Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Thomas D. Regan and Naomi Lawrence
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Bowen’s disease and erythroplasia of Queyrat (EQ) are defined as intraepidermal squamous cell carcinoma, the latter occurring on the penis. The clinical appearance is that of a sharply demarcated, erythematous plaque that is persistent and slowly enlarging. Risk factors for the development of Bowen’s disease and EQ vary according to the site of disease, but generally include sun exposure, HPV (human papilloma virus) infection, arsenic exposure, radiation exposure, and HIV or other forms of immunosuppression.
The goals of treatment in both Bowen’s disease and EQ are cure and prevention of progression to invasive squamous cell carcinoma, while maintaining function and cosmesis. Invasive transformation of EQ is more common (10%) and metastasizes earlier than Bowen’s disease (3%). Multiple treatment options are available and no one treatment is ideal for all situations. Definitive treatment is surgical excision if the lesion is small and well defined. Mohs micrographic surgery (MMS) is recommended in the treatment of larger, ill-defined lesions, especially when preservation of normal tissue is crucial, as with EQ. Surgical ablation may be achieved with electrodesiccation and curettage, cryotherapy, or laser. Non-surgical options include imiquimod cream (a topical immunomodulator), topical 5-fluorouracil (5-FU), photodynamic therapy (PDT), and radiation therapy.
Standard of care requires that a follow-up period of no less than 5 years be observed to claim clinical cure of Bowen’s disease and EQ. Therefore, the extremely brief duration of follow-up for many studies is inadequate.
Skin biopsy
Dermoscopy
Immunoperoxidase studies for human papillomavirus
Zalaudek I, Argenziano G, Leinweber B, Citarella L, Hofmann-Wellenhof R, et al. Br J Dermatol 2004; 150: 1112–16.
The small sample size limits the application of this newly described diagnostic tool.
Iftner A, Klug SJ, Garbe C, Blum A, Blum A, Stancu A, et al. Cancer Res 2003; 63: 7515–19.
The study found an odds ratio of 59 (95% confidence interval 5.4–645) for non-melanoma skin cancer in patients who were DNA positive for the high-risk mucosal HPV types 16, 31, 35, and 51.
Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. J Am Acad Dermatol 2005; 52: 997–1002.
A case series evaluating 270 cases of Bowen’s disease treated with MMS with 5-year follow-up demonstrating recurrence rates of approximately 6%. The majority of lesions treated were on the head and neck, and many were recurrent at the time of MMS.
Yasuda M, Tamura A, Shimizu A, Takahashi A, Ishikawa O. J Dermatol 2005; 32: 210–13.
A case report highlighting the importance of early and definitive treatment of EQ.
Moritz DL, Lynch WS. J Dermatol Surg Oncol 1991; 17: 374–8.
MMS is the only therapy that allows for definitive demonstration of tumor-free margins. Appropriate surgical therapy should be based on lesion size, anatomic location, and history of recurrence.
Ahmed I, Berth-Jones J, Charles-Holmes S, O’Callaghan CJ, Ilchyshyn A. Br J Dermatol 2000; 143: 759–66.
Eighty lesions were randomized to two groups, cryotherapy (n = 36) or curettage (n = 44), and followed for a median of 2 years. Curettage produced comparable cure rates with more rapid healing, less pain, and fewer complications.
Nordin P. Br J Dermatol 1999; 140: 291–3.
Three lesions treated showed no recurrence at 5-year follow-up, with good cosmetic results.
This therapy may be beneficial in areas such as the pinna that are prone to deformity after surgical excision.
Bargman H, Hochman J. J Cutan Med Surg 2003; 7: 101–5.
Only two of 26 biopsy-confirmed lesions recurred up to 10 years after treatment.
Morton C, Horn M, Keman J, et al. Arch Dermatol 2006; 142: 729–35.
Complete response rates at 1 year were highest for methyl aminolevulinate PDT at 80% (two treatments spaced 1 week apart with the methyl aminolevulinate applied for 3 hours prior to red light illumination) compared to cryotherapy at 67% (a minimum 20 second freeze/thaw cycle) and 5% 5-FU cream at 69% (4 weeks of treatment applied once a day for the first week then twice a day). Cosmetic outcomes were best after methyl aminolevulinate PDT.
International Society for Photodynamic Therapy in Dermatology, 2005. Braathen LR, Szeimies RM, Basset-Seguin N, Bissonnette R, Foley P, Pariser D, et al. J Am Acad Dermatol 2007; 56: 125–43.
A consensus article and review of the literature comparing PDT with other modalities, including 5-FU and cryosurgery. Overall, PDT was found to be equally as effective and as well, if not better, tolerated than other treatments.
Axcrona K, Brennhovd B, Alfsen GC, Giercksky KE, Warloe T. Scand J Urol Nephrol 2007; 41: 507–10.
A small sample of patients (n = 10) were treated with PDT for EQ with good cosmetic and functional outcome. A high histologic recurrence rate of 3/10 was observed.
Patel GK, Goodwin R, Chawla M, Laidler P, Price PE, Finlay AY, et al. J Am Acad Dermatol 2006; 54: 1025–32.
Seventy-three percent of patients achieved clinical remission with no recurrence at the 9-month follow-up.
A small sample size (n = 31) limits the validity of this otherwise well-controlled study.
Rosen T, Harting M, Gibson M. Dermatol Surg 2007; 33: 427–31.
Forty-two of 49 patients (86%) treated with 5% imiquimod cream once daily for a mean of 9 weeks achieved complete clinical remission at 1.5-year follow-up.
MacFarlane DF, El Tal AK. Arch Dermatol 2011; 147: 1326–7.
Thirty-one patients with SCCIS were treated with liquid nitrogen (5 second freeze/thaw × 2 cycles) followed 1 week later by a 5-days-on–2-days-off regimen of daily 5% imiquimod cream for 6 weeks. A 0% recurrence rate was reported for SCCIS after a mean follow-up of 43.5 months.
Micali G, Nasca MR, De Pasquale R. J Am Acad Dermatol 2006; 55: 901–3.
Case report of an elderly man with EQ treated with 5% imiquimod with clinical and histologically confirmed cure.
Lukas VanderSpek LA, Pond GR, Wells W, Tsang RW. Int J Radiat Oncol Biol Phys 2005; 63: 505–10.
Forty-four cases of Bowen’s disease treated with radiation therapy were reviewed, demonstrating remission in 42 patients with three recurrences at a mean follow-up period of 2.5 years. A broad range of radiation schedules were used and compared for efficacy and safety. These demonstrated no significant differences between low to medium- and high-dose radiation schedules on disease remission or recurrence.
Fader DJ, Lowe L. Dermatol Surg 2002; 28: 97–9.
Three patients showed complete resolution at 4 months, with epidermal and follicular epithelium restored 2 weeks postoperatively.
Use of the diode laser for lesions in non-glabrous skin may enhance the efficacy of the CO2 laser by targeting lesions that extend down the follicular infundibula.
Gordon KB, Roenigk HH, Gendleman M. Arch Dermatol 1997; 133: 691–3.
One patient was treated with oral isotretinoin 1 mg/kg daily and subcutaneous interferon-α2a 3 million U three times per week with no recurrence at 15 months.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Standard excision
Mohs micrographic surgery
Cryosurgery
Electrodesiccation and curettage
5-Fluorouracil
Photodynamic therapy
Imiquimod 5% cream
Radiation therapy
Laser ablation
Isotretinoin and interferon-α
