key: cord-0810956-o5rmn1ov
authors: Nahm, William J.; Shen, John; Kirsner, Robert S.; Nichols, Anna J.; Harris, Zechariah C.; Phillips, Andrew R.; Badiavas, Evangelos V.
title: Treating Keratinocyte Carcinomas with a Combination of Imiquimod, 5-fluorouracil, and Tretinoin Using Store-and-Forward Telemedicine in the Age Of COVID-19 to Promote Social Distancing
date: 2020-07-25
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.07.024
sha: 80d3945ca3ae25ee77af8f0b0b4e17601191cb74
doc_id: 810956
cord_uid: o5rmn1ov

nan

(standard deviation) age, 62 (9.7) years] who had no clinic visits during their treatment period (Table 1) . 64

Conversely, the other 28 cases involved patients who used the app but also had multiple in-person clinic 65 visits during their treatment phases. For their treatment, these 13 patients (15 cases) applied 1/5 of a 66 packet of IMI, one drop of 5-FU, and 1/5 of a pea-sized quantity of TRET to a bandage, which was 67 subsequently applied to their KC overnight. The patients were instructed to use this combination for five 68 days a week for six weeks (30 applications over 42 days) but were allowed to extend the treatment 69 phase up to 9.5 weeks (30 applications over 76 days). 70

The 13 patients who utilized the app and avoided clinic visits were all able to complete the 71 treatment protocol (30 applications) within the 9.5 weeks. Four cases involved high-risk types with 72 clearance seen up to 10, 17, 26, and greater than 48 months (Table 1) . A cure was defined as the clinical 73 lack of tumor persistence or recurrence following the completion of treatment. Four cases were 74 identified to have greater than four years of cancer-free follow-up. The rest had less than three years, 5 and four cases had limited follow-up up to 3 months. As of this time, there has been no reported 76 recurrence of any of the tumors at these treated sites. All 15 sites were also found to have good 77 cosmetic acceptability after treatment (Figure 1) . 78 6 DISCUSSION 79

Despite a limited sample size, we report success for a KC treatment protocol that eliminates in-office 80 visits and promotes social distancing. Using a non-surgical approach and tracking patients through a 81 store-and-forward app, 13 patients were able to have complete clearing of their KCs. The Dermtrac app 82 was developed by engineers and validated for specific endpoints by independent dermatologists. It is 83 implemented through a software subscription service, and interaction occurs asynchronously with the 84 physician on a computer dashboard and the patient on their phone app. The use of the dashboard 85 allows the physician to remotely initiate treatment of a patient's KC with the triple combination therapy 86 (IMI/5-FU/TRET) and monitor the patient's progress. Every two weeks, through the app, patients report 87 their symptoms on a numerical scale, input topical application events, and upload treatment site 88 pictures through template model photography (Figures 1, 2) . The app compiles all relevant data points, 89 including subjective patient side effects, answers about inflammatory responses, application treatment 90 logs, and comparative images from the patient that could be transformed via scale, translation, and 91 rotation (Figure 2 ). The information on the dashboard permits the physician to make decisions, 92 authorize prescriptions, and impart standardized or custom instructions. 93

We chose to study the cases of KCs treated with IMI/5-FU/TRET instead of cases treated with 94 other topical combinations. Previous studies with limited cryotherapy have demonstrated superior 95 clearance rate of KCs with IMI/5-FU/TRET (99%) over those of IMI/TRET (94%) and 5-FU/TRET (79%). 5 96

The complete clearance rate observed in our series is commensurate with these previous studies. 5 97

Although there was marked inflammation with the topical treatments, there was full compliance with 98 the treatment. This complete compliance level contrasts to those of other studies with monotherapy 99 topical treatments for KCs. 6 Among the cohort using IMI/5-FU/TRET, lesion sizes were similar among app 100 users and non-app users. However, mean age of patients was lower in the app user-group [62 (9. 

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Management of Non-Melanoma Skin Cancer (NMSC)

A non-surgical and cost-effective treatment approach 141 employing topical imiquimod, 5-fluorouracil, and tretinoin for primary non-melanoma skin 142 cancers

Imiquimod 5% cream monotherapy for cutaneous 144 squamous cell carcinoma in situ (Bowen's disease): a randomized, double-blind, placebo-145 controlled trial

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