10.5826/dpc.1301a42
text/xml
2160-9381
2687
en
Nicola di Meo
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Eyelid Lentigo Maligna Treated With Imiquimod 5%: Should We Fear of Ocular Side Effects?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2023-01-31
2022-07-06
2023-01-31
2023-03-01
e2023042
Dermatol Pract Concept
Nicola di Meo
2023/01/31
10.5826/dpc.1301a42
e2023042
Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy
2160-9381
en
e2023042
Murchison AP, Washington CV, Soloman AR, Bernardino CR. Ocular effects of imiquimod with treatment of eyelid melanoma in situ. Dermatol Surg. 2007;33:1136–1138. DOI: 10.1111/j.1524-4725.2007.33232.x. PMID: 17760609.
Eyelid Lentigo Maligna Treated With Imiquimod 5%: Should We Fear of Ocular Side Effects?
https://dpcj.org/index.php/dpc/article/download/2687/1918
Eyelid Lentigo Maligna Treated With Imiquimod 5%:
       Should We Fear of Ocular Side Effects?
Claudio Conforti1, Carmen Dell’Aquila2, Daniele Tognetto2, Iris Zalaudek1, Nicola Di Meo1


1 Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy
2 Eye Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy



Citation: Conforti C, Dell’Aquila C, Tognetto D, Zalaudek I, Di Meo N. Eyelid lentigo maligna treated with imiquimod 5%: should we
fear of ocular side effects? Dermatol Pract Concept. 2023;13(1):e2023042. DOI: https://doi.org/10.5826/dpc.1301a42
Accepted: July 25, 2022; Published: January 2023
Copyright: ©2023 Conforti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: CC and CD wrote the article; DT and IZ reviewed the literature; NDM provided images of the patients.
Corresponding Author: Claudio Conforti, MD, Dermatology clinic, Maggiore Hospital of Trieste, Trieste, Italy. Phone +390403992056
E-mail: claudioconforti@yahoo.com




To the Editor,                                                            pigmentation and obliterations of follicles (Figure 1B). A
                                                                          4mm punch biopsy was performed, confirming the dermo-
Lentigo maligna (LM) represents the most common subtype                   scopic diagnosis of lentigo melanoma. The patient was dis-
of melanoma in the elderly, affecting predominantly the head              cussed in our multidisciplinary tumor board because surgery
and neck region in photodamaged patients. Surgery with                    would have an impact on the functionality of the eye and
5 mm margins is the treatment of choice but patient comor-                also because the patient refused further surgery. Based on the
bidities, impact of surgery intervention and the reduction of             data suggesting a good response of LM to topical treatment
quality of life resulting from surgery can limit its application.         with IMQ 5%, it was started five days per week. Consider-
In situations for which surgery would have a major impact                 ing the tumor closeness to conjunctiva and cornea and the
on the functionality of the anatomic region or would results              risk of occasional applications of the drug in the eye during
in cosmetically devasting outcome, radiotherapy or imiqui-                the treatment, a close dermatological and ophthalmological
mod (IMQ) represent valid alternatives. IMQ could cause                   evaluations were performed every two weeks. After 4 weeks
significant skin reactions and little is currently known on its           a partial response was observed (­Figure 1, C and D) and
impact of the eye if applied in the periorbital region. Herein,           after 6 weeks a complete response was achieved (Figure 1,
we report the case of a 74-year-old woman, referred to our                E and F). At the ophthalmologic evaluation after 2 weeks
skin cancer department for a brownish macule located on                   of treatment, redness, burning and foreign body sensation
left lower eyelid. Previous history revealed the excision with            of the conjunctivae was noted, without any decreased vi-
5 mm margins of a LM 4-years before. A first recurrence                   sual acuity. However, to limit discomfort, a combination
appeared two years later and was surgically treated.                      of topical steroid and hyaluronic acid eyedrops were pre-
    At current visit, a brownish macule of about 6-mm located             scribed every day for ten days with a rapid improvement of
on the lower eyelid was observed (Figure 1A). Dermoscopic                 the symptoms. Then, to prevent redness and burning sensa-
evaluation showed a brown pseudo-network with intense                     tion, hyaluronic acid eyedrops were prescribed for the entire


Letter to Editor | Dermatol Pract Concept. 2023;13(1):e2023042                                                                        1
Figure 1. A brownish macule of about 6-mm located on the lower eyelid was observed. [Fig.1A] Dermoscopic evaluation showed a brown
pseudo-network with intense pigmentation and obliterations of follicles. [Fig1B]. After 4 weeks of treatment with imiquimod 5%, a partial
response was observed [Fig1C, Fig1D] and after 6 weeks a complete response was achieved. [Fig1E, Fig1F]




treatment period. At 6 months follow up visit, no clinical            inflammation which, if it occurs, can be treated, and pre-
and dermoscopic signs of recurrence were observed and the             vented with topical therapy.
conjunctiva did not show inflammation or impairment. The
optimal response of LM to IMQ and its dermoscopic eval-
                                                                      References
uation has been already proved (1,2); moreover, clinicians
may be reluctant to prescribe IMQ on the eyelid because of             1. Lallas A, Moscarella E, Kittler H, et al. Real-world experience
                                                                          of off-label use of imiquimod 5% as an adjuvant therapy after
risk of ocular adverse effects. However, O’Neill et al (3) de-
                                                                          surgery or as a monotherapy for lentigo maligna. Br J Derma-
scribed the case of a 52-year-old woman affected by LM,
                                                                          tol. 2021;185(3):675-677. DOI: 10.1111/bjd.20407. PMID:
successfully treated with IMQ and, despite the patient giving             33894006.
a history of having applied treatment into the eye on occa-            2. Hamilko de Barros M, Conforti C, Giuffrida R, Seabra Resende
sion (in error) there were no adverse effects. Other reports              FS, Di Meo N, Zalaudek I. Clinical usefulness of dermoscopy in
show that the most common side effects during treatment                   the management of lentigo maligna melanoma treated with topi-
                                                                          cal imiquimod: A case report. Dermatol Ther. 2019;32(5):e13048.
of LM of the eyelids with IMQ are redness and burning,
                                                                          DOI: 10.1111/dth.13048. PMID: 31365164.
improved without permanent ocular damages after its dis-
                                                                       3. O’Neill J, Ayers D, Kenealy J. Periocular lentigo maligna treated
continuation (4,5).                                                       with imiquimod. J Dermatolog Treat. 2011;22(2):109-112. DOI:
    To prevent ocular redness and burning, the first advice to            10.3109/09546630903559798. PMID: 20666668.
be given to patients is undoubtedly to use daily hyaluronic            4. Elia MD, Lally SE, Hanlon AM, et al. Periocular Melanoma
acid tears associated with good eyelid hygiene. In more se-               In Situ Treated With Imiquimod. Ophthalmic Plast Re-
                                                                          constr Surg. 2016 Sep-Oct;32(5):371-373. DOI: 10.1097/
vere scenarios, non-steroid tears should be prescribed to
                                                                          IOP.0000000000000554. PMID: 26325381.
reduce discomfort and to increase therapeutic compliance.
                                                                       5. Murchison AP, Washington CV, Soloman AR, Bernardino CR.
Therefore, considering the benefits of IMQ and the absence                Ocular effects of imiquimod with treatment of eyelid mel-
of permanent ocular side effects, the use of IMQ in the perio-            anoma in situ. Dermatol Surg. 2007;33:1136–1138. DOI:
cular area should not be avoided for fear of conjunctival                 10.1111/j.1524-4725.2007.33232.x. PMID: 17760609.




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