Lentigo maligna, the in situ phase of lentigo maligna melanoma, is frequently located on the head, and surgical excision can be a formidable procedure. While surgical excision, either with conventional surgery or Mohs micrographic technique, remains the treatment of choice for lentigo maligna,^1-3 sometimes surgical excision is not a viable option. A recent report⁴ described successful treatment using imiquimod cream on a large lentigo maligna on the scalp of an elderly man. Following this lead, I used imiquimod to successfully treat an extensive recurrent lentigo maligna in a 90-year-old woman.

Since 1980, I have been treating a 90-year-old woman with basal cell carcinomas and actinic keratoses. In 1994, a pigmented lesion of the left upper cheek area, clinically a lentigo, was frozen with liquid nitrogen and had cleared on follow-up 1 month later. A recurrence 1 year later prompted tangential excision (shave removal) of the entire 14 × 8-mm lesion. The pathologic diagnosis was "atypical junctional melanocytic proliferation," and clinical follow-up was recommended. The patient did not return for follow-up until 1 year later, in January 1997, when the lesion had recurred, measuring 21 × 17 mm. After repeated urgings, the patient consented to having a plastic surgeon excise the lesion in March 1998. The pathologic diagnosis was "lentigo maligna with probable focal microinvasion." Extension of the lesion to 1 margin led to further surgery to achieve a clear margin, and then a flap and graft repair of the defect was performed. Initial healing was followed by evidence of marginal recurrence 16 months after the surgery. Because of the patient's age, the decision was made to manage marginal recurrences with repeated liquid nitrogen freezings.