Background

First described by the American dermatologist John T. Bowen in 1912, Bowen disease is a squamous cell carcinoma (SCC) in situ with the potential for significant lateral spread.^[1]Larger lesions can reach several centimeters in diameter.

The image below depicts Bowen disease of the right temple.

Bowen disease right temple.

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See Nonmelanoma Skin Cancers You Need to Know, a Critical Images slideshow, to help correctly identify these lesions.

Pathophysiology

Bowen disease is a form of intraepidermal carcinoma, a malignant tumor of keratinocytes. Bowen disease may ultimately progress to an invasive squamous cell carcinoma.

Etiology

Bowen disease may arise de novo or from a preexisting actinic keratosis. The etiology is most likely multifactorial.Note the following:

Chronic UV radiation exposure: The age and sun-exposed body distribution of Bowen disease suggests the importance of chronic sun damage as a factor in the carcinogenesis of Bowen disease.^[2]
Arsenic exposure: The literature supports an association between Bowen disease and arsenic exposure, often occurring after a time lag of 10 years. The main sources of arsenic exposure include Fowler solution, a medication formerly used to treat psoriasis; Gay solution, a medication formerly used to treat asthma; contaminated well water; and certain pesticides.^{[3, 4]}
Human papillomavirus: Human papillomavirus type 16 is by far the most common subtype isolated from lesions of Bowen disease, although other subtypes, such as HPV 2, 18, 31, 33, 54, 56, 61, 62, and 73 also have been found.^{[5, 6, 7, 8]}
Immunosuppression: Immunosuppressed patients with Bowen disease are more likely to have multiple tumors and more aggressive tumors.^[9]

Other possible causes include genetic factors, trauma, other chemical carcinogens, and x-ray radiation.

US frequency

Because no national health databases collect the numbers of nonmelanoma skin cancers and because of regional differences in incidence rates, estimating the frequency of Bowen disease is difficult. In 1991, a study from Minnesota reported the annual average rate of Bowen disease as 14.9 cases per 100,000 whites.^[10]In 1994, a study from Hawaii reported a rate 10 times that, 142 cases per 100,000 whites.^[11]

Race

Bowen disease is most commonly reported in sun-exposed sites of whites. Bowen disease rarely occurs in patients with darker-pigmented skin; if it does, it usually affects nonexposed sites.^[12]

Sex

The ratio of Bowen disease is approximately equal between males and females. Bowen disease is more commonly found on the head and neck of men and on the lower limbs and cheeks of women.^[2]

Age

Bowen disease occurs in adulthood, with the highest incidence in patients older than 60 years.^[13]

Prognosis

The prognosis for Bowen disease is favorable. The majority of studies report a risk of progression to invasive SCC at 3-5%. According to a retrospective case series with multiple potential biases, of those that become invasive SCC, one third may metastasize. The risk of invasive carcinoma is estimated to be higher for genital Bowen disease or erythroplasia of Queyrat at 10%.^[14]

Much controversy surrounds whether Bowen disease is associated with internal malignancies.^{[15, 16, 17, 18, 19]}Many early papers reported such an association in 15-70% of cases. Some later reports supported an association of internal malignancies with Bowen disease that was associated with arsenic ingestion but not with Bowen disease from other causes.^[3]In 1989, a meta-analysis of 12 studies showed no significant association. The most recent population-based cohort study of 1147 Bowen disease patients in Denmark demonstrated no statistically significant increased risk of internal cancers. Currently, Bowen disease is not believed to be a paraneoplastic condition.^[19]

Patient Education

Patients with a history of Bowen disease should be counseled on safe sun behavior, to include avoiding the sun when it is most intense (between 10 am and 4 pm), wearing hats and other sun protective clothing, and using a dual-spectrum sunscreen with an SPF of 30 or higher.

For patient education resources, visit the Cancer Center and First Aid and Injuries Center. Also, see the patient education articles Skin Cancer, Skin Biopsy, and Sunburn.

Clinical Presentation

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Kossard S, Rosen R. Cutaneous Bowen's disease. An analysis of 1001 cases according to age, sex, and site. J Am Acad Dermatol. 1992 Sep. 27(3):406-10. [QxMD MEDLINE Link].
Shannon RL, Strayer DS. Arsenic-induced skin toxicity. Hum Toxicol. 1989 Mar. 8(2):99-104. [QxMD MEDLINE Link].
Hunt KM, Srivastava RK, Elmets CA, Athar M. The mechanistic basis of arsenicosis: Pathogenesis of skin cancer. Cancer Lett. 2014 Aug 27. [QxMD MEDLINE Link].
Derancourt C, Mougin C, Chopard Lallier M, Coumes-Marquet S, Drobacheff C, Laurent R. [Oncogenic human papillomaviruses in extra-genital Bowen disease revealed by in situ hybridization]. Ann Dermatol Venereol. 2001 Jun-Jul. 128(6-7):715-8. [QxMD MEDLINE Link].
McKee P, Calonje E, Granter S. Tumors of the surface epithelium. Pathology of the Skin. 3rd. London: Elsevier Mosby; 2005. 2: 1193-1197.
Shim WH, Park HJ, Kim HS, et al. Bowenoid Papulosis of the Vulva and Subsequent Periungual Bowen's Disease Induced by the Same Mucosal HPVs. Ann Dermatol. 2011 Nov. 23(4):493-6. [QxMD MEDLINE Link]. [Full Text].
Euvrard S, Chardonnet Y, Pouteil-Noble C, et al. Association of skin malignancies with various and multiple carcinogenic and noncarcinogenic human papillomaviruses in renal transplant recipients. Cancer. 1993 Oct 1. 72(7):2198-206. [QxMD MEDLINE Link].
Drake AL, Walling HW. Variations in presentation of squamous cell carcinoma in situ (Bowen's disease) in immunocompromised patients. J Am Acad Dermatol. 2008 Jul. 59(1):68-71. [QxMD MEDLINE Link].
Chute CG, Chuang TY, Bergstralh EJ, Su WP. The subsequent risk of internal cancer with Bowen's disease. A population-based study. JAMA. 1991 Aug 14. 266(6):816-9. [QxMD MEDLINE Link].
Reizner GT, Chuang TY, Elpern DJ, Stone JL, Farmer ER. Bowen's disease (squamous cell carcinoma in situ) in Kauai, Hawaii. A population-based incidence report. J Am Acad Dermatol. 1994 Oct. 31(4):596-600. [QxMD MEDLINE Link].
Gupta S, Nutan, Dogra S, Kanwar AJ. Bowen Disease over photoprotected site in an Indian male. Dermatol Online J. 2009 Oct 15. 15(10):16. [QxMD MEDLINE Link].
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[Guideline] Morton CA, Birnie AJ, Eedy DJ. British Association of Dermatologists' guidelines for the management of squamous cell carcinoma in situ (Bowen's disease) 2014. Br J Dermatol. 2014 Feb. 170(2):245-60. [QxMD MEDLINE Link].
Arbesman H, Ransohoff DF. Is Bowen's disease a predictor for the development of internal malignancy? A methodological critique of the literature. JAMA. 1987 Jan 23-30. 257(4):516-8. [QxMD MEDLINE Link].
Graham JH, Helwig EB. Bowen's disease and its relationship to systemic cancer. AMA Arch Derm. 1959 Aug. 80(2):133-59. [QxMD MEDLINE Link].
Jaeger AB, Gramkow A, Hjalgrim H, Melbye M, Frisch M. Bowen disease and risk of subsequent malignant neoplasms: a population-based cohort study of 1147 patients. Arch Dermatol. 1999 Jul. 135(7):790-3. [QxMD MEDLINE Link].
Poole S, Fenske NA. Cutaneous markers of internal malignancy. II. Paraneoplastic dermatoses and environmental carcinogens. J Am Acad Dermatol. 1993 Feb. 28(2 Pt 1):147-64. [QxMD MEDLINE Link].
Jaeger AB, Gramkow A, Hjalgrim H, Melbye M, Frisch M. Bowen disease and risk of subsequent malignant neoplasms: a population-based cohort study of 1147 patients. Arch Dermatol. 1999 Jul. 135(7):790-3. [QxMD MEDLINE Link].
Boer-Auer A, Jones M, Lyasnichaya OV. Cytokeratin 10-negative nested pattern enables sure distinction of clonal seborrheic keratosis from pagetoid Bowen's disease. J Cutan Pathol. 2012 Feb. 39(2):225-33. [QxMD MEDLINE Link].
Terada T. Pigmented Bowen disease arising in pigmented reticulated seborrheic keratosis. Int J Clin Oncol. 2010 Dec. 15(6):608-10. [QxMD MEDLINE Link].
Jung SE, Kim SK, Kim YC. Photodynamic therapy in Bowen disease of the first web space of the hand. Ann Dermatol. 2015 Feb. 27 (1):76-8. [QxMD MEDLINE Link].
Perruchoud DL, Varonier C, Haneke E, Hunger RE, Beltraminelli H, Borradori L, et al. Bowen disease of the nail unit: a retrospective study of 12 cases and their association with human papillomaviruses. J Eur Acad Dermatol Venereol. 2016 Sep. 30 (9):1503-6. [QxMD MEDLINE Link].
Saxena A, Kasper DA, Campanelli CD, Lee JB, Humphreys TR, Webster GF. Pigmented Bowen's disease clinically mimicking melanoma of the nail. Dermatol Surg. 2006 Dec. 32(12):1522-5. [QxMD MEDLINE Link].
Kalegowda IY, Böer-Auer A. Clonal Seborrheic Keratosis Versus Pagetoid Bowen Disease: Histopathology and Role of Adjunctive Markers. Am J Dermatopathol. 2017 Jun. 39 (6):433-439. [QxMD MEDLINE Link].
Boer-Auer A, Jones M, Lyasnichaya OV. Cytokeratin 10-negative nested pattern enables sure distinction of clonal seborrheic keratosis from pagetoid Bowen's disease. J Cutan Pathol. 2012 Feb. 39(2):225-33. [QxMD MEDLINE Link].
Fernandez-Flores A. Cytokeratin 17 immunoexpression in actinic keratosis (bowenoid and nonbowenoid) and in Bowen disease. Ann Diagn Pathol. 2016 Feb. 20:1-6. [QxMD MEDLINE Link].
Idriss MH, Misri R, Böer-Auer A. Orthokeratotic Bowen disease: a histopathologic, immunohistochemical and molecular study. J Cutan Pathol. 2016 Jan. 43 (1):24-31. [QxMD MEDLINE Link].
Bargman H, Hochman J. Topical treatment of Bowen's disease with 5-Fluorouracil. J Cutan Med Surg. 2003 Mar-Apr. 7(2):101-5. [QxMD MEDLINE Link].
Fulton JE Jr, Carter DM, Hurley HJ. Treatment of Bowen's disease with topical 5-fluorouracil under occlusion. Arch Dermatol. 1968 Feb. 97(2):178-80. [QxMD MEDLINE Link].
Sturm HM. Bowen's disease and 5-fluorouracil. J Am Acad Dermatol. 1979 Dec. 1(6):513-22. [QxMD MEDLINE Link].
Welch ML, Grabski WJ, McCollough ML, et al. 5-fluorouracil iontophoretic therapy for Bowen's disease. J Am Acad Dermatol. 1997 Jun. 36(6 Pt 1):956-8. [QxMD MEDLINE Link].
Mackenzie-Wood A, Kossard S, de Launey J, Wilkinson B, Owens ML. Imiquimod 5% cream in the treatment of Bowen's disease. J Am Acad Dermatol. 2001 Mar. 44(3):462-70. [QxMD MEDLINE Link].
van Egmond S, Hoedemaker C, Sinclair R. Successful treatment of perianal Bowen's disease with imiquimod. Int J Dermatol. 2007 Mar. 46(3):318-9. [QxMD MEDLINE Link].
Alessi SS, Sanches JA, de Oliveira WR, Messina MC, Pimentel ER, Festa Neto C. Treatment of cutaneous tumors with topical 5% imiquimod cream. Clinics (Sao Paulo). 2009. 64(10):961-6. [QxMD MEDLINE Link]. [Full Text].
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Fernandez-Vozmediano J, Armario-Hita J. Infiltrative squamous cell carcinoma on the scalp after treatment with 5% imiquimod cream. J Am Acad Dermatol. 2005 Apr. 52(4):716-7. [QxMD MEDLINE Link].
Dupree MT, Kiteley RA, Weismantle K, Panos R, Johnstone PA. Radiation therapy for Bowen's disease: lessons for lesions of the lower extremity. J Am Acad Dermatol. 2001 Sep. 45(3):401-4. [QxMD MEDLINE Link].
Anna Z, John K, Maria T, et al. The potential role of radiation therapy in Bowen's disease: a review of the current literature. Rev Recent Clin Trials. 2012 Feb. 7(1):42-6. [QxMD MEDLINE Link].
[Guideline] Braathen LR, Szeimies RM, Basset-Seguin N, et al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. International Society for Photodynamic Therapy in Dermatology, 2005. J Am Acad Dermatol. 2007 Jan. 56(1):125-43. [QxMD MEDLINE Link].
Jones CM, Mang T, Cooper M, Wilson BD, Stoll HL Jr. Photodynamic therapy in the treatment of Bowen's disease. J Am Acad Dermatol. 1992 Dec. 27(6 Pt 1):979-82. [QxMD MEDLINE Link].
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Tantikun N. Treatment of Bowen's disease of the digit with carbon dioxide laser. J Am Acad Dermatol. 2000 Dec. 43(6):1080-3. [QxMD MEDLINE Link].
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Media Gallery

Squamous cell carcinoma in situ, Bowen disease. Courtesy of Hon Pak, MD.
Bowen disease right temple.
Erythroplasia of Queyrat, squamous cell carcinoma in situ of the glans penis.

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Author

Mary V Kaldas, MD Resident Physician in Anatomic Pathology, National Institutes of Health

Disclosure: Nothing to disclose.

Coauthor(s)

Mark P Eid, MD Founder and Director, Virginia Dermatology and Skin Surgery Center

Mark P Eid, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Kelly M Cordoro, MD Assistant Professor of Clinical Dermatology and Pediatrics, Department of Dermatology, University of California, San Francisco School of Medicine

Kelly M Cordoro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Medical Society of Virginia, Society for Pediatric Dermatology, Women's Dermatologic Society, Association of Professors of Dermatology, National Psoriasis Foundation, Dermatology Foundation

Disclosure: Nothing to disclose.

Bryan E Anderson, MD Associate Professor, Department of Dermatology, Pennsylvania State University College of Medicine

Bryan E Anderson, MD is a member of the following medical societies: American Academy of Dermatology, Pennsylvania Medical Society, American Contact Dermatitis Society

Disclosure: Nothing to disclose.

Acknowledgements

Theresa Dressler Conologue, DO, FAAD Physician, Department of Dermatology, Geisinger Medical Center

Disclosure: Nothing to disclose.

Carrie A H Hall, MD Resident Physician, National Capital Consortium Dermatology Residency Program, National Naval Medical Center

Disclosure: Nothing to disclose.

Mark L Welch, MD Clinical Assistant Professor, Department of Dermatology, Howard University; Assistant Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

Disclosure: Nothing to disclose.