Showing posts with label imiquimod. Show all posts
Showing posts with label imiquimod. Show all posts

Wednesday, May 30, 2012

Skin Cancer in Renal Transplant Patient

The patient is a 64 yo man who received a renal transplant x years ago and is maintained on prednisone and Prograf.  He presented with a 4 cm biopsy proven superficial squamous cell carcinoma on the left parietal scalp.  This lesion would have necessitated a large micrographic surgical procedure with a graft.

An attempt was made to treat with topical chemotherapy.  Imiquimod was inititiated, but there was only minimal response after two weeks.  Five fluorouracil was then added and this achieved a moderate response.  The combination of imiquimod/5FU was continued for a total of six weeks, then stopped.  One month later there appears to be a clinical cure.  He will be followed closely.  

There is a possibility that this combination therapy can help selected transplant patients with low risk superficial nonmelanoma skin cancers.

Clinical Photos:
After Six Weeks Imiquimod/5FU






One month after Stopping Imiquimod/5FU


Comment:  This treatment made me a little nervous, but the surgical approach would have been major for a lesion that had only a small chance of of metastasizing.  The benefits and risks were discussed with the patient; however, his oncologist was unhappy about this approach.



Friday, April 20, 2012

Imiquimod and Keloids

The patient is a 42 yo man who had a cyst I&D's on his mid-back four years ago. Postoperatively,  a keloidal scar developed.  It is very painful and pruritic.  He has had intralesional triamcinalone acetonide 40 mg/cc without much effect.

The lesion measures almost 4 cm in diameter, but, being sessile, the base is only ~ 2 cm wide.

Plan and Question:  We propose to shave this off and use imiquimod post-operatively as has been done with earlobe keloids.  Does anyone have any experience with this for keloids at sites other than earlobes?  Any other suggestions?  The literature on imiquimod use after keloid removal is all over the map.  One wonders whether employing imiquimod followed by judicial use of intralesional triamcinaloine might be appropriate.

5 Weeks p Shave excision: C&E, followed by imiquimod 5 days per week.  At this point we will stop the imiquimod and follow.  Patient does not live near to my office and can be seen only once a month or less frequently.

8 weeks p shave excision:  The patient stopped imiquimod 2 - 3 weeks ago and just applied Vaseline.  The wound is looking better.  There's a slightly raised area in the middle of the erythema.

6 months after surgery.  These is a subtle scar in the mid-portion of the excision.  The area is still quite pruritic.  Will try clobetasol ointment to area, Monday, Wednesday and Friday.  Scars are rich in mast cells and this likely explains the itching;
1 year follow-up shows small hypertrophic scar which is a considerable improvement over baseline.

 References:
1.  Treatment of keloid scars post-shave excision with imiquimod 5% cream: A prospective, double-blind, placebo-controlled pilot study. J Drugs Dermatol. 2009 May;8(5):455-8.  URL

2.  Successful treatment of earlobe keloids with imiquimod after tangential shave excision. Dermatol Surg. 2006 Mar;32(3):380-6.  URL

3.  Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids.  Dermatol Surg. 2009 Apr;35(4):629-33.  URL

Monday, March 30, 2009

Ear Keloids and Imiquimod


We presented this patient around a year ago (she is patient # 2). The woman, now 19 years old, presented in March of 2008 for a keloidal scar in the left triangular fossa. On 12/18/08 based on suggestions and a report in MEDLINE, the lesion was shave excised and a week after surgery, imiquimod was applied nightly for six weeks. She is now one month out after stopping imiquimod. At this point, she looks very good. We will have to see if this is a long term solution.

Reference:
1. Berman B, Kaufman J. Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids. J Am Acad Dermatol. 2002 Oct;47(4 Suppl):S209-11.
New adjunctive treatments are needed to reduce the high recurrence rates (50%) of excised keloids. Interferon alfa injections have been shown to decrease the size of stable keloids. This study examined the effects of postoperative imiquimod 5% cream on the recurrence of 13 keloids excised surgically from 12 patients.Starting on the night of surgery, imiquimod 5% cream was applied for 8 weeks. Patients were examined at weeks 4, 8, 16, and 24 for local erythema, edema,
erosions, pigment alteration, and/or recurrence of keloids. Of the 11 keloids evaluated at 24 weeks, none (0%) recurred. Incidences of hyperpigmentation were 63.6%. Two cases of mild irritation and superficial erosion cleared withtemporary discontinuation of imiquimod. Both patients completed the 8 weeks of topical therapy and the final 24-week assessment. At 24 weeks, the recurrence rate of excised keloids treated with postoperative imiquimod 5% cream was lower than recurrence rates previously reported in the literature.