Treatment of Verrucous Carcinoma of the Lower Lip with Topical Imiquimod (AldaraⓇ) and Debulking Therapy Fig. 1. (A) Extensive verrucous, hyperkeraotic tumor on the central aspect of the lower lip. (B) After treatment, all skin lesions disappeared. Fig. 2. (A) A biopsy specimen revealed the presence of an endophytic epidermal proliferation with bulbous, blunted projections composed of large, well-differentiated, squamous epithelial cells extending into the reticular dermis (H&E, ×20). (B) Cellular pleomorphism was minimal and mitotic activity was confined to the basal layer (H&E, ×200). layer (Fig. 2B). Based on these findings, the patient was diagnosed with verrucous carcinoma. Carbon dioxide laser treatment was then performed following tumescent local anesthesia using lidocaine 0.2%. After 10 days, the wound was completely epithelialized. At this point, topical treatment with imiquimod was started, with application of cream to the washed and dried tumor surface and then washed off 12 hours after application 3 times per week. After 4 weeks of treatment, the verrucous plaques had decreased in size; however, formation of mild erythema and crust with oozing was observed on the tumor and the patient complained of local pain. Therefore, application of imiquimod was then stopped and the patient received oral administration of analgesics and topical application of antibiotics to the tumor. Over a 4-week period of treatment with analgesics and topical antibiotics, local pain, erythema, and crust slowly disappeared. At this point, administration of imiquimod was started again, with application of treatment 3 times per week over a period of 4 weeks. Treatment was well tolerated by the patient and no unwanted side effects occurred. After 3 months of treatment, the tumor was clinically resolved (Fig. 1B). Case 2 A 75-year-old male developed painful hyperkeratotic plaques on the right aspect of his lower lip, which had persisted for more than 6 months (Fig. 3A). Prior to his visit to our hospital, the patient had been diagnosed with verrucous carcinoma based on the results of a histologic examination conducted at another hospital. Because the lesions progressed in size after the biopsy, he visited our hospital without treatment. The patient was a heavy smoker, but had no previous history of trauma or exposure to radiation. Physical examination revealed verrucous plaques with fissuring on the right aspect of the lower lip. Micro- scopically, the specimen showed marked parakeratosis, neoplastic proliferation, and downward invasion of epi- dermal keratinocytes with a blunt border and a pushed- down, bulldozing appearance. Inflammatory cell infiltrates surrounding the tumor were also observed (Fig. 4). Vol. 23, Suppl. 1, 2011 S69