Dermatology Online Journal

Basal cell carcinoma on the toe
Yuko Suzuki, Taeko Nakamura-Wakatsuki, Masataka Satoh, Akiko Nishibu, Yoshio Kawakami, Noritaka Oyama, Toshiyuki Yamamoto
Dermatology Online Journal 16 (2): 15

Department of Dermatology, Fukushima Medical University, Fukushima, Japan. toyamade@fmu.ac.jp

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Introduction

Basal cell carcinoma (BCC) is a common malignant skin tumor that frequently develops on the sun-exposed areas such as head and neck [1]. On the contrary, BCCs on sun-protected sites are uncommon. The toe is an extremely rare location for BCC. We report here a case of BCC on the toe in an elderly Japanese female and review the literature regarding BCCs on the toe. Our case was unique not only for its location, but also for its hypopigmented clinical appearance.

Case report

Figure 1	Figure 2

An 85-year-old woman visited our department complaining of a lesion on her right hallux, which had been growing slowly for 10 years. She had no significant histories of immune deficiency or malignancies and denied prior trauma or exposure to artificial ionizing radiation on this site. A physical examination showed a well-circumscribed, dome-shaped elevated, reddish nodule, sized 12 mm in diameter, with an ulcer at the center (Figure 1). Inguinal lymph nodes were not palpable.

A biopsy specimen showed several basaloid island nests in the dermis. The tumor cells had small hyperchromatic nuclei and scant cytoplasms. The periphery of the nests showed palisading; the tumor nests were surrounded by clefts (Figure 2). Some of the tumor nests were connected with the overlying epidermis. A diagnosis of BCC (nodular type) was made. The remaining tumor was totally excised with a 5 mm margin, according to the Japanese clinical practice guidelines for the management of BCC, and the defect was repaired with a full-thickness skin graft. No recurrence has been observed for over 3 years after the surgery.

Discussion

About 85 percent of BCCs develop in the head and neck areas, which often occur as a result of chronic ultraviolet exposure. BCC of the foot region is rare accounting for only 0.42 percent of BCCs [2]. Including our case, only 8 cases of BCC on the toes have been reported [3-9]. There were 1 male and 6 females (one case was unknown); the age range was from 67 to 88 years. Four of them were located on the hallux and others occurred on the 2nd, 3rd, 4th, and 5th toe in each. Some of them were located on the nail units. Clinical manifestations of BCCs on the toes tended to be different from typical features, such as ulcerative erythematous lesions suggestive of chronic dermatitis [7], Bowen disease [5], and small brown-colored plaque [6]. Histologically, the nodular type was the most common (4 cases including ours) and the superficial type was found in 1 case. None of the cases showed local recurrence or distant metastasis. Only 2 were Japanese cases, including ours. Although most BCCs occurring in the Japanese are melanotic, our case presented a hypopigmented nodule mimicking eccrine poroma. Another Japanese case showed a small, slightly elevated, brown-colored plaque; this was a superficial BCC [6]. In our case, minor trauma may have played a triggering role in the development of BCC. Basal cell carcinoma should be included in the differential diagnosis of the tumors on the toes in elderly people.

References

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2. Betti R, Urbani CE, Lodi A, et al. Unusual sites of basal cell epitheliomas according to anatomical distribution and relative tumour density index. Eur J Dermatol 1992; 2: 154-156.

3. Orsini RC, Catanzariti A, Saltrick K, et al. Basal cell carcinoma of the nail unit: A case report. Foot Ankle Int 2001; 22: 675-678. [PubMed]

4. McCarthy DJ. Basal cell carcinoma in the lower extremities. J Am Podiatry Assoc 1984; 74: 330-340. [PubMed]

5. Herzinger T, Flaig M, Diederich R, et al. Basal cell carcinoma of the toenail unit. J Am Acad Dermatol 2003; 48: 277-278. [PubMed]

6. Matsushita K, Kawada A, Aragane Y, et al. Basal cell carcinoma on the right hallux. J Dermatol 2003; 30: 250-251. [PubMed]

7. De Giorgi V, Salvini C, Massi D, et al. Ungual basal cell carcinoma on the fifth toe mimicking chronic dermatitis: Case study. Dermatol Surg 2005; 31: 723-725. [PubMed]

8. Stashower ME. Resolution of tinea pedis with imiquimod cream 5% in a patient with nodular basal cell carcinoma. Cutis 2006; 78: 66-69. [PubMed]

9. Abeldaño AM, Tiscornia J, Cendeño LP, et al. Basal cell carcinoma in palm and sole. SKIN Med 2006; 5: 40-42. [PubMed]

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