Moh's surgery followed by Efudex treatment --pending photodynamic therapy in January, is this unusual?

Effudex, PDT and some of the newer topical treatments all do basically the same thing, target and kill abnormal cells. I'm in the vast minority of dermatologists as I have never prescribed any of those treatments. As a resident, I screened patients receiving 5-FU and found that most, if not all, hated it and were so uncomfortable that they cut their treatment time short. So why use it? While this was my first thought, there is more to it than that. These modalities target abnormal cells and leave normal cells alone. They also do no harm to cells that I call transitional cells. These are cells that are changing from normal to abnormal. Since they are not damaged by the treatment, they go on to be abnormal at which time another treatment is necessary. Having these painful treatments at least annually is not my idea of good treatment. I'm more interested in offering my patients a single treatment that will last for years.

I would not use efudex to treat a squamous cell ca but if someone has had many cancers and lots of precancers I always recommend a field therapy to clean up the background.  I call it seek and destroy.. 5fu or aldara will "light up" lesions that are not yet apparent and get rid of them..After field therapy is completed, maintenance is essential.. sometimes with retinoid acid or sometimes with 1-2 times a week 5fu.  after many years i came to realize that if someone has gazillions of lesions and they dont do maintenance then lesions will return.. like brushing your teeth.... If you stop brushing you will get cavities.

If you are growing multiple squamous cell cancers, you likely have a significant amount of underlying precancerous damage and maybe visible precancerous damage, AKA “actinic keratoses” or “solar keratoses.”  PDT (photodynamic therapy) or topical chemotherapy medicines (i.e. 5-FU or imiquimod) are routinely used as treatments for reducing precancerous damage. 
When it comes to treating actual squamous cell cancers, there are a variety of options.  Treatment alternatives include traditional surgery, Mohs surgery, radiation, chemotherapy, topical chemotherapy, cyrosurgery (freezing), and EDC (burning and scraping).  We are fortunate to have so many options, but each option has advantages and disadvantages.

In our practice, we favor Mohs surgery for most facial skin cancers because it typically has the highest cure rate, in the upper 90-percentile range.  The downside is that it is a more invasive procedure.  In patients with multiple skin cancers and extensive sun damage, we typically will biopsy and use Mohs surgery to treat the cancers, and later follow-up with either PDT or topical chemotherapy to reduce the future risk of more skin cancers.