Infiltrative basal cell carcinoma of the scalp: five-month post-excision follow-up with z-plasty reconstruction

Abstract

Introduction: Basal cell carcinoma (BCC) is the most common non-melanoma skin cancer, accounting for 75–80% of cases. Although typically slow-growing and rarely metastatic, certain histological variants, such as infiltrative BCC, can exhibit aggressive local behaviour and high recurrence risk. Commonly associated with prolonged ultraviolet exposure, BCC may also arise from non-traditional risk factors such as chronic trauma.

Case Illustration: We report a case of infiltrative BCC on the scalp of a 48-year-old male physician with a history of chronic trauma. The lesion evolved over three years from a 0.5 cm pruritic, erythematous papule into a 2.2 cm ulcerated nodule. The patient underwent wide local excision and Z-plasty reconstruction. Histopathology revealed basaloid cell nests infiltrating the dermis with fibrotic stroma, consistent with the infiltrative subtype. At five-month follow-up, the surgical site had healed, but a new erythematous papule was noted, raising concern for recurrence. The patient denied systemic symptoms but reported mild pruritus.

Discussion: This case highlights an unusual presentation of BCC in a non-sun-exposed region, possibly triggered by chronic mechanical irritation. Infiltrative BCC is characterized by its subclinical extension and higher recurrence rates. Subtle changes at post-operative sites may indicate early recurrence, necessitating vigilant long-term follow-up. Clinical examination, dermoscopy, and histopathological confirmation are essential for early detection and intervention.

Conclusion: Infiltrative BCC can present in atypical locations and behave aggressively despite initial treatment. Early recognition and multidisciplinary follow-up are key to optimizing outcomes and preventing recurrence.