Journal of Clinical and Aesthetic Dermatology

Updates on Psoriasis & Cutaneou Oncology

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

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S29 P r o c e e D i n G s JCAD jOUrnAl Of ClInICAl And AEsthEtIC dErMAtOlOgy september 2017 • volume 10 • number 9 • supplement of the lesion should suece; a larger Ka may require multiple injections around the edges, all directed toward the center. in many ways, this technique is similar to injecting corticosteroids into hypertrophic scars. local anesthesia may be needed prior to intralesional or perilesional therapy, particularly if the procedure is diecult or the patient is very anxious. Prior to treatment, it may be helpful to discuss treatment and listen to the patient's objectives to make sure the patient does not harbor unrealistic expectations. it may be appropriate to use luer-lok™ syringes for the injection (30- gauge needle or similar). the clinician should consider eye protection and other protective measures when administering the injections. During injection, some of the chemotherapeutic agent may leak through the central crust or incisions from a previous biopsy; this should not diminish clinical eecacy. the patient should be advised that crusting and necrosis is normal and expected about 7 to 10 days after each injection. a gentle debridement of necrotic tissue may be useful prior to the next injection to make sure the injection is able to deliver the chemotherapeutic agent to viable neoplastic tissue. injections should be carried out once every week or two; if the patient does not respond after two injections, a change in treatment should be evaluated. some patients, such as those with renal failure, may require lab monitoring throughout the course of treatment. in some instances, a post-treatment biopsy should be considered as well. the end to our war on skin cancer? there are many ways to manage skin cancers, and war metaphors may be outmoded. topical and pharmacological approaches are less invasive and may be edective in many patients. indeed, they may be the only option for fragile or compromised patients. these medical treatments are associated with less pain, improved cosmesis, and are edective in treating multiple lesions and subclinical disease. avoiding surgery oders many benefts: it may save time, money, and patient anxiety and apprehension. topical treatments have some drawbacks, however: no margin control and not appropriate for high-risk Bcc or most invasive forms of scc. furthermore, there is a lack of long-term data on recurrence for the newer treatments. thus, surgery must remain the "gold standard," but today there are many new options to consider as well. WhAt's nEW In lEntIgO MAlIgnA nbAsAl CEllO And MErKEl CEll CArCInOMA? Confocal microscopy. confocal microscopy is a technique that increases the optical resolution of an image by means of a spatial pinhole at the confocal plane of the lens; this eliminates out-of-focus light. Modern guorescence-correlation microscopy (fcM) devices allow dermatologists to gain a quasi- histological view of a skin tumor. in guorescence mode, fcM can be used to assess freshly excised specimens; in regectance mode, tumor margins in vivo on the patient's own skin can be assessed. regectance confocal microscopy (rcM) has been used bedside as a supplemental tool for mapping and monitoring of lentigo maligna (lM) and Bcc. 165 When evaluating Bcc, cancer margins can be frst marked out with dermoscopy and then re- checked with rcM. rcM showed Bcc outside of presurgical mark in 30 percent of lesions. 165 this occurs because deep tumor margins cannot always be assessed with limited depth-laser penetration. rcM may also be an important tool for the rapid detection of residual tumor in a tAblE 8. the pros and cons of topical imiquimod 5% cream for Bcc and scc in situ f ACtOrs A dVAntAgEs d IsAdVAntAgEs C OMMEnt adverse edects n/a May include erythema, crusting, scabbing, pain, gu- like symptoms; Hypopigmentation occurs in 67%, scarring 15% adverse events can be treatment limiting cost n/a May be higher than other therapies c osts may vary and should be assessed on a case-by-case basis time none takes more time than surgery none edectiveness Good cure for superfcial Bcc (75% to 90%) scc in situ clearance rates 70% to 80% clearance rates are lower than surgery imiquimod is not as edective with other types of lesions adherence Patients can be educated about product use and the importance of adherence crucial to good outcomes none cosmesis Generally superior to conventional surgery none none application May be used for multiple tumors over large area none none Bcc: basal cell carcinoma; scc: squamous cell carcinoma; n/a: not applicable;

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