(CS-121) Wound Management of Unresectable Basal Cell Carcinoma of the Scalp

James Basset, B.S. – University of Toledo College of Medicine and Life Sciences; Jerrin George, B.A. – University of Toledo College of Medicine and Life Sciences; Amulya Marellapudi, B.S. – University of Toledo College of Medicine and Life Sciences; Richard Simman, M.D. – University of Toledo College of Medicine and Life Sciences

Introduction: Basal Cell Carcinoma (BCC) is the most common neoplasm in the United States, with sunlight exposure being the most common risk factor [1]. We present the unique case of a 52-year-old male presenting with advanced and locally invasive BCC affecting the scalp and nose.

Methods:

Results: The carcinoma measured 18cm² on the nose and 390cm² around the scalp, with varied discoloration and draining. The patient suffered from severe pain, necrotic tissue, and an unexpected complication of maggot infestation within the wound and skull. Given the disease's advanced stage and extensive involvement, Moh’s micrographic surgery and other traditional surgical methods of resection for definitive treatment were deemed impractical. Instead, the patient was initiated on vismodegib, an oral chemotherapy agent targeting the Hedgehog pathway, along with wound management strategies. Despite these efforts, only modest improvement in the affected areas was observed, delaying further discussions regarding surgical intervention.

Discussion:

While surgical excision remains the gold standard for localized BCC, targeting signaling pathways like the Hedgehog pathway has emerged as a promising approach for challenging cases. The limitations in conventional surgical options due to the extensive involvement prompt consideration of advanced reconstructive techniques such as free muscle flaps, contingent upon the disease's manageability and the patient's candidacy. This case highlights the complexity in managing advanced BCC and the importance of palliative wound management for cases where surgical management is delayed or cannot be performed. Palliative wound care focuses on comfort rather than optimal healing strategies and includes management of pain, bleeding, odor, and exudate [2]. While inhibition of gene signaling pathways showed some benefit, further investigation and long-term follow-up are essential to assess the efficacy of such treatments in complicated BCC cases. Additionally, addressing unexpected complications like maggot infestation necessitates specialized interventions for control and prevention. 

In conclusion, this case emphasizes the need for a comprehensive understanding of various treatment modalities and warrants continued research to determine optimal wound management strategies for complex BCC presentations.