Bowen's disease D04.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 23.04.2021

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Synonym(s)

Bowen`s disease; Bowen's disease; carcinoma in situ; Carcinoma in situ type Bowen's disease; dyskeratosis maligna; M. Bowen; squamous cell carcinoma in situ

History
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Bowen, 1912

Definition
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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.

Etiopathogenesis
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Mainly UV radiation over longer periods of time; less frequently chemical carcinogens (e.g. arsenic; see also arsenic intoxication) and human papilloma viruses (in individual cases the following HPV types have been detected: 1, 2, 4, 5, 6, 11, 15, 16, 20, 25, 34, 35, 38).

Manifestation
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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.

Localization
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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.

Clinical features
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Mostly solitary, more rarely multiple, red or brown-red, sharply and mostly irregularly limited, slightly raised plaque that slowly expands peripherally (eczematoid) over months.

Size very variable: 2.0-10.0 cm.

Surface texture: Covered with scales or rough scaly crusts (surface rarely sour).

Possibly flat or circumscribed erosions occur. In the centre of the plaque also scarring.

Painfulness is often reported when the focus is sharply painted over.

Histology
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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.

Differential diagnosis
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Therapy
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  • 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 withCO2 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.

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

Case report(s)
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Sharply defined plaque that has existed for 2 years, interspersed with scales and crusts and erosion. Clear actinic damage to the skin of the back of the hand. After initial ablative laser therapy ( Erbium-YAG-Laser), recurrence within 12 weeks. This time occlusive local therapy with 5% Imiquimod cream, 3 times/week; including recurrence-free complete healing. The follow-up 1 year after therapy showed no recurrence.

Literature
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  1. Bowen JT (1912) Precancerous dermatosis: a study of two cases of chronic atypical epithelial proliferation. J Cutan Dis 30: 241-255
  2. Gordon KB et al (1994) Carbon dioxide laser vaporization for bowens disease of the finger. Arch Dermatol 130: 1250-1252
  3. Hengge UR, Stark R (2001) Topical imiquimod to treat intraepidermal carcinoma. Arch Dermatol 137: 709-711
  4. Nakayama C et al (2014) HPV16-related pigmented Bowen's disease on the palm. J Eur Acad Dermatol Venereol doi: 10.1111/jdv.12628
  5. Pai K et al (2014) Acantholytic Variant of Bowen's Disease with Micro-invasive Squamous Cell Carcinoma: A Case Report of a Unique Variant. Indian J Dermatol 59:635
  6. Ramrakha-Jones VS et al (2003) Treating Bowen's disease: a cost-minimization study. Br J Dermatol 148: 1167-1172
  7. Shirai A et al (2014) Multiple clear cell acanthoma associated with multiple Bowen's disease. Int J Dermatol 53:e386-368
  8. Wigbels B et al (2001) Imiquimod: a new treatment possibility in bowenoid papulosis? dermatologist 52: 128-131
  9. Weisenseel P et al (2006) Treatment of paraungual HPV73-positive Bowen disease with imiquimod cream. dermatologist: 57: 309-312
  10. Wollina U (2015) Bowen's disease of the nail apparatus: a series of 8 patients and a literature review. Vienna Med Weekly 165:401-405
  11. Yoo SS et al (2003) Unilesional mycosis fungoides mimicking Bowen's disease. J Dermatol 30: 417-419

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 23.04.2021