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Response rates vary from series to series.104 While an 85% clinical response rate with histologic confirmation has been reported,91 in most cases evaluation was done by punch biopsy of a previously positive area.2 In 3 studies, after initial imiquimod treatment full tumor excision was achieved, with histologic clearance rates of 75%, 63%, and 53%.105108 Progression to LMM was reported during treatment in 3 patients.5,109,110 Because of variations in study design, it is not possible to identify optimal parameters or predictors of treatment failure or absence of response.110,111 Imiquimod has been associated with a hypothetical risk of favoring tumor progression.103,112 One study showed that treatment efficacy was significantly related only to a moderate to severe clinical inflammatory response.113 Different strategies have been used to improve inflammatory response, including increasing frequency of application (twice a day) or using occlusion, cryotherapy, or tazarotene 0.1% in gel.110,114,115 Clinical response should not be used on its own to evaluate treatment response, as clinical and histologic findings may not match (Fig
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