He instructs them on how to use the medication, explaining they need to rub it into the lesion twice a day very well. "A pinhead amount is all that’s needed," he said, only a small portion of the 0.25 g included in each packet. His patients typically get a few to several applications from each packet.
He also educates patients about possible side effects from imiquimod, including redness, crusting, oozing, and some tenderness. "Nausea, malaise, pain, and secondary infection are rare," he said. "Patients are advised to call the office with any significant treatment related concerns and are generally offered the option of a same day add-on appointment."
At the 2-week follow-up visit he gauges the response as very brisk, brisk, moderate, mild, or none. If the response is very brisk, he halts therapy for 3-7 days, re-initiates treatment once daily for 4 weeks, and schedules a follow-up visit after 2 more weeks of treatment.
If the response is brisk, he halts therapy for 1-3 days, and then continues therapy once daily for 4 weeks.
If the response is moderate he continues therapy once daily for 4 weeks, and if the response is mild he continues therapy twice daily for 4 weeks.
"If there is no response, consider further imiquimod treatment with 2-4-week re-evaluation, or consider application of a small (less than a pea-sized) amount of 5% 5-FU after imiquimod twice daily," Dr. Kraffert said. "Or, you could consider nonimiquimod management of the problem. Sometimes imiquimod just doesn’t work."
After the 2-week follow-up, further visits are discretionary, he said, but some patients require closer follow-up, including nonresponders and patients with severe reactions, systemic complaints, and large or challenging tumors.
"Scheduling a follow-up visit for 3-6 months is best because the reaction takes a month or 2 to diminish," he said. "Taking photos pretherapy and at each visit thereafter improves surveillance."
"There are many approaches to skin cancer," Dr. Kraffert concluded. "Excision or destruction is often the best, but having more options is a plus. Imiquimod doesn’t replace what we have, it just adds to it."
Dr. Kraffert said he had no relevant financial conflicts.