DermHelpCentral

Imiquimod Cream

This valuable tool used predominantly for actinic keratoses and some skin cancers.  (It may also be used for genital warts and molluscum.) Presently, in the U.S., it is available as Zyclara and as a generic (both are equivalent).  We find it especially useful in the treatment of large superficial skin cancers. 

How to Use.  The following is taken from DermNet:

Wash your hands before and after applying imiquimod cream.

Pierce the sachet with a needle and squeeze out a tiny amount of cream onto your fingertip. Apply this to the affected areas.

Although the information on the packet states that the sachet is for single use, you could seal it using a paper clip or tape and store in a closed container to prevent the cream drying out.

Imiquimod may be used at any time of year, as it is not photosensitising. However, when outdoors, you should protect yourself from the sun with clothing and sunscreen as usual.

What to expect

Areas treated with imiquimod will be come inflamed. The effects include itching, burning, redness, ulceration (sores), scabbing, flaking and pain. These reactions indicate that the cream is likely to be effective - if there is no inflammation, imiquimod is unlikely to clear the lesions. An exaggerated response may clear the skin lesion sooner than expected - sometimes after as few as three or four applications. In some patients, surrounding untreated areas also become inflamed but this will settle when treatment is discontinued.

If you develop a severe reaction with black scabs and ulceration, stop applying the cream and arrange to see your doctor as soon as possible.

For more information see: DHC  and DermNet.

 

5 Fluorouracil Cream (5 FU)

5 FU is a commonly used modality for the treatment of actinic keratoses (AKs).  It is a "field treatment" not a spot treatment, and is employed when a large area is affected.  Cryotherapy with liquid nitrogen is used for spot treatment, and many AKs can be just left alone if they do not bother you.

An excellent article on how to use 5 FU can be found on DermNet. If you use 5 FU it will be an invaluable guide.

Blink Power

BLINK is a checklist devised by Dr. Peter Bourne, an Australian skin cancer expert, to help patients and doctors  more easily decide what skin lesions need to be biopsied and which ones can be observed.  This posting is intended to inform patients so that they can be real partners in the process.  The handout has been created by Yoon Cohen, a medical student who plans a career in dermatology.  Please contact her with questions, comments and suggestions.  Email Y.C.

See the BLINK pdf: Download BLINK Patient Handout

BLINK Checklist

B (Benign): Is the lesion immediately recognizable as a common benign lesion?

If the answer is ‘yes’, no further action is required.

If the answer is ‘no’, then proceed to the following:

L (Lonely): Is the lesion the only one of its type on that region of the body?

 ‘Yes’ scores 1

I (Irregular): Is the lesion dermatoscopically irregular? An asymmetrical pigmentation pattern and more than one color?

‘Yes’ scores 1

N (Nervous and/or Change): Is the patient nervous that lesion may be a skin cancer? Does the patient, or another observer, feel that the lesion is changing?

‘Yes’ scores 1

K (Known clues): Does the lesion have any dermatoscopic clues to malignancy?

‘Yes’ scores 1

If the lesion scores 2 or more out of 4, it is recommended to be biopsied.

Yoon Cohen, a 4th year medical student from Maine produced this document

Melanoma on the Rise -- or is it being overdiagnosed?

An important article in the NY Times addresses a recent study on melanoma published from England.  It is important to read the Times piece and come to your own conclusions. Sadly, one of the American dermatologists who is quoted and who "pooh-poohs" the study is in the pay of sunscreen companies and a founder of the Skin Cancer Foundation which takes large sums from industry.

In recent years there has been a sharp rise in reported cases of malignant melanoma, the deadliest form of skin cancer. But a British study has found evidence that the epidemic may be due at least in part to “diagnostic drift,” a growing tendency to identify and treat benign lesions as malignant cancers. The findings may raise the temperature in an already-heated controversy.  Full Times article. 

Skin Cancer Grand Rounds

On April 10 - 11, I gave Grand Rounds on Skin Cancer at the Thayer Hospital in Waterville, Maine and the MId-Maine Medical Center in Augusta, Maine.  The handout is attached here:  Download grand_rounds_april_web.pdf  

Skin Cancer Primer

This posting is intended as a guide for physicians and patients who may want a bit of education about skin cancer.  One caveat:
"A little learning is a dangerous thing; drink deep, or taste not the Pierian spring: there shallow draughts intoxicate the brain, and drinking largely sobers us again."  Alexancer Pope, Essay on Criticism.

The common skin cancers are: basal cell carcinoma (BCC), melanoma (MM) and squamous cell carcinoma (SCC)
You will also want to know about actinic (solar) keratoses, keratoacanthoma (KA) and dysplastic nevi.  This page will address all of these entities but may take a month or two to complete.

Skin Cancers are commonly encountered.

yet the death rate from nonmelanoma (NMSC) skin cancer is very low. Note: these are deaths per 100,000 people.

Actinic (Solar) Keratoses (AK)

AK is a UV light–induced lesion that is common in light-complected individuals.  Few if any progress to SCC, but some lesions that look like AK can actually be SCC-in situ. These are larger that the typical ones and usually hypertrophic.

A group of dermatologists and pathologists are trying to say that AKs are really very early skin cancers.  This creates a lot of anxiety for patients and increased income for patients.  Robin Marks of Australia has done the most research on the subject and wrote a recent editorial in the British J. of Dermatology. "Who benefits from calling AK SCC?" Download ak_marks.pdf

Hypertrophic AK (lesions like this should  be biopsied since they could also be in-situ SCC)
The majority of AKs can be observed

Here's a chapter on AKs from eMedicine 

Basal Cell Carcinoma (BCC)

These are common lesions that all physicians see with regularity.  The variants that you need to be aware of are nodular, superficial and morphea (sclerosing or scarring)  Please go to BCC/eMedicine for more information.

Dysplastic (Atypical) Nevi

Atypical moles and dysplastic nevi are acquired melanocytic lesions of the skin whose clinical and histologic definitions are controversial and still evolving. Numerous definitions and criteria have been proposed, including the use of the term "atypical moles" for clinically abnormal nevi and "dysplastic nevi" for histologically abnormal nevi. Unfortunately, when clinically abnormal nevi are evaluated histologically, some studies have shown a lack of concordance, with some clinically abnormal nevi having no dysplastic features and some normal-appearing nevi having some dysplastic features.
For a good discussion see: ATYPICAL MOLE in eMedicine.com.

The term "Ugly Duckling" was proposed in 1998 by two French dermatologists to help observers discern those nevi which are worrisome. The UGLY DUCKLING (UD) is the one that is not like his brothers. 
Nevi in patients generally resemble each other.  UD nevi stand out and can be identified by dermatologists, indeed by most observers.  These lesions require attention and possibly biopsy.

A recent article in the Archives of Dermatology, "The "ugly duckling" sign: agreement between observer" discussed the utility of Dermoscopy in helping to diagnose worrisome moles.  It can be found here in pdf: Download dysplastic_nevus.pdf

Another important article on Atypical Nevi appeared in the European Journal of Dermatology in 2006:Download burgdorf_pdf.pdf It is a bit on the long side, but worth reading for anyone who wants to learn about this topic.

Turtles, Birds and Bears

Cancers follow three basic patterns: turtles, birds and bears.
1. Turtles move so slowly that you can still capture them while they’re moving slowly along;
2. The birds fly away so quickly that you can’t catch them in time;
3. The bears can escape if you ignore them, but if you catch them in time, you can capture them.

This simple but brilliant formula comes from a superb article by Christie Aschwanden on sunscreens and skin cancer that appeared in the July 10, NY Times.

Doctors Balk at Cancer Ad, Citing Lack of Evidence  See Permalink.

This is a reasoned piece based on the best evidence based information we have.  It is clear that the companies that make sunscreens benefit from a public that is running scared for many of the wrong reasons. Please read the article and draw your own conclusions.

Melanoma Surgery and Interferon

An editorial was published in the June 2007 Archives of Dermatology which brings into question the value of sentinel lymph node biopsy (SLN) and interferon therapy.

While many clinic dermatologists have questioned the value of these procedures for years, the dermatologists and oncologists in most U.S. melanoma centers advocated them and coerced patients to accept them as "standards of care."  It is said that "Every peddler praises his needles."

Unfortunately, it appears that SLN and subsequent lymph node biopsy if SLN is positive do not improve survival.  Similarly, interferon's toxic side-effects appear to outweigh the slightly longer survival it affords patients while not impacting on long term survival.

You will need to read the editorial to make informed decisions  for yourself or family members.  Download MelanomaArchDermatol.pdf

The Editors

Aldara

Aldara Cream (Imiquimod)

    Imiquimod is an immune response modifier. It is manufactured as a 5% cream called Aldara.  Imiquimod is mainly used to treat actinic keratoses, some basal cell and squamous cell skin cancers, genital warts and molluscum.  Your doctor may prescribe it for some other uses.

    Imiquimod works by stimulating the immune system to release a number of chemicals called cytokines, which are important in fighting viruses and destroying cancer cells.

    Aldara comes in boxes of 12 individual sachets or foil packs.  The FDA mandates that these are “For Single Use,” but this is costly and unnecessary.  Many patients get two, three and four applications from a single foil pack.

How To Use
    Here’s a method that was recommended to me by Doug Johnson a dermatologist from Honolulu.

1.  Make a small pin hold in a corner of the foil pack (click photo to enlarge).
2. Squeeze out a tiny amount of Aldara.
3. Rub well into treatment area with a finger and leave on overnight.
4. Fold over packet edge and secure with paper clip.  Store in a cool place.

It’s simple, frugal, and allows you to use the product more economically.

What to Expect
After a few days, the areas treated with Aldara will be come inflamed. (See photos below) The effects may include itching, burning, redness, ulceration (sores), scabbing, flaking and pain. These reactions indicate that the cream is likely to be effective.  If there is no inflammation, imiquimod is unlikely to clear the lesions. An exaggerated response may clear the skin lesion sooner than expected - sometimes in as few as three or four applications. In some patients, surrounding untreated areas also become inflamed but this will settle when treatment is discontinued.

If you develop a severe reaction with black scabs and ulceration, stop applying the cream and arrange to see your doctor as soon as possible.

Systemic side effects
These are unusual, but may include flu-like symptoms, such as low- grade fever, fatigue, headache, nausea, diarrhoea and muscle pain. These are generally mild and may be treated with Tylenol.  However, if they are troublesome, stop applying imiquimod cream and contact your doctor.  Enlarged lymph nodes can rarely appear in sites near the treated area.  The systemic side effects should resolve within a few days of stopping treatment. They may also resolve with continuing treatment.

Length of Treatment will depend on the frequency of use, the area treated and an individual’s response to the agent.  There are many protocols for use and each physician has his or her personal modifications.

Final Results
Healing after treatment is usually excellent. In spite of the marked inflammation there is rarely any permanent mark at the treatment site.

Photos of a Severe Reaction

Superficial Skin Cancer after 9 days

Same Lesion after 3 weeks

Same area 3 weeks after stopping Aldara