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Bowen disease and erythroplasia of Queyrat
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Introduction
Bowen disease (in situ squamous cell carcinoma [in situ SCC]) and erythroplasia of Queyrat (EQ) are forms of intraepidermal squamous cell carcinoma, with the latter located on the penis. Lesions typically present as well-demarcated, erythematous, hyperkeratotic plaques with an irregular border that are persistent and slowly enlarging. Plaques of EQ develop on the glans or inner aspect of the foreskin and can be smooth, scaly or warty. Risk factors for the development of Bowen disease and EQ vary according to site, but include sun exposure, human papilloma virus infection, arsenic exposure, radiation exposure, HIV, or other forms of immunosuppression.
Diagnosis
An initial diagnostic biopsy is recommended, especially for EQ and atypical presentations of Bowen, but many dermatologists will initiate treatment of typical Bowen disease on the basis of clinical diagnosis, aided by dermoscopy.
The specific dermoscopic criteria of Bowen’s disease
Zalaudek I, Di Stefani A, Argenziano G. J Eur Acad Dermatol Venereol 2006; 20: 361–2.
Dermoscopic features include irregular clusters of coiled ‘glomerular vessels’ together with a scaly surface characteristic, with small, pigmented globules and/or homogeneous pigmentation present in pigmented variants.
Management Strategy
Curative therapy aims to prevent progression to invasive SCC. SCC arises in approximately 3–5% of typical Bowen disease and about 10% for EQ. Several treatment options are available, and evidence-based guidelines seek to balance efficacy, tolerability, and cosmesis with cost effectiveness. Sexual partners of patients with EQ should be screened for other forms of intraepithelial neoplasia caused by human papillomavirus (HPV) in the genital area.
British Association of Dermatologists’ guidelines for the management of squamous cell carcinoma in situ (Bowen’s disease) 2014
Morton CA, Birnie AJ, Eedy DJ. Br J Dermatol 2014; 170: 245–60.
Quality of evidence for reported treatments for Bowen disease and EQ was reviewed in detail. The strongest evidence was for topical photodynamic therapy (PDT), 5-fluorouracil, and imiquimod, as well as cryotherapy. Non-surgical options are increasingly used and offer advantages for large/multiple lesions. Surgical excision and curettage remain in common use, although with lower-quality evidence available. Similar therapeutic options are available for patients with EQ; however, treatment tolerability is a greater challenge.
Direct surgical excision can be considered if a lesion is small and well defined, especially if there is doubt over possible invasive SCC. Lesion ablation may also be achieved with electrodesiccation and curettage or cryotherapy. Mohs micrographic surgery (MMS) is the surgical treatment of choice in severe/recurrent cases of EQ and indicated for certain sites (e.g., digital Bowen disease) where tissue-sparing benefits are important. Laser and radiotherapy have a more limited evidence base, with poor healing reported after radiotherapy. Several treatment combinations are also reported in the literature but lack a substantial evidence base.
Interventions for cutaneous Bowen’s disease
Bath-Hextall FJ, Matin RN, Wilkinson D, et al. Cochrane Database Syst Rev 2013; 6: CD007281.
Review of interventions for SCC in situ by the Cochrane Skin Group identified nine randomized, controlled trials but noted limited data for surgery and topical therapies. Methyl-aminolevulinate–photodynamic therapy (MAL-PDT) was shown to be more efficacious than cryotherapy, but equivalent to topical 5-fluoruracil.
ALA-PDT achieved a higher clearance rate compared with 5-fluorouracil, whereas 5-fluorouracil and cryotherapy showed similar efficacy.
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