Initial systemic therapy in locally advanced or metastatic basal cell carcinoma not amenable to locoregional therapy

BCC: basal cell carcinoma; HHI: hedgehog pathway inhibitors.
* Itraconazole is a reasonable alternative option in resource-limited settings.
¶ For patients without access to HHI who are eligible for immunotherapy, cemiplimab is a reasonable alternative.
Δ Patients who are unable to tolerate the toxicities of continuous dosing of vismodegib may be offered an intermittent dosing schedule. Refer to UpToDate content on systemic treatment of advanced cutaneous basal cell carcinomas.
◊ Multiple clinical factors influence eligibility for immunotherapy including patient performance status, medical comorbidities, history of autoimmune disease, and use of immunosuppressive therapy or glucocorticoids. Refer to UpToDate content on systemic treatment of metastatic melanoma with molecular alterations.
§ Response rates are limited for these agents, based on available data. Carboplatin plus paclitaxel may result in higher rates of clinical response and is administered intravenously, whereas itraconazole may be better tolerated and is available orally. Clinical trials are encouraged.