Sarah Peters

Northland Health

5-FLUOROURACIL CREAM (5%) (Efudix)

MECHANISM OF ACTION

Solar keratoses

Bowen disease (SCC in situ)

Occasionally Superficial BCC

Other: Psoriasis, Viral

•Superficial only (masking effect)

•No diagnostic doubt/ biopsy•Not surgical candidate

•Compliant with Rx•Not recurrent

INDICATIONS: SELECTION:

Which Lesion? Which Patient?

•Locked up, instructed areas only•Winter months for 2-8 weeks•+/- tretinoin priming•+/- pulsed (Crabb)

•Wash & Dry Area•Wash finger or use glove to apply• BD application in general area (not just visible lesions), morning/ evening (not night)•Wash hands after applying

Avoid sun!

Make up and UV protection after acute course

No swimming

Can get wet in shower

2-4 weeks for healthy new skin after stopping 5FU

EFUDIX: INSTRUCTIONS FOR USE

•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

PATIENT EDUCATION

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.

SIDE EFFECTS

Efudix – before, during, after

$3 Fully subsidised

No special authority required

Pharmac schedule:Fluorouracil sodium

Crm 5%

Efudix 253065 $26.49 per 20 g OP

Subsidised

COST

IMIQUIMOD 5% (Aldara)

MECHANISM OF ACTION

Solar keratoses

Basal cell carcinoma (especially superficial types)

Bowen disease (aka SqCC in situ)- unregistered indication

Viruses – genital warts, molluscum, HSV

INDICATIONS

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% clearanceVehicle only 3% clearance

FOR AKs:Median % decrease in AKs 3x/week 86%, 2x/week 83.3%

Efficacy

SYSTEMIC

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

HOW TO USE:

Duration: 4-16 weeksBiopsy to confirm dx before startingBCC: 5x/wk for 6 weeksSK: 2x/wk for 6 weeks, repeat if necessary after a 4 week break.

Apply sparingly

If problematic inflammation, pause for few days.

Apply evening. SPF creams mane.

Variable effect: dependent on skin lesion and genetic factors (TL7

expression)

WHERE/WHEN TO USE:

Areas where surgery may be difficult or undesirable especially face + lower legs.

ALDARA: INSTRUCTIONS FOR USE

PHARMAC funded under special authority $3

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

Without special authority:

$110/pack of 12

COST

Which patient?

Which lesion?

Which cream?

GPs?

TREATMENT DECISIONS

Comparison

Efudix (5FU) Aldara (Imiquimod)

Winter Summer

Inhibits DNA synthesis

Consistent response

Immune response modifier

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 pulsed rounds 3

Compliance - od 5/7 on, 2/7 off

6 weeks

Good option for Solar keratoses, Bowens, sometimes used for

sBCC.

Not registered for Bowens

Not fully investigated for use on the face

Should have histologyBCCs are slow growing, usually

without significant expansion over 8 weeks.

A GP may treat a BCC topically without a histological diagnosis but

in that case f/u is mandatory“A Practitioner should refer a

person with a clinically suspected or histologically confirmed BCC to a specialist where the practitioner deems management of the lesion

beyond their skill set”.

SCC are non healing keratinizing or crusted

lesions larger than 1 cm with significant induration on palpation, documented

expansion over 8 weeks and typically face, scalp, back of

hand.-Obtain histology or refer to

specialist

BCC Good practice points: -SCC Good practice points:

GP Guidelines (NZGG)

http://northlandent.blogspot.co.nz/2012/06/how-to-do-punch-biopsy.html

CURRENT SITUATION IN WHANGAREI

Plastics 1/4Dermatology 1/6GPSI x5 – Skin Cancer Project

Replenex

Extreme

An Ounce of Prevention is Better than a Ton Of Cure

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]

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

References

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

THE END

Other Non surgical approahces – PDT (photodynamic therapy – slightly less clearance rates c/t excision but better cosmetic

results especially hard to get to.

PDT