It’s pretty good & up there with Efudix, PDT, & laser therapy. Efficacy is proportional to compliance. Inflammation is expected in most cases.

Aldara (Imiquimod) is applied for 3 days a week (alternate days) for 4 weeks. It should be left on for 6-10 hours. Ideally applied in the evening. The course can be repeated after 4 weeks, if necessary, for a maximum of 16 weeks.

In the United States, the application frequency is twice a week for 16 weeks. Your dermatologist may have their own protocols for Aldara, be guided by them.

Advantages: Cheap, on the PBS for BCCs, your GP does not need equipment.

Disadvantages: compliance needed, flu like symptoms, autoimmune disease activation, a wee bit of hand holding needed

The current literature supports the use of combination therapy for sunspots. Aldara can be used as a ‘mop up treatment’ (this is my most frequent mode of application), following field treatments such as PDT, laser assisted PDT & fractional laser resurfacing.

An example is twice a week application of Aldara for a total of 12 weeks to isolated solar keratosis, starting 4 weeks after laser assisted PDT.

Be guided by your dermatologist as many of us use this medication for both on label & off label treatments (eg molluscum, warts). As a rule-

• Don’t use if pregnant or breastfeeding
• Caution on eyelids & mucous membranes
• Caution on lower limbs
• Caution if you have a history of lupus, autoimmune thyroid, polymyositis or undiagnosed muscle aches & pains

It is important to differentiate the difference between expected effects & side effects. Remember, Aldara works by stimulating your immune system, hence if you do not have inflammation, chances are Aldara may not work for you. Expected outcomes-

• Localised inflammation (red, sore, itchy, angry) within 3-6 days of application.
• Moderate to severe inflammation, at week 2-4. It may seem that the number of actinic keratoses is increasing. This is due to the cream causing inflammation in the treated & surrounding areas (subclinical sun spots). Don’t stress. These will also get better with the treatment.

Be guided by your dermatologist as we all have a different way of modulating inflammation.

Yup. they are. This is because Aldara works by revving up your immune system. This upregulation of immune cells causes inflammation in the treated areas. The flipside is that inflammation within your body can give you muscle aches, pains, flu like illness, lymph nodes, low grade fever & lethargy. Paracetamol every four hours may help.

As with every medication, sh*t hits the fan in a minority of cases. This is based upon probability & not possibility. Rare side effects include-

• Ulceration & scarring. Usually on the lower limbs, usually in patients who do not know how to modulate dosing or are not taught by their treating physician. Higher in diabetic & in those with poor circulation.
• True allergies are uncommon (actual allergies & not inflammation which is normal)
• Autoimmune disease flare ups, including lupus, thyroid disease, polymyositis. Imiquimod may either initiate or potentiate autoimmunity. Roll the dice.

Nope. Again, it’s a probability percentage that physicians work on. Hence in a very small number of patients (if you are special), the toll receptor expression on your skin is diminished or absent. If this is the case, your treating dermatologist may try one of two things-

1. Try another treatment (PDT, Efudix, cryotherapy, lasers, curette)
2. Try to stimulate your immune system (topical retinoids, cryo)

Not much. It is subsidised by the PBS for the treatment of superficial Basal Cell Cancers, but there is no subsidy for solar keratosis. It costs about $90 to $160.

Lots. Dermatologists employ imiquimod to treat gential warts, warts, plantar warts, plane warts, molluscum infection, palliative melanoma in-situ, Paget’s disease, & other skin cancers. Be guided by their decision & direction.