Basal Cell Carcinoma of the Eyelid

Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common eyelid malignancy, accounting for approximately 90% of all eyelid cancers. It arises from basal keratinocytes of the epidermis and is strongly associated with cumulative UV exposure, fair skin, and immunosuppression. The lower eyelid accounts for ~50% of cases, followed by the medial canthus (~25%), upper eyelid (~15%), and lateral canthus (~10%).

Clinical subtypes:

• Nodular BCC (most common) — pearly or translucent nodule with telangiectatic vessels and a rolled, indurated border; may ulcerate centrally (“rodent ulcer”)
• Morpheaform (sclerosing) BCC — flat, waxy, scar-like plaque with ill-defined margins; most aggressive subtype, frequently underestimated clinically; requires widest surgical margins
• Superficial BCC — flat, erythematous plaque; more common on the trunk; less frequent on the eyelid

Surgical management: Mohs micrographic surgery with same-day oculoplastic reconstruction is the gold standard for periocular BCC. Mohs achieves the highest cure rate (5-year recurrence <1% for primary BCC) with the greatest tissue preservation — critical in the eyelid where even a few millimeters matter for function. For nodular BCC of the lower lid not involving the lid margin, wide local excision with frozen-section margin control is an alternative.

BCC is locally destructive but rarely metastasizes (<0.1%). Orbital invasion, though uncommon, can occur with neglected medial canthal BCC and may require orbital exenteration. Hedgehog pathway inhibitors (vismodegib, sonidegib) are used for locally advanced or metastatic BCC not amenable to surgery.