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[Dermatology Reports 2010; 2:e4] [page 9]

Acitretin systemic and retinoic
acid 0.1% cream supression of
basal cell carcinoma
Xi-Bao Zhang,1 San-Quan Zhang,1
Chang-Xing Li,2 Zhen-Ming Huang,1
Yu-Wu Luo1

1Guangzhou Institute of Dermatology,
Guangzhou, China; 2Dongguan Institute of
Dermatology, Dongguan, China 

Abstract 

Retinoids have been used for years as
monotherapy and/or in combination for treat-
ment and suppression of cutaneous malignan-
cies in patients with basal cell nevus syn-
drome, xeroderma pigmentosum, or cutaneous
T-cell lymphoma (CTCL) basal cell carcinoma
(BCC). We report 4 cases with BCC confirmed
by histopathology who were treated by short-
term systemic acitretin combined with retinoic
acid 0.1% cream. The 4 cases with BCC showed
good response to the treatment without severe
adverse effects during treatment and follow-
up. The finding suggests that acitretin may be
an appropriate treatment option for elderly
patients who require less invasive treatment
for BCC.

Introduction

BCC may be treated by surgery, curettage
and electrodesiccation, cryosurgery, Mohs’
micrographic surgery, CO2 laser surgery and
topical 5-fluorouracil.1-3 A recent study by
Giannotti et al.4 demonstrated that topical
application of imiquimod 5% cream and oral
acitretin treated a 15-year old boy with xero-
derma pigmentosum (XP) who presented with
multiple facial BCC previously treated by surgi-
cal excision. Acitretin, a recommended treat-
ment option for anogenital warts, has been
shown to be effective in treating many other
skin disorders, such as human papilloma
virus-associated warts and skin carcinomas
including BCC.5-8 We report a novel method of
treating facial BCC patients with oral acitretin
and combination with topical application of
retinoic acid 0.1% cream. 

Case Reports

Case #1 
An 82-year old Chinese man presented with

an ulcer on the right nasal wall that persisted
for six years. The first appearance of lesion
was a brownish papule on the right nasal wall,
and size progressively increased with advanc-
ing age. The lesion developed into an ulcer
with bleeding and pruritus in the past year.
Physical examination showed a freckle and
sable ulcer, measuring 2¥1 cm in diameter on
the right nasal wall. The edge of the lesion has
a characteristic rolled border, and hemorrhag-
ic effusion on the surface of the ulcer (Figure
1A). A punch biopsy specimen of the lesion
showed nets of basaloid cells infiltrated in the
dermis characteristic of peripheral palisading
and cleft, which is between tumor focal and
matrix (Figure 1B). The patient was treated
with oral acitretin at a dose of 30 mg/d (0.6
mg/kg) and topically applied retinoc acid 0.1%
cream two times daily. Within eight weeks, the
ulcer had been progressively reduced in size.
We reduced the acitretin dose to 20 mg daily
(0.4 mg/kg). The ulcer was completely cleared
after six months of treatment (Figure 1C). The
patient has undergone follow-up every four
weeks for four years and there has been no
relapse of the lesion. Skin biopsy revealed no
tumor cells in the slide (Figure 1D). During
the course of treatment, the patient showed no
side effects except mild skin fragility, cheilitis
and mild local erythema. On follow-up, labora-
tory results have remained within normal lim-
its.

Case #2
A 70-year old Chinese woman presented

with an ulcer she had had on the right temple
for five years. The first appearance of lesion
was initially reported at the age of 65 years. As
the ulcer grew, the lesion developed into an
ulcer with bleeding. The lesion was asympto-
matic and the size progressively increased
with advancing age. In May 2006, the patient
presented at our department with increasingly
rapid growth of the ulcer with pruritus.
Physical examination showed an ulcer with

blood crust measuring 2.0¥1.5 cm in diameter
on the right temple. The lesion had a charac-
teristic rolled border (Figure 2A). A punch
biopsy specimen of the lesion showed cystic
spaces or necrosis in the centre of mass
(Figure 2B).The patient was initially treated
with oral acitretin at a dose of 20 mg/d (0.4
mg/kg) and topical applied retinoc acid 0.1%
cream two times daily. Within four weeks the
size of the lesion had been progressively
reduced and the acitretin dose was slowly
increased up to 40 mg/d (0.8 mg/kg). After 16
weeks, the lesion has disappeared (Figure 2C).
Skin biopsy revealed infiltration of lympho-
cytes around the vessels in dermis and no focal
of tumor was seen (Figure 2D). The patient
has undergone follow-up every four weeks for
two years and there has been no relapse of the
lesion. During the course of treatment, the

patient showed no side effects except mild skin
fragility, cheilitis and mild local erythema. On
follow-up, laboratory results have remained
within normal limits.

Case #3
An 82-year old Chinese woman presented

with two nodules on the left temple that had
persisted for two years. Two years ago, the
patient had had two nodules on the left temple
with pruritus and hemorrhagic effusion after
scratching. The nodule is characterized by
chronicity and gradual enlargement over time.
In June 2005, the patient presented at our
department with increasingly rapid growth of
the ulcer over the last three months.
Physical examination showed two tight con-

jointed nodules on the left temple, measuring
2.0¥2.0 cm and 1.0¥1.0 cm in diameter, respec-
tively. The center of the lesions had hemor-
rhagic effusion on the surface of the nodule.
The edge of the lesions had a characteristic
rolled border (Figure 3A). A punch biopsy spec-
imen of the lesions showed cystic spaces or
necrosis in the center of mass (Figure 3B).
The patient was prescribed oral acitretin 30 mg
two times daily (1 mg/kg) and topically applied
retinoc acid 0.1% cream two times daily. Two
weeks later the size of lesions had been pro-
gressively reduced. The lesions were complete-
ly clear after eight weeks treatment (Figure
3C). Skin biopsy revealed infiltration of lym-
phocytes around the vessels in dermis and no
focal of tumor cells was seen (Figure 3D).
During the course of treatment, the patient did
not report any adverse events. The patient has
undergone follow-up every four weeks for
three years and there has been no relapse of
the lesions. During the course of treatment,
the patient showed no side effects except mild
skin fragility, cheilitis and mild local erythema.
On follow-up, laboratory results have remained

Dermatology Reports 2010; volume 2:e4

Correspondence: Xi-Bao Zhang, Department of
Dermatology, Guangzhou Institute of Dermato-
logy, Guangzhou 510095, Guangdong Province, 
P R of China. E-mail: lilichangxing@163.com 

Key words: acitretin, basal cell carcinoma.

Conflict of interest: the authors report no con-
flicts of interest.

Received for publication: 5 September 2009.
Revision received: 12 December 2009.
Accepted for publication: 14 December 2009.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright X-B Zhang et al., 2010
Licensee PAGEPress, Italy
Dermatology Reports 2010; 2:e4
doi:10.4081/dr.2010.e4

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[page 10] [Dermatology Reports 2010; 2:e4]

within normal limits.
Case #4
A 77-year old Chinese man presented with a

pigmented patch on the left nasal wing that
had persisted for three years. The first appear-
ance of a lesion was a 0.5¥0.5 cm papula on
the left nasal wing that was incorrectly initial-
ly diagnosed as seborheic keratosis. The size
of the lesion progressively increased with pru-
titus and bleeding following a slight injury was
a common sign. In May 2008, the patient pre-
sented at our department with rapidly increas-
ing growth of the lesions over the last six
months, and partially infiltrated with obvious
pruritus. 
Physical examination showed a patch with

blood crust measuring 2¥1.5 cm in diameter
on the right temple. The edge of the lesion had
swollen up with a characteristic rolled border
(Figure 4A). Telangiectases were seen through
the lesion. A punch biopsy specimen of the
lesion showed large islands of tumor predomi-
nate (Figure 4B). The patient was prescribed
oral acitretin 30 mg two times daily 
(1 mg/kg) and topically applied retinoc acid
0.1% cream two times daily. Two weeks after
treatment, the size of lesion had been progres-
sively reduced. The tumor was completely clear
at the 6-week follow-up visit (Figure 4C). Skin
biopsy revealed epidermis infiltrated by lym-
phocytes (Figure 4D). The patient has under-
gone follow-up every four weeks for five
months and there has been no relapse of the
lesion. During the course of treatment, the
patient showed no side effects except mild skin
fragility, cheilitis and mild local erythema. On
follow-up, laboratory results have remained
within normal limits.  

Discussion

BBC lesions are most frequently found on
the face (85% are found in the head and neck
regions) and especially on the nose. Excessive
sunlight exposure, chemical cocarcinogens,
and genetic determinants are implicated as
causes of BBC.1 For this reason it is mostly
seen in middle-aged and elderly subjects. In
the current cases, the lesion found on the nose
and temple suggest common features of BCC.
Systemic therapy including cisplatin, doxoru-
bicin, cyclophosphamide, and adriamycin have
all been used in various degrees. No single
treatment method is ideal for all lesions, such
as biopsy, excision, Mohs’ microsurgery, ioniz-
ing radiation, cryosurgery, curettage, electro-
surgery, laser therapy, or topical cytotoxic ther-
apy such as 5-fluorouracil. These methods,
although effective on isolated carcinomas, are
not ideal treating facial BCC, primarily
because of a higher risk of causing disfiguring
scarring.1,4,5 The aim in treatment is for a per-

Case Report

Figure 1 (A) A freckle and
sable ulcer, measuring
2cm×1cm in diameter on
the right nasal wall. (B)
Histology showed nets of
basaloid cells infiltrated
in the dermis (×200). (C)
The tumor was complete-
ly cleared at the 6-month
follow-up visit. (D) After
treatment, there are no
tumor cells in this slide
(×100).

Figure 2 (A) An ulcer with
blood crust, measuring
2.0cm×1.5 cm in diameter
on the right temple. (B)
Histology showed cystic
spaces or necrosis in the
centre of mass (×100). (C)
The tumor was complete-
ly cleared at the 4-month
follow-up visit. (D) Skin
biopsy revealed infiltra-
tion of lymphocytes
around the vessels in der-
mis, and no focal of
tumor being seen (×100).

Figure 3 (A) Two tightening
conjointed nodules on the
left temple, measuring 2.0
cm×2.0cm and 1.0
cm×1.0cm in diameter,
respectively. (B) A punch
biopsy specimen of the
lesion showed cystic spaces
or necrosis in the centre of
mass (×100). (C) The
tumor was completely
cleared at the 8-week fol-
low-up visit. (D) Skin biop-
sy revealed infiltration of
lymphocytes around the
vessels indermis, and no
focal of tumor cell being
seen (×40).

Figure 4 (A) A patch with
blood crust, measuring
2cm×1.5cm in diameter
on the right temple. (B)
Histology showed large
islands of tumor predomi-
nate (×100). (C) The
tumor was completely
cleared at the 8-week fol-
low-up visit. (D) Skin
biopsy revealed epidermis
was infiltrated by lym-
phocytes (×100).

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[Dermatology Reports 2010; 2:e4] [page 11]

manent cure with the best cosmetic results,
important because the most frequent site of
the basal cell carcinoma is the face.
Retinoids, natural and synthetic derivatives

of vitamin A, are biological regulators of differ-
entiation, proliferation, apoptosis, and
immune response.9 Retinoic acid receptor
selective retinoids have been used for years as
monotherapy and/or in combination for treat-
ment of CTCL and BBC.9-12 Recently, one case
report showed that a 15-year old boy with XP
presented with multiple facial BCC because of
the risk of scarring, and the patient refused
further surgery. As an alternative, three times
weekly application of imiquimod 5% cream in
combination with oral acitretin (20 mg daily)
was prescribed for 4-6 weeks. All tumors had
resolved at the 6-month follow-up visit, high-
lighting the therapeutic potential with a com-
bination of oral acitretin and imiquimod 5%
cream.4 Ingves et al. also reported a 48-year old
woman with BCC who was successfully treated
with topical imiquimod and systemic
acitretin.13 This evidence suggests that
acitretin combination with imiquimod seem to
be possible when treating superficial tumors
in areas where the cosmetic outcome is partic-
ularly important. 
In the current 4 cases of BCC confirmed by

clinical and histopathology, the patients
refused surgery. As an alternative, twice daily
application of retinoic acid 0.1% cream in com-
bination with oral acitretin (0.4-1 mg/kg daily)
was prescribed after appropriate discussion
with the patient and his or her sons. During

follow-up, laboratory results remained within
normal limits and examined by histopathology
on completion of therapy. The 4 cases showed
good response to the treatment without severe
adverse effects. All cases have been followed
up to date with no evidence of recurrence. This
evidence highlights the therapeutic potential
of oral acitretin for BCC. 

References

1. Drake LA, Ceilley RI, Cornelison RL, et al.
Guidelines of care for basal cell carcinoma.
The American Academy of Dermatology
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Acad Dermatol 1992;26:117-20.

2. Kopera D, Cerroni L, Fink-Puches R, et al.
Different treatment modalities for the
management of a patient with the nevoid
basal cell carcinoma syndrome. J Am Acad
Dermatol 1996;345:937-9.

3. Hamouda B, Jamila Z, Najet R, et al.
Topical 5-fluorouracil to treat multiple or
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4. Giannotti B, Vanzi L, Difonzo EM, et al.
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5. Edwards L, Ferenczy A, Eron L, et al. Self-

administered topical 5% imiquimod cream
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8. Beutner KR, Geisse JK, Helman D, et al.
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9. Duvic M, Cather JC. Emerging therapies in
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10. Zackheim HS. Treatment of cutaneous T-
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11. Zhang C L, Duvic M. Treatment of cuta-
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12. Chen K, Craig JC, Shumack S. Oral
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systematic review of randomized con-
trolled trials. Br J Dermatol 2005;152:518-
23.

13. Ingves C, Jemec GB. Combined imiquimod
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Case Report

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