After the suspicious lesion is evaluated, the medical therapy is divided based on low-risk and high-risk basal cell carcinoma patients. Medical therapy consists of topical and systemic therapy. Among topical therapy imiquimod, photodynamic therapy, 5-fluorouracil are included. Systemic therapy consists of sonic hedgehog pathway inhibitors like vismodegib, sonidegib.

Once the suspicious lesion is evaluated, the medical therapy is based upon the low-risk and high-risk basal cell carcinoma patients.

The table below summarizes the characteristics in low-risk and high-risk lesions^[1].

Area H = “mask areas” of face (central face, eyelids, eyebrows, periorbital, nose, lips [cutaneous and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet

Area M = cheeks, forehead, scalp, neck, and pre-tibial area

Area L = trunk and extremities (excluding pre-tibial area, hands, feet, nail units, and ankles)

The algorithm below demonstrates a treatment protocol for low-risk lesions^[2].

The algorithm below demonstrates a treatment protocol for high-risk lesions^[3].

After the primary treatment, a follow-up is performed to evaluate for recurrence of the tumor.

The algorithm below demonstrates a follow-up protocol^[4].

The medical therapy for basal cell carcinoma is divided into^[5][6]:

• Toipcal
• Systemic

Topical therapy

• Imiquimod
  • It is an immunomodulatory agent that binds to toll-like receptor 7 and induces the release of pro-inflammatory cytokines including IFN-alpha, TNF-alpha and IL-12.
  • It is approved for treatment of small superficial basal cell carcinoma and is applied nightly five times a week for six weeks.
  • The complete cure rate was around 80%.
• Photodynamic therapy
  • The other available option for basal cell carcinoma is photodynamic therapy (PDT) with 5-amino levulinic acid(MAL) or with its methyl ester plus red light.
  • The MAL cream is applied to the tumor and covered with an occlusive dressing for three hours.
  • The tumor cells then form increasing amounts of protoporphyrin IX, which is stimulated by irradiation with red light to form reactive oxygen species which are in turn cytotoxic.
  • It should be repeated after 1–4 weeks.
  • The achieved complete remission is expected to be 92%.
  • The main disadvantages of photodynamic therapy are the pain during the irradiation and the local inflammatory reaction (erythema, erosions, pustules, and crusts).
• 5-fluorouracil
  • It is a cytostatic agent which is available as a 5% prescription cream that is designed to be applied twice daily for 3–12 weeks until erosions develop.

Systemic therapy

• Sonic hedgehog pathway inhibitors(vismodegib, sonidegib)
  • They are markedly teratogenic and embryotoxic.
  • The commonest adverse effects of vismodegib include muscle cramps, hair loss, taste disturbances and weight loss.

Cryotherapy

• Small and superficial basal cell carcinoma is occasionally still treated with liquid nitrogen (–196°C) either with direct contact or using a spray.
• The wounds may heal with either hypopigmentation or scarring so making it a major disadvantage.