A 76-year-old woman who resides in an extended-care facility presents with a several-month history of rash involving her right buttock. The rash has not responded to therapy with topical ketoconazole and triamcinolone creams. The patient is moderately obese and has diabetes. Her medical history is negative for skin cancer, psoriasis, and eczema. Physical examination reveals a well-demarcated, slightly indurated erythematous plaque. Inguinal nodes are nonpalpable.
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Bowen disease was first described in 1912 by the American dermatologist Thomas Bowen. Cutaneous lesions present as well-demarcated, scaly, erythematous patches, and therefore, the differential diagnosis should include psoriasis and eczema.
The most common sites are the head, neck, and extremities. Peak incidence is in the sixth to eighth decades of life, and the condition usually affects fair-skinned individuals. Chronic ultraviolet light exposure often plays a role in the pathogenesis of Bowen disease.
Bowen disease is an intra-epidermal squamous cell carcinoma in situ. The risk for invasive carcinoma developing is 3% to 5% in extragenital lesions and 10% in genital lesions.1 Bowen disease was first linked with internal malignancy in 19592; however, the association is tenuous and has been disputed by more robust studies.3-5
If untreated, the lesions of Bowen disease persist and progress gradually. As exemplified by the patient in our case, the rash can attain a size of several centimeters. Surgical excision, when feasible, is the preferred therapy.6-8 High cure rates can also be achieved using curettage and electrodessication, cryotherapy, or radiation. Topical therapy with imiquimod or 5-fluorouracil is appropriate for suitable patients, although both agents can cause severe localized inflammatory reactions.
Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.
- Cox NH, Eedy DJ, Morton CA. Guidelines for management of Bowen’s disease. British Association of Dermatologists. Br J Dermatol. 1999;141(4):633-641.
- Graham JH, Helwig EB. Bowen’s disease and its relationship to systemic cancer. AMA Arch Dermatol. 1959;80(2):133-159.
- Arbesman H, Ransohoff DF. Is Bowen’s disease a predictor for the development of internal malignancy? A methodological critique of the literature. JAMA. 1987;257(4):516-518.
- Lycka BA. Bowen’s disease and internal malignancy. A meta-analysis. Int J Dermatol. 1989;28(8):531-533.
- Jaeger AB, Gramkow A, Hjalgrim H, Melbye M, Frisch M. Bowen disease and risk of subsequent malignant neoplasms: a population-based cohort study of 1,147 patients. Arch Dermatol. 1999;135(7):790-793.
- Ferrandiz L, Ruiz-de-Casas A, Trakatelli M, et al. Assessing physicians’ preferences on skin cancer treatment in Europe. Br J Dermatol. 2012;167 (Suppl 2):29-35.
- Neubert T, Lehmann P. Bowen’s disease—a review of newer treatment options. Ther Clin Risk Manag. 2008;4(5):1085-1095.
- 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;170(2):245-260.