Abstract
Introduction
Basal cell carcinoma (BCC) is the most common skin cancer, primarily affecting the head and neck region. This study aimed to evaluate the characteristics of BCCs in different facial areas using polarized dermoscopy (PD) and ultraviolet-induced fluorescence dermoscopy (UVFD).
Methods
BCCs were examined using a Dermlite DL5 dermatoscope in polarized and UVFD modes. The tumors were categorized based on their location within the high-risk H-zone (ear and periauricular region, temple, eyes and periorbital area, nose and paranasal region, oral region, chin) and non-H-zone (forehead, cheek, rest of the face, scalp, neck). PD features were characterized according to standard dermoscopic criteria for skin cancer assessment. UVFD characteristics included dark silhouettes, interrupted follicle patterns, ulcerations/erosions, white-blue scales, arborizing vessels, absence of pink-orange or blue-green fluorescence, blue-fluorescent fibers, pink-orange fluorescence, black globules, white depigmentation, white clods, and well-defined margins.
Results
A total of 151 BCCs were analyzed, with 61.6% located in the H-zone, where the nose and paranasal region were the most affected area (37.6%). Nodular (65.6%) and nonpigmented (86%) subtypes predominated in the H-zone. PD most commonly revealed arborizing vessels (52.7%), short fine telangiectasias (46.2%), red-white homogeneous areas (40.9%), and ulcerations/micro-ulcerations (40.9%). Under UVFD, BCCs in the H-zone frequently exhibited dark silhouettes (77.4%), interrupted follicle patterns (51.6%), absence of blue-green (51.6%) or pink-orange fluorescence (44%), and well-defined lesion borders (43%). Compared to non-H-zone tumors, BCCs in the H-zone were significantly more likely to display ulcerations/micro-ulcerations under PD (p = 0.021), and erosions/ulcerations (p = 0.019), blue-fluorescent fibers (p = 0.009), and absence of blue-green fluorescence (p = 0.019) under UVFD.
Conclusion
BCCs in the head and neck exhibit distinct characteristics under UVFD, with certain findings more commonly observed in H-zone tumors. The addition of UVFD to PD serves as a valuable, noninvasive diagnostic tool that enhances early detection of BCCs in this anatomically and cosmetically significant region.
Keywords: Dermoscopy, Dermatoscopy, Basal cell carcinoma, UV-dermoscopy, Ultraviolet-induced fluorescence dermoscopy, Head, Skin cancer
Key Summary Points
| Accurate diagnosis of basal cell carcinoma (BCC) is essential for effective treatment, especially in the high-risk facial region—H-zone. |
| This study examined the findings in ultraviolet-induced fluorescence dermoscopy (UVFD) alongside polarized dermoscopy (PD) in BCCs in different areas of the head and neck. |
| UVFD revealed erosions or ulcerations, the presence of blue fluorescent fibers, and the absence of blue-green fluorescence significantly more frequently in tumors located in the H-zone than in the non-H-zone. |
| UVFD provides additional clues, such as the presence of interrupted follicle patterns or absence of follicular fluorescence within the tumor, especially for lesions located within the nose and paranasal area, oral region, or on the neck. |
| This study underscores the complementary role of UVFD alongside PD in the evaluation of BCCs of the head and neck area. |
Introduction
Basal cell carcinoma (BCC) is the most common type of skin cancer and the most frequently diagnosed cancer overall [1, 2]. According to global statistics, one in five individuals will develop BCC in their lifetime, with incidence increasing with age [3]. Although its prognosis is generally favorable owing to its rare metastatic potential (the reason why the classical TNM cancer classification is not typically applied), BCC remains locally aggressive [4]. As it grows, it progressively invades and destroys surrounding tissues, with a high recurrence rate, particularly in non-pigmented subtypes [5].
BCC predominantly develops in sun-exposed areas, particularly on the head and neck, where cosmetic outcomes are of significant concern [6]. Therefore, early detection methods that improve treatment outcomes and aesthetics are highly desirable. The advancement of dermoscopy has been a major breakthrough in this field. Its role in the diagnosis, treatment planning, and monitoring of BCC has been extensively studied and well established [5, 7, 8]. However, despite its proven utility, there is still a need for improved diagnostic accuracy, as certain benign and malignant tumors may remain difficult to differentiate using conventional dermoscopy alone [8].
In recent years, ultraviolet-induced fluorescence dermoscopy (UVFD) has emerged as a novel approach, integrating UV light (365 nm) into dermoscopic imaging. The present study aimed to analyze the PD and UVFD characteristics of BCCs located in the head and neck region, with a particular focus on the H-zone—a high-risk area known for its aggressive tumor behavior and increased recurrence rates [9, 10]. Understanding UVFD patterns in these locations could enhance early detection strategies and improve treatment outcomes.
Methods
The study was conducted at the Department of Dermatology in Rzeszów, southeastern Poland. Patients who visited the department with clinical and dermoscopic features suggestive BCC were enrolled.
For each patient, clinical data were collected, including sex, Fitzpatrick skin phototype, tumor location, lesion diameter, and clinical subtype. The tumor locations were categorized using the surface anatomy terminology described by Beltrami et al. in 2024 [11]. Subsequently, these regions were further classified into H-zone and non-H-zone categories following the scheme presented by Blechman et al. [12]. The H-zone consisted of the ear and periauricular region, temple, eyes and periorbital region, nose and paranasal region, as well as the oral region and chin. The non-H-zone included the forehead, cheeks, remaining facial areas (including malar eminence, mandibular region, angle of jaw), scalp and neck.
Dermoscopic imaging was performed using a Dermlite DL5 dermatoscope, employing both PD and UVFD. Each lesion was photographed under PD and UV light (365 nm) using an iPhone 7 Plus, and the images were stored for subsequent analysis.
Histopathological examination was performed in all cases to confirm the preliminary diagnosis of BCC. Cases with other histopathological diagnoses or with poor-quality dermoscopic images were excluded. Two experienced dermatologists (IW and MŻ) analyzed the images independently and resolved any disagreements through discussion.
The dermoscopic evaluation was based on established criteria in dermato-oncology for categorizing the features seen in PD [13]. The analysis included vascular patterns, pigmented structures, and other notable findings. Vascular patterns included arborizing vessels, short fine telangiectasia, and hairpin vessels. Pigmented structures encompassed gray ovoid nests, maple leaf-like areas, spoke wheel areas, concentric structures, blue-gray globules, blue-gray peppering, blue-white veil, and peripheral striations. Additionally, various other findings were assessed, such as the presence of multiple erosions, hemorrhage, red-white homogeneous areas, shiny white lines, white structureless zones, milia-like cysts, comedo-like openings, scaling, follicular plugging, perifollicular white rings, keratin masses, and well-defined lesion borders.
The UVFD features of BCC were previously described by the authors in the scientific literature [14]. That study, based on clinical observations, identified a spectrum of diagnostic features including arborizing vessels, white clods, blue-fluorescent fibers, white-blue scales, and black globules. Alterations in fluorescence patterns were also noted, such as the presence or absence of pink-orange follicular fluorescence and the loss of the typical blue-green background signal. Additional hallmarks included dark silhouettes, interrupted follicular patterns, erosions or ulcerations, white depigmented areas, and well-demarcated lesion borders. All of these previously described features were systematically re-evaluated and analyzed in the present study.
A “dark silhouette” was identified when the tumor area exhibited a noticeably darker shade than the surrounding skin. The “interrupted follicle pattern” was described as the presence of evenly spaced, round or oval dark structures—corresponding to follicular ostia—in the unaffected skin, while being absent within the tumor itself. The “lack of blue-green fluorescence” and “lack of pink-orange fluorescence” referred to the presence of these fluorescence patterns in the surrounding skin but their complete absence within the tumor. Additionally, “white depigmentation” was characterized by a bright, structureless whitish zone that stood out against both the tumor and the adjacent skin. The term “well-demarcated borders” was used to describe tumors with sharply outlined edges that distinctly separated them from surrounding tissue.
This research was carried out in compliance with the ethical principles outlined in the Declaration of Helsinki. Prior to participation, all individuals provided written informed consent, which also covered the use of clinical images for publication purposes.
Statistical Analysis
Data analysis was performed using SPSS. Categorical variables were expressed as absolute counts and percentages, while continuous variables were reported as means ± standard deviations (SD) and medians with ranges. Fisher’s exact test was applied to compare the distribution of dermoscopic features, with statistical significance set at p < 0.05.
Results
Clinical Characteristics
In total, 80 patients (52 women and 28 men) with histopathologically confirmed 151 BCCs, all located on the head and neck region, were included in the study. Twelve patients with 18 lesions, clinically suspected to be BCC, were excluded because of different histopathological diagnoses (mainly adnexal tumors or squamous cell carcinoma). One patient was excluded because of poor quality of dermoscopic images.
All participants had Fitzpatrick skin phototypes I–III. The BCCs were categorized into two clinical subtypes: nodular (n = 90; 59.6%) and superficial (n = 61; 40.4%). The majority of the tumors were nonpigmented (n = 119; 78.8%). The average tumor size measured 8.3 ± 6 mm. Detailed demographic and clinical characteristics of the patients are summarized in Table 1.
Table 1.
Clinical characteristics
| Clinical characteristics | |
|---|---|
| Patients, n | 80 |
| Gender, n (%) | |
| Male | 28 (35.0) |
| Female | 52 (65.0) |
| Fitzpatrick skin phototype, n (%) | |
| I | 68 (45.0) |
| II | 79 (52.3) |
| III | 4 (2.6) |
| Total number of BCC, n | 151 |
| Location of BCC, n (%) | |
| Face | 141 (93.4) |
| Scalp | 6 (4.0) |
| Neck | 4 (2.6) |
BCC basal cell carcinoma, n number of cases, SD standard deviation
PD Findings
Head and neck BCCs under PD most frequently showed vascular structures, including arborizing vessels (52.3%) and short fine telangiectasias (45.7%), occurring on red-white homogeneous areas (40.4%) with ulcerations or micro-ulcerations (33.8%). The occurrence frequencies of these and other dermoscopic features are presented in detail in Table 2.
Table 2.
Comparison of the clinical characteristics, polarized dermoscopy findings, and ultraviolet-induced fluorescence dermoscopy features of BCCs located in the H-zone and non-H-zone
| Total n = 151 | % | H-zone (n = 93) | % | Non-H-zone (n = 59) | % | p value | |
|---|---|---|---|---|---|---|---|
| Clinical subtype | |||||||
| Nodular | 90 | 59.6 | 61 | 65.6 | 30 | 50.8 | 0.227 |
| Superficial | 61 | 40.4 | 32 | 34.4 | 29 | 49.2 | |
| Pigmented | 32 | 21.2 | 13 | 14.0 | 19 | 32.2 | < 0.001 |
| Non-pigmented | 119 | 78.8 | 80 | 86.0 | 40 | 67.8 | |
| Size | |||||||
| Mean ± SD | 8.3 ± 6 | 8.2 ± 6 | 8.3 ± 6 | 0.550 | |||
| Diameter 0–4 mm | 38 | 25.2 | 23 | 24.7 | 15 | 25.4 | 0.331 |
| Diameter 5–10 mm | 86 | 56.9 | 50 | 53.8 | 36 | 61.0 | |
| Diameter > 10 mm | 27 | 17.9 | 20 | 21.5 | 8 | 13.6 | |
| PD findings | |||||||
| Vascular structures | |||||||
| Arborizing vessels | 79 | 52.3 | 49 | 52.7 | 31 | 52.5 | 1.000 |
| Short fine telangiectasias | 69 | 45.7 | 43 | 46.2 | 26 | 44.1 | 0.868 |
| Hairpin vessels | 2 | 1.3 | 1 | 1.1 | 1 | 1.7 | 1.000 |
| Linear irregular vessels | 51 | 33.8 | 34 | 36.6 | 17 | 28.8 | 0.387 |
| Pigmented structures | |||||||
| Maple leaf-like areas | 13 | 8.6 | 7 | 7.5 | 6 | 10.2 | 0.570 |
| Gray ovoid nests | 11 | 7.3 | 5 | 5.4 | 6 | 10.2 | 0.341 |
| Spoke wheel areas | 6 | 4.0 | 2 | 2.2 | 4 | 6.8 | 0.210 |
| Blue-gray globules | 17 | 11.3 | 7 | 7.5 | 10 | 16.9 | 0.069 |
| Concentric structures | 7 | 4.6 | 6 | 6.5 | 1 | 1.7 | 0.483 |
| Blue-gray peppering | 23 | 15.2 | 13 | 14.0 | 10 | 16.9 | 0.649 |
| Peripheral striations | 2 | 1.3 | 1 | 1.1 | 1 | 1.7 | 0.561 |
| Blue-white veils | 2 | 1.3 | 2 | 2.2 | 0 | 0.0 | 0.521 |
| Other findings | |||||||
| Ulcerations/micro-ulcerations | 51 | 33.8 | 38 | 40.9 | 14 | 23.7 | 0.021 |
| Multiple erosions | 19 | 12.6 | 14 | 15.1 | 5 | 8.5 | 0.463 |
| Hemorrhages | 29 | 19.2 | 23 | 24.7 | 7 | 11.9 | 0.033 |
| Red-white homogenous areas | 61 | 40.4 | 38 | 40.9 | 25 | 42.4 | 1.000 |
| Milia-like cysts | 11 | 7.3 | 5 | 5.4 | 6 | 10.2 | 0.341 |
| Comedo-like openings | 1 | 0.7 | 1 | 1.1 | 0 | 0.0 | 1.000 |
| Follicular pluggings | 7 | 4.6 | 6 | 6.5 | 1 | 1.7 | 0.405 |
| Perifollicular white rings | 5 | 3.3 | 4 | 4.3 | 1 | 1.7 | 0.649 |
| Keratin masses | 6 | 4.0 | 5 | 5.4 | 1 | 1.7 | 0.405 |
| Scales | 44 | 29.1 | 29 | 31.2 | 15 | 25.4 | 0.467 |
| White structureless areas | 37 | 24.5 | 24 | 25.8 | 14 | 23.7 | 0.699 |
| Shiny white lines | 8 | 5.3 | 6 | 6.5 | 2 | 3.4 | 0.483 |
| Well-demarcated borders | 54 | 35.8 | 34 | 36.6 | 21 | 35.6 | 0.731 |
| UVFD findings | |||||||
| Dark silhouettes | 119 | 78.8 | 72 | 77.4 | 48 | 81.4 | 0.685 |
| Interrupted follicle pattern | 80 | 53.0 | 48 | 51.6 | 32 | 54.2 | 0.741 |
| Erosions/ulcerations | 36 | 23.8 | 28 | 30.1 | 9 | 15.3 | 0.019 |
| White-blue scales | 50 | 33.1 | 35 | 37.6 | 15 | 25.4 | 0.115 |
| Arborizing vessels | 49 | 32.5 | 29 | 31.2 | 21 | 35.6 | 0.859 |
| Lack of blue-green fluorescence | 67 | 44.4 | 48 | 51.6 | 19 | 32.2 | 0.019 |
| Pink-orange fluorescence | 7 | 4.6 | 4 | 4.3 | 3 | 5.1 | 1.000 |
| Lack of pink-orange fluorescence | 60 | 39.7 | 41 | 44.1 | 19 | 32.2 | 0.173 |
| Blue-fluorescent fibers | 14 | 9.3 | 13 | 14.0 | 2 | 3.4 | 0.009 |
| Black globules | 36 | 23.8 | 20 | 21.5 | 16 | 27.1 | 0.339 |
| White depigmentation | 9 | 6.0 | 5 | 5.4 | 4 | 6.8 | 0.712 |
| White clods | 17 | 11.3 | 8 | 8.6 | 9 | 15.3 | 0.291 |
| Well-demarcated borders | 65 | 43.0 | 40 | 43.0 | 26 | 44.1 | 1.000 |
PD polarized dermoscopy, UVFD ultraviolet-induced fluorescence dermoscopy, n number of BCCs
UVFD Findings
Under UVFD, BCCs appeared as dark silhouettes (78.8%) with an interrupted follicle pattern (53.0%), lacking follicular fluorescence observed in the area surrounding the tumor—either blue-green (44.4%) or pink-orange (39.7%). A considerable number of lesions showed well-demarcated borders (43%). Table 2 presents the occurrence frequencies of these findings.
H-Zone and Non-H-Zone
A total of 61.6% (93/151) of the analyzed BCCs on the head and neck were located within the H-zone. Among these, 65.6% (61/93) were classified as nodular, while 34.4% (32/93) were superficial. The majority of tumors in this region (86%, 80/93) were non-pigmented, whereas 14% (13/93) exhibited pigmentation. Regarding tumor size, 24.7% (23/93) measured between 0–4 mm in diameter, 53.8% (50/93) were within the 5–10 mm range, and 21.5% (20/93) exceeded 10 mm. One large BCC extended across both the H-zone and non-H-zone.
No statistically significant difference was found in the size or clinical subtype between tumors located in the H-zone and non-H-zone. However, the non-pigmented subtype was significantly more frequent in the H-zone (p = 0.008).
Under PD, ulcerations/micro-ulcerations (40.9% vs. 23.7%, p = 0.021) and hemorrhages (24.7% vs. 11.9%, p = 0.033) were observed more frequently in the H-zone compared to the non-H-zone. Similarly, under UVFD, a higher prevalence of erosions/ulcerations (30.1% vs. 15.3%, p = 0.019) and blue-fluorescent fibers (14% vs. 3.4%, p = 0.009) was noted in the H-zone. Moreover, lack of blue-green fluorescence (51.6% vs. 32.2%, p = 0.019) within the tumor was observed more frequently in the H-zone.
Table 2 and Figs. 1 and 2 present the clinical and dermoscopic characteristics of BCCs by location in the H-zone or non-H-zone.
Fig. 1.
Polarized light dermoscopy (PD) presentation of basal cell carcinoma (BCC) in the H-zone of the face including BCC (a, c) on the nose and (b) in the oral region. d–f Corresponding images in ultraviolet-induced fluorescence dermoscopy (UVFD). d Dark silhouette, ulceration (red arrow), pink-orange follicular fluorescence at the periphery of the tumor (yellow arrowheads), blue-green follicular fluorescence at the periphery of the tumor (pink arrowheads), absence of both types of fluorescence within the BCC, follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion, follicular plugging (orange arrow). e Dark silhouette, ulceration (red arrow), blue fluorescent fibers (yellow arrowheads), follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion. f Dark silhouette, erosion (red arrow), arborizing vessels (yellow arrow), follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion, blue-green follicular fluorescence at the periphery of the tumor (pink arrowheads), absence of this type of fluorescence within the BCC
Fig. 2.
PD presentation of BCC in the a–c non-H-zone of the face including BCC (a) on the neck and (b, c) on the cheek. d–f Corresponding images in UVFD. d Dark silhouette, arborizing vessel (yellow arrow), blue-green follicular fluorescence at the periphery of the tumor (pink arrowheads), absence of this type of fluorescence within the BCC. e Dark silhouette, follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion, blue-green follicular fluorescence at the periphery of the tumor (pink arrowheads), absence of this type of fluorescence within the BCC. f Dark silhouette, pink-orange follicular fluorescence at the periphery of the tumor (yellow arrowheads), absence of this type of fluorescence within the BCC, follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion
Specific Locations
The frequency of pigmented BCCs varied significantly (p < 0.001) according to anatomical site. All of the scalp BCCs were pigmented followed by tumors located in the forehead region (42.1%), eyes and periorbital region (22.2%), rest of the face (18.2%), cheeks (15.8%), oral region (12.5%), nose and paranasal region (11.4%). Lower frequencies were noted in the temple or ears and periauricular region (each 9%) while no pigmented BCCs were detected on the neck.
PD and UVFD revealed several significant differences in the dermoscopic presentations of BCCs across specific anatomical sites. Under PD, red-white homogeneous areas (p = 0.045) were most frequently observed on the temple (90.9%), followed by the neck (50.0%), nose and paranasal region (45.7%), rest of the face (45.5%), cheek (42.1%), and oral region (31.3%). Blue-gray globules showed the highest occurrence (p = 0.004) on the scalp (66.7%), with lower frequencies on the forehead (21.0%), ears and periauricular region (18.2%), and temple (18.2%). Moreover, the blue-white veil (p = 0.004)—a feature often associated with melanoma—was exclusively seen in the ears and periauricular region with an 18.2% occurrence at these sites.
Under UVFD, an interrupted follicle pattern (p = 0.012) was most frequently observed in the oral region (75.0%), followed by the nose and paranasal region (71.4%), forehead (57.9%), and cheeks (52.6%). Erosions or ulcerations (p = 0.04) were most common on the neck (50.0%), followed by the ears and periauricular region (45.5%), nose and paranasal region (40.0%), scalp (33.3%), and oral region (31.3%). A lack of blue-green fluorescence (p < 0.001) showed the highest occurrence in the neck (75%), nose and paranasal region (74.3%), and oral region (62.5%). Similarly, the absence of pink-orange fluorescence (p = 0.001) was most frequent in the nose and paranasal region (65.7%) and oral region (56.3%).
Tables 3 presents the frequencies of PD features across various anatomical locations, while Table 4 summarizes the distribution of UVFD findings. Examples of BCCs in the nose and paranasal region are presented in Fig. 3, while those in the oral region are shown in Fig. 4.
Table 3.
Prevalence of PD features in various anatomical locations
| Location of BCC, n (%) | Nose and paranasal region (n = 35) | Forehead (n = 19) | Cheeks (n = 19) | Eyes and periorbital region (n = 18) | Oral region (n = 16) | Temple (n = 11) | Ears and periauricular region (n = 11) | Chin (n = 1) | Rest of face (n = 11) | Scalp (n = 6) | Neck (n = 4) | p value |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Vascular structures | ||||||||||||
| Arborizing vessels | 19 (54.3) | 12 (63.2) | 9 (47.4) | 11 (61.1) | 10 (62.5) | 4 (36.4) | 4 (36.4) | 0 (0.0) | 6 (54.5) | 2 (33.3) | 2 (50.0) | 0.763 |
| Short fine teleangiectasias | 17 (48.6) | 10 (52.6) | 4 (21.1) | 7 (38.9) | 8 (50.0) | 6 (54.5) | 5 (45.5) | 0 (0.0) | 7 (63.6) | 1 (16.7) | 4 (100.0) | 0.132 |
| Hairpin vessels | 1 (2.9) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 0.715 |
| Linear irregular vessels | 12 (34.3) | 5 (26.3) | 4 (21.1) | 7 (38.9) | 5 (31.3) | 4 (36.4) | 6 (54.5) | 0 (0.0) | 4 (36.4) | 3 (50.0) | 1 (25.0) | 0.844 |
| Pigmented structures | ||||||||||||
| Maple leaf-like areas | 1 (2.9) | 4 (21.1) | 1 (5.3) | 3 (16.7) | 2 (12.5) | 0 (0.0) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 1 (16.7) | 0 (0.0) | 0.413 |
| Gray ovoid nests | 0 (0.0) | 2 (10.5) | 0 (0.0) | 1 (5.6) | 1 (6.3) | 1 (9.1) | 2 (18.2) | 0 (0.0) | 2 (18.2) | 2 (33.3) | 0 (0.0) | 0.133 |
| Spoke wheel areas | 1 (2.9) | 3 (15.8) | 1 (5.3) | 0 (0.0) | 1 (6.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.446 |
| Blue-gray globules | 1 (2.9) | 4 (21.1) | 1 (5.3) | 1 (5.6) | 1 (6.3) | 2 (18.2) | 2 (18.2) | 0 (0.0) | 1 (9.1) | 4 (66.7) | 0 (0.0) | 0.004 |
| Concentric structures | 2 (5.7) | 1 (5.3) | 0 (0.0) | 0 (0.0) | 2 (12.5) | 1 (9.1) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.798 |
| Blue-gray peppering | 6 (17.1) | 3 (15.8) | 2 (10.5) | 3 (16.7) | 1 (6.3) | 1 (9.1) | 1 (9.1) | 1 (100.0) | 1 (9.1) | 3 (50.0) | 1 (25.0) | 0.178 |
| Peripheral striations | 0 (0.0) | 0 (0.0) | 1 (5.3) | 1 (5.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.794 |
| Blue-white veils | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (18.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.004 |
| Other findings | ||||||||||||
| Ulcerations/micro-ulcerations | 17 (48.6) | 2 (10.5) | 4 (21.1) | 7 (38.9) | 6 (37.5) | 2 (18.2) | 5 (45.5) | 0 (0.0) | 3 (27.3) | 3 (50.0) | 2 (50.0) | 0.199 |
| Multiple erosions | 5 (14.3) | 1 (5.3) | 1 (5.3) | 2 (11.1) | 2 (12.5) | 1 (9.1) | 4 (36.4) | 0 (0.0) | 1 (9.1) | 2 (33.3) | 0 (0.0) | 0.369 |
| Hemorrhages | 11 (31.4) | 0 (0.0) | 2 (10.5) | 5 (27.8) | 2 (12.5) | 2 (18.2) | 2 (18.2) | 0 (0.0) | 1 (9.1) | 3 (50.0) | 1 (25.0) | 0.137 |
| Red-white homogenous areas | 16 (45.7) | 6 (31.6) | 8 (42.1) | 3 (16.7) | 5 (31.3) | 10 (90.9) | 4 (36.4) | 0 (0.0) | 5 (45.5) | 2 (33.3) | 2 (50.0) | 0.045 |
| Milia-like cysts | 2 (5.7) | 3 (15.8) | 0 (0.0) | 3 (16.7) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (18.2) | 1 (16.7) | 0 (0.0) | 0.279 |
| Comedo-like openings | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (6.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.581 |
| Follicular pluggings | 4 (11.4) | 1 (5.3) | 0 (0.0) | 0 (0.0) | 2 (12.5) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.454 |
| Perifollicular white rings | 1 (2.9) | 1 (5.3) | 0 (0.0) | 0 (0.0) | 2 (12.5) | 0 (0.0) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.628 |
| Keratin masses | 2 (5.7) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (6.3) | 1 (9.1) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 1 (16.7) | 0 (0.0) | 0.676 |
| Scales | 13 (37.1) | 1 (5.3) | 6 (31.6) | 5 (27.8) | 4 (25.0) | 2 (18.2) | 5 (45.5) | 0 (0.0) | 4 (36.4) | 2 (33.3) | 2 (50.0) | 0.425 |
| White structureless areas | 7 (20.0) | 2 (10.5) | 5 (26.3) | 6 (33.3) | 5 (31.3) | 1 (9.1) | 3 (27.3) | 1 (100.0) | 2 (18.2) | 2 (33.3) | 3 (75.0) | 0.168 |
| Shiny white lines | 2 (5.7) | 1 (5.3) | 0 (0.0) | 0 (0.0) | 1 (6.3) | 2 (18.2) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (25.0) | 0.426 |
| Well-demarcated borders | 13 (37.1) | 5 (26.3) | 9 (47.4) | 8 (44.4) | 6 (37.5) | 4 (36.4) | 2 (18.2) | 0 (0.0) | 5 (45.5) | 0 (0.0) | 2 (50.0) | 0.563 |
n number of BCCs
Table 4.
Summary of the distribution of UVFD findings
| Location of BCC, n (%) | Nose and paranasal region (n = 35) | Forehead (n = 19) | Cheeks (n = 19) | Eyes and periorbital region (n = 18) | Oral region (n = 16) | Temple (n = 11) | Ears and periauricular region (n = 11) | Chin (n = 1) | Rest of face (n = 11) | Scalp (n = 6) | Neck (n = 4) | p value |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Dark silhouettes | 28 (80.0) | 15 (78.9) | 15 (78.9) | 13 (72.2) | 9 (56.3) | 10 (90.9) | 10 (90.9) | 1 (100.0) | 8 (72.7) | 6 (100.0) | 4 (100.0) | 0.398 |
| Interrupted follicle pattern | 25 (71.4) | 11 (57.9) | 10 (52.6) | 3 (16.7) | 12 (75.0) | 4 (36.4) | 3 (27.3) | 1 (100.0) | 6 (54.5) | 3 (50.0) | 2 (50.0) | 0.012 |
| Erosions/ulcerations | 14 (40.0) | 1 (5.3) | 2 (10.5) | 2 (11.1) | 5 (31.3) | 1 (9.1) | 5 (45.5) | 0 (0.0) | 2 (18.2) | 2 (33.3) | 2 (50.0) | 0.040 |
| White-blue scales | 17 (48.6) | 2 (10.5) | 6 (31.6) | 5 (27.8) | 4 (25.0) | 2 (18.2) | 7 (63.6) | 0 (0.0) | 4 (36.4) | 1 (16.7) | 2 (50.0) | 0.088 |
| Arborizing vessels | 14 (40.0) | 8 (42.1) | 6 (31.6) | 5 (27.8) | 4 (25.0) | 2 (18.2) | 3 (27.3) | 0 (0.0) | 5 (45.5) | 0 (0.0) | 2 (50.0) | 0.606 |
| Lack of blue-green fluorescence | 26 (74.3) | 7 (36.8) | 4 (21.1) | 4 (22.2) | 10 (62.5) | 4 (36.4) | 3 (27.3) | 1 (100.0) | 5 (45.5) | 0 (0.0) | 3 (75.0) | < 0.001 |
| Pink-orange fluorescence | 2 (5.7) | 2 (10.5) | 1 (5.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (18.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.492 |
| Lack of pink-orange fluorescence | 23 (65.7) | 4 (21.1) | 9 (47.4) | 2 (11.1) | 9 (56.3) | 2 (18.2) | 4 (36.4) | 1 (100.0) | 4 (36.4) | 0 (0.0) | 2 (50.0) | 0.001 |
| Blue-fluorescent fibers | 5 (14.3) | 0 (0.0) | 1 (5.3) | 1 (5.6) | 2 (12.5) | 1 (9.1) | 3 (27.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (25.0) | 0.350 |
| Black globules | 6 (17.1) | 8 (42.1) | 4 (21.1) | 7 (38.9) | 3 (18.8) | 3 (27.3) | 0 (0.0) | 1 (100.0) | 1 (9.1) | 2 (33.3) | 1 (25.0) | 0.124 |
| White depigmentation | 0 (0.0) | 1 (5.3) | 2 (10.5) | 0 (0.0) | 3 (18.8) | 2 (18.2) | 0 (0.0) | 0 (0.0) | 1 (9.1) | 0 (0.0) | 0 (0.0) | 0.209 |
| White clods | 4 (11.4) | 3 (15.8) | 2 (10.5) | 2 (11.1) | 0 (0.0) | 2 (18.2) | 0 (0.0) | 0 (0.0) | 2 (18.2) | 2 (33.3) | 0 (0.0) | 0.586 |
| Well-demarcated borders | 19 (54.3) | 9 (47.4) | 9 (47.4) | 8 (44.4) | 4 (25.0) | 5 (45.5) | 2 (18.2) | 1 (100.0) | 6 (54.5) | 0 (0.0) | 2 (50.0) | 0.194 |
n number of BCCs
Fig. 3.
PD presentation of BCC in the a, b nose and c paranasal region. d–f Corresponding images in UVFD. d Dark silhouette, arborizing vessel (yellow arrow), pink-orange follicular fluorescence at the periphery of the tumor (red arrowheads), blue-green follicular fluorescence at the periphery of the tumor (pink arrowheads), absence of both types of fluorescence within the BCC, follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion. e Dark silhouette, arborizing vessel (yellow arrow), follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion. f Dark silhouette, arborizing vessel (yellow arrow), pink-orange follicular fluorescence at the periphery of the tumor (red arrowheads), absence of this type of fluorescence within the BCC, follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion
Fig. 4.
a, b PD presentation of BCC in the oral region. c, d Corresponding images in UVFD. c Dark silhouette, black globules (red arrows), pink-orange follicular fluorescence at the periphery of the tumor (yellow arrowheads), absence of this type of fluorescence within the BCC. e Dark silhouette, arborizing vessel (yellow arrow), pink-orange follicular fluorescence at the periphery of the tumor (pink arrowheads), absence of this type of fluorescence within the BCC, follicle pattern in the surrounding skin (green arrowheads), interrupted follicle pattern within the lesion
Discussion
The available data on the application of UVFD in BCCs has been limited [14–16]. In a recent study by Navarrete-Dechent et al. [16], the authors underscored the role of UVFD in detecting the white-bluish fluorescence of the multiple aggregated yellow-white (MAY) globules. In the aforementioned study, UVFD contributed to the better visualization of MAY globules (95% under UVFD vs. 81% under PD). In another study, UVFD was demonstrated to facilitate biopsy site identification prior to BCC surgery [15]. However, the biggest comprehensive study to date on the UVFD findings in BCCs was conducted by the authors in 2024 [14]. UVFD has been recognized as a valuable complementary tool to PD, particularly for detecting small lesions (< 5 mm), facial tumors, and nodular or non-pigmented BCC subtypes [14].
To better understand the features of BCC, it is necessary to know what normal skin looks like under UVFD. In most cases, regularly distributed gray round/oval structures corresponding to the follicular openings are present. Within the openings of hair follicles, more or less regular fluorescence may be visible—either pink-orange or green-blue. In sebum-rich areas, the follicles often display pink-orange fluorescence associated with porphyrins produced by Cutibacterium acnes. This phenomenon is most prominent in younger individuals with higher sebaceous activity [17–19]. On the other hand, green-blue follicular fluorescence has been identified as a probable marker of Malassezia colonization, particularly in seborrheic areas [20–22].
In the current study, the most frequently observed UVFD feature of BCCs was the presence of dark silhouettes (78.8%), consistent with the authors’ previous research and the findings of Navarrete-Dechent et al. [14, 15]. These studies demonstrated that BCC-affected areas appear darker than the surrounding skin under UVFD, aiding in precise surgical margin delineation. This characteristic is particularly useful for distinguishing BCCs from healthy tissue, especially in non-pigmented facial lesions, where conventional PD may be less effective. UVFD enhance the visualization of lesion margins, which were determined to be well demarcated in 43.0% of tumors examined under UVFD, compared to 35.8% of cases visualized under PD. This may offer practical advantages in preoperative planning, particularly in the high-risk H-zone of the face, where complete tumor removal is critical to reducing recurrence rates. In addition to its oncologic significance, precise excision is also essential for aesthetic outcomes, particularly important in cosmetically sensitive areas, which is undoubtedly the face region.
Additionally, UVFD showed interrupted follicle pattern and the absence of blue-green or pink-orange follicular fluorescence within the tumor compared to the surrounding unaffected skin. These features were significantly more frequently noted in the nose, paranasal, and oral regions. This likely corresponds to the increased number of dilated follicular openings and higher sebaceous gland activity in these areas.
The absence of fluorescence patterns in BCC-affected areas may suggest that tumor growth disrupts follicular structures and alters the local microenvironment. We postulate that this feature, observed only under UV light, may constitute another premise for the preliminary diagnosis of BCC. However, as highlighted before, one of the main assumptions of this clue is that the fluorescence is present in the surrounding healthy skin. In our analysis, the phenomenon was particularly common (> 50% of cases) in specific areas of the head and neck, namely the nose and paranasal area, the oral region, and the neck. Presumably, it is in the assessment of tumors in these locations that the UVFD may be particularly useful.
Despite its advantages, UVFD has certain drawbacks. The technique enables detection of erosions or ulcerations at a lower rate than PD (23.8% vs. 33.8%). Similarly, in the current study vascular structures were less frequently noted under UVFD than under classical PD examination (32.5% vs. 52.3%). It should be underscored at this point that both erosions/ulcerations and arborizing vessels constitute important dermoscopic clues for BCC. These observations are in line with those reported in our previous study [2], highlighting the need to consider UVFD as a complementary rather than a standalone diagnostic tool. This strengthens the importance of an integrative approach in BCC assessment.
There are some limitations to this study that should be acknowledged. The relatively small number of BCCs in certain anatomical regions, such as the chin, scalp, and neck, may have affected statistical power and the generalizability of our findings. Future studies should focus on expanding sample sizes. Additionally, investigating the potential of UVFD in distinguishing BCC from other non-melanoma skin cancers could further refine its clinical utility.
Conclusions
This study underscores the complementary role of UVFD alongside PD in the evaluation of BCCs of the head and neck area. UVFD revealed erosions or ulcerations, the presence of blue fluorescent fibers, and the absence of blue-green fluorescence significantly more frequently in tumors located in the H-zone than in the non-H-zone. UVFD provides additional clues, such as presence of interrupted follicle patterns or absence of follicular fluorescence within the tumor, especially for lesions located in the nose and paranasal area, oral region, or on the neck.
Acknowledgements
We thank the participants of the study.
Author Contribution
Irena Wojtowicz: Data curation, Methodology, Writing—Original draft preparation; Adam Reich: Supervision; Magdalena Żychowska: Conceptualization, Methodology, Supervision. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.
Funding
No funding or sponsorship was received for this study or publication of this article.
Data Availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Conflict of Interest
Adam Reich is an Editorial Board member of Dermatology and Therapy. Adam Reich was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. Irena Wojtowicz and Magdalena Zychowska have nothing to disclose.
Ethical Approval
The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee at the Regional Medical Chamber in Rzeszow (protocol code 50/2024/B, date of approval 21st October 2024). The patients in this manuscript have given written informed consent to the publication of their case details.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.