eMedicine Specialties > Dermatology > Viral Infections

Bowenoid Papulosis

Edward A DiPreta, MD, Dermatologist, Brunswick Dermatology
Kurt Maggio, MD, Director of Dermatologic Surgery and Cutaneous Oncology, Assistant Chief, Department of Dermatology, Walter Reed Army Medical Center

Updated: Dec 8, 2008

Introduction

Background

Originally described in 1977 by Kopf and Bart as papules on the penis, bowenoid papulosis (BP) now is known to occur on the genitalia of both sexes in sexually active people. Bowenoid papulosis is manifested as papules that are induced virally by human papillomavirus (HPV) and demonstrate a distinctive histopathology (bowenoid dysplasia). Many of the lesions appear to run a benign course, although a number of case reports associate bowenoid papulosis with malignant invasive transformation (2.6%).

Bowenoid papulosis may be considered to be a transitional state between a genital wart and Bowen disease. The rate of transformation is unknown. Clearly, lesions have some malignant potential, but they may be treated with locally destructive modalities, sparing the surrounding tissues. The lesions often are multifocal, and patients should be observed for recurrence and for the possibility of invasive or in situ malignancy.

The Medscape HPV and Cervical Cancer Resource Center may be of interest.

Pathophysiology

Bowenoid papulosis is a focal epidermal hyperplasia and dysplasia induced by HPV infection (most commonly by HPV 16). The result is a papule demonstrating scattered atypical cells or full-thickness epidermal atypia that some view as analogous to squamous cell carcinoma in situ. This epidermal atypia is sometimes known as bowenoid dysplasia.

Frequency

United States

Bowenoid papulosis lesions are related clinically to genital warts. They share the same age of onset in patients and are transmitted sexually. Since bowenoid papulosis lesions frequently are treated destructively as warts and without histopathologic examination, the true frequency of bowenoid papulosis is unknown but is believed to be underestimated. With locally destructive therapy, the risk of invasive carcinoma appears to be low.

Mortality/Morbidity

Cervical lesions are associated with an increased incidence of abnormal cervical smears. Although bowenoid papulosis has a low rate of developing invasive characteristics (2.6%), yearly serial examinations are recommended because of the possibility of recurrence.

Race

Bowenoid papulosis affects all races equally.

Sex

The male-to-female ratio is equal.

Age

The disease occurs primarily in young, sexually active adults, with a mean age of 31 years.

Clinical

History

Bowenoid papulosis typically occurs in young sexually active persons. The disease tends to be benign with spontaneous regression occurring within several months. A more protracted course is believed to occur in older patients and, possibly, with lesions consistent with certain HPV types. These lesions may last as long as 5 years, or they may never regress completely. The lesions tend to be asymptomatic but can be inflamed, pruritic, or painful.

Physical

Bowenoid papulosis presents as solitary or multiple, small, pigmented (red, brown, or flesh-colored) papules with a flat-to-verrucous surface. The lesions can coalesce into larger plaques. Lesions occur most commonly on the shaft of the penis or the external genitalia of females, although they can occur anywhere on the genitalia and in the perianal region. Of note, 6 cases of nongenital bowenoid papulosis have been reported.¹

Causes

HPV, particularly HPV 16, has been linked closely to bowenoid papulosis. Other HPV types implicated include 18, 31, 32, 33, 34, 35, 39, 42, 48, 51, 52, 53, and 54. Consequently, the risk of acquiring bowenoid papulosis is identical to that for other genital HPV-associated conditions via sexual contact or, possibly, via vertical transmission from mother to newborn.

Differential Diagnoses

Bowen Disease	Squamous Cell Carcinoma
Lichen Planus	Warts, Genital
Molluscum Contagiosum	Warts, Nongenital
Seborrheic Keratosis	Warty Dyskeratoma

Workup

Laboratory Studies

Select a typical bowenoid papulosis lesion for cutaneous biopsy, and send it for routine histologic evaluation.
White vinegar (5% acetic acid) application may make subclinical bowenoid papulosis lesions visible within 5-10 minutes.

Other Tests

HPV subtyping is not performed routinely. If subtyping the lesion is considered necessary, this can be accomplished via Southern blot hybridization, dot blot hybridization, reverse blot hybridization, or polymerase chain reaction.

Histologic Findings

Histopathologic findings with routine hematoxylin and eosin stain vary from those of a genital wart with buckshot atypica to full-thickness epidermal atypia. This is characterized by a circumscribed epidermal proliferation composed of pleomorphic cells with clumped nuclei and numerous occasionally abnormal mitoses. The integrity of the dermal-epidermal border is preserved. The pattern occasionally has been described as windblown and may be identical to Bowen disease or squamous cell carcinoma in situ, occurring on nongenital skin.

Treatment

Medical Care

The most effective treatment for bowenoid papulosis is simple local destruction of the lesions. Various modalities have been used, although recurrences are common with all. The modalities include simple local excision, electrodesiccation, cryosurgery, laser surgery, and use of topical retinoic acid, podophyllum resin, and topical 5-fluorouracil.
Immunomodulators have been reported as effective treatment for bowenoid papulosis and may lengthen the remission period of lesions. Among immunomodulators, 2 of the agents include imiquimod 5% and interferon.^2,3,4,5 Application of interferon beta may decrease the relapse rate by reducing transcription of viral RNA oncogenes E6 and E7.

Consultations

Dermatologist: Reexamine lesional skin serially every 3-6 months because of the possibility of transformation to Bowen disease or invasive squamous cell carcinoma. The risk of transformation is higher in patients who are immunocompromised and in elderly patients.
Gynecologist: Female patients and women who have had sexual relations with male patients should be seen for a thorough cervical examination because of the increased risk of malignancy.
Urologist: Patients with urethral involvement should consider receiving an examination by a urologist.
Proctologist: Patients with perianal involvement should consider scheduling an examination with a proctologist.

Activity

Condom use may decrease the risk of transmission.
Patients with HPV infection may be lifelong carriers of the virus. Partners should have regular evaluations. Female partners should be evaluated regularly using Papanicolaou smears.
In male partners, periodic anogenital examination may be of benefit.

Medication

Destruction of the lesion is the treatment of choice. Most medications act to some degree as both destructive and immunomodulating agents.

Keratolytic agents

Inhibit cell proliferation by blocking the progression of the cell cycle at specific stages.

Podophyllum resin (Pod-Ben, Podocon-25, Podofin)

Topical treatment for benign growths including external genital and perianal warts, papillomas, and fibroids.
Arrests mitosis in metaphase; active agent is podophyllotoxin; type of podophyllum resin used determines strength. American podophyllum contains one fourth of the amount reported by an Indian source.

Dosing

Adult

Apply 10-25% concentration sparingly (1 drop at a time) onto lesions weekly (variations exist on frequency of treatment), allow drying between drops until area is covered
Treat only intact lesions; wash treatment area 1-2 h after first application; in subsequent treatments, patient can wait 4-6 h before washing off agent

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; diabetes; impaired peripheral circulation; avoid use on mucous membranes, eyes, bleeding warts, moles, birthmarks, or unusual warts with hair

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Powerful caustic and severe irritant; do not use if surrounding tissue is swollen or irritated; 25% solution should not be applied near mucous membranes; do not use large amounts; avoid contact with cornea; systemic absorption of large quantities has resulted in toxicity, particularly polyneuritis, paralytic ileus, thrombocytopenia, and leukopenia; histologic changes can be noted in squamous cells, which can be misread as squamous cell carcinoma

Trichloroacetic acid (Tri-Chlor)

Cauterizes skin, keratin, and other tissues. Although caustic, causes less local irritation and systemic toxicity than others in the same class; however, response often is incomplete and recurrence occurs frequently.

Dosing

Adult

Apply 25-50% topical liquid to lesion, wash off in 1-2 h; avoid uninvolved skin; can be used in anal areas; repeat q1-2wk

Pediatric

Not established

Interactions

Topical medications that are irritants

Contraindications

Documented hypersensitivity; premalignant or malignant lesions

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

External use only; restrict use to treatment areas only; may cause pain, burning, erythema, and erosion

Imiquimod (Aldara)

Induces secretion of interferon alpha and other cytokines; mechanisms of action are unknown.

Dosing

Adult

Apply overnight for 3 nights per wk; wash off in 6-10 h

Pediatric

Not established

Interactions

Topical medications that are irritants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal HPV infection; following surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed; may cause local irritation and erythema

5-Fluorouracil cream (Efudex, Adrucil, Fluoroplex)

For treatment-resistant bowenoid papulosis. Interferes with DNA synthesis by blocking the methylation of deoxyuridylic acid, and inhibits thymidylate synthetase, which subsequently reduces cell proliferation.

Dosing

Adult

Apply 5% cream overnight qwk for up to 10 wk; adjust dose in patients tolerant to skin irritation

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; potentially serious infections

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Protect sensitive areas (eg, vulva, urethra, anus) using petroleum, zinc oxide, or 0.5% hydrocortisone as needed; inflammatory reactions may occur with occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction; may cause pain, burning, erythema, and erosions

Follow-up

Further Inpatient Care

Bowenoid papulosis may show malignant change; therefore, follow-up treatment is warranted every 3-6 months if the lesions recur or do not resolve.

Further Outpatient Care

Perform serial examinations.

Deterrence/Prevention

Advise patients to avoid direct contact with lesions.
Advise patients to seek prompt treatment.

Complications

Bowenoid papulosis has an increased potential to cause cervical neoplasia, vulvar neoplasia, Bowen disease, and invasive squamous cell carcinoma.

Prognosis

Prognosis is variable. Younger patients tend to have a self-limiting course lasting months. Patients who are older or immunocompromised can have a protracted course lasting years and, possibly, no resolution.

Patient Education

Educate patients regarding the malignant potential of bowenoid papulosis and the avoidance of direct sexual contact to decrease transmission of the disease.

Miscellaneous

Medicolegal Pitfalls

Failure to refer female patients with BP for appropriate gynecologic examination
Failure to counsel patients regarding the sexual transmission and malignant potential of this condition

Multimedia

Media file 1: Bowenoid papulosa histopathology (hematoxylin and eosin, magnification 40X).

Media file 2: Bowenoid papulosa histopathology (hematoxylin and eosin, magnification 400X).

Media file 3: Typical appearance of bowenoid papulosis in the female.

References

Johnson TM, Saluja A, Fader D, Blum D, Cotton J, Wang TS, et al. Isolated extragenital bowenoid papulosis of the neck. J Am Acad Dermatol. Nov 1999;41(5 Pt 2):867-70. [Medline].
Goorney BP, Polori R. A case of Bowenoid papulosis of the penis successfully treated with topical imiquimod cream 5%. Int J STD AIDS. Dec 2004;15(12):833-5. [Medline].
Lucker GP, Speel EJ, Creytens DH, van Geest AJ, Peeters JH, Claessen SM, et al. Differences in imiquimod treatment outcome in two patients with bowenoid papulosis containing either episomal or integrated human papillomavirus 16. J Invest Dermatol. Mar 2007;127(3):727-9. [Medline].
Orengo I, Rosen T, Guill CK. Treatment of squamous cell carcinoma in situ of the penis with 5% imiquimod cream: a case report. J Am Acad Dermatol. Oct 2002;47(4 Suppl):S225-8. [Medline].
Ricart JM, Cordoba J, Hernandez M, Esplugues I. Extensive genital bowenoid papulosis responding to imiquimod. J Eur Acad Dermatol Venereol. Jan 2007;21(1):113-5. [Medline].
Champion RH, Burton JL, Burns DA. Rook/Wilkinson/Ebling Textbook of Dermatology. Vols 1-2. 6^th ed. London, UK: Blackwell Science; 1998:1047, 1676, 3197-8, 3233.
de Belilovsky C, Lessana-Leibowitch M. [Bowen's disease and bowenoid papulosis: comparative clinical, viral, and disease progression aspects]. Contracept Fertil Sex. Mar 1993;21(3):231-6. [Medline].
Elder D, Elenitsas R, Jaworsky C. Lever's Histopathology of the Skin. 8^th ed. Philadelphia, Pa: Lippincott-Raven; 1997:579, 584-6.
Grekin RC, Samlaska CP, Vin Christian K. Andrews Diseases of the Skin. 9^th ed. Philadelphia, Pa: WB Saunders; 2000:515.
Majewski S, Jablonska S. Human papillomavirus-associated tumors of the skin and mucosa. J Am Acad Dermatol. May 1997;36(5 Pt 1):659-85; quiz 686-8. [Medline].
Patterson JW, Kao GF, Graham JH, Helwig EB. Bowenoid papulosis. A clinicopathologic study with ultrastructural observations. Cancer. Feb 15 1986;57(4):823-36. [Medline].
Schwartz RA, Janniger CK. Bowenoid papulosis. J Am Acad Dermatol. Feb 1991;24(2 Pt 1):261-4. [Medline].
Schwartz RA, Stoll HL. Epithelial precancerous lesions. In: Freedberg IM, Fitzpatrick T, eds. Fitzpatrick's Dermatology in General Medicine. Vol 1. 5^th ed. New York, NY: McGraw-Hill; 1999:831-2.

Keywords

bowenoid papulosis, human papillomavirus, human papilloma virus, HPV, viral keratosis, bowenoid papulosis of the penis, bowenoid papulosis of the genitalia, multifocal indolent pigmented penile papules

Contributor Information and Disclosures

Author

Edward A DiPreta, MD, Dermatologist, Brunswick Dermatology
Edward A DiPreta, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: medicis Consulting fee Review panel membership

Coauthor(s)

Kurt Maggio, MD, Director of Dermatologic Surgery and Cutaneous Oncology, Assistant Chief, Department of Dermatology, Walter Reed Army Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates
Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Further Reading