Best treatment for each patient guiding principle in treating lentigo maligna

Monotherapy with the topical immune response modifier (IRM) imiquimod 5 percent cream (Aldara, 3M Pharmaceuticals) can be a viable alternative for treatment of lentigo maligna under the right circumstances, although most often the IRM may be best used as an adjuvant to surgery, Mark Naylor, M.D., says.

"Combination therapy using conservative excision followed by imiquimod may give you the best of both worlds because it provides a complete specimen for histological evaluation to minimize the chance of missing an invasive melanoma and results in cure rates in the 96 to 99 percent range that is higher than can be achieved with either surgery or medical treatment alone," Dr. Naylor says.

When using imiquimod as an adjuvant treatment, Dr. Naylor has patients apply the cream three times a week, including the skin at least 1 cm beyond the visible margin of the tumor. Ulceration should be avoided to achieve the best cosmetic outcome, and so patients should be given a rest period as needed. For the best efficacy results, it is important to continue treatment for a full three months.

Dr. Naylor notes that he considers simple excision first-line treatment for small lesions, whereas there are circumstances where topical IRM treatment might be considered as primary therapy or monotherapy. Those would include when cosmetic outcome is important, such as in younger patients with a facial lesion, if surgery has already failed, or if surgery is not feasible or advisable for any reason.

"Those situations are relatively common in clinical practice, and if you consider imiquimod for monotherapy, there are a lot of data in the literature from case series and open label studies to support its use," Dr. Naylor says.