Letter to the Editor

Basal cell carcinomas (BCCs) represent the most common cutaneous malignancy. It most commonly affects the nose, accounting for 25–30 percent of all primary BCCs. Local tumor invasiveness often characterizes nasal BCCs, and routine excision frequently results in positive margins. Because of the difficulties in complete extirpation, as well as the need to conserve tissue, nasal BCCs are an indication for Mohs micrographic surgery. There are various alternative approaches to their treatment, one of which is the use of imiquimod, a synthetic toll-like receptor agonist with a low molecular weight that offers a topical, non-invasive and non-surgical therapeutic option. It is currently approved for treatment of non-facial, superficial BCCs. The authors report their positive experience with a nasal ulcerated nodular BCC. In the authors’ opinion, topical imiquimod might be a reasonable candidate for adjunctive therapy of ulcerated nodular, nasal BCCs, especially in elderly patients.

Basal cell carcinomas (BCCs) represent the most common cutaneous malignancy, with an estimated lifetime risk of 30 percent in Caucasian populations.¹ Surgery remains the preferred treatment, but patient and tumor characteristics should be taken into account when choosing the most suitable treatment. In recent years, topical imiquimod has been found to be effective in superficial and nodular types of BCC,² although nasal BCCs may be more resistant.3 The authors report their positive experience with an ulcerated nasal nodular BCC.

A 96-year-old Caucasian female presented to the authors’ office with an asymptomatic 3 by 2.5 cm nasal BCC. The patient had Fitzpatrick skin type 1, reported significant sun exposure and no family history of skin cancer. Cutaneous examination revealed a solitary well-defined ulcerated node on her nose (Figure 1). There were no regional lymphadenopathic or systemic symptoms. Systemic examination was normal. After the patient refused all conventional interventions, topical treatment with imiquimod 5% cream was initiated. After four weeks of application, she developed mild erythema with a burning sensation over the lesion, which subsided in due course. At 12 weeks there was resolution of the tumor with residual peripheral activity remaining. She had no systemic side effects. The treatment was continued on alternate days for four weeks, after which there was complete clearance (Figure 2).

BCC commonly affects the nose, accounting for 25–30 percent of all primary BCCs. Local tumor invasiveness often characterizes nasal BCCs, and routine excision frequently results in positive margins. With the increasing incidence of cutaneous tumors, imiquimod, a synthetic imidazoquinoline, may offer an alternative treatment option that avoids surgical or ablative therapy, particularly in patients who present a challenge to surgery (the elderly, patients on anticoagulation medication, multimorbid patients, patients with multiple lesions and patients with recurrent or incompletely excised tumors). Imiquimod received Food and Drug Administration (FDA) approval in 2004 for the treatment of nonfacial superficial BCCs.⁴ Targeting toll-like receptors 7 and 8, it acts as an immune response modifier, although the exact mechanism of action is unknown. It is capable of enhancing both innate and cell-mediated immune pathways. It has been suggested that greater expression of Notch 1, lower expression of bcl-2 with a higher BCC apoptotic index and interferon-induced expression of Fas-receptor on BCCs all contribute to imiquimod’s antitumor activity.⁴

Its antitumorigenic effects are mediated by the up-regulation of local IFN-α levels, suggesting that increased natural killer cell activity may be an important factor for both spontaneous and induced regression of basal cell carcinomas. Yet, in contrast to the literature, which limits its use for the treatment of superficial BCCs and low-risk tumors, it appears to the authors that their outcome was superior to traditional approaches in this case. Although not indicated for treating ulcerated nasal nodular BCCs, since local inflammatory reactions limit imiquimod’s usefulness, it may be a viable option when patients are unable or unwilling to have surgical interventions. Furthermore, imiquimod is a relatively low-cost treatment with tolerable side effects⁵ and a high cure rate, especially for elderly patients. This patient continued treatment for 16 weeks and experienced only minimal transient application site reactions.