To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. Design: Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. Setting: Mohs surgical clinic in an academic institution. Patients: Ninety patients with biopsy-confirmed LM. Interventions: Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. Main Outcome Measure: The presence or absence of residual LM at the time of staged excision. Results: Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P =.17). There have been no recurrences to date, with a mean follow-up period of 42 months. Conclusions: Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence.

Background Our previous experience monitoring nevi in high risk patients by serial digital epiluminescence microscopy (DELM) photography achieved low biopsy rates, but was limited by melanomas presenting as new lesions or arising from nevi that had not been photographed. Objective To determine whether biopsy rates, efficiency of melanoma detection, and melanoma origin (de novo vs. nevus-derived) differed in a similar patient population monitored by total body (TB) photography. Methods 1076 patients (including 187 from prior cohort) underwent TB photography and were monitored using photographs obtained at the initial visit. Risk factors and median monitoring periods for these patients were comparable to patients previously monitored by DELM photography. Results 275 biopsies were performed in 467 patients on follow-up visits. Of 12 melanomas detected on follow-up, five were invasive; five presented as changing lesions and two as new lesions; nine arose de novo and the remainder was nevus-derived. Conclusions In our experience with both approaches, monitoring patients at risk for melanoma by TB (compared to DELM) photography was associated with lower biopsy rates and lower nevus to melanoma ratios, and facilitated detection of both new and changing lesions. In both cohorts, the majority of melanomas detected on follow-up arose de novo.

IMPORTANCE Staged excision of lentigo maligna (LM) often requires multiple stages and can result in significant cosmetic morbidity. Imiquimod cream has been used off-label as monotherapy in the treatment of LM and may be used in the neoadjuvant setting prior to staged excision as a strategy to reduce the size of the surgical margins required to confirm negative histologic margins. OBJECTIVE To examine the rate of recurrence of LM in patients treated with neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective medical record review of 334 patients with 345 biopsy-confirmed LM tumors from June 2004 to January 2012 who were treated with imiquimod prior to undergoing staged excisions at the University of Utah Medical Center and Huntsman Cancer Institute, large academic hospitals in Salt Lake City. INTERVENTIONS Patients were treated with off-label imiquimod, 5%, cream 5 nights per week for 2 to 3 months. Those deemed to have an inadequate inflammatory response were also treated with tazarotene, 0.1%, gel twice weekly. Conservatively staged excisions, beginning with 2-mm margins, were then performed. MAIN OUTCOMES AND MEASURES The rate of recurrence of LM after long-term follow-up. RESULTS Patients included 235 men (70%) and 99 women (30%) with a mean (SD) age of 67 (13) years. Patients were treated with imiquimod cream for a mean of 2.5 months prior to undergoing conservatively staged excisions. There were 12 local recurrences (a rate of 3.9%) with a mean time to recurrence of 4.3 years and a mean length of follow-up of 5.5 years. CONCLUSIONS AND RELEVANCE Neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions for LM allowed for negative histologic margins with a median final margin of 2 mm and a rate of recurrence similar to reported recurrence rates with standard staged excisions by either Mohs surgery or en face permanent sections.