Basal Cell Carcinoma Actinic Keratosis

In this month's "Conversations with a Mentor" series, DERMATOLOGY TIMES talks to David M. Pariser, M.D., professor of dermatology, Eastern Virginia Medical School, Norfolk, Va. Dr. Pariser has been in practice for more than three decades and has participated as a clinical investigator in pre-marketing clinical trials for new modalities for the treatment of both AKs and BCCs, including the Metvix and Levulan Kerastick photodynamic therapy (PDT) systems and Aldara Cream. He was the lead author of a paper published in the Journal of the American Academy of Dermatology in 2003 reporting patient outcomes of a multicenter clinical study of PDT with topical aminolevulinate for actinic keratoses.

Q Is BCC a serious disease?

Q Are you usually the one to diagnose BCC or do more patients come to you through referral from their primary care physician?

The vast majority of patients I treat for BCC are established patients whom I see on a continuing basis, and I suspect the same situation applies to any dermatologist who has been in practice for more than a year or two. There are some individuals who come in as a self-referral because of concern about a specific skin lesion and another subgroup who have been referred by another physician.

In general, I think internists are more likely to refer patients to a dermatologist for BCC treatment, while family practitioners may be more prone to make a first attempt at treatment and send the patient to a specialist only, if the pathology report indicates the tumor was not completely removed, or there is an obvious recurrence of BCC.

Q What are your first- and second-line treatments for BCC?

I have no algorithm for first- and second-line treatments that apply to all lesions, because the approach will depend on the type of BCC and its location on the body. Patient preference is also a factor, and that incorporates issues relating to pain tolerance, convenience, and cost.

In general, small nodular BCCs, which represent the most common type, are almost always treated surgically, although the method used depends on location. If the lesion is on the center of the face, Mohs surgery would be preferred, while for BCCs at sites where tissue conservation and cosmesis are lesser concerns, my preferences would be for excision and primary closure, or even curettage and electrodessication. For a person with multiple superficial BCCs on the lower extremities, it may be desirable to use a non-surgical alternative, such as topical treatment with imiquimod 5 percent cream (Aldara) or even 5-fluorouracil or 5-aminolevulinate photodynamic therapy (ALA PDT). Although those techniques might be associated with a lower efficacy rate than surgery, they would still offer an advantage if they are able to eradicate many or most of the lesions and thereby reduce the amount of surgery that is necessary. On the other hand, surgery, and particularly Mohs surgery, is indicated for a morpheaform BCC, regardless of anatomic location.

Q What approaches do you use to treat AKs?

Historically, most AKs have been treated with liquid-nitrogen cryosurgery, and that still is the mainstay for the thicker and more hyperkeratotic lesions. Topical 5-fluorouracil (5-FU) has also been a tried and true treatment for a number of years, and a new preparation was introduced just a few years ago featuring a 0.5 percent 5-FU in a microsphere delivery system (Carac).