bcc may be treated by surgery , curettage and electrodesiccation , cryosurgery , mohs ' micrographic surgery , co2 laser surgery and topical 5-fluorouracil . a recent study by giannotti et al . demonstrated that topical application of imiquimod 5% cream and oral acitretin treated a 15-year old boy with xeroderma pigmentosum ( xp ) who presented with multiple facial bcc previously treated by surgical excision . acitretin , a recommended treatment 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 . we report a novel method of treating facial bcc patients with oral acitretin and combination with topical application of retinoic acid 0.1% cream . 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 advancing age . physical examination showed a freckle and sable ulcer , measuring 21 cm in diameter on the right nasal wall . the edge of the lesion has a characteristic rolled border , and hemorrhagic 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 patient has undergone follow - up every four weeks for four 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 , figure 1(a ) a freckle and sable ulcer , measuring 2cm1 cm in diameter on the right nasal wall . ( b ) histology showed nets of basaloid cells infiltrated in the dermis ( 200 ) . ( c ) the tumor was completely cleared at the 6-month follow - up visit . ( d ) after treatment , there are no tumor cells in this slide ( 100 ) . ( a ) a freckle and sable ulcer , measuring 2cm1 cm in diameter on the right nasal wall . ( b ) histology showed nets of basaloid cells infiltrated in the dermis ( 200 ) . ( c ) the tumor was completely cleared at the 6-month follow - up visit . ( d ) after treatment , there are no tumor cells in this slide ( 100 ) . a 70-year old chinese woman presented with an ulcer she had had on the right temple for five years . the lesion was asymptomatic 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 2.01.5 cm in diameter on the right temple . 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 ) . skin biopsy revealed infiltration of lymphocytes 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 figure 2(a ) an ulcer with blood crust , measuring 2.0cm1.5 cm in diameter on the right temple . ( b ) histology showed cystic spaces or necrosis in the centre of mass ( 100 ) . ( c ) the tumor was completely cleared at the 4-month follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels in dermis , and no focal of tumor being seen ( 100 ) . ( a ) an ulcer with blood crust , measuring 2.0cm1.5 cm in diameter on the right temple . ( b ) histology showed cystic spaces or necrosis in the centre of mass ( 100 ) . ( c ) the tumor was completely cleared at the 4-month follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels in dermis , and no focal of tumor being seen ( 100 ) . 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 conjointed nodules on the left temple , measuring 2.02.0 cm and 1.01.0 cm in diameter , respectively . a punch biopsy specimen 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 . skin biopsy revealed infiltration of lymphocytes 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 figure 3(a ) two tightening conjointed nodules on the left temple , measuring 2.0 cm2.0 cm and 1.0 cm1.0 cm 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 follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels indermis , and no focal of tumor cell being seen ( 40 ) . ( a ) two tightening conjointed nodules on the left temple , measuring 2.0 cm2.0 cm and 1.0 cm1.0 cm 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 follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels indermis , and no focal of tumor cell being seen ( 40 ) . a 77-year old chinese man presented with a pigmented patch on the left nasal wing that had persisted for three years . the first appearance of a lesion was a 0.50.5 cm papula on the left nasal wing that was incorrectly initially diagnosed as seborheic keratosis . the size of the lesion progressively increased with prutitus and bleeding following a slight injury was a common sign . in may 2008 , the patient presented at our department with rapidly increasing growth of the lesions over the last six months , and partially infiltrated with obvious pruritus . physical examination showed a patch with blood crust measuring 21.5 cm in diameter on the right temple . the edge of the lesion had swollen up with a characteristic rolled border ( figure 4a ) . a punch biopsy specimen of the lesion showed large islands of tumor predominate ( 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 . the tumor was completely clear at the 6-week follow - up visit ( figure 4c ) . the patient has undergone 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 figure 4(a ) a patch with blood crust , measuring 2cm1.5 cm in diameter on the right temple . ( c ) the tumor was completely cleared at the 8-week follow - up visit . ( a ) a patch with blood crust , measuring 2cm1.5 cm in diameter on the right temple . ( c ) the tumor was completely cleared at the 8-week follow - up visit . 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 advancing age . physical examination showed a freckle and sable ulcer , measuring 21 cm in diameter on the right nasal wall . the edge of the lesion has a characteristic rolled border , and hemorrhagic 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 patient has undergone follow - up every four weeks for four 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 , figure 1(a ) a freckle and sable ulcer , measuring 2cm1 cm in diameter on the right nasal wall . ( b ) histology showed nets of basaloid cells infiltrated in the dermis ( 200 ) . ( c ) the tumor was completely cleared at the 6-month follow - up visit . ( d ) after treatment , there are no tumor cells in this slide ( 100 ) . ( a ) a freckle and sable ulcer , measuring 2cm1 cm in diameter on the right nasal wall . ( b ) histology showed nets of basaloid cells infiltrated in the dermis ( 200 ) . ( c ) the tumor was completely cleared at the 6-month follow - up visit . ( d ) after treatment , there are no tumor cells in this slide ( 100 ) . a 70-year old chinese woman presented with an ulcer she had had on the right temple for five years . the lesion was asymptomatic 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 2.01.5 cm in diameter on the right temple . 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 lymphocytes 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 . figure 2(a ) an ulcer with blood crust , measuring 2.0cm1.5 cm in diameter on the right temple . ( b ) histology showed cystic spaces or necrosis in the centre of mass ( 100 ) . ( c ) the tumor was completely cleared at the 4-month follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels in dermis , and no focal of tumor being seen ( 100 ) . ( a ) an ulcer with blood crust , measuring 2.0cm1.5 cm in diameter on the right temple . ( b ) histology showed cystic spaces or necrosis in the centre of mass ( 100 ) . ( c ) the tumor was completely cleared at the 4-month follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels in dermis , and no focal of tumor being seen ( 100 ) . 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 conjointed nodules on the left temple , measuring 2.02.0 cm and 1.01.0 cm in diameter , respectively . a punch biopsy specimen 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 . skin biopsy revealed infiltration of lymphocytes 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 figure 3(a ) two tightening conjointed nodules on the left temple , measuring 2.0 cm2.0 cm and 1.0 cm1.0 cm 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 follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels indermis , and no focal of tumor cell being seen ( 40 ) . ( a ) two tightening conjointed nodules on the left temple , measuring 2.0 cm2.0 cm and 1.0 cm1.0 cm 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 follow - up visit . ( d ) skin biopsy revealed infiltration of lymphocytes around the vessels indermis , and no focal of tumor cell being seen ( 40 ) . a 77-year old chinese man presented with a pigmented patch on the left nasal wing that had persisted for three years . the first appearance of a lesion was a 0.50.5 cm papula on the left nasal wing that was incorrectly initially diagnosed as seborheic keratosis . the size of the lesion progressively increased with prutitus and bleeding following a slight injury was a common sign . in may 2008 , the patient presented at our department with rapidly increasing growth of the lesions over the last six months , and partially infiltrated with obvious pruritus . physical examination showed a patch with blood crust measuring 21.5 cm in diameter on the right temple . the edge of the lesion had swollen up with a characteristic rolled border ( figure 4a ) . a punch biopsy specimen of the lesion showed large islands of tumor predominate ( 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 . the tumor was completely clear at the 6-week follow - up visit ( figure 4c ) . the patient has undergone 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 figure 4(a ) a patch with blood crust , measuring 2cm1.5 cm in diameter on the right temple . ( c ) the tumor was completely cleared at the 8-week follow - up visit . ( a ) a patch with blood crust , measuring 2cm1.5 cm in diameter on the right temple . ( c ) the tumor was completely cleared at the 8-week follow - up visit . 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 . 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 systemic therapy including cisplatin , doxorubicin , 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 , ionizing radiation , cryosurgery , curettage , electrosurgery , laser therapy , or topical cytotoxic therapy 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 . the aim in treatment is for a permanent 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 differentiation , proliferation , apoptosis , and immune response . retinoic acid receptor selective retinoids have been used for years as monotherapy and/or in combination for treatment of ctcl and bbc . 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 46 weeks . all tumors had resolved at the 6-month follow - up visit , highlighting the therapeutic potential with a combination of oral acitretin and imiquimod 5% cream . ingves et al . also reported a 48-year old woman with bcc who was successfully treated with topical imiquimod and systemic acitretin . this evidence suggests that acitretin combination with imiquimod seem to be possible when treating superficial tumors in areas where the cosmetic outcome is particularly 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 combination with oral acitretin ( 0.41 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 .
retinoids have been used for years as monotherapy and/or in combination for treatment and suppression of cutaneous malignancies in patients with basal cell nevus syndrome , 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 .