Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept 2021;11(1):e2021129 1 Dermatology Practical & Conceptual Scalp Basal Cell Carcinoma Presenting as Alopecia Alexandra C. Goetze1, Giovana Liz Marioto de Campos2,3, Felipe Bochnia Cerci3,4, Betina Werner5 1 Clínica Newestetic, Curitiba, Brazil 2 Department of Dermatology, Hospital Universitário Evangélico Mackenzie, Curitiba, Brazil 3 Clínica Cepelle, Curitiba, Brazil 4 Department of Dermatology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil 5 Department of Pathology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil Key words: basal cell carcinoma, alopecic plaque, arborizing vessels, Mohs micrographic surgery, skin cancer Citation: Goetze A, Marioto de Campos GL, Cerci FB, Werner B. Scalp basal cell carcinoma presenting as alopecia. Dermatol Pract Concept. 2021;11(1):e2021129. DOI: https://doi.org/10.5826/dpc.1101a129 Accepted: August 6, 2020; Published: January 29, 2021 Copyright: ©2021 Goetze et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Alexandra C. Goetze, MD, Clínica Newestetic, Rua Pedro Viriato Parigot de Souza, 318, Curitiba, Brazil. Email: alexandracgoetze@gmail.com Case Presentation A healthy 32-year-old woman presented with a 7-year history of a slowly growing asymptomatic alopecia plaque on the scalp. Physical examination revealed a 4.7 × 2.4 cm erythem- atous indurated alopecic plaque on the left parieto-occipital scalp (Figure 1A). A 3 mm papule could be noticed on the inferior area of the plaque. Dermoscopy showed multiple arborizing vessels in the plaque with no follicular open- ings (Figure 1B). Histopathologic examination revealed an infiltrative basal cell carcinoma (BCC) with no evidence of sebaceous nevus (Figure 1C). The patient was treated with Mohs micrographic surgery followed by primary closure. At a 3-year follow-up, no recurrence was noted. Figure 1. (A) Indurated alopecic plaque on the left parieto-occipital scalp. Trichotomy was performed around the plaque prior to the sur- gery. (B) Dermoscopy demonstrated multiple arboriform vessels. (C) Histopathology revealed infiltrative chords and irregular small nests of basaloid cells with palisading and clefting in some areas surrounded by a desmoplastic dermis. There was no sign of follicular germ or papilla formation throughout the neoplasia (H&E, original magnification ×10). 2 Image Letter | Dermatol Pract Concept 2021;11(1):e2021129 Teaching Point Alopecia of the scalp caused by BCC can manifest without pearly borders and ulceration and can be mistaken for other conditions such as discoid lupus erythematosus or alopecia areata [1]. An indurated plaque of alopecia with arborizing vessels on dermoscopy should raise the suspicion for BCC. Reference 1. Scheinfeld, N. Review of scalp alopecia due to a clinically unap- parent or minimally apparent neoplasm (SACUMAN). Acta Derm Venereol. 2006;86(5):387-392. DOI: 10.2340/00015555-0160.