Many cases of basal cell carcinoma (BCC) can be treated with surgery or radiotherapy successfully. However, in advanced BCC—including locally advanced BCC and metastatic BCC—surgery and radiotherapy may be inappropriate and/or result in considerable morbidity or deformity.

Hedgehog pathway inhibitors (HHIs) were developed to block aberrant Hedgehog signaling found in most cases of BCC. Inhibition of the Hedgehog pathway is among the few pharmacologic treatment mechanisms available for patients with advanced BCC.

One of the most common adverse events observed in patients receiving HHIs is muscle spasms, hypothesized to result from noncanonical Hedgehog signaling causing calcium influx into the muscle cell.

We describe an alternate etiology of muscle spasms due to potentially increased actin expression in a case series of patients with advanced BCC.