Procedures

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.

Treatment & Management

Zhan W, Liao X, Tian T, Zhang RY, Li P, Wu XP, et al. Perianal multiple Bowen's disease: a case report. Int J Clin Exp Pathol. 2015. 8 (11):15039-41. [QxMD MEDLINE Link]. [Full Text].
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].
Kovacs A, Yonemoto K, Katsuoka K, Nishiyama S, Harhai I. Bowen's disease: statistical study of a 10 year period. J Dermatol. 1996 Apr. 23(4):267-74. [QxMD MEDLINE Link].
[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].
Imiquimod for superficial and in situ skin malignancy. Drug Ther Bull. 2009 Oct. 47(10):113-6. [QxMD MEDLINE Link].
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].
O'Connell KA, Okhovat JP, Zeitouni NC. Photodynamic therapy for Bowen's Disease (squamous cell carcinoma in situ) current review and update. Photodiagnosis Photodyn Ther. 2018 Dec. 24:109-114. [QxMD MEDLINE Link].
[Guideline] Christensen E, Warloe T, Kroon S, et al. Guidelines for practical use of MAL-PDT in non-melanoma skin cancer. J Eur Acad Dermatol Venereol. 2010 May. 24 (5):505-12. [QxMD MEDLINE Link].
Ferrandiz L, Ruiz-de-Casas A, Trakatelli M, et al. Assessing physicians' preferences on skin cancer treatment in Europe. Br J Dermatol. 2012 Aug. 167 Suppl 2:29-35. [QxMD MEDLINE Link].
Cleary RK, Schaldenbrand JD, Fowler JJ, Schuler JM, Lampman RM. Treatment options for perianal Bowen's disease: survery of American Society of Colon and Rectal Surgeons Members. Am Surg. 2000 Jul. 66(7):686-8. [QxMD MEDLINE Link].
Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Cutaneous squamous carcinoma in situ (Bowen's disease): treatment with Mohs micrographic surgery. J Am Acad Dermatol. 2005 Jun. 52(6):997-1002. [QxMD MEDLINE Link].
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].
Neubert T, Lehmann P. Bowen's disease - a review of newer treatment options. Ther Clin Risk Manag. 2008 Oct. 4(5):1085-95. [QxMD MEDLINE Link]. [Full Text].
Moreno G, Chia AL, Lim A, Shumack S. Therapeutic options for Bowen's disease. Australas J Dermatol. 2007 Feb. 48(1):1-8; quiz 9-10. [QxMD MEDLINE Link].
Mun JH, Park JM, Song M, et al. The use of dermatoscopy to monitor therapeutic response of Bowen disease: a dermatoscopic pathological study. Br J Dermatol. 2012 Dec. 167(6):1382-5. [QxMD MEDLINE Link].
Arnold HL, Odom RB, James WD. Bowen's disease. Arnold HL, Andrews GC, Odom RB, James WB, eds. Andrews' Diseases of the Skin. 8th ed. Philadelphia, Pa: WB Saunders; 1990. 783-5.

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.