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.

Topical Steroid Potency Chart

 Topical steroid preparations are grouped according to relative anti-inflammatory activity, but activity may vary considerably depending upon the vehicle (cream, ointment, solution, foam, etc.), the site of application (face, skin folds and genitalia), disease, the individual patient and whether or not an occlusive dressing is used.  In addition,there are a number of these charts and they are not entirely consistent.  The National Psoriasis Foundation's Potency Chart is well-prepared and a good general guide.

Topical steroids should be used under your doctor's direction, since overuse can cause thinning of the skin, rosacea, acne, stretch marks if used on the wrong part of the body and for too long.  .

Topical Steroids

Hywell Williams, professor of dermato-epidemiology, at the Centre of Evidence Based Dermatology, Queen's Medical Centre, University of Nottingham has written an important article on the use of steroid creams.  He believes that most steroid creams can be effectively used in once daily applications as opposed to twice or more times a day. This will cut down on side-effects and expense.

The article was published in the British Medical Journal in June of 2007.  Here's a Download corticosteroid_creams.pdf -- the Key Points follow:

Established topical corticosteroids such as betamethasone valerate have typically been used twice
daily or more frequently for treating inflammatory episodes of eczema
Reducing the frequency of application to once daily does not seem to result in loss of efficacy and
could lead to fewer local side effects
Using topical corticosteroids just once a day may be more convenient for patients and may save costs
if established preparations are used

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