The most common skin cancer is basal cell carcinoma. The neoplasm is characterized by several different morphologic presentations; the most frequent morphologic variants are superficial and nodular. Each clinical presentation of the tumor has a corresponding histologic presentation. The biological behavior of a basal cell carcinoma depends not only on its histologic subtype but also on its location. Surgical excision is the treatment of choice for most basal cell carcinomas; this intervention is typically used for basal cell carcinomas that demonstrate aggressive behavior. Nonsurgical treatment, such as topical 5% imiquimod cream, may be considered for lower-risk tumors. After consultation with the dermatologist, I (a 65-year-old man) decided to treat my primary nodular basal cell carcinoma on my right periocular temple by applying 5% imiquimod cream daily to the neoplasm and the adjacent skin. The cancer was treated for a total of 45 days; during treatment, I had to discontinue the therapy twice because I developed severe, medication-related, local cutaneous adverse side effects, which included inflammation, eschar, and ulcers. I achieved complete clinical clearance of the carcinoma; the only residual finding at the previous tumor site was an atrophic patch. The management of basal cell carcinoma includes noninvasive and invasive modalities. Mohs micrographic surgery is the treatment of choice for most facial basal cell carcinomas and tumors of infiltrative histologic subtype. Mohs surgery is an invasive procedure; it can be associated with not only postoperative complications and scar but also possibly inferior cosmetic results. However, the advantages of Mohs surgery are not only its 97.5% cure rate for primary basal cell carcinomas but also the very low rate of tumor persistence following the procedure. Superficial basal cell carcinomas on the neck, trunk, or extremities can be treated with a daily topical application of 5% imiquimod cream, five times per week, for six weeks. In contrast to surgical excision, topical imiquimod has a lower cure rate; however, it is a noninvasive therapy and may result in cosmetically superior results. Nodular basal cell carcinomas, including periocular tumors, have also been successfully treated with topical 5% imiquimod cream. Treatment using topical 5% imiquimod cream for a basal cell carcinoma, compared to Mohs surgical excision, has several potential disadvantages. Some of these include a lower cure rate, a longer treatment duration (such as six weeks with five daily applications each week to treat a superficial basal cell carcinoma versus a single day of surgery), and the development of localized adverse cutaneous reactions that occur both on the tumor-containing epithelium and the skin surrounding the cancer. In conclusion, the management of basal cell carcinoma is an individualized decision for which several factors need to be evaluated. Although surgery is the gold standard of treatment, patients who do not want surgical intervention and possibly a better cosmetic result without a surgical scar may appropriately elect potentially effective noninvasive therapies, which have lower cure rates, longer treatment duration, and more frequently have associated adverse cutaneous reactions. This experience has taught me as a patient and as a physician that the topical management of a basal cell carcinoma with 5% imiquimod cream can result in more complicated adverse cutaneous effects than anticipated.
Philip R Cohen (Fri,) studied this question.
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