Related to this topic:  | UK GuidelinesWeblinks | Equipment | Books | Your Experience | Other resources | Glossaries
Print options: Printer friendly version of this leaflet (html)     Other options:  AddThis Social Bookmark Button (what's this?)

PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Bowen's Disease

Bowen's disease is squamous cell carcinoma in situ of the skin that was first described by John Bowen in 1912. In the past is has been thought of as indicative of underlying malignancy but more recent surveys of better methodology have suggested that it is not a paraneoplastic disease.1,2

Epidemiology

The incidence in the UK is around 14 per 100,000 per year but a study of white people from Hawaii gave 10 times that figure, presumably because of exposure to strong sunlight.3 When associated with sunlight the risk is much higher in white races. Some sources state that there is no difference in incidence between the sexes whilst others state that it is 3 times as common in women as in men. It tends to appear between the ages of 60 and 70.

Risk Factors
  • Exposure to sunlight, especially with fair skin, is a strong risk factor.
  • Exposure to inorganic arsenic is less important than it was.
  • Virus infection has been implicated, particularly human papillomavirus (usually HPV 16 but more rarely HPV 2).
  • Other chemical carcinogens and trauma have been suggested but often no specific risk factor is found.
  • Arsenic used to be found in Fowler's solution used to treat psoriasis, Gay's solution used to treat asthma, contaminated well water and some pesticides.
  • More travel to exotic locations and a shrinking ozone layer make it an increasing problem.
  • Suppression of the immune system appears to be a risk. Malignant and premalignant skin tumours are more common in patients who have received organ transplants. The risk is higher for heart recipients than kidney recipients, perhaps as they are more strongly immunosuppressed.4 The literature also contains a number of reports of Bowen's disease, quite often extensive, in patients with HIV infection.
Presentation
  • It presents as a slowly growing erythematous, patch or plaque. It is sharply demarcated, scaling or hyperkeratotic, with a pink or red surface. There may be a small erosion or it may be crusted.
  • Lesions are usually asymptomatic but can bleed. It may be a solitary or multiple lesions. Two thirds are solitary.
  • They are often found on sites exposed to sun and are commonest on the head and neck followed by the limbs but they may occur elsewhere, for example as a disorder of the vulva. When it arises on the glans penis, it is referred to as erythroplasia of Queyrat. They vary in size from a few millimetres to a few centimetres. They are rarely pigmented. Diagnosis is often delayed as it is asymptomatic and may appear similar to benign skin lesions.

BOWEN'S DISEASE (OM1211a.jpg)

A red, symmetrical, well demarcated lesion with some scaling may well not be thought of as pre-malignant.

Differential Diagnosis

A characteristic feature is that it is well demarcated.

Investigations

A shave or punch biopsy is required for histological diagnosis. Where possible include a hair follicle in the biopsy.

Management:
  • Surgical excision is usually satisfactory for small lesions not on the face or digits. Although the lesion looks clearly demarcated it may extend beyond the apparent boundary and so at least 5mm of clearance should be allowed.
  • Mohs micrographic surgery5 is excellent for larger lesion and those on the face or digits where it is important to be as sparing as possible with the extent of excision.
  • Cautery, curettage and cryotherapy may be satisfactory but they give no histological diagnosis and may fail to reach all the affected tissue.
  • Superficial x-ray treatment may be best for those unsuitable for surgery, especially with multiple lesions.
  • Topical 5 fluouracil cream may be used. It may be preceded by keratolytic or cryotherapy. It can be used under occlusion or with iontophoresis where an electrical current drives it into the tissues.6
  • Photodynamic therapy (PDT) may be valuable.7 It is gaining wider acceptance and appears better for patients who developed the disease whilst immunosuppressed for transplantation.8 It may be used for a number of other skin conditions too.9 It can be rather painful and some form of topical anaesthesia is often required.10
  • Imiquimod 5% cream appears to be an effective treatment for Bowen's disease on the lower limbs.11
Prognosis

This is excellent, especially with treatment. Untreated, 3 to 5% progress to invasive squamous cell carcinoma but metastases are rare.


Document References
  1. 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. [abstract]
  2. Jaeger AB, Gramkow A, Hjalgrim H, et al; Bowen disease and risk of subsequent malignant neoplasms: a population-based cohort study of 1147 patients. Arch Dermatol. 1999 Jul;135(7):790-3. [abstract]
  3. Reizner GT, Chuang TY, Elpern DJ, et al; 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. [abstract]
  4. Euvrard S, Kanitakis J, Pouteil-Noble C, et al; Comparative epidemiologic study of premalignant and malignant epithelial cutaneous lesions developing after kidney and heart transplantation. J Am Acad Dermatol. 1995 Aug;33(2 Pt 1):222-9. [abstract]
  5. Mooney M; Mohs Micrographic Surgery; emedicine February 2007
  6. 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. [abstract]
  7. Varma S, Wilson H, Kurwa HA, et al; Bowen's disease, solar keratoses and superficial basal cell carcinomas treated by photodynamic therapy using a large-field incoherent light source. Br J Dermatol. 2001 Mar;144(3):567-74. [abstract]
  8. Perrett CM, McGregor JM, Warwick J, et al; Treatment of post-transplant premalignant skin disease: a randomized intrapatient comparative study of 5-fluorouracil cream and topical photodynamic therapy. Br J Dermatol. 2007 Feb;156(2):320-8. [abstract]
  9. Calzavara-Pinton P, Venturini M, Sala R; Photodynamic therapy: update 2006 Part 2: Clinical results. J Eur Acad Dermatol Venereol. 2007 Apr;21(4):439-51. [abstract]
  10. Borelli C, Herzinger T, Merk K, et al; Effect of subcutaneous infiltration anesthesia on pain in photodynamic therapy: a controlled open pilot trial. Dermatol Surg. 2007 Mar;33(3):314-8. [abstract]
  11. Mackenzie-Wood A, Kossard S, de Launey J, et al; Imiquimod 5% cream in the treatment of Bowen's disease. J Am Acad Dermatol. 2001 Mar;44(3):462-70. [abstract]

Internet and Further Reading Acknowledgements EMIS is grateful to the Mentor authoring team for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 1881
Document Version: 20
DocRef: bgp1211
Last Updated: 3 Jun 2007
Review Date: 2 Jun 2009
Patient UK Current Health News








Health Matters



Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.

Advertise on this site



PS - Health and Poverty

Perhaps the biggest cause of ill health in the world is poverty. Help to Make Poverty History. For example, why not lend some of your money to disadvantaged communities to enable them to trade their way out of poverty through schemes such as Shared Interest.

See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

^ Top of Page