Bowen’s disease

Latest update 05/08/11

This chapter is divided as follows:

• Aetiology
• History
• Clinical findings
• Investigations
• Management

Aetiology

• An intra-epidermal (in situ) squamous cell carcinoma of the skin
• More common in women
• The main cause is UVR
• Patient with fair skin, blue eyes and blond hair are more at risk
• The rate of transformation in to invasive SCC is approximately 3-5%. The risk is particularly high for Bowen’s disease of the penis (Erythroplasia of Queryat)

History 

• Can be single or multiple
• Lesions are reported as being very slow growing and generally asymptomatic

Clinical findings

• Distribution
  • Sun exposed sites predominate, especially lower legs in woman
• Appearance
  • Well-defined pink and scaly patches or plaques. They tend to have little substance and have finer scale than AK
  • As lesions grow they may become crusty, fissured or ulcerated
• Dermoscopy
  • Erythema, keratin, relatively uniform arrangement of glomerular vessels  

Investigations

• A punch biopsy is only needed if there are diagnostic uncertainties

Step 1 - general       

 Step 2 - first line treatments (primary care)

• Either of the following is appropriate for most lesions:
  • A single freeze-thaw cycle with liquid nitrogen for 20-30 seconds - avoid in the gaiter area of the leg and others areas of poor skin healing. For larger patches treatment may be better tolerated if the half of the lesion is treated initially and the other half 6-8 weeks later
  • Efudix ® cream (5-FU cream) can be used once a night for four weeks. Hands should be washed thoroughly after application. The treated area must be left uncovered and washed the following morning. Warn the patient to expect some redness, crusting and mild discomfort. After four weeks stop the treatment and use Eumovate ® cream BD for 2-4 weeks to help settle down any inflammation 

Step 3 - second line treatments

• Photodynamic therapy (where available) - can be very useful for large and multiple lesions

Step 4 - follow up

• Patients should be followed up 3 months later to make sure the lesion has resolved. It is common to find smooth patches of post-inflammatory hyperpigmentation, especially on the lower legs

Please click on the following link - 'Guidelines for the Managament of Bowen's Disease' for more in-depth guidelines

	Figure 1 – Bowen’s disease of the thigh Patches of Bowen’s disease can become very large. This measured 8 cm and was treated by photodynamic therapy
	Figure 2 – Bowen’s disease of the calf A common site
	Figure 3 – Bowen’s disease
	Figure 4 – Dermoscopic view of figure 3 Dermoscopy can reveal groups of glomerular-like vessels
	Figure 5 – Bowen’s disease The scale was removed from this lesion to make certain that there was not an indurated area lurking underneath. Where any doubt exists about the diagnosis histology is needed to rule out an SCC or alternative diagnosis. Excision biopsies are preferable, if practical.
	Figure 6 – Dermoscopic view of figure 5  Groups of glomerular-like vessels. Yellow keratin.
	Figure 7 – Bowen’s disease with atypical pigmentation
	Figure 8 – Dermoscopic view of figure 7 Given the abnormal pigmentation the lesion was fully excised to confirm the diagnosis
	Figure 9 - Bowen's disease post-treatment It is quite common, especially on the lower legs for areas of post-inflammatory hyperpigmentation to remain for many months after treatment. In this patient two lesions had been treated with Efudix (black arrows). The skin is smooth as opposed to the rough feel of Bowen's. The patient can be reassured