Is it Worth Trying Aldara/Zyclara Before Going Through with Mohs Surgery?

I agree that Aldara is not recommended for a micronodular basal cell cancer.   I recommend Mohs surgery for micronodular BCC which is considered a more aggressive subtype.  Mohs surgery will remove the cancer and give you the highest cure rate.  Surgical closure of a wound on the cheek typically leaves excellent results with an inconspicuous scar. 

Aldara only works for the most superficial of skin cancers (and obviously pre-cancers).  If you treat a lesion with Aldara instead of surgically removing it and getting pathological confirmation that it is gone, you run the risk of allowing the roots to continue to grow down and around the scar of the superficially treated lesion.  While this may be a risk willing to be taken off the face, it is not a good place to wind up having a recurrent skin cancer years down the road and needing major reconstructive surgery for.

I helped with a study that examined this when I was a resident.  Unfortunately, I cannot post links anymore.  Go to pubmed.org and search for 19018814 to get the abstract.

Basically, the benefit is questionable (if there is any).  The absorption of imiquimod is not deep enough to get the dermal component of many basal cell carcinomas.  A micronodular BCC is a more aggressive histologic subtype of BCC.  Therefore, imiquimod (Aldara / Zyclara) is not appropriate for this subtype.  You need histologic clearance with the Mohs technique performed by a fellowship-trained surgeon to get the best outcome. 

Most often we recommend Mohs because some cancers can have a form of roots, which run deeper and wider under the skin layers. Using a topical treatment like Aldara/Zyclara cannot get to these roots. So even if you use it and the top of the skin appears better, the deeper roots and layers can still be effected by the BCC and can continue growing and expanding. This is why it's not recommended for this type of cancer.

Second, the purpose of Mohs is to take as minimal amounts of skin out as possible. That's why slides are made during the procedure so your doctor only has to take out the affected, cancerous areas. Thus, you will be left with the most minimized scar possible. Mohs is your best option here, and trying Aldara/Zyclara will only delay and possibly worsen what needs to be taken out.