By Gary M. White, MD
Bowen's disease (BD) represents squamous cell carcinoma in situ. (The term Bowenoid AK is used to represent a severe actinic keratosis and may be identical histologically to BD, but occurs in the sun-exposed skin and has solar elastosis.)
A slowly enlarging, sharply demarcated, red, scaly plaque is characteristic of BD. The most common site is unclear. In one study it was the head and neck and in another, the legs. Arsenic exposure predisposes to these lesions. Many patients have a prior history of either basal cell carcinoma or squamous cell carcinoma. Many lesions have irregular contours and one histologic study provided evidence that partial spontaneous regression may be the mechanism for central clearing and other irregular features. Occasionally, it may occur in the groin or perianal area or affect the nail unit.
Rarely, BD may be pigmented--see below and Dermatology Online Journal.
Curettage and electrodessication is simple, rapid, and effective. It is preferable to cryotherapy in terms of pain, healing, and recurrence rate [British J Dermatology March 2014].
Cryotherapy is simple, inexpensive, and quick. In one study, a single 20 sec freeze with 2-3 mm margin cured 18/20 [BJD 1996;135;766].
Excision is straightforward and effective. A 5 mm surgical margin has been recommended.
5-FU (e.g., BID for 1-2 months) has also been used. It is most appropriate for larger lesions where surgery is less of an option. Efficacy rates have been thought less than photodynamic therapy.
Imiquimod may be considered for larger lesions where surgery is less of an option. Imiquimod was applied once daily for 16 weeks to Bowen's disease of 1 cm or larger. Fourteen of the 15 patients had no residual tumor present in their 6-week post-treatment biopsy [J Am Acad Dermatol 2001;44:462-70].
Photodynamic therapy (PDT) may be of particular benefit for lesions that are large (> 3 cm diameter), on the lower leg, or at otherwise difficult sites.
Mohs surgery may be indicated if the lesion is ill-defined or for areas that need tissue-sparing, e.g., the nail or genitalia.
Laser has been used for more challenging treatment sites including the digits and genitalia.
Some have argued that for slowly growing lesions on the legs of the elderly, observation is appropriate.
Radiotherapy can be considered for areas where surgical modalities are difficult.
Bowen's disease in the pubic region of two separate women.
Bowen's disease in the perineum.
A large lesion.
Rarely, Bowen's disease may be pigmented.
Pigmented Bowen's disease in the groin of a 65-year-old woman. Dermatology Online Journal 17(11)
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