Journal of Clinical and Aesthetic Dermatology

APR 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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47 JCAD journal of clinical and aesthetic dermatology April 2017 • Volume 10 • Number 4 B V ismodegib, a potent inhibitor of the hedgehog pathway, is an effective treatment for a dvanced basal cell carcinoma. More recently, it has become recognized that other oral and topical medications exist that also inhibit this pathway. Multifocal inhibition has been shown to work more eBcaciously than a single pathway inhibition when treating melanocytic tumors. The authors report the successful treatment of a patient with advanced basal cell carcinoma using the combination of vismodegib, itraconazole, and imiquimod, each of which inhibits a different part of the hedgehog pathway. J Clin Aesthet Dermatol. 2017;10(4):47–49. A B S T R A C T C A S E R E P o R T Triple Hedgehog Pathway Inhibition for Basal Cell Carcinoma a XINYI YANG, BMed/MD; b MATTHEW S. DINEHART, BA, MEd a The Royal Prince Alfred Hospital, Camperdown, NSW, Australia; a University of Arkansas for Medical Sciences, Little Rock, Arkansas A 71-year-old man with a history of nonmelanoma skin cancer presented with a nonhealing plaque around his right lower eyelid and medial canthus measuring 3.2x1.8cm (Figure 1A). The tumor had been present for several years, but recently became symptomatic, causing intermittent irritation of the eye and occasional bleeding. Clinically, the tumor appeared to surround the lower lacrimal canaliculus and involve the caruncle. A biopsy showed invasive basal cell carcinoma (BCC) with an aggressive growth pattern. The patient refused surgery because he is the only caregiver for his wife who has severe dementia. In addition, his right eye is his only functioning eye; the left eye is blind. The patient was treated with a combination of vismodegib 150mg daily and itraconazole 100mg daily for four months. Side effects included muscle cramps, dysgeusia, and mild hair thinning. Two months into this therapy, topical imiquimod 5% cream daily to the affected area was added. After two weeks, he developed severe crusting of the lower eyelid and right cheek, but did not develop a reaction in the medial canthus (Figure 1B). At this point, and upon the authors' advice, the patient discontinued the imiquimod. Clinically, there was no sign of tumor at the involved site after four months (Figure 1C). Punch biopsies 4mm in size taken from the involved areas of the medial canthus and lower eyelid were negative for BCC. At this point, the patient was directed to discontinue the vismodegib and itraconazole therapy. He received three monthly follow-ups and there was no clinical reappearance of the tumor at 18 months to date. DISCUSSION Hedgehog pathway upregulation has been found in almost all cases of BCC. 1 From the authors' experience, combination blockade targeting different points in the hedgehog (Hh) Disclosure: The authors report no relevant conCicts of interest. Author correspondence: Xinyi Yang, BMed/MD; E-mail: cynthiayang91@gmail.com

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