Welcome back to the journal review. This month we're in the Journal of the American Academy of Dermatology, July 2026 issue, and we've got one substantial piece to work through — Part Two of a continuing medical education series titled "Minimally Invasive Modalities for Keratinocyte Carcinomas," this installment focused on treatment. This is a CME review article, not an original study, so there's no methods or limitations section in the traditional sense — instead it's a synthesis of the evidence base across a broad menu of nonsurgical options, organized by modality, with an eye toward guiding decisions when surgery isn't the right fit.

The framing point up front, which you already live with clinically, is that surgical excision remains the gold standard for basal cell and squamous cell carcinoma, but a meaningful subset of patients either can't or won't have it. The authors lay out a table of who those patients are — those who prefer to avoid surgery, those with metastatic or locally invasive disease not amenable to excision, extensive field cancerization across face, trunk, or limbs, lesions in poor-healing acral or facial sites, patients with comorbidities like advanced dementia or terminal illness limiting cooperation or lifespan, immunosuppression or uncontrolled diabetes impairing healing, social barriers to surgical access, and simple cosmetic or tolerance preferences. The review's stated goal is to organize the now-crowded landscape of pharmacologic, photodynamic, laser, and other minimally invasive treatments — lesion-directed, field-directed, or systemic — into something you can actually use to counsel these patients.

This section covers the lesion-directed ablative therapies first: electrodessication and curettage, cryosurgery, and lasers. Electrodessication and curettage — ED&C — is the familiar scrape-and-cauterize approach, and the data support it strongly for well-defined, low-risk basal cell carcinoma and squamous cell carcinoma in situ. Five-year recurrence runs about one to four percent for low-risk basal cell carcinoma and around five percent for in-situ squamous disease — numbers worth quoting to a patient directly since they inform the surgery-versus-ED&C conversation. But recurrence climbs meaningfully with higher-risk features — high-risk facial basal cell carcinoma recurs after ED&C anywhere from about one percent up to two in ten, and aggressive histologic subtypes push recurrence toward one in four. The NCCN guidance the authors cite is one you already apply reflexively: avoid ED&C in terminal hair-bearing areas, since the whole technique depends on being able to feel the difference between firm tumor stroma and normal dermis.

Cryosurgery gets similar treatment — cheap, fast, useful for small well-defined actinic keratoses, superficial basal cell carcinoma, and in-situ squamous disease, with the usual tradeoffs of dyspigmentation and scarring. Randomized trials using a standard two freeze-thaw cycle protocol show complete response in the low-to-high eighty percent range for superficial and nodular basal cell carcinoma, but this is consistently inferior to excision head-to-head. For superficial squamous cell carcinoma and in-situ disease, a large meta-analysis found recurrence in the high single digits to low double digits, which drops substantially — down to essentially one to five percent — when cryotherapy is paired with prior curettage debulking. That combination point is clinically actionable: curettage-plus-cryo outperforms cryo alone by a wide margin.

Lasers round out the ablative section. Ablative CO2 laser gives complete response rates for superficial basal cell carcinoma in the high seventies — comparable to cryotherapy but still inferior to surgery — with the expected risks of imprecise margin control, recurrence, and cosmetic sequelae. Fractional lasers trade some efficacy for better tolerability and healing, with actinic keratosis control rates roughly on par with other minimally invasive and topical options. Nonablative lasers are the least well-studied of the group, with only a systematic review suggesting a possible edge for basal cell carcinoma control, but the authors are appropriately cautious given how thin that comparative literature is.

The section then pivots to photodynamic therapy, presented through a table of randomized trials and meta-analyses, and this is where the numbers matter most for how you counsel patients. Short-term, photodynamic therapy looks excellent — complete response rates in the low-to-mid nineties for nodular and superficial basal cell carcinoma at three months, and readouts near ninety percent at twelve months for many of these trials. But the long-term recurrence data tell a different story, and this is the clinically important takeaway from the whole table: one trial following nodular basal cell carcinoma out to five years found recurrence approaching one in three, and a three-year interim analysis in a separate nodular basal cell carcinoma trial showed a cumulative failure rate in the same neighborhood — roughly thirty percent. A meta-analysis pooling nodular basal cell carcinoma trials against surgical excision found no significant difference in complete response initially, but a significantly higher cumulative recurrence probability with photodynamic therapy over time. For cutaneous squamous cell carcinoma, a large meta-analysis across nearly three hundred patients found complete response around seventy percent, but average recurrence near one in four — significantly higher than other treatment modalities in that same analysis. Superficial basal cell carcinoma fares better than nodular disease in these tables, with twelve-month treatment-failure-free rates in the low nineties in a couple of the larger trials, which fits the general teaching that photodynamic therapy is a superficial-disease tool, not a nodular- or invasive-disease tool.

So what should you actually do with this. The ablative therapies section is not practice-changing for you as a Mohs surgeon — it largely confirms what you already know and likely already communicate: ED&C and cryosurgery are reasonable, inexpensive, quick options for genuinely low-risk, well-defined lesions in patients who need or want a nonsurgical path, but the recurrence data give you exact numbers to quote when a patient asks "why not just freeze it" for a higher-risk lesion. The photodynamic therapy data are more useful as ammunition for a specific counseling conversation you probably have often — when a patient with a nodular basal cell carcinoma requests photodynamic therapy because a friend had it, you now have a clean, citable long-term recurrence figure, around thirty percent at three to five years, to explain why that modality is better reserved for superficial disease and not extended to nodular or invasive tumors. None of this changes your own surgical practice, but it sharpens the evidence you can lean on when guiding patients who are choosing among these alternatives, or when you're asked to see a lesion after one of these modalities has already failed.

That's where the excerpt of this review leaves off for today — the fuller article goes on to cover topical, intralesional, and systemic therapies, which we'll pick up in coverage of the pharmacologic sections. That wraps this month's discussion — thanks for listening, and I'll see you next time.