Neglected cutaneous clear-cell squamous cell carcinoma of the scalp in an elderly patient with medical avoidance: a case report

BACKGROUND: Clear-cell squamous cell carcinoma (ccSCC) is an exceptionally rare variant of cutaneous SCC characterized by tumor cells with abundant clear cytoplasm. Its pathogenesis, behavior, and clinical significance remain poorly defined, and it is not formally classified in head-and-neck sites. Reported risk factors include chronic ultraviolet exposure, prior radiation, arsenic ingestion, immunosuppression, and long-standing ulceration. In this article, we report a case of an 80-year-old male who suffered from a gradually progressive ccSCC on his frontal scalp, which was neglected due to fear-driven medical avoidance. CASE PRESENTATION: An 80-year-old Syrian farmer with extensive lifetime sun exposure presented with a painful, ulcerated, and fungating 7 × 4 cm frontal scalp mass that had progressively enlarged over 2 years. The patient repeatedly declined diagnostic and surgical procedures due to fear of malignancy, influenced by a prior history of lower-lip SCC. Psychological consultation eventually enabled acceptance of treatment. Following appropriate imaging, wide local excision with periosteal dissection and outer-table bone burring was performed, followed by split-thickness skin grafting. Histopathology confirmed Type II non-keratinizing clear-cell SCC with ≥ 80% clear-cell differentiation. A concurrent right-hand lesion was diagnosed as actinic keratosis. At 6-month follow-up, the surgical site showed satisfactory healing with no evidence of recurrence. CONCLUSIONS: This case demonstrates how psychological factors can significantly shape clinical decisions. It also highlights the need for further research to better define ccSCC as a distinct subtype with specific diagnostic and surveillance considerations. Given its rarity and potential for rapid growth, pathologists should remain alert to this variant, particularly in elderly individuals with extensive sun exposure.