Low‐Risk Basal Cell Carcinoma: Surgery First, but Not Surgery Only—Toward Protocolised Active Surveillance

To the Editor,

We read with great interest the phase II trial by Pereira et al. on perioperative oral itraconazole in low‐risk basal cell carcinoma (BCC) and the subsequent correspondence by Wan and Quan [1, 2]. Together, these papers prompt a useful clarification. The incremental contribution of this Letter is not to propose observation of selected low‐risk BCCs as a new concept; this possibility is already recognised in principle. Rather, our point is that this limited allowance should now be translated into a protocolised active surveillance approach with explicit eligibility, monitoring and intervention criteria. This distinction matters. Active surveillance is not synonymous with watchful waiting. Watchful waiting generally reflects a less interventional, often symptom‐led approach, typically adopted when age, frailty, or competing comorbidities reduce the expected benefit of treatment [3]. By contrast, active surveillance implies predefined patient selection, structured follow‐up and clear triggers for intervention. Nor should active surveillance be conflated with pharmacologic stabilisation or other nonsurgical treatments, which remain active therapeutic strategies. In this regard, the itraconazole trial suggests biological activity, but it does not establish the safety of observation [1, 2]. Current guidance provides only indirect support for this discussion. The 2023 EADO guideline maintains surgery as first‐line treatment and states that clinical follow‐up ‘could also be considered’ for non‐aggressive, small (< 2 cm) lesions on the trunk [4]. Importantly, however, this statement appears in section 8.1.4, addressing management after incomplete excision and does not constitute a recommendation for active surveillance of an untreated primary BCC. Applying this statement to untreated primary lesions would therefore be an extrapolation requiring prospective validation. Nevertheless, this cautious allowance supports further investigation of whether protocolised active surveillance may be appropriate in a separately defined population of untreated, low‐risk primary BCCs. If active surveillance is to move from vague allowance to clinically credible strategy, three elements should be specified. First, patient selection: the most plausible candidates are immunocompetent patients with histologically confirmed superficial BCC, or very small low‐risk nodular BCC, on the trunk, without aggressive histological features, and with reliable capacity for follow‐up. Second, monitoring: baseline clinical and dermoscopic documentation, standardised photography and predefined review intervals are essential. Third, triggers for intervention: accelerated growth, ulceration, symptoms, morphologic change suggesting higher‐risk behaviour, diagnostic uncertainty, or patient preference should prompt treatment. This framework also helps distinguish active surveillance from therapeutic passivity. It requires informed shared decision‐making, patient reliability and readiness to intervene if prespecified changes occur. In that sense, active surveillance is not ‘doing nothing’; it is a structured management pathway for a narrow subset of biologically indolent BCCs. This issue is not merely semantic. Given the very high incidence of low‐risk BCC, even a narrow and carefully regulated surveillance pathway could have meaningful implications for patient burden, cosmetic outcomes, use of healthcare resources and overtreatment. The key unmet need is therefore not broader permission to observe, but a clinically accountable framework that distinguishes appropriate surveillance from undertreatment and defines when observation remains safe, and when intervention should no longer be deferred. In this sense, protocolised active surveillance should be viewed as a method of risk‐governed care, not as a relaxation of standards. Existing clinical debate and observational data suggest that this question is legitimate, but prospective studies are now needed to define eligibility, monitoring schedules and intervention criteria more rigorously [3, 5].

Author Contributions

Vincenzo De Giorgi conceived the Letter and drafted the initial manuscript. Gabriella Perillo and Giovanni Cecchi contributed to the development of the argument and revision of the manuscript. Federica Fazzari and Biancamaria Zuccaro critically reviewed the manuscript for important intellectual content. All authors read and approved the final version.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Linked Articles

This article is linked to Pereira et al. papers. To view this article, visit https://doi.org/10.1111/exd.70264.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.