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Presentation

Localized Non-Surgical Treatments for Keratinocyte Carcinomas: Decision-Making, Topicals, PDT, Cryotherapy, and Image-Guided Radiation

Description

The speaker reviewed localized non-surgical options for keratinocyte carcinomas and emphasized individualized decision-making based on tumor features, patient anxiety, comorbidities, ability to adhere to treatment, and location. Mohs surgery remains appropriate for many lesions because of its high cure rate, especially when there is concern for true invasion, failed prior therapy, or a highly anxious patient who wants maximal certainty, but it carries surgical risks and cosmetic tradeoffs. Non-surgical approaches are often favored for patients with extensive actinic damage, multiple prior skin cancers, advanced age, comorbidities, or when surgery would be difficult to monitor or close. The talk covered topical therapies such as 5-fluorouracil, imiquimod, and combination calcipotriene/5-FU, noting variable cure rates, common off-label use patterns, and the importance of follow-up after treatment. Photodynamic therapy was presented as a useful option for very superficial, diffuse lesions, often with better cosmetic outcomes and better tolerability than creams. Cryotherapy, sometimes paired with curettage or topicals, was described as a practical adjunct. Image-guided superficial radiation therapy was outlined as a nonsurgical option for superficial, low-risk tumors less than 3 mm deep, especially in older patients, though long-term cosmetic durability and follow-up data are limited. The speaker closed by noting emerging approaches and briefly mentioning intralesional 5-FU for eruptive squamous atypia/keratoacanthomas.

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Conclusions

For low-risk superficial or in situ keratinocyte carcinomas, non-surgical treatments can be appropriate alternatives to Mohs surgery when patient and lesion factors are favorable.
Mohs surgery remains the most reliable clearance option and is preferred when lesions are suspicious for deeper invasion, have failed prior therapy, or the patient is highly anxious about residual cancer.
Patient preference and ability to tolerate or adhere to treatment are central to choosing therapy, because some patients will value avoiding surgery while others need the psychological reassurance of excision.
Topical therapies such as 5-fluorouracil and imiquimod can work well for superficial disease, but their outcomes are variable and they are less dependable for deeper tumors.
Combination topical regimens, especially 5-fluorouracil with calcipotriene, appear promising and may achieve high response rates for superficial keratinocyte carcinomas.
Photodynamic therapy can provide good cosmetic outcomes and reasonable cure rates for diffuse superficial disease, especially when surgery would be morbid or cosmetically undesirable.
Cryotherapy combined with curettage or used as part of a sequential approach may improve success for selected superficial lesions, though side effects such as hypopigmentation remain a concern.
Image-guided superficial radiation therapy is a reasonable option for carefully selected thin, superficial tumors, especially in older patients with appropriate lesions who may want to avoid surgery.
The main tradeoffs of non-surgical approaches are less certain margin control, variable recurrence risk, treatment burden, and less predictable long-term cosmesis compared with surgery.
Overall, the best treatment choice depends on matching tumor depth, location, prior therapy, comorbidity, and patient goals rather than using a single approach for all keratinocyte carcinomas.

Combined topical 5-fluorouracil and calcipotriene effectively treats superficial keratinocyte carcinomas: A retrospective cohort study from 2 academic centers.#10.1016/j.jaad.2024.10.074
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