Imiquimod 5% Cream as an Adjunct to Mohs Micrographic Surgery in Basal Cell Carcinoma: A Mixed Methods Systematic Review

Abstract

Background: Basal cell carcinoma (BCC) is the most common cutaneous malignancy worldwide. Although Mohs Micrographic Surgery (MMS) is the gold standard treatment, challenges including poorly defined margins, subclinical extension, large tumor size, and proximity to critical structures increase the risk of functional and cosmetic complications. Imiquimod 5% cream, a topical immune response modifier, has been investigated as an adjunct to MMS to improve patient outcomes.

Objective: This mixed method systematic review evaluated the use of imiquimod 5% cream as an adjunct to MMS in BCC.

Materials and methods: Databases were searched for studies assessing imiquimod's neoadjuvant and adjuvant roles in MMS. Outcomes included tumor and defect size, MMS stages, clearance, reconstruction type and timing, recurrence, adverse events, and cost.

Results: Neoadjuvant imiquimod reduced tumor size, facilitating fewer MMS stages, smaller defects, and simpler reconstructions. Imiquimod also demonstrated value in treating residual BCC after incomplete MMS. However, benefits were inconsistently reported, and data on long-term outcomes were limited. Adverse events were generally mild and well-tolerated. The cost-saving implications of imiquimod were underexplored.

Conclusion: Imiquimod shows promise as an adjunct to MMS in specific scenarios, but standardized protocols, cost-effectiveness analysis, and long-term studies are required to validate its efficacy and clinical utility.