Bowen Disease

Background

• Bowen disease, or squamous cell carcinoma in situ (SCCis), is a nonmelanoma skin cancer confined to the epidermis. This topic covers SCCis of nongenital sites.
  • For suspected SCCis localized to the vulva, see Vulvar intraepithelial neoplasia (VIN).
  • For suspected squamous cell carcinoma in situ of the penis, see Squamous cell carcinoma of penis.
  • For suspected anal intraepithelial neoplasia, see Anal cancer.
• Bowen disease is usually the result of damage due to chronic sun or other carcinogenic exposure such as human papillomavirus (HPV).
• Older patients, patients with fair skin or hair, or chronic exposure to ultraviolet (UV) light or immunosuppression, and patients who live in sunny climates or near the equator appear at increased risk for Bowen disease.
• Prognosis is very good with only 3%-5% of Bowen disease lesions progressing to invasive squamous cell carcinoma (SCC).

Evaluation

• Suspicious lesions are usually flat and erythematous with a white/yellow crusted surface, and often appear on sun-exposed skin, though it can appear in non-sun-exposed areas.
• Diagnosis is usually made by close, visual examination, but histopathological evaluation of excised lesion or biopsy that includes full-depth epidermis and dermis is required for diagnostic confirmation, and to rule out invasive squamous cell carcinoma (SCC).

Management

• The goal of treatment is complete removal or destruction of the lesion to prevent invasive squamous cell carcinoma and metastases while achieving an acceptable cosmetic outcome.
• Treatment choice is influenced by size, number, and location of lesions and effect of treatment on function and cosmetics.
• For a single or a few, small (< 2 cm) lesions in areas that heal well, consider curettage, although cryotherapy, surgical excision, or 5-Fluorouracil (5-FU) are also commonly used, and photodynamic therapy (PDT) or imiquimod are other options.
• For large, single lesions, or multiple lesions in areas that heal well, consider PDT ; alternatively, 5-FU, imiquimod, or cryotherapy may be used.
• For lesions in areas that heal poorly, consider 5-FU, imiquimod, or PDT.
• For high-risk lesions, such as lesions on eyelids, lips, central face, genitalia, hands, or feet or large lesions (> 10 mm on cheeks, forehead, scalp, neck, and pretibial sites, or > 20 mm on trunk or extremities), consider Mohs micrographic surgery.
• For patients with large lesions who are unwilling or unable to tolerate surgery, consider radiation therapy.
• For organ transplant patients or patients with field cancerization, consider field-directed therapy using PDT or topical medication, such as 5-FU or imiquimod.