The margins are read immediately, and a complex repair, such as a flap or a graft, is done on-site by the same physician that day or the next day. Although this procedure can be relatively costly, it is associated with the lowest recurrence rate of all treatment options for BCC.

In addition, Mohs micrographic surgery often provides the most elegant cosmetic result, and in some cases is the only good option for maintaining normal function of surrounding structures. The 5-year recurrence rate of BCC following Mohs surgery has been reported to be as low as 1% in some studies.2

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Radiation therapy is an option for patients who have large, advanced BCC lesions or who are not candidates for surgery based on location of the tumor or the person’s general health status. Both topical 5-fluorouracil (Carac, Efudex, Fluoroplex) and imiquimod (Aldara, Zyclara) are FDA-approved for the treatment of basal cell skin cancers, and often are used to treat diffuse areas of sun damage in patients who have a history of BCC or who are at high risk for BCC or SCC.

These agents should be applied only to superficial BCC in low-risk areas, such as the arms and the back, and require close clinical follow-up by a dermatology provider following use.

5-fluorouracil typically is applied twice a day for 3 to 6 weeks. Crusting, erythema, and stinging of the skin are common and expected reactions to 5-fluorouracil.3 Cure rates for the treatment of superficial BCC with 5-fluorouracil vary, but a 90% clearance rate has been reported.4

Imiquimod has various dosing regimens, but a common routine is to apply the cream 5 days a week for 6 to 12 weeks. Inflammation, irritation, and crusting are expected side effects during treatment with imiquimod as with all topical therapies for BCC.4 (When skin does not react this way during such treatment, it is an indication that the area has become cancer-free.)

Studies suggest that cure rates with topical imiquimod range from 73% to 82%. Selection of this treatment option should be based on the tumor’s histologic subtype and location, and a careful analysis of risk-to-benefit ratio that requires the clinician to take into account the risk of recurrence of the original lesion.

A recurrence of BCC on the back, for example, is less of a concern than a recurring lesion on the ear, where there is very little spare tissue. In addition, certain subtypes are more vulnerable to topical therapy. Superficial basal cells are much more responsive to topical therapy than are micronodular BCCs, which tend to be more aggressive and go deeper.

Whereas some providers use imiquimod as their first-line agent, others prefer 5-fluorouracil, which is less expensive (albeit still costly) and has been observed by some anecdotally to have better clearance.

Vismodegib (Erivedge), an oral therapy, was approved in January 2012 as a once-a-day capsule, representing the first FDA-authorized treatment for advanced forms of BCC.

This inhibitor of the Hedgehog signaling pathway is intended for the treatment of adults with metastatic BCC or with locally advanced BCC that has recurred after surgery, and for adults who are not candidates for surgical or radiation therapy.5

This article originally appeared on Clinical Advisor