Rodent under the hat

This report describes a case of neglected scalp basal cell carcinoma (BCC) resulting in total destruction of soft tissue and underlying cranium, with remarkably preserved dura and no parenchymal involvement. A 57-year-old woman presented with a 2-week history of lethargy. On removal of her hat, a large round ulcer was revealed. It transpired that the patient noticed a pruritic scalp lesion 9 months ago. As the lesion and wound enlarged, she was too embarrassed to inform her family and hid it under a hat at all time. She never experienced meningitic symptoms. Biopsy confirmed BCC. Subsequently, she underwent two free latissimus dorsi flap reconstructions to cover the wound and palliative radiotherapy. She responded well to treatment. This case provides a rare opportunity to observe the natural history of scalp BCC. The reasons for the rarity of this mode of presentation and the low incidence of intracranial infection are discussed.