Bowen Disease Workup

Updated: Nov 07, 2019
  • Author: Mary V Kaldas, MD; Chief Editor: Dirk M Elston, MD  more...
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Skin biopsy

Perform a shave or punch biopsy to confirm the diagnosis of Bowen disease. Incorporating follicular structures in the biopsy material is helpful, as is sampling many areas of larger lesions to exclude evidence of invasion amounting to a cutaneous squamous cell carcinoma. These procedures are typically performed in an office setting with the patient under local anesthesia. Pathologic analyses are best completed by dermatopathologists.

Complete skin examination

Perform a total body skin examination on patients with Bowen disease on sun-exposed skin. Studies indicate a higher incidence of nonmelanoma skin cancers may exist in these patients.


Histologic Findings

Bowen disease is a full-thickness anaplasia of the epidermis, with loss of the normal maturation of its components. Keratinocytes are atypical and disorderly, often described as having a windblown appearance. Although the basal cell layer is intact, extension of keratinocyte atypia down the follicular epithelium is seen. Vacuolization, mitoses, individually keratinizing cells, and multinucleated cells are present in the epidermis. Large pale keratinocytes with abundant ground-glass cytoplasm, so-called pagetoid cells, often are distributed haphazardly throughout the epidermis. Hyperkeratosis, parakeratosis, and acanthosis are seen to some degree in lesions of Bowen disease. The upper dermis has a moderate lymphocytic infiltrate.

Neoplastic cells tend to crowd the adnexal structures. The histological and nested pattern can appear similar to clonal seborrheic keratosis. [25] They can be distinguished by negative cytokeratin 10 immunohistochemical staining in nests of atypical cells found in seborrheic keratosis. [26] Tumor cells in Bowen disease typically stain positive for p53, HPV, and high molecular weight cytokeratin (which includes cytokeratin 10). [27, 28]

Genetically, an increased expression and mutation of TP53 has been observed. In addition, lesions have been reported to have one or more deletions in the 9q markers.