Non-healing, non-tender ulcer on shin

For most BCCs, surgical excision will be required

Each BCC must be thoroughly evaluated for size, location, and histologic subtype. Surgical excision is the preferred treatment in most cases.⁵ Indications for Mohs micrographic surgery include skin cancers with aggressive histologic subtypes, such as infiltrative BCC, and tumors larger than 2 cm that are located on the extremities.^1,5 Due to the limited amount of excess skin on the lower leg, skin flaps or grafts may be required.

Electrodessication and curettage, topical therapy with 5% imiquimod or 5-fluorouracil, and cryotherapy are reserved for certain low-risk superficial and nodular BCCs.^1,5 Radiation therapy is an option for tumors that are not amenable to surgery. Treatment is tailored to the patient’s needs based on age, medical history, and the characteristics of the skin cancer.

Inadequate treatment of BCCs can result in recurrences, which may appear 4 to 12 months after treatment.⁵ Close followup with regular full body skin exams is indicated.

Our patient was treated with Bactrim DS (800 mg sulfamethoxazole and 160 mg trimethoprim) one tablet PO BID for 10 days and acetic acid soaks for the MRSA. While it was clear that the patient needed Mohs surgery, it was important to first address his lower extremity edema. He was evaluated by a vascular surgeon and resumed using compression stockings regularly.

The patient then underwent Mohs surgery.

After 2 stages of the surgery, the patient’s ulcer healed partially by secondary intention. After 5 months, the ulcer was covered with a split-thickness skin graft. Nine months after diagnosis, the patient had no clinical recurrence.

Physicians subsequently identified 2 BCCs on his face and scalp that were also treated with Mohs surgery. Our patient continues to have regular skin examinations.

CORRESPONDENCE
Jane Hwang, MD, Capt, USAF, MC, Kunsan Air Base, PSC 2 Box 205, APO, AP 96264; jane.hwang.1@us.af.mil