While other subtypes of basal cell carcinoma (BCC) primarily affect individuals with light eyes and hair, fair complexion, and an inability to tan, pigmented BCC has a predilection for darker-skinned populations with dark brown eyes.1- 3 Commonly mistaken as melanoma because of its often dark and irregular pigmentation, pigmented BCC is marked by its firm consistency, translucence, and occasional surface ulceration.2 We present 2 cases of pigmented basal cell carcinoma in a fair skinned patient with blue eyes.
Patient 1 (Figure, A) is a 75-year-old woman with type I skin, blue eyes, and a history of BCC. She presented with a new pink-brown papule on the back. A biopsy specimen showed masses of basaloid cells within a fibrocellular stroma. Pigment was found both within the tumor cells and in melanophages (Figure, B).
A, Clinical photograph of patient 1 showing blue eyes and fair complexion. B, Histopathologic specimen from patient 1 showing basaloid proliferation with prominent areas of pigmentation consistent with pigmented basal cell carcinoma (hematoxylin-eosin, original magnification ×200). C, Pigmented plaque on the back of patient 2. D, Histopathologic specimen from patient 2 is consistent with a pigmented basal cell carcinoma (hematoxylin-eosin, original magnification ×200).
Patient 2 is a 77-year-old man with type I skin and blue eyes and no history of melanoma or nonmelanoma skin cancer. He presented with a brown and pink plaque on the posterior shoulder (Figure, C). A biopsy specimen showed masses of basaloid cells with dense areas of pigment (Figure, D).
Pigmented BCC has been very well documented in patients with darker eyes and skin; however, the number of cases reported in lighter-skinned individuals, including those with type I skin, is limited.1,2,4,5 Tan et al5 in 2008 proposed that the predilection for African American, Hispanic, and Asian populations could be owing to the ability to tan along with the greater melanogenic capacity of dark-haired patients. In a study by Bart and Schnall1 in 1973, only 10% of patients with pigmented BCC had light brown eyes, while the eyes of the remaining 90% were dark brown. There were no cases reported in other eye colors. Rossiello and colleagues6 in 2006 described a case of pigmented BCC in a 29-year-old white woman. There have been few cases of pigmented BCC reported in white patients with blue eyes, further supporting an association with darker skin and eye color.7 Differentiating pigmented BCC from melanoma or atypical melanocytic nevi is essential; in our case, the diagnosis was determined by characteristic histologic findings of benign proliferation of melanocytes throughout the basaloid tumor islands and numerous pigment-laden melanophages within the fibrocellular tumor stroma. Despite the fact that only 7% of BCCs are pigmented,6 and they are uncommon in fair-skinned populations, pigmented BCC should be included in the differential diagnosis of atypical pigmented lesions in patients with lighter skin or eyes.
Corresponding Author: William D. James, MD, Department of Dermatology, University of Pennsylvania, 3600 Spruce St, 2 Maloney Bldg, Philadelphia, PA 19104 (William.James@uphs.upenn.edu).
Published Online: June 5, 2013. doi:10.1001/jamadermatol.2013.491
Conflict of Interest Disclosures: None reported.
Coleman CI, Wine-Lee L, James WD. Pigmented Basal Cell CarcinomaUncommon Presentation in Blue-Eyed Patients. JAMA Dermatol. 2013;149(8):995-996. doi:10.1001/jamadermatol.2013.491