DOI: 10.1111/j.1468-3083.2011.03977.

x JEADV

ORIGINAL ARTICLE

Effectiveness and satisfaction with imiquimod for the

treatment of superficial basal cell carcinoma in daily
dermatological practice
E. Dauden,* on behalf of the BASALE Study Group1
Service of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain
*Correspondence: E. Dauden. E-mail: estebandauden@medynet.com

Abstract
Background The use of imiquimod for the treatment of superficial basal cell carcinoma (sBCC) in actual conditions
of the daily practice has been poorly studied.
Objective A prospective, observational and multicentre study was designed to gather information on the
effectiveness and safety of imiquimod therapy in patients with sBCC in daily practice. Patients satisfaction with
imiquimod was also assessed.
Methods A total of 370 adult patients with sBCC were included in the study. Patients were treated with imiquimod
5% cream five times per week for 6 weeks. A maximum of three lesions per patient were treated. Patients were
requested to complete diary cards to register treatment-related events and had a final visit within 16 weeks after the
end of treatment.
Results Target sBCCs included 471 tumours, with a mean (SD) 1.3 (0.6) lesions per patient. Most sBCC were
primary tumours (92.6%). Tumours were clinically diagnosed in 63.2% of cases and histologically confirmed in
36.8%. Previous sBCC had occurred in 42% of the patients. The mean number of daily applications of imiquimod
was 1.0 (0.1) for a mean of 4.9 (0.5) days per week. The mean duration of treatment was 6.0 (1.0) weeks. In 13
patients (14 target sBCCs), rest periods were indicated with a mean of 5.0 (2.8) rest days. The clearance rate was
83.2%. Clearance rate was independent of the tumour size. Local skin reactions (mostly erythema) occurred in 85%
of cases (mild 37%, moderate 39% and severe 24%). Nine patients discontinued imiquimod treatment because of
severity of application site reactions. Most patients (82.1%) were very satisfied or satisfied with imiquimod.
Conclusions The present data from a prospective study carried out in a community setting adds evidence of the
usefulness and favourable clinical profile of imiquimod 5% cream when administered for treating sBCC.
Received: 31 January 2010; Accepted: 10 January 2011

Conflicts of interest
Dr. Esteban Dauden has the following conflict of interests: Advisory Board member, consultant, grants, research
support, participation in clinical trials, honorarium for speaking, research support, with the following pharmaceutical
companies: Abbott, Astellas, Biogen, Centocor Ortho Biotech Inc., Galderma, Glaxo, Janssen-Cilag, Leo Pharma,
Merck-Serono, Novartis, Pfizer, Schering-Plough, Stiefel, Wyeth Pharmaceuticals, 3M.

Funding sources
This study was sponsored by MEDA Pharma, Madrid, Spain.

Introduction comprises up to 25% of all histological subtypes and appears as

Basal cell carcinoma (BCC) is the most common skin cancer in
fair skinned populations and the incidence of BCC continues to
rise by approximately 10% per year.1 Although mortality is low,
this malignancy causes considerable morbidity and places a huge
burden on healthcare services worldwide.2 Superficial BCC (sBCC)
1
See Appendix.
erythematous, slightly scaly and well-defined patches mostly found
on the trunk and limbs. In highly sun-exposed populations,
lesions are also common on the face.3
There are a variety of treatment options for BCC, including
surgery and different destructive procedures, photodynamic ther-
apy and other non-invasive modalities, such as topical 5-fluoroura-
cil and the immune-response modifier imiquimod. Imiquimod

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JEADV 2011, 25, 13041310 Journal of the European Academy of Dermatology and Venereology 2011 European Academy of Dermatology and Venereology
Imiquimod for superficial basal cell carcinoma
available as a 5% cream is approved in different countries for use
in sBCC using a regimen of once daily, five times per week for
6 weeks. Imiquimod acts as a Toll-like receptor (TLR)-7 agonist
stimulating the dendritic cells in the epidermis and dermis to
release interferon a and other cytokines. It is thought to exert its
anti-tumour effect via modification of the innate and cell-mediated
immune response pathway with activity against tumour cells
resulting in apoptosis.4,5
Data from clinical trials with imiquimod 5% cream for the
treatment of sBCC have shown encouraging results with short-
term clearance rates (clinical and histological combined) in the
range between 73% and 90%.615 In two identical randomized,
double-blind vehicle-controlled phase III studies, subjects with
one sBCC were dosed with imiquimod or vehicle cream once daily
5 or 7 times per week for 6 weeks. The difference in clearance rates
between the two imiquimod dosing groups was not statistically
significant and according to these results, the five times per week
regimen was recommended.9 On the other hand, in large phase III
studies the histological clearance rates have been consistently
found to be higher than the clinically observed clearance rate.9,10
In a 5-year long-term follow-up study carried out in Europe, the
estimate of overall treatment success for all treated patients at the
end of follow-up was 78% (81% if histological data were consid-
ered).16 Application site reactions, which are the most common
adverse effects, are seen in up to 87% of patients treated for sBCCs
with imiquimod applied five times per week for 6 weeks.17 The
most common local site reactions are erythema, oedema, indura-
tion, erosion, scaling, crusting, pruritus and burning sensations. In
some patients, the severity of application site reaction warrants
transient discontinuation of treatment. Rest periods, however, do
not affect the efficacy of treatment.
Imiquimod trials and several published clinical series provide
evidence of the benefits of imiquimod therapy for sBCC. However,
there is limited data on the use of imiquimod 5% cream in routine
daily practice. To our knowledge, no previous study carried out in
a community setting in a large sample of patients with sBCC trea-
ted with imiquimod has been reported. Therefore, a nationwide
prospective multicentre study was conducted with two aims: (i) to
assess the effectiveness, safety and tolerability of treatment with
imiquimod 5% cream for sBCC in conditions of daily practice,
and (ii) to determine patients satisfaction with topical imiquimod
application.
Methods
Study design
A prospective, observational and multicentre study was designed
to assess the effectiveness, safety and tolerability of imiquimod 5%
cream for the treatment of patients with sBCC in conditions of
daily dermatological practice. Secondary objectives of the study
were the assessment of the patients satisfaction with topical imiq-
uimod and compliance with treatment as well as to assess whether
JEADV 2011, 25, 13041310 Journal of the European Academy of Dermatology and Venereology 2011 European Academy of Dermatology and Venereology
1305
dermatologists prescribed imiquimod in accordance with the
product technical specifications. The study was carried out at the
outpatient clinics of the services of dermatology of different hospi-
tals throughout Spain in the routine clinical setting. The partici-
pating centres belonged to the public Spanish National Health
Care System. A total of 92 dermatologists from 32 hospitals agreed
to participate voluntarily in the study. Ten patients per site had to
be enrolled over a 3-month period.
The study protocol was approved by the ethics committee of
the participating centres and the local agencies of the Autonomous
Communities. All patients were fully informed about the charac-
teristics of treatment with imiquimod 5% cream and gave written
informed consent.
Patients
Between 1st January 2006 and 31st March 2007, all consecutive
patients of both sexes aged 18 years or older, with histologically
proven sBCC or lesions clinically consistent with sBCC in which
treatment with imiquimod 5% cream was indicated by the derma-
tologist in charge according to the product technical specifications
were eligible, provided that they gave written informed consent
and were able to understand and follow the study procedures.
Patients with other subtypes of BCC were excluded as were those
in whom the use of imiquimod was contraindicated according to
the product technical specifications. Pregnant women and nursing
mothers were also excluded.
Study procedures and data collection
The study was based on a first (baseline) visit, a variable number of
follow-up visits during and after treatment with topical imiquimod
scheduled by the participating dermatologist according to his her
practice, and a final visit at 3 months to assess the effectiveness of
treatment within a maximum interval of 16 weeks after the end of
treatment. Baseline and final visits were mandatory by study proto-
col. The baseline visit was the initiation of treatment with imiqui-
mod 5% cream (12.5 mg imiquimod in monodose sachets of
250 mg cream) (Aldara, 3M Espana, Madrid, Spain). The rec-
ommended dosing frequency was once daily five times per week
(5 times per week) for 6 weeks prior to normal sleeping hours. The
cream was to remain on the skin for at least 8 h without occlusion,
and then removed with mild soap and water. Dermatologists could
prescribe treatment-free rest periods at their own decision. A maxi-
mum of three sBCCs per patient were selected for treatment.
At the first visit the following variables were recorded: demo-
graphics, underlying chronic diseases and use of concomitant med-
ications, previous sBCC (site and treatment), and characteristics of
the target lesion(s), such as date and diagnostic method, site, size,
primary or recurrent sBCC, previous treatment, and date of start-
ing imiquimod. Patients were given a diary card, one per sBCC to
be treated, to register all days in which imiquimod was applied,
missed doses and rest days (according to the prescribed regimen or
as a result of local site reactions). Clinical evolution of lesions, local
2011 The Author
1306 Dauden

skin reactions and their treatment, rest periods, adverse events Subjects screened, n = 373
(AEs) and compliance with treatment were recorded in the follow-
up visits. At the final visit, effectiveness of imiquimod 5% cream sBCC diagnosis not confirmed, n = 2

and patients satisfaction with treatment were also evaluated. Missed baseline data, n = 1

For each lesion, effectiveness of treatment was assessed in terms

of presence or absence of clearance defined according to clinical or Enrolled, n = 370
histological criteria used in the routine clinical practice by the par-
Withdrew in treatment, n = 18
ticipating dermatologist. Biopsy was only carried out if this proce-
Local skin reactions, n = 9
dure was indicated according to the standard clinical practice of
Patients decision, n = 6
each centre. A 7-point Likert scale was used to assess patients sat- Lack of improvement, n = 1
isfaction, which included the following categories: extremely satis- Good response, n = 1
fied, satisfied, somewhat satisfied, neither satisfied nor dissatisfied, Concurrent herpes zoster, n = 1
somewhat dissatisfied, dissatisfied and extremely dissatisfied. Safety
was assessed by recording the AEs observed by the investigator or Withdrew in follow-up, n = 3

reported by the patient either spontaneously or answering to open

questions. Details on the seriousness, severity, action taken, out-
Completed the study, n = 349
come and relationship to imiquimod treatment were also
recorded. With regard to tolerability, frequency and severity of Figure 1 Subject disposition.
local skin reactions were evaluated. Compliance with treatment
was assessed by checking diary cards.
Table 1 Baseline characteristics and location of target superfi-
Statistical analysis cial basal cell carcinoma (sBCC)
The Statistical Package for Social Sciences (SPSS Inc., Chicago, IL,
Data n (%)
USA) (version 15.0) for Windows was used for the analysis of
Total patients 370
data. Double data entry was carried out with a subsequent valida-
Gender
tion to guarantee the quality and consistency of the data. Continu- Male 200
ous variables are expressed as mean and standard deviation (SD) Female 170
and qualitative variables are described as frequencies and percent- Age, years, mean (SD) 68.4 (13.2)
ages. The chi-squared test or the Fishers exact tests were used for Concurrent malignancy or immunosuppressive disorder 34 (9.2)
the comparison of categorical variables and the Students t-test for History of previous sBCC 154 (41.6)
continuous variables. Statistical significance was set at P < 0.05. Treatment of previous sBCC
Surgery 124 (80.5)
Results Electrocoagulation 10 (6.5)
A total of 373 eligible patients were recruited but three patients Curettage 3 (1.9)
were excluded (the diagnosis of sBCC was not confirmed in two Cryosurgery 10 (6.5)
and missing baseline data in one patient). Twenty-one patients 5-FU 8 (5.2)
discontinued the study, 18 during the treatment period and three Imiquimod 14 (9.1)
during the post-treatment period. Subject disposition during the Radiotherapy 8 (5.2)
Target tumours 471
study is shown in Fig. 1.
Location
The study population included 370 patients, 200 men and 170
Face 164 (34.8)
women, with a mean (SD) age of 68.4 (13.2) years. The total num-
Ear and external auditory canal 11 (2.3)
ber of sBCCs was 471, with a mean of 1.3 (0.6) target lesions per
Neck and scalp 41 (8.7)
patient. Target sBCCs were diagnosed clinically in 63.2% of cases
Trunk 138 (29.3)
and histologically confirmed in 36.8%. Most sBCCs were primary Upper extremity 92 (19.5)
tumours (92.6%), recurrent tumours occurred in 35 (7.4%) cases. Lower extremity 22 (4.7)
Tumours were located on the face in 34.8% of cases, in the trunk Not specified 3 (0.6)
in 29.3% and in the extremities in 24.2%. Concomitant malig- Size, cm2, mean (SD) 1.6 (2.9)
nancy or immunosuppressive disorders were present in 34 (9.2%) sBCC, superficial basal cell carcinoma.
patients. History of previous sBCC was recorded in 154 (41.6%)
patients, 14 of which had been treated with imiquimod. The base- The mean number of daily applications of imiquimod 5%
line characteristics of patients and site of target tumours are shown cream was 1.0 (0.1) for a mean of 4.9 (0.5) days per week. The
in Table 1. The mean (SD) size of target sBCC was 1.6 (2.9) cm2. mean duration of treatment was 6.0 (1.0) weeks. Deviations from

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Imiquimod for superficial basal cell carcinoma 1307

100 Clearance Table 2 Clearance rates according to site of lesions in 446

No clearance evaluable tumours at the final visit
90
Site of lesion Clearance, n (%)
80
Face, n = 156 131 (84)
70 Ear and external auditory canal, n = 11 8 (72.7)
60 Neck and scalp, n = 37 32 (86.5)
50 Trunk, n = 130 109 (83.8)
Upper extremity, n = 87 73 (83.9)
40
Lower extremity, n = 22 16 (72.7)
30 Not specified, n = 3 2 (66.7)
20
10
Table 3 Local skin reactions in 471 target superficial basal cell
0 carcinoma (sBCC) treated with imiquimod 5% cream
<0.5 0.5 to 1 1 to 2 >2
Target tumour size (cm2) Type of reaction Total Intensity
Figure 2 Clearance rates of target superficial basal cell carcino-
mas (sBCCs) (clinical and histological combined) in relation to Mild Moderate Severe
tumour size. Erythema 364 (77.3) 141 (38.7) 158 (43.4) 65 (17.9)
Crusting 179 (38.0) 63 (35.2) 69 (38.5) 47 (26.3)
Oedema 153 (32.5) 58 (37.9) 77 (50.3) 18 (11.8)
the product technical specifications in the number of applications Erosion 128 (27.2) 59 (46.1) 44 (34.4) 25 (19.5)
per week were recorded in 39 sBCCs and in the number of treat- Scaling 105 (22.3) 70 (66.7) 27 (25.7) 8 (7.6)
ment weeks in 90. In 13 patients (14 target sBCCs), rest periods Vesicles 67 (14.2) 26 (38.8) 30 (44.8) 11 (16.4)
were indicated by the dermatologist in charge, with a mean of 5.0 Itching 47 (10) 12 (25.5) 26 (55.3) 9 (19.1)
(2.8) rest days. The mean number of follow-up visits including the Bleeding 29 (6.2) 14 (48.3) 10 (35.7) 5 (17.9)
final visit was 2.9 (0.8). Pain 22 (4.7) 7 (31.8) 13 (59.1) 2 (9.1)
A total 446 target tumours from 346 patients were evaluable at Burning 30 (6.4) 7 (23.3) 15 (50) 8 (26.7)
the final visit. The clearance rate was 83.2% (371 446). In the large Hypopigmentation 102 (21.7) 81 (79.4) 20 (19.6) 1 (1.0)
majority of lesions, the final outcome was defined clinically, with a Hyperpigmentation 26 (5.5) 22 (84.6) 3 (15.4) 1 (3.8)
clinical clearance rate of 94.9% (352 371). In only 19 cases, biop- Percentages in parenthesis.
sies were also performed to confirm histological clearance. The
clearance rate was similar in primary tumours (83.1%) than in Application site reactions were observed in 401 target sBCC
recurrent lesions (83.9%) (P = 0.92). On the other hand, clearance (85.1%) (mild 36.7%, moderate 38.9% and severe 24.4%). Type,
rate was independent of the tumour size. Although tumours in frequency and intensity of local site reactions are shown in
which clearance was obtained showed a lower size [mean 1.5 (2.6) Table 3. Erythema, crusting, oedema, erosion and scaling were the
cm2) than those in which clearance was not obtained [mean 1.9 most common application site reactions. Local infection was sus-
(4.1) cm2], differences were not statistically significant (P = 0.20). pected in 15 cases (4.2%), 11 of which were treated with fusidic
Clearance rates were higher in tumours 2 cm2 than in larger acid. Post-treatment hypopigmentation was observed in 22% of
tumours (>2 cm2) but differences were not significant (Fig. 2). cases. Nine patients discontinued imiquimod during the treatment
As shown in Table 2, clearance rates were higher in tumours period because of severity of local site reactions. There were no
located on the face (84%) than in tumours located on the ear and significant differences in the percentage of local site reactions
external auditory canal (72.7%) or the lower extremities (72.7%) between target tumours with or without rest periods (100% vs.
but statistically significant differences according to site were not 93.5%, P = 0.8). However, the occurrence of severe reactions was
observed (P = 0.70). In addition, clearance rates were also similar significantly higher in the group of lesions with rest periods (50%)
in patients without malignancy or immunosuppressive disease than in those without rest periods (28.1%) (P = 0.03) given that
(84.3%) than in those with malignancy or immunosuppressive rest periods were mostly indicated in patients with more (or more
disorder (73.8%) (P = 0.13). severe) local site reaction. Treatment for application site reactions
During the treatment period, AEs (excluding local reactions) was prescribed in 30.2% of cases and included topical antibiotics
were reported by four patients, with an incidence of 1.1%. Adverse in 46.7%, corticosteroids in 20.6%, combined corticosteroids and
events included headache in two patients, influenza-like symptoms antibiotics in 21.5% and antiseptics in 13.1%.
in one, and irritative dermatitis in one. The intensity of AEs was Most patients (82.1%) were extremely satisfied or satisfied with
mild in three patients and moderate in one but no patient discon- imiquimod therapy; only 4.3% of patients manifested to be dissat-
tinued imiquimoid treatment because of an AE. isfied or extremely dissatisfied (Fig. 3).

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1308
Extremely satisfied
Satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Dissatisfied
Extremely dissatisfied
0 10 20 30 40
Figure 3 Patients satisfaction with imiquimod treatment of
superficial basal cell carcinoma (sBCC) (data in percentages).
At the final visit, diary cards were collected in 206 cases
(46.2%). Compliance with treatment was very high, with applica-
tion of topical imiquimod for a mean of 31.1 (16.7) days and 7.7
(9.3) days off. The mean number of missed doses was 0.3 (0.8)
days. Compliance >80% with imiquimod regimen was observed
in 99% of the patients.
Discussion
The therapeutic potential of imiquimod in clinical practice has
been recognized for the past decade. Following an approved indi-
cation for the treatment of external genital warts, imiquimod 5%
topical cream has received further approval for treating actinic
keratosis and small sBCC in adults. Currently, imiquimod 5% top-
ical cream is a widely studied and characterized TLR-7 agonist
available in the clinical milieu.18,19 The present prospective and
multicentre study carried out in a large sample of patients with
sBCC provides data on the effectiveness and safety of imiquimod
topical therapy in real life conditions. To our knowledge, no previ-
ous prospective study in a large sample of patients with sBCC trea-
ted with imiquimod in actual conditions of the daily practice has
been reported. Therefore, this study adds descriptive information
on the use of this immune response modulator in patients seeking
medical care at dermatological clinics in Spain. The present find-
ings may be useful to gather postapproval safety and efficacy data.
In this clinical series of 370 patients, with a total of 471 target
sBCCs treated with imiquimod 5% cream, a clearance rate of
83.2% was obtained. In the majority of patients, the final outcome
was defined clinically only (clinical clearance rate of 94.9%), histo-
logically in 3.2% of cases and clinically and histologically in 1.9%
of cases. The high clearance rate confirms the efficacy of imiqui-
mod for treating sBCC reported in clinical trials.6,8,9,14,16,20 The
fact that the final outcome was histologically defined in only 19
patients supports the dermatologists ability to clinically determine
that the tumour is gone at the end of treatment and that clinical
clearance is ultimately used in clinical practice. On the other hand,
the low rate of histological confirmation is related to the naturalis-
tic design of the study. Because the study was carried out in daily
practice conditions, no indications regarding histological assess-
ment of the final outcome were predefined, which is different than
JEADV 2011, 25, 13041310 Journal of the European Academy of Dermatology and Venereology 2011 European Academy of Dermatology and Venereology
Dauden
strict requirements imposed in phase III clinical trials. Moreover,
in accordance with the objective of the study to assess how derma-
tologist used imiquimod 5% cream for sBCC in their routine
practices, there were no restrictions regarding excluding patients
with recurrent lesions or concomitant malignancies or immuno-
suppression. All patients were visited at 3 months but visits at 6
and 12 months were not scheduled because assessment of recur-
rences was not the purpose of the study. However, there is a need
50 for continued follow-up of these patients as recurrences can occur
later than 3 months post-treatment. On the other hand, our find-
ings of a similar clearance rate for primary and recurrent tumours
may be related to the small number of recurrent lesions in this
study.
On the other hand, the present findings support the effective-
ness of topical imiquimod in sBCC located on the face. In contrast
to target tumour locations in clinical trials predominating in the
trunk and extremities,9,10 the face was the most common site in
our study followed by the trunk and extremities. In this respect,
the effectiveness of imiquimod was unrelated to size and location
of lesions.
Application site reactions occurred in a high percentage of cases
(85%) but the intensity was mild or moderate in most of them.
These consisted largely of erythema followed by erosion, crusting
and oedema, and in general were managed adequately with rest
periods. The fact that rest periods were only indicated in 3.3% of
the tumours (with a mean of five rest days) is a further indicator
of the mild intensity of local site reactions. However, in nine
(2.4%) patients, local skin reactions were severe enough to cause
discontinuation. In a pooled analysis of two phase III, random-
ized, vehicle-controlled studies,9 4% of subjects in the imiquimod
five times per week group discontinued because of an AE or local
site reaction. In this study, it was observed that the proportion of
subjects experiencing application site reactions during the treat-
ment period was significantly higher in the seven times per week
imiquimod group compared with the five times per week group.9
In this study, the five times per week dosing regimen was used.
Moreover, deviations from the product technical specifications in
the number of applications per week were recorded in only 8.3%
of cases (39 471 target sBCC). This finding is clinically relevant
and confirms the correct prescription of imiquimod.
Despite the fact that the high prevalence of application site reac-
tions noted in daily practice conditions, the degree of patients sat-
isfaction with imiquimod was very high (82% of patients were
very satisfied or satisfied), which may be explained by the high
clearance rate and the mild intensity of local skin reactions. In two
studies evaluating the use of imiquimod for the treatment of exter-
nal genital warts, patients satisfaction was 86.5% and 89.1%
respectively.21,22 Patients satisfaction with the use of topical imiq-
uimod in sBCC has not been addressed in previous studies.
In our study, a compliance of more than 80% with imiquimod
regimen was found in 99% of the patients. This high compliance
rate should be interpreted with caution, taking into account that
2011 The Author
Imiquimod for superficial basal cell carcinoma
diary cards were only collected for 46% of the target tumours.
However, no previous data on compliance with imiquimod ther-
apy in patients with sBCC in routine daily practice have been
reported.
In summary, the present data from a prospective, observational
and multicentre study carried out in daily practice conditions adds
evidence for the usefulness and favourable clinical profile of imiq-
uimod 5% cream when used for the treatment of sBCC.
Acknowledgements
The authors are grateful to Patricia Ramrez, DPharm, Medical
Department, MEDA Pharma, for valuable support in the logis-
tics aspects of the study and critical comments of the final
draft and Marta Pulido, MD, for editing the manuscript and
editorial assistance.
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Appendix
BASALE Study Group: N Perez Oliva, C Raya, J Sanchez del
Ro, and J Santos Juanes, Hospital Universitario Central de
Asturias, Oviedo; JR Curto, Ambulatorio de Mieres Norte,
Mieres; A Vila, A Llambrich, R Taberner, and C Nadal, Hospi-
tal Son Lla`tzer, Palma de Mallorca; V Rocamora, MC Sanchez
Bermejo, B Bartolome Gonzalez, and M Pascual Lopez, Hospi-
tal de Manacor, Manacor; F Mestre Bauza, T Alabau Sabater,
A Bauza Alonso, J del Pozo Hernando, A Martn Santiago, and
MA Ventayol Ventayol, Hospital Son Dureta, Palma de Mall-
orca; A Noda, M Saez Rodrguez, M Garca Bustnduy, M
Rodrguez Martn, and N Perez Robayna, Hospital Universitar-
io de Canarias, Santa Cruz de Tenerife; L Borrego, E Soler
Cruz, and B Hernandez Machn, Hospital Insular, Las Palmas
de Gran Canaria; J Suarez Hernandez, S Dorta Alom, L Felici-
ano Divasson, and R Villalba Caballero, Hospital Nuestra Sen-
ora de la Candelaria, Santa Cruz de Tenerife; MA Rodrguez
Prieto and I Ruiz Gonzalez, Hospital de Leon, Leon; T Herna-
dez Llorente, Hospital Provincial de Avila, Avila; R Gimenez
Garca, Hospital Ro Hortega, Valladolid; P de Unamuno, I
Hernandez Vicente, and M Romero Riesco, Hospital de Salam-
anca, Salamanca; MC Gutierrez Ortega, Hospital Militar de
Burgos; E Dauden and Y Delgado, Hospital de la Princesa,
Madrid; M Garca Rodrguez, L Trasobares Marugan, S Med-
ina Montalvo, and M Ruano del Salado, Hospital Prncipe de
Asturias, Alcala de Henares, Madrid; C Vidaurrazaga, Hospital
La Paz, Madrid; JL Lopez Estebaranz, E Naz Villalba, and E
Gomez de la Fuente, Fundacion Alcorcon, Alcorcon, Madrid; J
Liron de Robles, Hospital Central de la Defensa, Madrid; JM
Arrazola, C Garca Millan, and L Ros, Hospital Ramon y
Cajal, Madrid; C Zarco and M Gonzalez, Hospital Doce de Oc-
tubre, Madrid; P Fernandez Lopez, C Galvan Casas, C Lamon-
eda Herrern, J Sopena Barona, and E Zamora Martnez,
2011 The Author
1310
Hospital de Mostoles, Madrid; M Gallego Cullere, ME Iglesias
Zamora, and JI Yanguas Bayona, Hospital Virgen del Camino,
Pamplona; L Cascante Daz and M Hervella Garces, Hospital
Garca Orcoyen, Estella, Navarra; R Matheu Lozano, MC Mar-
tn de Aguilera Moro, MP Hernandez Orta, and RF Lafuente
Urrez, Hospital Reina Sofa, Tudela, Navarra; S Aparicio, Fun-
dacion Hospital Calahorra, Calahorra, La Rioja; R Soloeta
Arechavala, R Gonzalez Perez, I Attue Mitxelena, L Carnero
Gonzalez, I Garca Ro, I Trebol Urra, and MA Arregui Mur-
JEADV 2011, 25, 13041310 Journal of the European Academy of Dermatology and Venereology 2011 European Academy of Dermatology and Venereology
Dauden
ura, Hospital Santiago, Vitoria-Gasteiz; E Aramburu Aguirre,
Hospital Oncologico, San Sebastian; A Lopez Pestana, J Zubi-
zarreta Salvador, B Aseginolatza Zabaleta, P Eguino Gorroc-
hategui, and A Tuneu Valls, Hospital de Donostia, San
Sebastian; JM Careaga Alzaga, A Sanchez Dez, I Martnez de
Lizarduy, and O Lasa Elgezua, Hospital de Basurto, Bilbao;
and MP Manrique Martnez, S Vildosola Esturo, A Arechalde
Perez, and I Bilbao Badiola, Hospital de Galzakao, Galdakao,
Bizcaia, Spain.
2011 The Author
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