Bowen's diseaseD04.9

Keratinocyte-derived, mostly solitary carcinoma in situ of the skin (see also carcinoma kutanes), clinically characterized by a slowly growing, red plaque with scaly or scaly-crusty, rarely smooth, red or red-brown surface. When occurring on the genital mucosa, Bowen's disease is called erythroplasia.

Occurs in older people (> 60 years), preferably in fair-skinned people. However, this does not apply to cases which are intertriginous and in the genito-anal region.

Possible on the entire integument; especially light-exposed skin areas (face, hands) are affected.

However, other non light-exposed areas may also be affected (HPV induction?) such as groin region, penile shaft or vulva, perianal region.

Mostly solitary, more rarely multiple, red or brown-red, sharply and usually irregularly circumscribed, slightly raised, slowly extending peripherally over months (eczematoid) plaque.

Size very variable: 2.0-10.0 cm.

Surface structure: Covered with scales or rough scaly crusts (rarely verrucous surface).

There may be two-dimensional or circumscribed erosions. In the center of the plaque also scarring.

Painfulness is often reported when sharply brushing over the focal area.

Inthe light microscope , grouped dot/cluster vessels, scaling, the erythema tends to recede into the background.

Acanthosis of the epidermis, lengthening and significant thickening of the reteleal ridges. Complete loss of the physiological epidermal structure; the cells are irregularly scattered and show a high degree of nuclear polymorphism, numerous mitoses and typical dyskeratotic keratinization of single cells ( dyskeratosis). Occasionally vacuolated cells in the upper epidermal layers. Sharp demarcation from the corium, intact basal membrane. Bulky round cell infiltrate in the upper dermis. Rarer is an acantholytic variant.

• Excision in healthy tissue is considered the first-line therapy.
• In case of unfavorable localization and size, curettage or X-ray soft-beam technique may be used in the elderly (daily 3-5 Gray up to GD of 40-60 Gray, GHWT 1.0 mm).
• Alternative: cryosurgery (freezing cycle twice).
• Alternative: Treatment with externally applied cytostatics such as 5-fluorouracil (e.g. Efudix cream) every second day for 1 week can be considered and is particularly suitable in combination with curettage.
• Alternatively, removal with_CO2 laser or photodynamic therapy.
• An experimental approach, especially in HPV-positive Bowen's disease, is occlusive treatment (3-4 times/week overnight for 8-12 hours; duration of therapy about 3-6 weeks) with a 5% Imiquimod cream (Aldara). Such an option should be considered especially in case of unfavorable localization (e.g. fingers; caution! highly probable HPV-induced). Careful follow-up is absolutely necessary! If irritation is too severe, especially in the case of weeping inflammation, reduce therapy to 2 times/week. Danger of superinfection and pyoderma. Currently only available as off-label medication in Germany.

After years or decades of horizontal growth, transition to invasive squamous cell carcinoma (so-called Bowen's carcinoma) possible; metastasis possible .

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