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I wonder whether Imiquimod 5% cream (US brand: Aldara) is not helpful as an adjunctive treatment of a facial basal cell carcinoma (BCC) prior to a Mohs surgery. Helpful in this context means 1) Reducing amount of cells removed during Mohs surgery 2) Reducing recurrence likelihood.

The closest study I could find so far, a published in 2009 {1}, concluded:

Imiquimod 5% cream was not helpful as an adjunctive treatment of nodular, nasal BCCs before Mohs surgery, but a larger study might show a benefit. Clearance of nodular, nasal BCCs treated with imiquimod prior to Mohs surgery was less than described in previous studies. Nasal BCCs may be more resistant to imiquimod treatment. Local inflammatory reactions limit imiquimod's usefulness in this setting. Histologic assessment of nasal BCCs treated with imiquimod is recommended.

4 limitations:

  1. Small sample size (12),
  2. Published over a decade ago,
  3. Focused on nodular BCCs, whereas I also wonder whether it helps for superficial BCCs too (in the case where imiquimod didn't fully treat the BCC),
  4. Focused on nasal BCCs, whereas I'm interested in other part of the face (forehead).

Is Imiquimod 5% cream (US brand: Aldara) helpful as an adjunctive treatment of a facial basal cell carcinoma (BCC) prior to a Mohs surgery?


References:

  • {1} Butler, David F., Palak K. Parekh, and Armando Lenis. "Imiquimod 5% cream as adjunctive therapy for primary, solitary, nodular nasal basal cell carcinomas before Mohs micrographic surgery: a randomized, double blind, vehicle‐controlled study." Dermatologic surgery 35, no. 1 (2009): 24-29. https://doi.org/10.1111/j.1524-4725.2008.34378.x
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The 2018 systematic review {1} whether Imiquimod 5% cream (US brand: Aldara) is helpful as an adjunctive treatment of a facial basal cell carcinoma (BCC) prior to a Mohs surgery. Summary: Two studies show it is beneficial, and one shows it wasn't but that's unlikely because they looks at nasal BCC, which tends not to respond well to Imiquimod 5% cream. Quote from {1} with more details:

Some of the literature explores the option of pretreatment with imiquimod 5% cream before Mohs surgery. In one study, a total of 70 adults with primary nodular BCC were identified, with one group given imiquimod 5% cream for 4 weeks prior to Mohs and the other treated only with Mohs surgery. It was found that there was less of an increase in tumor size and area from baseline, fewer Mohs stages, and shorter reconstruction times in the group given neoadjuvant imiquimod [22]. Another study used reflectance-mode confocal microscopy as well as histological imaging to confirm decreased tumor burden with the use of 5% imiquimod cream used before Mohs excision. When two, four, and six week regimens were tested in comparison to vehicle cream, the four and six week regimen groups showed significant reduction or clearance of tumors with confocal microscopic findings that paralleled histologic diagnosis [23].

Of note, one study was found to have different findings. In this study, a total of 31 patients were followed. Some applied imiquimod cream each night for 6 weeks and underwent a 4 week rest period prior to having Mohs surgery, while the others underwent only Mohs surgery. No differences were found in the number of Mohs stages, tumor sizes, or costs between the two groups. In the treatment group, 5 of 12 remaining patients were confirmed on histology to be clear of tumor. In this study adjunctive imiquimod 5% cream before Mohs surgery was not found to be useful in treating nodular BCC, in fact the clearance of the nasal nodular BCC pre-treated with imiquimod before Mohs was less than what had been found in prior studies [24]. However, compared to other studies, this study had a smaller sample size. Furthermore, this study specified nasal BCCs, which may respond less to imiquimod therapy.

  • [22]. van der Geer S, Martens J, van Roij J, Brand E, Ostertag JU, Verhaegh ME, et al. Imiquimod 5% cream as pretreatment of Mohs micrographic surgery for nodular basal cell carcinoma in the face: a prospective randomized controlled study. Br J Dermatol. 2012;167(1):110–5. https://doi.org/10.1111/j.1365-2133.2012.10924.x
  • [23]. Torres A, Niemeyer A, Berkes B, Marra D, Schanbacher C, Gonzalez S, et al. 5% imiquimod cream and reflectance-mode confocal microscopy as adjunct modalities to Mohs micrographic surgery for treatment of basal cell carcinoma. Dermatol Surg. 2004;30(12 Pt 1):1462–9. https://doi.org/10.1111/j.1524-4725.2004.30504.x
  • [24]. Butler DF, Parekh PK, Lenis A. Imiquimod 5% cream as adjunctive therapy for primary, solitary, nodular nasal basal cell carcinomas before Mohs micrographic surgery: a randomized, double blind, vehicle-controlled study. Dermatol Surg. 2009;35(1):24–9. https://doi.org/10.1111/j.1524-4725.2008.34378.x

References:

  • {1} Kamath, Preetha, Evan Darwin, Harleen Arora, and Keyvan Nouri. "A review on imiquimod therapy and discussion on optimal management of basal cell carcinomas." Clinical drug investigation 38, no. 10 (2018): 883-899. https://doi.org/10.1007/s40261-018-0681-x

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