Basal Cell Carcinoma and Melanoma are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Basal Cell Carcinoma vs Melanoma at a glance
Basal Cell Carcinoma: Most common human cancer; slow-growing locally invasive tumor of basal keratinocytes driven by UV-induced PTCH/Hedgehog mutations.
Melanoma: Malignancy of melanocytes; deadliest common skin cancer; early detection by ABCDE criteria saves lives.
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Question 1DermatologyMedium
A 72-year-old fair-skinned man presents for a slowly enlarging lesion on the side of his nose that he first noticed over a year ago, describing it as a "pimple that never healed" that occasionally bleeds when he washes his face. He has a long history of outdoor work and a prior actinic keratosis. On examination there is a 7 mm pearly translucent papule with a rolled border, arborizing telangiectasias, and central crusting. There is no regional lymphadenopathy. Which of the following is the most appropriate next diagnostic test to confirm the diagnosis?
ACT scan of the face and neck
BSentinel lymph node biopsy
CPunch or shave skin biopsy
DDermoscopic examination
Reveal answer & full explanation
Correct answer: C — Punch or shave skin biopsy
ACT scan of the face and neck
BSentinel lymph node biopsy
CPunch or shave skin biopsy✓
DDermoscopic examination
Why Punch or shave skin biopsy is correct
The pearly translucent papule with a rolled border, arborizing telangiectasias, and central crusting and ulceration on a sun-exposed nose of an older fair-skinned adult is the classic picture of nodular basal cell carcinoma.
Tissue diagnosis is required for any suspected cutaneous malignancy. A shave or punch biopsy provides histopathologic confirmation (basaloid cells in palisading nests with retraction artifact and myxoid stroma) and identifies the subtype, which directs management such as Mohs surgery for high-risk facial/H-zone or morpheaform tumors.
Why the others are wrong
CT scan of the face and neck — cross-sectional imaging reserved for advanced or recurrent tumors with suspected perineural invasion or deep involvement, not for a typical small primary BCC.
Sentinel lymph node biopsy — unnecessary because BCC metastasizes in fewer than 0.05% of cases. Nodal staging belongs to the workup of melanoma or high-risk SCC, not BCC.
Dermoscopic examination — supports the clinical impression (arborizing vessels, blue-gray nests) but cannot establish a tissue diagnosis or subtype, so it never substitutes for biopsy in a suspected malignancy.
Question 2DermatologyMedium
A 50-year-old male has a new pigmented lesion on his back that has enlarged over the past 3 months. Examination shows asymmetry, irregular borders, multiple colors, and 8 mm diameter. Which of the following is the most likely diagnosis?
AMelanoma
BSeborrheic keratosis
CDysplastic nevus
DSolar lentigo
Reveal answer & full explanation
Correct answer: A — Melanoma
AMelanoma✓
BSeborrheic keratosis
CDysplastic nevus
DSolar lentigo
Why Melanoma is correct
ABCDE criteria: Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolution over time — this lesion meets all criteria (asymmetric, irregular borders, multiple colors, 8 mm diameter, new and enlarging)
Staging is determined by Breslow depth and presence of ulceration
Treatment: wide local excision; sentinel lymph node (SLN) biopsy is discussed and considered for T1b tumors (0.8–1.0 mm, or thinner with ulceration) and discussed and offered for tumors thicker than 1.0 mm
Why the others are wrong
Seborrheic keratosis — typically a stuck-on, waxy, verrucous papule with horn cysts; it can be large and irregularly pigmented, but none of those surface features are described, and a new lesion meeting every ABCDE criterion is melanoma until biopsy proves otherwise
Dysplastic nevus — atypical nevi often share asymmetry, irregular borders, color variegation, and diameter >5 mm, so ABCD alone cannot separate them from melanoma; the discriminator is evolution, and a new, enlarging pigmented lesion in a 50-year-old (new nevi seldom arise after about age 40) is melanoma until proven otherwise
Solar lentigo — uniform tan macule; no asymmetry, irregular borders, or color variation
Additional high-yield points
Melanoma subtypes: superficial spreading (most common), nodular, lentigo maligna (face, sun-damaged elderly skin), acral lentiginous (palms, soles, nail beds — most common subtype in non-white skin types)
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Most common human cancer; slow-growing locally invasive tumor of basal keratinocytes driven by UV-induced PTCH/Hedgehog mutations.
Malignancy of melanocytes; deadliest common skin cancer; early detection by ABCDE criteria saves lives.
Classic presentation
Pearly translucent nodule with rolled border, telangiectasias, and central ulcer on a sun-exposed area of an older fair-skinned adult.; Often asymptomatic; patient notices 'pimple' or 'sore that won't heal' for months to years; Occasional bleeding with minor trauma; rarely painful unless ulcerated/infected; Nodular BCC (most common,…
ABCDE positive pigmented lesion + ugly duckling; for acral/subungual — Hutchinson sign (periungual pigment extension).; New or changing pigmented lesion (ABCDE criteria); Pruritus, bleeding, tenderness, ulceration (later signs); Most patient-detected — emphasize self-examination and 'ugly duckling' sign; ABCDE criteria: Asymmetry,…
Workup / key labs
Histopathologic confirmation of basaloid tumor cells in palisading nests with retraction artifact and myxoid stroma.; Tissue diagnosis required — skin biopsy (shave or punch); Histopathology subtype determines management (nodular, superficial, morpheaform/infiltrative, basosquamous, micronodular)
Histopathology + AJCC 8th edition staging: Breslow depth and ulceration (T), nodal status (N), distant metastases and LDH (M). Mitotic rate is still reported but is no longer used for T staging. Breslow depth is the single most important prognostic factor for clinically localized melanoma; Clark level is no longer part of staging.;…
Imaging
CT/MRI only for advanced or recurrent tumors with suspected perineural invasion or deep tissue involvement; Routine imaging not indicated for typical primary BCC
Stage IA-IIA: typically no imaging if asymptomatic; Stage IIB-IIC: imaging generally only to evaluate specific signs or symptoms (CT or PET/CT may be considered); routine chest X-ray is no longer recommended; Stage III-IV: baseline CT chest/abdomen/pelvis and/or PET/CT plus brain MRI (optional when stage IIIA disease is found only on…
First-line treatment
Surgical excision with 4 mm margins for low-risk primary BCC (cure rate ~95%); Mohs micrographic surgery (preferred for high-risk BCC): face (especially H-zone — central face, periocular, periauricular, perinasal), morpheaform/infiltrative subtypes, recurrent tumors, large tumors (>2 cm), positive margins after standard excision — cure…
Wide local excision based on Breslow depth (AAD/NCCN):; • In situ — 5-10 mm margins; • ≤1.0 mm — 1 cm margins; • 1.01-2.0 mm — 1-2 cm margins; • >2.0 mm — 2 cm margins; Sentinel lymph node biopsy for stages T1b (≥0.8 mm or ulcerated) through T4; if the sentinel node is positive, completion lymph node dissection is no longer routine…
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Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.