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Therapeutics in Dermatology
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Bowen’s disease

18 June 2015, by PAGES C. & STAVRIANEAS N.G.

1 - REMINDER

Bowen’s disease is a relatively rare intraepithelial squamous cell carcinoma in situ. Described by John T. Bowen in 1912 who had already recognized his precancerous nature, it was then described clinically and histologically by Darier in 1914. Bowen’s disease affects mainly adults at any age. The age curve spans from 18 to 95 years, with a median of 65 years [1]. Lesions may be isolated or multiple (10 to 20% of cases).

Bowen’s disease mainly affects areas exposed to the sun but can affect any area of the skin whether exposed or not and the mucous membranes, especially in the genital area. The genital forms mostly affect young adults with a female predominance [2].

On the skin, it presents as a slightly elevated, very slowly progressing scaly, erythematous plaque that is disc-shaped and may be variably associated with erythema, surface crusting or scaling and keratosis.

On palpation, the lesion may be slightly infiltrated. When Bowen’s disease occurs in a fold or the mucosa, it appears velvety, pink and oozing, or as erythroplakia, leukoplakia or erythroleukoplakia.

Its clinical diagnosis can be difficult: subungual, perianal, pigmented, verrucous Bowen’s disease. Histological verification is therefore required for the diagnosis of Bowen’s disease, used to confirm the absence of microinvasion on serial sections. Bowen’s disease can progress to invasive carcinoma in 3 to 5 per cent of cases over very variable periods [3]. It is often combined with other skin cancers (basal cell or squamous cell carcinomas) [4]. The fact that it may have paraneoplastic properties and may be used as an internal cancer marker is currently refuted [5].

Factors contributing to Bowen’s disease include: sunlight, arsenic exposure, immunosuppression, HPV infection (HPV 16 for Bowen’s disease with an anal or genital location; also implicated in palmoplantar and periungual lesions) [6]. It may occur together with or complicate certain chronic skin diseases: lupus vulgaris, chronic lupus erythematosus.

Clinical diagnosis of Bowen’s disease can be difficult. The following conditions should be considered in the differential diagnosis of cutaneous Bowen’s disease: psoriasis, lupus erythematosus, seborrheic warts, actinic keratosis, verrucous lichen planus or superficial basal cell carcinoma.

in genital Bowen’s disease, the conditions to be considered in the differential diagnosis include leukoplakia, Zoon-type inflammatory erythroplakia, Paget’s disease, lichen sclerosus or lichen planus, psoriasis and immediately invasive squamous cell carcinoma.

Histological examination of Bowen’s disease specimens shows generally typical images. They show significant alteration of the Malpighian cells that are very unequal in size and very different in structure. The same epidermal changes may also be observed in the hair follicles. From the outset, a loss of normal epithelial architecture is observed: the more numerous, more compact and darker cells are abnormally orientated and haphazardly arranged. This cellular anarchy and the atypical observations are confined to the epidermis with the basal layer of the epidermis remaining unaffected. Serial sections should be made to ensure that there is no break in the basal layer at any of the sampling points, particularly in cases of genital Bowen’s disease.

Bowen’s disease (BD), erythroplasia of Queyrat (EQ) and Bowenoid papulosis are three clinical variants of carcinoma in situ of the genital mucosa. It is currently proposed to use the terms of vulvar intraepithelial neoplasia or penile intraepithelial neoplasia (PIN) to replace the previous terms. The lack of circumcision, oncogenic HPV infection, genital lichen sclerosus are risk factors for occurrence of the three forms of PIN.

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