1. Sarah Peters
Northland Health

3. 5-FLUOROURACIL CREAM (5%)
(Efudix)

4. MECHANISM OF ACTION

5. Which Lesion? Which Patient?
INDICATIONS: SELECTION:
Solar keratoses •Superficial only (masking effect)
Bowen disease (SCC in situ) •No diagnostic doubt/ biopsy
•Not surgical candidate
Occasionally Superficial BCC •Compliant with Rx
•Not recurrent
Other: Psoriasis, Viral

6. EFUDIX: INSTRUCTIONS FOR USE
•Locked up, instructed areas only
•Winter months for 2-8 weeks
•+/- tretinoin priming
•+/- pulsed (Crabb) Avoid sun!
Make up and UV protection after
•Wash & Dry Area acute course
•Wash finger or use glove to apply No swimming
• BD application in general area (not Can get wet in shower
just visible lesions), morning/ evening
(not night) 2-4 weeks for healthy new skin after
stopping 5FU
•Wash hands after applying

7. PATIENT EDUCATION
•60% failure rate - compliance
“You will look worse before you get better”,
“Expect major changes”
•Expect inflammation  blistering, peeling,
cracking. Sores/pain. This means it is working.
•Expect:
•Wk 1: mild redness/ minimal reaction
•Wk 2: red, crusted, possibly uncomfortable
•End Wk 3: Follow up/Cessation
•Wk4-6: RECOVERY: pink 1- 10 weeks

8. SIDE EFFECTS
MILD:
Severe stinging
Redness + irritation/ raw areas at 5-
10/7
COMPLICATIONS:
Excessive inflammation  ulceration
Persistent white marks/scarring
Irritant contact dermatitis/ allergic
contact dermatitis
Secondary infection
Undiagnosed skin cancers – may
appear to heal but recur later requiring
surgery.

9. Efudix – before, during, after

10. COST
Subsidised
$3 Fully subsidised
No special authority required
Pharmac schedule:
Fluorouracil sodium
Crm 5%
Efudix 253065 $26.49 per 20 g OP

11. IMIQUIMOD 5%
(Aldara)

12. MECHANISM OF ACTION

13. INDICATIONS
Solar keratoses
Basal cell carcinoma (especially
superficial types)
Bowen disease (aka SqCC in situ)-
unregistered indication
Viruses – genital warts, molluscum,
HSV

14. Efficacy
FOR sBCC:
•Schulze: 7x/week Aldara 80% histological clearance
Vehicle alone 6% clearance
•Geisse: 6 week course - 5x/week Aldara 82% clearance
7x/week Aldara 79% clearance
Vehicle only 3% clearance
FOR AKs:
Median % decrease in AKs 3x/week 86%, 2x/week 83.3%

15. SYSTEMIC
•Flu like symptoms: fever,
fatigue, headache, nausea,
diarrhoea, mm pain.

16. ALDARA: INSTRUCTIONS FOR
USE
Apply sparingly
If problematic inflammation, pause for few
days.
HOW TO USE: Apply evening. SPF creams mane.
Duration: 4-16 weeks Variable effect: dependent on skin lesion
Biopsy to confirm dx before starting and genetic factors (TL7 expression)
BCC: 5x/wk for 6 weeks
SK: 2x/wk for 6 weeks, repeat if WHERE/WHEN TO USE:
necessary after a 4 week break.
Areas where surgery may be difficult or
undesirable especially face + lower legs.

17. COST
PHARMAC funded under special Without special authority:
authority $3
$110/pack of 12
Conditions of Special Authority:
-Superficial BCC
-Surgery contraindicated/inappropriate
-surgery is first line because higher cure,
can assess clearance
-Not evaluated for within 1cm of
hairline, eyes, nose, mouth or ears
--not for recurrent, invasive, infiltrating,
nodular BCC

18. TREATMENT DECISIONS
Which patient?
Which lesion?
Which cream?
GPs?

19. Comparison
Efudix (5FU) Aldara (Imiquimod)
Winter Summer
Inhibits DNA synthesis Immune response modifier
Consistent response Variable response
Treats generalised area Used sparingly on points
Subsidised More expensive
Local side effects only Systemic Side effects
Compliance – BD for 3 weeks or BD in Compliance - od 5/7 on, 2/7 off
pulsed rounds 3 6 weeks
Good option for Solar keratoses, Bowens, Not registered for Bowens
sometimes used for sBCC. Not fully investigated for use on the face

20. GP Guidelines (NZGG)
BCC Good practice points: -SCC Good practice points:
Should have histology SCC are non healing keratinizing or
BCCs are slow growing, usually without crusted lesions larger than 1 cm with
significant expansion over 8 weeks. significant induration on palpation,
A GP may treat a BCC topically without a documented expansion over 8 weeks
histological diagnosis but in that case f/u is and typically face, scalp, back of hand.
mandatory
“A Practitioner should refer a person with a -Obtain histology or refer to specialist
clinically suspected or histologically
confirmed BCC to a specialist where the
practitioner deems management of the lesion
beyond their skill set”.
http://northlandent.blogspot.co.nz/2012/06/h
ow-to-do-punch-biopsy.html

21. CURRENT SITUATION IN
WHANGAREI
Plastics 1/4
Dermatology 1/6
GPSI x5 – Skin
Cancer Project

22. An Ounce of Prevention is Better than a Ton
Of Cure
Replenex
Extreme

23. References
Basic pharmacology of topical imiquimod, 5-fluorouracil
, and diclofenac for the dermatologic surgeon. [Review]
Desai T. Chen CL. Desai A. Kirby W.
Dermatologic Surgery. 38(1):97-103, 2012 Jan.
[Journal Article. Review]
Treatment of squamous cell carcinoma in situ: a review. [Review]
Shimizu I. Cruz A. Chang KH. Dufresne RG.
Dermatologic Surgery. 37(10):1394-411, 2011 Oct.
[Journal Article. Review]
[Non-surgical treatment of skin carcinomas and their precursors]. [French]
Lourari S. Paul C. Meyer N.
Presse Medicale. 40(7-8):690-6, 2011 Jul-Aug.
[English Abstract. Journal Article]

24. References
Agreement on the clinical diagnosis and management of cutaneous squamous neoplasms.
Terushkin V. Braga JC. Dusza SW. Scope A. Busam K. Marghoob AA. Gill M. Halpern AC.
Dermatologic Surgery. 36(10):1514-20, 2010 Oct.
[Journal Article]
UI: 20698872
Superficial basal cell carcinoma on face treated with 5% imiquimod cream.
Malhotra AK. Bansal A. Mridha AR. Khaitan BK. Verma KK.
Indian Journal of Dermatology, Venereology & Leprology. 72(5):373-5, 2006 Sep-Oct.
[Case Reports. Journal Article]
Treatment of an extensive superficial basal cell carcinoma of the face with imiquimod 5%
cream.
Micali M. Nasca MR. Musumeci ML.
International Journal of Tissue Reactions. 27(3):111-4, 2005.
[Case Reports. Journal Article]
UI: 16372477

25. Smith, Walton. Treatment of Facial Basal Cell carcinoma: A review. [Review]
2011. Journal of Skin cancer.
Amini, Viera, Valins, Berman. Non surgical Innovations in the Treatment of
Non melanoma Skin Cancer. 2010. Journal of Clinical Aesthetic Dermatology.
June 2010 (3):6
Best Practice Guidelines. Bestpractice.bmj.com
Dermnet NZ. Dermnetnz.org
Medsafe Data Sheets. Medsafe.govt.nz
Pharmac. Pharmac.govt.nz

26. THE END

28. PDT
Other Non surgical approahces – PDT (photodynamic therapy – slightly less
clearance rates c/t excision but better cosmetic results especially hard to get to.