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Disadvantages include the lack of standardized protocols and regimens and of clinical and histologic response criteria.111 Furthermore, residual hyperpigmentation following treatment may be confused with recurrence.119 In conclusion, the use of imiquimod should be reserved for cases in which surgery and other nonsurgical treatments such as radiation therapy are contraindicated, at least until further evidence is available on its efficacy and safety.7 Imiquimod can be used as adjuvant therapy before surgery to reduce tumor size108,113 or after surgery to treat extensive melanoma in situ around the lesion excised.120 Some authors have recommended its use in recurrent LM following conventional excision or Mohs micrographic surgery, in cases with positive margins (as adjuvant therapy), or to prevent recurrence.37,100,121,122 Other Nonsurgical TreatmentsAzelaic Acid Azelaic acid (C9 dicarboxylic acid) 20% in cream or 15% to 35% in ointment has been used to treat LM since the 1970s

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1 2 "Introduction: The History of Arsenic Trioxide in Cancer Therapy"

Regarding manganese safety, it should be noted that the Mn 2+ content in the formulation is relatively low and predominantly exists in a coordinated state within MnUA rather than as free ions