follows, and the SmPC forbids the combination. FIRE HAZARD - this is not a routine cream warning. Tell the patient NOT to smoke and NOT to go near an open flame: the burns risked are severe. Anything woven that has touched the cream - clothes, bed linen, a dressing - catches fire more readily, and that is a genuine danger. Warn the patient what the skin will look like or they will stop the course. The expected sequence runs in three stages: first inflammation, severe, with redness that can turn intense and patchy; then a necrotic stage in which the skin erodes; then healing, as the surface re-epithelialises. It usually declares itself in the second week on fluorouracil, and it can go further than that - pain, blisters, ulceration. STOP APPLYING IT - do NOT put on any more fluorouracil where the inflammation is severe enough to blister or ulcerate. For discomfort short of that, an appropriate topical steroid cream may settle it. Keep the treated skin out of the sun. Ultraviolet exposure is to be avoided - daylight itself, and a tanning booth equally. DPD deficiency turns a skin cream into a systemic poisoning. Toxicity has been reported to run higher where the enzyme dihydropyrimidine dehydrogenase works at reduced capacity. Occlusion and broken skin both raise absorption, so a patient who becomes systemically unwell during treatment stops it and is investigated. SURGERY REMAINS THE DEFINITIVE TREATMENT, and topical therapy buys no histology. Treating from the surface has a real drawback: you get neither certainty that every tumour cell has gone, nor a specimen to confirm it. Follow the lesion up; if it is not clear, it goes to surgery. EGYPTIAN AVAILABILITY, STATED PLAINLY: the only topical fluorouracil product in the 25,070-product register is EZADEX 5% cream 20 g, and the register marks it NOT AVAILABLE. Every other fluorouracil product in Egypt is an intravenous chemotherapy vial or ampoule and is deliberately hidden from this row. Imiquimod, on the row above, is stocked. Egypt EZADEX 5% CREAM 20 GM KAHIRA > MULT... 18.00 EGP [discontinued] Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)