Basosquamous carcinoma (BC) is a malignancy of the skin that rarely happens with histopathological picture shows basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) [1]. Some experts believe that the disease is a variant of BCC [1,2]. However, some studies indicate that biologically more similar BCC than SCC. Basosquamous carcinoma also more aggressive, destructive, more commonly metastasize, and post-therapy recurrence rate is also more tinggi [1,3]. Synonyms BC are a basal cell carcinoma with squamous metaplasia [4]. Therapeutic options in the facial skin malignancies is excision followed by full-thickness skin graft [1].

A woman, aged 51 years with a chief complaint that there are ulcers on the nose. History of this disease is approximately 3 years ago with raised nodule. Patients complain of blackish like a small mole on the nose, sometimes itchy, not easy bleeding, no pain, and often scratched by the patient to bleed and cause injuries. Moles are widening, and develop into such ulcers, blackish colour, sometimes itchy, bleed easily when scratched and ulcers that increase in width. These ulcers shallow, ± 4 cm diameter, demarcated, irregular, blackish brown colour, erythematous edge, no bleeding. Palpation rough surface, uneven, hard, no tenderness (Figure 1). Results of histopathological examination showed epidermal atrophy, looked pearl horn, cells oval, partially keratinized, supporting the diagnosis of BC (Figure 2). Excision accompanied by full-thickness skin graft on a tumour in his nose (Figure 3).

Figure 1: BC shallow, ± 4 cm diameter, demarcated, irregular, blackish brown colour, erythematous edge, no bleeding.

Figure 2: Epidermal atrophy, looked pearl horn, cells oval, partially keratinized.

Figure 3: Excision followed by full-thickness skin graft. (A) Mapping performed on the recipient area in the nose that will excision with a limit of 5 mm from the edge of the lesion and the donor area in the left submandibular region for full-thickness skin graft. (B) Excision appropriate mapping, tumor tissue removed. (C,D) Placed on a donor tissue recipient area, then do the sewing thread is interrupted simple monocryl 5-0 suture.

Diagnosis BC is established based on histopathological examination. The history and clinical picture BC looks like BCC. The incidence increases with age and is more common in men than women. Several studies in Indonesia showed that the incidence in women more often than men. Research in Semarang Indonesia mentioned that in 5 years (1998-2002) 54 cases of BCC were found, which consisted of 36 women (66.7%) and 18 men (33.3%) [5]. Pathogenesis depends on several factors, including genetics, sunlight, carcinogens, chronic skin damage, exposure to the drug, and other factors [6].

In the last few years it has been discovered that gene nevoid basal cell carcinoma syndrome is located on chromosome 9q22 [3]. Mutations in these genes have been identified in sporadic basal cell carcinoma. Fair skin that contains very little melanin is also a risk factor. Extrinsic risk factors mainly happen to BC upon exposure to sunlight. Exposure to sunlight after the age of 20 years can trigger the process of carcinogenesis manifestations which will appear 40-60 years later [7]. Besides artificial radiation such as phototherapy and photochemotherapy is also a pathogenetic factor. Chronic exposure to inorganic arsenic components that contaminate well water can trigger carcinoma 10-30 years later, although it is not exposed to sunlight. Cancer can occur on damaged skin such as scarring caused by immunization, trauma, varicella, burns and tattoos. Chronic ulcers such as severe stasis dermatitis can develop into BC. Nitrogen mustard used in the topical treatment of cutaneous T-cell lymphoma, PUVA is used in the treatment of psoriasis and other dermatoses, especially in patients who received the therapy time, this will increase the risk for BC.

Patients who are immunosuppressed have a substantial risk for the occurrence of BC, but immunologic factors that certainly could not be determined. Factors that affect the incidence of carcinoma in these patients suspected of exposure rays of sunlight continuously for several decades earlier [7,8]. Basosquamous carcinoma can arise in all places, but most often in areas exposed to sunlight such as the ala, columella, nasal septum and the edges, sulcus nasolabial, upper lip, ear front, sulcus pre and post aurikular, canthus medial, and limit petals eyes, scalp hair and forehead, all of this area is referred to as zone H [5,9]. This carcinoma can also occur in regional body, nipples, penis, scrotum, vulva and perianal area. Tumors never grow on the surface of mucosa [6]. Complaints are usually asymptomatic but can sometimes be found as itching, a little discomfort from inflammation or secondary infections [9]. Lesions usually grows as a small lump that gradually increase in size, with ulceration in the middle and edges rising. The surface of the tumor is usually smooth but sometimes coarse, hyperchromatic or crusted, and found teleangiektasi, and easy bleeding from mild traumatic [3,10]. Basosquamous carcinoma has several variants form noduloulseratif, pigmented, superficial, morphoea and fibroepitelioma [1,3,11,12]. Histopathologic picture in this patient skin preparation nose showed epidermal atrophy, looked pearl horn, cells oval, partly keratinized. According to literature basosquamous carcinoma histopathological picture is composed of basaloid cells and squamoid but still retains the typical organization of BCC [1,13]. In this case excision therapy followed by full-thickness skin graft was done because of the location and extent of the lesion, wherein only when excision alone, it will cause an asymmetrical skin, which will be interested and give cosmetically ugly result [14,15]. Therapy which was administered to this patient is excision followed by full-thickness skin graft. The goal of therapy of skin carcinoma is the eradication of the entire tumor perfectly up healing, both clinically and cosmetically [1,6,12]. In determining the method of treatment in carcinoma of the skin, a lot of things that must be considered depending on the characteristics of tumor sufferers, the condition of the patient, and facilities and surgeons available. Patient factors to consider are age, history of other diseases, psychological factors and medical history. Tumor factors that must be considered is the type of tumor, size, location, nature of growth and whether primary or recurrent tumor. Surgical excision with or without skin graft or flap continued to give a cure rate of about 90% and cosmetically satisfying. Limit excision of lesions 3-5 mm is recommended to achieve the best cure rate that also provides good cosmetical results [16]. Split-thickness skin graft is composed of the entire epidermis and dermis as well as some partial thickness or without adnexal structures [8,17]. Full-thickness skin graft is often used to repair abnormalities of reconstructive surgery as well as the removal of skin cancer and can give good results in terms of color, thickness and texture. Defects in the nose, the lower eyelid and ear are difficult for primary closing with FTSG [17-19].

Basosquamous carcinoma is a malignancy of the skin that rarely happens with histopathological picture that shows basal cell carcinoma and squamous cell carcinoma. Therapeutic treatment is excision followed by full-thickness skin graft.