# Creams, light and cold for basal cell carcinoma

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## TL;DR

For a thin basal cell carcinoma there are four treatments that avoid an operation: two creams, a light treatment and freezing. All of them cure fewer people than surgery does, and all of them leave a better-looking face. The trials that measured the difference are the ones to read before choosing.

## Summary

Most basal cell carcinomas are small and superficial, and most of them are on a face. That is why the non-surgical options exist, and why the choice is genuinely a choice rather than a compromise: the question is how much cure rate a person will trade for not being cut.

The four options have been compared properly. In 601 Dutch patients with superficial basal cell carcinoma randomised between methyl aminolevulinate photodynamic therapy, imiquimod cream and fluorouracil cream, tumour-free survival at five years was 62.7 per cent for photodynamic therapy, 80.5 per cent for imiquimod and 70.0 per cent for fluorouracil; against photodynamic therapy the hazard ratio for failure was 0.48 for imiquimod and 0.74 for fluorouracil, and imiquimod also beat fluorouracil at 0.65 (0.43 to 0.98, p=0.04). A separate randomised comparison found no difference in five-year recurrence between photodynamic therapy and cryotherapy, 22 against 20 per cent, but an excellent cosmetic outcome in 60 against 16 per cent.

Against surgery all of them lose. SINS randomised 501 people in the United Kingdom to imiquimod or excision and found clinical success at five years of 82.5 against 97.7 per cent, a relative risk of 0.84 whose confidence interval lay below the non-inferiority margin, so imiquimod was shown to be inferior rather than merely unproven. For the thicker nodular form the gap is wider still: photodynamic therapy gave 14 per cent five-year recurrence against 4 per cent for excision, and curettage followed by imiquimod in the SCIN trial gave 77.8 per cent freedom from failure at five years against 98.2 per cent for excision.

Two practical points sit under the numbers. Failures are early: in both SINS and SCIN most happened in the first year, so a lesion still clear twelve months after a cream is likely to stay clear, and the follow-up visit at a year is doing real work. And cost runs the other way from efficacy: alongside the Dutch trial, twelve-month costs were 680 euros for photodynamic therapy, 526 for imiquimod and 388 for fluorouracil, so the least effective option was also the most expensive.

None of this applies to squamous cell carcinoma, which is invasive by definition. Creams and light are used there only for in-situ disease and for actinic damage, never for an invasive tumour.

## Fields

- Kind: Term
- Last checked: 2026-09-25
- Also known as: non-surgical treatment of basal cell carcinoma; imiquimod versus fluorouracil versus photodynamic therapy; field treatment of skin cancer; topical therapy for skin cancer

## Sources

- Five-year three-arm comparison (Journal of Investigative Dermatology 2018): https://doi.org/10.1016/j.jid.2017.09.033
- Cost-effectiveness alongside the trial (British Journal of Dermatology 2014): https://doi.org/10.1111/bjd.13066

## Connected records

- cancers: [Basal cell carcinoma](https://onco.cc/cancers/basal-cell-carcinoma/), [Skin cancer (all types)](https://onco.cc/cancers/skin-cancer/)
- technologies: [Black salve and other escharotic pastes](https://onco.cc/technologies/black-salve-escharotics/), [Photodynamic therapy lasers and light sources](https://onco.cc/technologies/photodynamic-therapy-lasers/)
- terms: [Cryoablation](https://onco.cc/terms/cryoablation/), [Curettage and cautery](https://onco.cc/terms/curettage-and-cautery/), [The margin in skin cancer surgery](https://onco.cc/terms/surgical-margins-keratinocyte-cancer/)
- drugs: [Aminolevulinic acid (topical, for photodynamic therapy)](https://onco.cc/drugs/aminolevulinic-acid/), [Fluorouracil (5-FU)](https://onco.cc/drugs/fluorouracil/), [Imiquimod](https://onco.cc/drugs/imiquimod/)
- pathways: [Field cancerisation](https://onco.cc/pathways/field-cancerisation/)
- trials: [Photodynamic therapy against cryotherapy for superficial basal cell carcinoma](https://onco.cc/trials/mal-pdt-versus-cryotherapy-superficial-bcc/), [Photodynamic therapy against imiquimod against fluorouracil for superficial basal cell carcinoma](https://onco.cc/trials/mal-pdt-imiquimod-fluorouracil-superficial-bcc/), [Photodynamic therapy against surgery for nodular basal cell carcinoma](https://onco.cc/trials/mal-pdt-versus-surgery-nodular-bcc/), [SCIN (curettage then imiquimod against excision for nodular basal cell carcinoma)](https://onco.cc/trials/scin-trial/), [SINS (surgical excision against imiquimod cream for basal cell carcinoma)](https://onco.cc/trials/sins-trial/)

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