Aldara / Imiquimod
Best used: AM/PM | Caution: Variable response | Best for: Superficial skin cancers, solar keratosis |
Comments: Marked inflammatory response in some | Mode of action: Pro-inflammatory | Science Score: *****
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What is the science behind Imiquimod therapy?
Aldara or imiquimod is an immune modifier. It works by modulating the Tol-7 receptors found in the skin. This chemical upregulates your immune system to fight both skin cancer & viral infections by increasing chemicals known as cytokines.
What skin cancers & conditions respond to Aldara therapy?
Aldara is effective against the following pre-cancerous lesions & skin cancer-
- Solar keratosis or sunspots, including pigmented actinic keratosis.
- Basal cell cancers including superficial variants.
- Intraepidermal carcinomas or Bowen’s Disease
- Cancer associated papilloma virus
How long should I use Aldara for?
The duration of treatment will depend on the diagnosis. As a guide-
- BCCs or basal cell cancers: 5 nights a week for 6 weeks.
- Solar keratosis: 3 nights per week for 4 weeks. Repeat if required.
- Wart & viral infections: 2-5 nights a week for 4-12 weeks.
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What are the side effects associated with Aldara?
It is important to know the difference between expected effects & exaggerated side effects of treatment. As the name implies expected effects are what should happen or what is the norm of treatment.
Expected effects of Aldara treatment: Treated area should be red, itch, swollen & slight sore within 6 days of therapy. This can increase in intensity over the next few weeks. Inflammation will depend on your immune system’s response (sensitivity to imiquimod) as well as the application frequency. Your skin may crack, blister or have scabs. Inflammation is good & it is expected. Your physician will modulate application frequency based upon clinical reaction.
Skin surrounding the lesion/s may also experience redness & inflammation. This is known as the ‘spill over effect.’ It will settle down over a period of 4- 8 weeks after therapy. If inflammation is too uncomfortable, you can take 3-10 days break, then recommence application. You should notify your supervising physician if breaks beyond their recommendations are required.
Side effects are defined as effects beyond the normal range. With Aldara therapy, side effects include- ulceration, excessive blistering, flare up of autoimmune disorders, & systemic symptoms. The latter include muscle ache, joint swelling, headaches, fevers, chills, & lethargy. Majority of these side effects can be treated with Panadol & time.
Disclaimer**: I do not manage acne, my work is entirely procedural. For medical conditions, please consult my colleagues at Cutis.
Does Aldara affect normal skin?
Aldara targets abnormal skin, causing an immune response within the lesion itself. There may be a ‘spill over’ reaction on the skin surrounding the skin cancer. This will resolve once the inflammation settles.
How will I know if this cream is effective?
Your GP or dermatologist will supervise your treatment. Clinical examination coupled with comparison photos, usually 3-12 weeks after ceasing Aldara will give your clinician an idea about the efficacy of this treatment. If required, a biopsy may be taken. Be guided by your physician.
Can Aldara make you feel sick?
As imiquimod increases cytokines, flu like symptoms are not uncommon. Fevers, chills, malaise, tiredness, headaches, joint pains & muscle aches have all been reported. Low dose anti-inflammatories or Panadol can reduce these side effects. Most will resolve within a week or so after stopping Aldara.
What are other ways to treat sunspots & skin cancer?
There are many ways to manage sunspots including Bowens/IECs. Treatment modalities will depend on the location and size of the cancer, the number of lesions, the degree of functional impairment and costs. Each modality has both advantages and disadvantages.
Cryotherapy or liquid nitrogen
Liquid nitrogen can be an excellent method of treating IECs & superficial basal cell cancers. Most cases will require a double –freeze cycle of cryotherapy. This treatment is not recommended for IECs or BCCs below the knee, as poor healing may occur. Solar keratosis can be treated with this modality. A skin cancer GP, physician or dermatologist can perform this simple procedure.
Creams
Imiquimod (Aldara), Picato, or 5-fluorouracil (Efudix) are effective in the treatment of Bowen disease & solar keratosis. Clinical studies have shown cure rates approaching 80-90%. Treatment appears to be most successful when these creams are applied for 6-16 weeks. Duration of treatment is largely dependent on the type of lesion & your skin’s immune or inflammatory response. Be guided by your GP or dermatologist.
Curettage and Electrocautery
When small patches of IECs are present they may be treated via curettage and cautery. A local anaesthetic is given prior to the procedure to prevent pain and discomfort. Hypertrophic sunspots are also treated with this method, as can superficial basal cell cancers & keratoacanthomas.
Photodynamic therapy (PDT)
Photodynamic therapy or PDT can be an excellent non-surgical method of treating skin cancers such as Bowen’s/ IEC’ as well as sunspots. PDT uses a photosensitive cream called 5-aminolevulinic acid or methyl amino levulinate, that is applied to the skin cancer. The cancerous cells of Bowens/ IEC take up this chemical over a period of 3 hours. A low-level laser light then activates the chemical and destroys the skin cancer cells. Patients will require two treatments spaced a week or two apart.
PDT is ideal for IECs on cosmetically sensitive areas such as the face, or for IECs that occur on the legs where healing can be a problem. PDT can also be used for multiple or large IECs. The benefit of PDT is that it selectively targets neoplastic cells without affecting the surrounding epidermis. This results in improved cosmetic outcomes, and faster healing times.
Laser therapy
Ablative lasers such as CO2 or erbium can be used to treat sunspots, superficial BCCs, & precancerous lesions & IECs.
Surgery
Surgery is the ideal method of treating IECs or BCCs in certain areas including-
- BCCs &IECs associated in terminal hair bearing areas, such as the scalp or brows
- IECs that occur in the nail (periungual IECs)
- IECs that occur on the lip
- Recurrent BCCs & IECs that fail to respond to other treatments.
Surgery has the highest cure rate for Bowens/ IECs/ Basal Cell Cancers, but is an overkill for the management of sunspots.
Radiotherapy
Consider referral for consideration of radiotherapy for poor surgical candidates, or patients with multiple lesions. A field treatment of XRT can reduce skin cancer recurrence inducing solar keratosis, IECs & even Squamous Cell Cancers.
Peels
I do perform medium to deep peels including Jessner-TCA or phenol croton oil peels for field changes, including solar keratosis. Mild sun damage can be treated with high strength AHA-glycolic acid 70%. I do not treat superficial Basal Cell Cancers with peels.
What other ingredients are frequently combined with silymarin?
The most common ingredients that are used in synergy with silymarin include;
Vitamin C or L-ascorbic acid. Optimal formulations range between 10-15%. Vitamin C adds to the antioxidant role. This vitamin can reduce melanin formation as it is a tyrosinase inhibitor
Salicylic acid as this is a physical exfoliant. In lower concentrations it is also anti-inflammatory.
Ferulic acid, along with vitamin C can act synergistically with silymarin to provide antioxidant cover.
How does silymarin work as an antiaging molecule?
Silymarin has been used as an anti‐ageing agent as it has antioxidant, anti‐collagenase, and anti‐elastase activities in in‐vitro studies. This reduces breakdown of dermal collagen & elastin, in turn preserving the integrity of skin tone.
They found that the extracts might be added as a mixture to gain overall anti‐aging effects. Topical formulations can slow ageing processes by reducing oxidative stress due to UV damage & environmental pollution. A sensible anti-aging formulation consists of topical silymarin, combined with ascorbic acid prior to sunscreen application in the morning.
Does taking silymarin tablets benefit skin?
A recent study has shown that oral silymarin can accelerate wound healing in patients with burn scars. Wound healing is accelerated due to the anti-inflammatory & antioxidant properties of silymarin.
How do I incorporate silymarin in my skin care routine?
A sensible skin care routine that involves silymarin goes something like this;
AM: Gentle wash SPF, Make up, with the option of antioxidants (Silymarin, Ferulic acid Ascorbic acid)
PM: Cleanser. Silymarin in the PM, option for retinol 20 minutes before or after.
Davin’s Viewpoint on the use of Aldara
Dermatologist, Brisbane. Australia.
Though it has mainstream use, some dermatologists are not a fan of this topical as it has systemic side effects, including the warning about autoimmune conditions such as lupus & chronic fatigue syndrome. Regardless it has been cleared by the TGA for use in Australia for many skin conditions. Dermatologists use Aldara for the management of viral infections including genital warts, periungual warts, flat plane warts & even moluscum contagtousoum.
There are many options available for the management of sunspots. I personally perform procedural dermatology including lasers, peels & in some cases photodynamic therapy. Be guided by your GP, plastic surgeon or dermatologist regarding appropriate treatments.