Basal cell carcinoma (BCC) is the most common cutaneous malignancy worldwide, arising from the basal cells of the epidermis and adnexal structures.[1] Although characterized by slow growth and a low metastatic potential, BCC can cause significant local tissue destruction if left untreated.[2]Chronic ultraviolet (UV) radiation exposure is the principal etiological factor, with advancing age, ionizing radiation, immunosuppression, and certain genetic syndromes recognized as additional risk factors.[1,2]

BCC predominantly affects sun-exposed areas, particularly the head and neck region. While relatively uncommon in individuals with darker skin phototypes, including the Indian population, atypical clinical presentations may pose diagnostic challenges.[3] Dermoscopy is a valuable non-invasive diagnostic tool that facilitates the recognition of characteristic vascular and pigmented structures, thereby improving diagnostic accuracy.[4] However, histopathological examination remains the gold standard for confirmation.[1]

We report a case of synchronous pigmented basal cell carcinomas involving the face and dorsum of the hand in an elderly Indian agricultural worker with Fitzpatrick skin type IV, in whom dermoscopic features suggestive of  BCC were identified at both sites and subsequently confirmed on histopathological examination.

A 62 year old Indian male having Fitzpatrick type 4 skin presented with an irregular black coloured plaque present over the left malar area measuring in size 2cm×3cm with intact surface. There is another plaque in the same patient which is irregular yellow brown in appearance present over the dorsomedial aspect of right hand measuring in size 3cm × 3cm with small ulceration over the surface (Figure 1a and 1b). Patient first noticed a pigmented papule over the face area 8 yrs ago which gradually increased in size, after 3 years he noticed a similar papule over dorsum of hand area which also started gradually increasing in size to reach the present size. Patient is agricultural worker by occupation. There was no past history or family history of skin cancer. Besides that there was no history of immunosuppression or exposure to ionizing radiation. Dermoscopy was done using Dinolite USB dermatoscope on olarized light (80x) which revealedloss of pigment network, white structureless areas, arborizing vessels, spoke wheel like structures, haemorrhages, ulceration, blue-gray ovoid nests and maple leaf like structures (Figure 2a and 2b).  The features were highly suggestive of Basal Cell Carcinoma and to conform the same skin biopsy was done from both the sites. Histopathological examination from both sites revealed nests and islands of basaloid cells arising from the epidermis and infiltrating the dermis. The tumour cells exhibited peripheral palisading with retraction clefts. Melanin pigment was present within tumour islands and melanophages, consistent with a pigmented variant. The dermis showed a mixed chronic inflammatory infiltrate with few areas of focal haemorrhage. The findings were consistent with pigmented basal cell carcinoma at both sites (Figure 3a and 3b).

Figure legends

Figure -1a(Face) and 1b(Hand). An irregular black coloured plaque present over the left malar area measuring in size 2cm×3cm with intact surface and another plaque in the same patient which is irregular yellow brown in appearance present over the medial aspect of dorsum of right hand measuring in size 3cm × 3cm with small ulceration over the surface .

Figure- 2a(Face) and 2b(Hand). Dermatoscopy was done using Dinolite USB dermatoscope on polarised light (80x) which revealed loss of pigment network(purple arrow), white structureless areas (pink arrow), arborizing vessels(black arrow), spoke wheel like structures(white arrow), haemorrhages(blue arrow), ulceration (green arrow), blue-gray ovoid nests (yellow arrow) and maple leaf like structures(red arrow).

Figure -3a(Face) and 3b(Hand).Histopathological examination (10x) from both sites revealed nests and islands of basaloid cells arising from the epidermis and infiltrating the dermis. The tumour cells exhibited peripheral palisading with retraction clefts. Melanin pigment was present within tumour islands and melanophages, consistent with a pigmented variant.

Basal cell carcinoma accounts for the majority of non-melanoma skin cancers and is strongly associated with cumulative ultraviolet radiation exposure.[2] Although the head and neck region remains the most commonly affected site, the occurrence of multiple synchronous lesions at distinct anatomical locations is relatively uncommon, particularly in individuals with darker skin phototypes.[3] The present case is noteworthy because of the simultaneous occurrence of pigmented BCCs over the face and dorsum of the hand, in an elderly Indian agricultural worker with Fitzpatrick type IV skin. Pigmented BCC is a clinical variant characterized by increased melanin deposition within tumor nests and melanophages in the surrounding stroma.[1] Clinically, it may mimic melanoma, seborrheic keratosis, melanocytic nevus, pigmented actinic keratosis, or pigmented Bowen disease, thereby posing a diagnostic challenge, especially in darker skin.[1,3] Dermoscopy has emerged as a valuable adjunct in the evaluation of pigmented BCC. Characteristic dermoscopic findings include arborizing vessels, blue-gray ovoid nests, multiple blue-gray globules, maple leaf-like areas, spoke-wheel structures, ulceration, and shiny white structures.[4] In our patient, dermoscopic examination of both lesions demonstrated features suggestive of pigmented BCC, facilitating early recognition and guiding histopathological examination. Histopathology confirmed the diagnosis by revealing basaloid tumor islands with peripheral palisading and stromal retraction clefts along with prominent melanin pigmentation.[1] The concordance between dermoscopic and histopathological findings in both lesions highlights the utility of dermoscopy as a rapid, non-invasive tool for evaluating clinically suspicious pigmented lesions.[5] Furthermore, this case emphasizes that BCC should remain an important differential diagnosis for pigmented lesions arising on chronically sun-exposed sites even in individuals with Fitzpatrick type IV skin. This report contributes to the limited literature on synchronous pigmented BCCs in the Indian population and underscores the value of clinicodermoscopic–histopathological correlation in establishing an accurate diagnosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil Conflicts of interest There are no conflicts of interest Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the author without the use of artificial intelligence technologies.

1. Elder DE, Massi D, Scolyer RA, Willemze R. Lever's Histopathology of the Skin. 13th ed. Philadelphia: Wolters Kluwer; 2020.
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4. Lallas A, Apalla Z, Ioannides D, et al. Dermoscopy in basal cell carcinoma. Dermatol Clin. 2018;36(4):389-401.
5. Reiter O, Mimouni I, Gdalevich M, et al. The diagnostic accuracy of dermoscopy for basal cell carcinoma: a systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(5):1380-1388.