Basal cell carcinoma (BCC) is the most common form of skin cancer. The most commonly utilized surgical therapies for BCC are curettage and electrodesiccation (E and C) and surgical excision. Whereas surgical modalities have acceptable levels of morbidity and a high cure rate, effective non-invasive topical medical treatments of BCC are of great interest. Imiquimod is FDA approved for the treatment of superficial BCC (sBCC), actinic keratoses, and genital warts. There are several situations in which imiquimod is commonly utilized. Patients with multiple or large sBCCs may wish to avoid surgical approaches more likely to be complicated by scarring. We have also found imiquimod to be useful in elderly patients with marginal involvement of nodular BCC when the patient wishes to avoid additional surgery. Imiquimod is also useful when sBCC recurs following surgical treatments such as electrodessication and currettage and when sBCC occurs in areas that heal poorly after surgery. It is essential for physicians to explain to patients that an exuberant skin reaction is a positive indication of treatment success. Using clinical images to demonstrate the range of possible local reactions may be more effective than verbal descriptions. This minimizes the potential for premature discontinuation of therapy by patients.