Bowen’s disease: A favorable response to imiquimod: Through the Lens | Cutaneous Conditions | Dermatology

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  546  Indian Dermatology Online Journal - October-December 2014 - Volume 5 - Issue 4   Address for correspondence:  Dr. Joycelin Fernandes, Department of Dermatology,  Venereology and Leprology, Goa Medical College, Bambolim, Goa, India.E-mail: joycelin_fernandes@yahoo.comDepartment of Dermatology,  Venereology and Leprology, Goa Medical College, Bambolim Goa, India Bowen’s disease: A favorable response to imiquimod Prachi Barad, Joycelin Fernandes, Pankaj Shukla  A 70-year-old male having a sedentary lifestyle presented with history of a gradually increasing, single plaque over his back [Figure 1] for 20 years. There was no history of pain, ulceration, mucosal lesions, or any other skin lesions. Differential diagnoses of Bowen’s Disease (BD), lupus vulgaris, and basal cell carcinoma were considered and the patient was investigated. Investigations revealed a normal hematological work up, a negative Mantoux test and sputum for acid-fast bacilli, a normal chest radiograph and a skin biopsy consistent with BD [Figures 2 and 3]. The patient was started on imiquimod 5% cream for 5 days in a week for 12 weeks which resulted in complete resolution of the lesion clinically [Figure 4] with no adverse effects. Biopsy done six weeks after treatment revealed a normal epidermis [Figure 5]. The patient has been on regular 3-monthly follow up for the past eighteen months, with no recurrence of the lesion.BD, a form of squamous cell carcinoma in situ , was described in 1912 by John T. Bowen. The exact incidence in Indian population is not reported. In 1991, a study from Minnesota reported the annual average rate of BD as 14.9 cases per 100,000 whites. [1]  In 1994, a study from Hawaii reported a rate 10 times that, 142 per 100,000 persons. [2] BD typically presents as an asymptomatic, discrete, slowly enlarging erythematous scaly patch or plaque with well-demarcated irregular border. Hyperkeratotic, crusted, fissured, verrucous, or ulcerated surface changes may be seen. Psoriasiform, atrophic, verrucous, [3]  hypertrophic, pigmented, [4]  and irregular variants have been reported.The classic clinical history is a presentation of a chronic, slowly progressive, scaly plaque that is unresponsive to topical steroids. Ulceration is usually a sign of development of invasive carcinoma and may be delayed for many years after the appearance of intraepidermal changes.The prognosis of BD is favorable. The majority of studies place the risk of progression to invasive squamous cell carcinoma at 5%. [5]  Of those that become invasive, one-third may metastasize. [6] Access this article onlineWebsite:  www.idoj.in DOI:  10.4103/2229-5178.142570 Quick Response Code: Through the Lens Figure 1:  Plaque on the back showing erythema in places and hyperpigmentation in others, 6 × 7 cm, irregular, with rough, scaly surface with few fi ssures and well-demarcated borders in most areas, while at places its ill-de fi ned, breaking down to form another small plaque Figure 2:  Skin biopsy showing epidermal dysplasia with an intact basement membrane, and atypical keratinocytes having a windblown appearance. Hyperkeratosis, parakeratosis, and acanthosis is present with the dermis showing lymphocytic in fi ltrate consistent with the fi ndings of BD. (H and E, ×100) [Downloaded free from http://www.idoj.in on Friday, January 06, 2017, IP: 36.81.93.32]  Barad, et al. : Bowen’s disease Indian Dermatology Online Journal - October-December 2014 - Volume 5 - Issue 4    547 Because most treatments have a recurrence risk, follow-up at 6 to 12 months is recommended to evaluate for any recurrence. As BD mimics many dermatoses, a high degree of clinical suspicion is required to make a diagnosis in those dermatoses which fail to respond to conventional topical and systemic therapies. REFERENCES 1. Chute CG, Chuang TY, Bergstralh EJ, Su WP. The subsequent risk of internal cancer with Bowen’s disease. A population-based study. JAMA 1991;266:816-9.2. Reizner GT, Chuang TY, Elpern DJ, Stone JL, Farmer ER. Bowen’s disease (sqamous cell carcinoma in situ ) in Kauai, Hawaii: A population-based incidence report. J Am Acad Dermatol 1994;31:596-600.3. Grekin RC, Swanson NA. Verrucous Bowen’s disease of the plantar foot. J Dermatol Surg Oncol 1984;10:734-6.4. Ragi G, Turner MS, Klein LE, Stoll HL Jr. Pigmented Bowen’s disease and review of 420 Bowen’s disease lesions. J Dermatol Surg Oncol 1988;14:765-9.5. Kao GF. Carcinoma arising in Bowen’s disease. Arch Dermatol 1986;122:1124-6.6. Cox NH, Eedy DJ, Morton CA, Therapy Guidelines and Audit Subcommittee, British Association of Dermatologists. Guidelines for management of Bowen’s disease: 2006 update. Br J Dermatol 2007;156:11-21.7. van Egmond S, Hoedemaker C, Sinclair R. Successful treatment of  perianal Bowen’s disease with imiquimod. Int J Dermatol 2007;46:318-9.8. Moreno G, Chia AL, Lim A, Shumack S. Therapeutic options for Bowen’s disease. Australas J Dermatol 2007;48:1-8.9. Brodland DG, Zitelli JA. Surgical margins for excision of  primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992;27:241-8. Figure 5:  Posttreatment histopathology of skin showing resolution of epidermal changes with marked decrease in infiltrate in the dermis. (H and E, ×400) Figure 4:  Post treatment plaque shows complete fl attening with postin fl ammatory hyperpigmentation without any induration or scaling. Note, that the lower end shows some amount of fibrosis which represents healed sites of biopsies taken pre- and post treatment Multiple therapeutic options are available for treatment of BD, which include medical and surgical. [7]  Medical treatment includes topical chemotherapy with 5- fl uorouracil and imiquimod 5% cream, [8]  radiation therapy with X-rays or Grenz rays, and photodynamic therapy. Surgical options include simple excision with a minimum 4 mm margin around well-de fi ned tumors of less than 2 cm in diameter and wide excision with at least 6 mm margin for larger or less-differentiated tumors or tumors in high-risk locations (e.g. scalp, ears, eyelids, nose, and lips). [9]  Other surgical modalities include Mohs micrographic surgery, curettage and electrodessication, cryotherapy and laser ablation. Figure 3:  Section of skin showing atypical keratinocytes having a windblown appearance with lymphocytic in fi ltrate in the dermis suggestive of BD. (H and E, ×400) Cite this article as:  Barad P, Fernandes J, Shukla P. Bowen's disease: A favorable response to imiquimod. Indian Dermatol Online J 2014;5:546-7. Source of Support:  Nil, Con fl ict of Interest:  None declared. [Downloaded free from http://www.idoj.in on Friday, January 06, 2017, IP: 36.81.93.32]
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