Which Lesion? Which Patient? INDICATIONS: SELECTION: Solar keratoses •Superficial only (masking effect)Bowen disease (SCC in situ) •No diagnostic doubt/ biopsy •Not surgical candidateOccasionally Superficial BCC •Compliant with Rx •Not recurrent Other: Psoriasis, Viral
EFUDIX: INSTRUCTIONS FOR USE•Locked up, instructed areas only•Winter months for 2-8 weeks•+/- tretinoin priming•+/- pulsed (Crabb) Avoid sun! Make up and UV protection after•Wash & Dry Area acute course•Wash finger or use glove to apply No swimming• BD application in general area (not Can get wet in showerjust visible lesions), morning/ evening(not night) 2-4 weeks for healthy new skin after stopping 5FU•Wash hands after applying
PATIENT EDUCATION•60% failure rate - compliance“You will look worse before you get better”,“Expect major changes”•Expect inflammation blistering, peeling,cracking. Sores/pain. This means it is working.•Expect:•Wk 1: mild redness/ minimal reaction•Wk 2: red, crusted, possibly uncomfortable•End Wk 3: Follow up/Cessation•Wk4-6: RECOVERY: pink 1- 10 weeks
SIDE EFFECTS MILD: Severe stingingRedness + irritation/ raw areas at 5- 10/7 COMPLICATIONS: Excessive inflammation ulceration Persistent white marks/scarring Irritant contact dermatitis/ allergic contact dermatitis Secondary infection Undiagnosed skin cancers – may appear to heal but recur later requiring surgery.
Efficacy FOR sBCC:•Schulze: 7x/week Aldara 80% histological clearance Vehicle alone 6% clearance•Geisse: 6 week course - 5x/week Aldara 82% clearance 7x/week Aldara 79% clearance Vehicle only 3% clearance FOR AKs: Median % decrease in AKs 3x/week 86%, 2x/week 83.3%
SYSTEMIC•Flu like symptoms: fever,fatigue, headache, nausea,diarrhoea, mm pain.
ALDARA: INSTRUCTIONS FOR USE Apply sparingly If problematic inflammation, pause for few days. HOW TO USE: Apply evening. SPF creams mane.Duration: 4-16 weeks Variable effect: dependent on skin lesionBiopsy to confirm dx before starting and genetic factors (TL7 expression)BCC: 5x/wk for 6 weeksSK: 2x/wk for 6 weeks, repeat if WHERE/WHEN TO USE:necessary after a 4 week break. Areas where surgery may be difficult or undesirable especially face + lower legs.
COST PHARMAC funded under special Without special authority: authority $3 $110/pack of 12 Conditions of Special Authority: -Superficial BCC -Surgery contraindicated/inappropriate-surgery is first line because higher cure, can assess clearance -Not evaluated for within 1cm of hairline, eyes, nose, mouth or ears--not for recurrent, invasive, infiltrating, nodular BCC
TREATMENT DECISIONS Which patient? Which lesion? Which cream? GPs?
Comparison Efudix (5FU) Aldara (Imiquimod) Winter Summer Inhibits DNA synthesis Immune response modifier Consistent response Variable response Treats generalised area Used sparingly on points Subsidised More expensive Local side effects only Systemic Side effects Compliance – BD for 3 weeks or BD in Compliance - od 5/7 on, 2/7 off pulsed rounds 3 6 weeksGood option for Solar keratoses, Bowens, Not registered for Bowens sometimes used for sBCC. Not fully investigated for use on the face
GP Guidelines (NZGG) BCC Good practice points: -SCC Good practice points: Should have histology SCC are non healing keratinizing or BCCs are slow growing, usually without crusted lesions larger than 1 cm with significant expansion over 8 weeks. significant induration on palpation, A GP may treat a BCC topically without a documented expansion over 8 weeks histological diagnosis but in that case f/u is and typically face, scalp, back of hand. mandatory“A Practitioner should refer a person with a -Obtain histology or refer to specialist clinically suspected or histologically confirmed BCC to a specialist where thepractitioner deems management of the lesion beyond their skill set”. http://northlandent.blogspot.co.nz/2012/06/h ow-to-do-punch-biopsy.html
CURRENT SITUATION IN WHANGAREIPlastics 1/4Dermatology 1/6GPSI x5 – SkinCancer Project
An Ounce of Prevention is Better than a Ton Of Cure Replenex Extreme
References Basic pharmacology of topical imiquimod, 5-fluorouracil , and diclofenac for the dermatologic surgeon. [Review] Desai T. Chen CL. Desai A. Kirby W. Dermatologic Surgery. 38(1):97-103, 2012 Jan. [Journal Article. Review] Treatment of squamous cell carcinoma in situ: a review. [Review] Shimizu I. Cruz A. Chang KH. Dufresne RG. Dermatologic Surgery. 37(10):1394-411, 2011 Oct. [Journal Article. Review][Non-surgical treatment of skin carcinomas and their precursors]. [French] Lourari S. Paul C. Meyer N. Presse Medicale. 40(7-8):690-6, 2011 Jul-Aug. [English Abstract. Journal Article]
ReferencesAgreement on the clinical diagnosis and management of cutaneous squamous neoplasms. Terushkin V. Braga JC. Dusza SW. Scope A. Busam K. Marghoob AA. Gill M. Halpern AC. Dermatologic Surgery. 36(10):1514-20, 2010 Oct. [Journal Article] UI: 20698872 Superficial basal cell carcinoma on face treated with 5% imiquimod cream. Malhotra AK. Bansal A. Mridha AR. Khaitan BK. Verma KK. Indian Journal of Dermatology, Venereology & Leprology. 72(5):373-5, 2006 Sep-Oct. [Case Reports. Journal Article] Treatment of an extensive superficial basal cell carcinoma of the face with imiquimod 5% cream. Micali M. Nasca MR. Musumeci ML. International Journal of Tissue Reactions. 27(3):111-4, 2005. [Case Reports. Journal Article] UI: 16372477
Smith, Walton. Treatment of Facial Basal Cell carcinoma: A review. [Review] 2011. Journal of Skin cancer. Amini, Viera, Valins, Berman. Non surgical Innovations in the Treatment ofNon melanoma Skin Cancer. 2010. Journal of Clinical Aesthetic Dermatology. June 2010 (3):6 Best Practice Guidelines. Bestpractice.bmj.com Dermnet NZ. Dermnetnz.org Medsafe Data Sheets. Medsafe.govt.nz Pharmac. Pharmac.govt.nz