Bowens Disease and Erythroplasia of Queyrat

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Bowen's disease (BD) is squamous cell carcinoma (SCC) in situ most often caused by chronic solar damage. Therefore, lesions are found most often on the dorsal hands and forearms, neck, ears, bald scalp, and face. HPV also has been documented as a cause of BD, especially HPV-16. Inorganic arsenic ingestion, radiation dermatitis (x-ray damage), immunosuppression or HIV, burn scars, and chronic ulcers are also associated with BD.

Bowen's disease often presents with an asymptomatic, slowly enlarging, erythematous, scaly patch on the skin that mimics an eczematous dermatitis (Fig. 33-79). The head and neck are most frequently affected, followed by the extremities. As they enlarge, lesions may become hyperkeratotic, crusted, fissured, or ulcerated. When BD occurs on mucous membranes, it is a white, red, or erosive patch. SCC in situ on the penis is referred to as penile intraepithelial neoplasia (erythroplasia of Queyrat).

Treatment of BD depends on the location, size, number of lesions, clinician's expertise, patient factors (age, immune status, concomitant medication, comorbidities, compliance), cosmetic outcome, and patient preference. For the trunk or extremities, electrodesiccation and curettage (ED&C) is practical. Cryotherapy is also an option but often results in poorer wound healing. One prospective study suggests a superiority of ED&C over cryotherapy in treating BD, especially for lesions on the lower leg. Curettage was associated with a significantly shorter healing time, less pain, fewer complications, and a lower recurrence rate (Ahmed et al., 2000).

Erythroplasia Queyrat Pictures

Figure 33-80 Nodular basal cell carcinoma on nasal ala. © RichardP. Usatine.)

Erythroplasia Queyrat

Figure 33-79 Bowen's disease (squamous cell carcinoma in situ) on arm.

Figure 33-79 Bowen's disease (squamous cell carcinoma in situ) on arm.

For larger or poorly defined lesions, topical therapy with 5-FU or imiquimod can be used, working best when the patient can see and reach the lesion. In a randomized, double-blind, placebo-controlled trial of imiquimod daily for 16 weeks, 9 of 12 patients (75%) in the imiquimod group and none in the placebo group had complete clearance of BD, with no recurrence in the 9-month follow-up (Patel et al., 2006). Lesions can also be excised with 4-mm margins or referred for Mohs micrographic surgery when tissue sparring is crucial. Mohs surgery is recommended for BD at sites such as digits or penis, where it is important to limit removal of unaffected skin. It is also useful for poorly defined or recurrent head and neck BD (Cox et al., 2007). Excision should be an effective treatment with low recurrence rates, but the limited evidence cannot address specific lesion sites (Cox et al., 2007).

The overall risk of progression of BD to invasive cancer is about 3% to 5%, However, risk is greater for patients with oral and genital lesions (about 10%), as well as those with a history of arsenic exposure or lesions located in a chronic scar or ulcer.

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