Visual heuristics and basal cell carcinoma: pitfalls and strategies for clinical vigilance
-
Helena M. Nammour
Abstract
Objectives
To examine how visual heuristics contribute to the clinical misdiagnosis of basal cell carcinoma (BCC) and to identify common heuristic patterns that may lead to diagnostic error in dermatologic practice.
Methods
A review of published case reports and observational studies was conducted to identify instances in which BCC was misdiagnosed or mischaracterized prior to histopathologic confirmation. Articles were analyzed for recurring clinical features that influenced diagnostic reasoning. Heuristic patterns contributing to misdiagnosis were categorized thematically.
Results
Heuristics, or mental shortcuts used to streamline clinical decision-making, are widely used in dermatology due to their highly visual and pattern-based nature. While often efficient, they can introduce cognitive bias when lesions deviate from expected presentations. Analysis of misdiagnosed BCC cases revealed five key heuristic categories: pigmentation, lesion location, morphology or texture, patient age, and skin type. Misdiagnosis was most common in pigmented lesions, uncommon anatomical sites, and in patients with skin of color or younger age.
Conclusions
Visual heuristics play a central role in dermatologic diagnosis but may undermine accuracy when atypical features are present. Increased awareness of these diagnostic pitfalls, together with systematic dermoscopic evaluation and a low threshold for biopsy, can help reduce error and improve outcomes.
Acknowledgments
The authors would like to thank Dr. Rashid M. Rashid for his mentorship throughout this project and during preparation of this manuscript.
-
Research ethics: Not applicable.
-
Informed consent: Not applicable.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. Author contributions: Writing, editing, literature Review, table production, formatting (HMN); writing, editing, figure Production (TAB); literature Review, editing (MED, MN).
-
Use of Large Language Models, AI and Machine Learning Tools: None declared.
-
Conflict of interest: The authors state no conflict of interest.
-
Research funding: None declared.
-
Data availability: Not applicable.
References
1. Lowenstein, Ej., Sidlow, R. Cognitive and visual diagnostic errors in dermatology: part 1. Br J Dermatol 2018;179:1263–9. https://doi.org/10.1111/bjd.16932.Search in Google Scholar PubMed
2. Ferrari, A, De Angelis, L, Peris, K. Unusual clinical and dermoscopic features in two cases of pigmented basal cell carcinoma. J Am Acad Dermatol 2005;53:1087–9. https://doi.org/10.1016/j.jaad.2005.05.045.Search in Google Scholar PubMed
3. Pampena, R, Lai, M, Piana, S, Pellacani, G, Longo, C. Basal cell carcinoma or melanoma, that is the question. J Eur Acad Dermatol Venereol 2020;34:e425–7. https://doi.org/10.1111/jdv.16373.Search in Google Scholar PubMed
4. Suppa, M, Micantonio, T, Di Stefani, A, Soyer, HP, Chimenti, S, Fargnoli, MC, et al.. Dermoscopic variability of basal cell carcinoma according to clinical type and anatomic location. J Eur Acad Dermatol Venereol 2015;29:1732–41. https://doi.org/10.1111/jdv.12980.Search in Google Scholar PubMed
5. Stanganelli, I, Argenziano, G, Sera, F, Blum, A, Ozdemir, F, Karaarslan, IK, et al.. Dermoscopy of scalp tumours: a multi-centre study conducted by the international dermoscopy society. J Eur Acad Dermatol Venereol 2012;26:953–63. https://doi.org/10.1111/j.1468-3083.2011.04188.x.Search in Google Scholar PubMed
6. Karampinis, E, Georgopoulou, KE, Kampra, E, Zafiriou, E, Lallas, A, Lazaridou, E, et al.. Clinical and dermoscopic patterns of basal cell carcinoma and its mimickers in skin of color: a practical summary. Medicina 2024;60:1386. https://doi.org/10.3390/medicina60091386.Search in Google Scholar PubMed PubMed Central
7. Di Matteo, E, Pampena, R, Pizzichetta, MA, Cinotti, E, Chester, J, Kaleci, S, et al.. Unusual dermoscopic patterns of basal cell carcinoma mimicking melanoma. Exp Dermatol 2022;31:890–8. https://doi.org/10.1111/exd.14533.Search in Google Scholar PubMed PubMed Central
8. Hogue, L, Harvey, VM. Basal cell carcinoma, squamous cell carcinoma, and cutaneous melanoma in skin of color patients. Dermatol Clin 2019;37:519–26. https://doi.org/10.1016/j.det.2019.05.009.Search in Google Scholar PubMed
9. Tiyawatanaroj, A, Sudtikoonaseth, P, Chayangsu, O. Basal cell carcinoma trends in Thailand: a 10-year retrospective study of demographic, clinical and histopathological features. Dermatol Rep 2022;14:9413. https://doi.org/10.4081/dr.2022.9413.Search in Google Scholar PubMed PubMed Central
10. Martinelli, PT, Cohen, PR, Schulze, KE, Dorsey, KE, Nelson, BR. Periungual basal cell carcinoma: case report and literature review. Dermatol Surg Off Publ Am Soc Dermatol Surg Al 2006;32:320–3. https://doi.org/10.1111/j.1524-4725.2006.32062.x.Search in Google Scholar PubMed
11. Tsai, TY, Liao, CK, Zhang, BY, Huang, YL, Tsai, WS, You, JF, et al.. Perianal basal cell Carcinoma-A systematic review and meta-analysis of real-world data. Diagn Basel Switz 2023;13:1650. https://doi.org/10.3390/diagnostics13091650.Search in Google Scholar PubMed PubMed Central
12. Lombardi, M, Pampena, R, Borsari, S, Bombonato, C, Benati, E, Pellacani, G, et al.. Dermoscopic features of basal cell carcinoma on the lower limbs: a chameleon. Dermatol Basel Switz 2017;233:482–8. https://doi.org/10.1159/000487300.Search in Google Scholar PubMed
13. Neagu, N, Lallas, K, Maskalane, J, Salijuma, E, Papageorgiou, C, Gkentsidi, T, et al.. Minimizing the dermatoscopic morphologic overlap between basal and squamous cell carcinoma: a retrospective analysis of initially misclassified tumours. J Eur Acad Dermatol Venereol 2020;34:1999–2003. https://doi.org/10.1111/jdv.16207.Search in Google Scholar PubMed
14. Nerad, JA, Whitaker, DC. Periocular basal cell carcinoma in adults 35 years of age and younger. Am J Ophthalmol 1988;106:723–9.https://doi.org/10.1016/0002-9394(88)90708-8 Search in Google Scholar PubMed
15. Caviglia, M, Kaleci, S, Frascione, P, Teoli, M, Fargnoli, MC, Pellacani, G, et al.. A systematic review and meta-analysis of ocular and periocular basal cell carcinoma with first-time description of dermoscopic and reflectance confocal microscopy features of caruncle basal cell carcinoma. Diagnostics 2025;15:1244. https://doi.org/10.3390/diagnostics15101244.Search in Google Scholar PubMed PubMed Central
16. Giacomel, J, Zalaudek, I. Dermoscopy of superficial basal cell carcinoma. Dermatol Surg 2005;31:1710–13. https://doi.org/10.2310/6350.2005.31314.Search in Google Scholar PubMed
© 2025 Walter de Gruyter GmbH, Berlin/Boston
