Imiquimod 5 % Cream in Topical Treatment of Facial Basal Cell Carcinoma A

Introduction: Basal Cell Carcinoma (BCC) is a non-melanocytic skin neoplasm originating from the cells in the basal epidermal layer, hair follicle shell or other skin adnexa. It is the most frequent skin malignancy. Treatment is surgical or nonsurgical. Cases reports: Herein we present 2 patients with superfi cial type of BCC and actinic keratosis of the face. The patients have been diagnosed by dermoscopy DermLite dermatoscope by 3Gen Inc. manufacturer, and skin biopsy has been performed for histopathological examination. The superfi cial BCC of the face has been treated with 5% Imiquimod cream once a day for 5 days in a week, during 4 weeks, with erosions and crusts until complete skin restoration. Conclusion: Based on these case reports, it could be concluded that 5% Imiquimod cream is safe and eff ective treatment for superfi cial BCC and represents an optimal treatment to achieve good clinical and esthetic eff ect for the patients.


INTRODUCTION
Basal cell carcinoma (BCC) is a non-melanocytic skin tumor originating from the cells in the basal epidermal layer, hair follicle shell or other skin adnexa.It is the most frequent skin malignancy in Caucasian population, with skin phototype 1 and 2 [1].It appears aft er the age of 60 years, rarely in younger people, sometimes more in men because of the professional occupation with sun exposure [2].
Typical localization could be in photo exposed skin, such as the face, head /neck or the trunk, but mainly on the nose or cheek, usually with actinic keratosis that could evolve into squamous cell carcinoma (SCC).Clinical presentation may be diff erent, like superfi cial or nodular type, rarely ulcerating, or sometimes pigmented, resembling melanocytic lesions [3,4] Th e tumor can be diagnosed by dermatoscopy and verifi ed by histopathological examination of the excised tissue [5].
Th e treatment is: a) Surgical excision is the fi rst choice therapy in case of the large tumor, sometimes with plastic surgery technique [6]; b) Nonsurgical: 1) Imiquimod 5% cream as immunomodulator, targeting toll like receptors (TLR) 7, stimulates skins own immunity.Th is agonist TLR 7 induces increased production of interferonalpha, interleukin-12, tumor necrosis factoralpha and a Th 1 prone immune response.Also, it induces release of calcium from the internal store in cells, independently of TLR7 pathway, and causes pruritogenic eff ect.It is used for superfi cial tumors of the face [7,8,9,10]; 2) 5-fl uorouracil topical cream with cytotoxic eff ect, that inhibits DNA synthesis by blocking conversion of deoxyuridylic acid to thymidylic acid by the cellular enzyme thymidylate synthase.Th is method is used for superfi cial lesions of the trunk / extremities [11]; 3) Photodynamic therapy (PTD) uses specifi c light waves to photoexcited molecules in neoplastic cells.5-aminolevulinic acid is photo reactive molecule for PTD, and it is activated by blue light [12]; 4) Systemic retinoids could be found in the literature as a method of treating BCC, but their use is very rare because of many side effects [13]; 5) Radiotherapy used to be the fi rst choice treatment for BCC in the past.It takes a long time for procedure that is expensive and toxic, but could be recommended for the elderly patients with low-dose radiation [14]; 6) Cryotherapy as a cheap and easy to access therapy has limited usage in small number of patients for treating BCC with undesirable effect of tumor growth if it is not removed (completely) [15].

THE AIM
Th e aim of this paper is to show possibilities and results of non-surgical topical treatment of superfi cial BCC by Imiquimod 5% cream.Histopathological examinations diagnosed tumors as superfi cial BCC with immature basal cells protruding towards dermis.

CASES REPORTS
Th e superfi cial BCC of the face together with actinic keratosis has been treated with 5% Imiquimod cream once a day for 5 days in a week, during 4 weeks, (fi g 4, fi g 6) until complete restoration of epithelial layer instead of tumor (fi g 5-6 months aft er the therapy; fi g 7-3 months aft er the therapy without recidivant tumors).Th e patients have had local skin irritation such as redness, edema, erosion with crust and itching sometimes.

DISCUSSION
It is necessary to monitor the skin condition of those patients once diagnosed with BCC by regular clinical and dermatoscopy examinations in the following years.Th e prevention of new BCC is conducted from April to October every year by using sun protection factors (SPF) creams on the photo exposed skin, together with mechanical protection by clothing, ultraviolet fi ltered sunglasses.Sunbathing is absolutely forbidden in the interval from 11 am till 15 pm [2].Which method of tumor therapy should we choose depends on the age and general condition of the patient, the diameter, localization and type of the tumor, also.Th e aim of the treatment is good esthetic eff ect that could be obtained by optimal cooperation with the patient [3].Th ose patients treated by topical Imiquimod 5% cream have experienced local skin reactions on the application site, and that are the most common adverse reactions that corresponded positively with the immune response [16].Th ey should be advised to carry out thorough hygiene measures before and after cream applying.
Th e advantages of this topical treatment are many: aff ordable cost of the therapy that is conducted in domestic environment at home, the possibilities of removal of both manifested and invisible actinic keratosis.

CONCLUSION
Our fi ndings support the results of clinical trials that showed the Imiquimod as a safe and eff ective treatment option of superfi cial BCC, which might be able to prevent the disease progression to the squamous cell carcinoma [10,11,17,18].