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History
A 74-year-old woman presents with a 1-year history of a lesion on the dorsum of her middle finger. This has gradually increased in size over the last 12 months and is asymptomatic. Previously she had a similar lesion on her left leg, which had been treated successfully 18 months ago. She lived abroad as a child and is a keen gardener. She is otherwise well and takes 75 mg aspirin daily.
Examination
There is an erythematous plaque 1 cm in size with overlying scale on the dorsum of her middle finger, the surrounding skin being normal (Fig. 54.1).
Questions
• What are the differential diagnoses?
• How would you confirm the diagnosis?
• What are the options for treatment?
Medicine
This elderly patient has had significant sun exposure in childhood and now enjoys out-door activities. The lesion is on a sun-exposed site and has grown slowly. The diagnosis is Bowen’s disease – squamous cell carcinoma (SCC) in situ. She has had a similar lesion previously. The history of a solitary erythematous plaque with overlying scale on the dorsum of the finger led to a suspicion of Bowen’s disease, which was confirmed by tak-ing a biopsy for histopathological analysis.
Bowen’s disease appears as a sharply, demarcated, erythematous, patch or plaque with overlying hyperkeratosis. These lesions occur most commonly on the legs of older woman, but also occur on other sun-exposed sites such as the face, ears and the dorsi of the hands. Bowen’s disease is a pre-malignant condition, hence the term SCC in situ. A SCC is a cancer derived from squamous cells. These are cells that make up the epidermis. In situ means that the malignant cells are confined to the epidermis and have therefore not invaded deeper. A change in the appearance of Bowen’s disease such as development of a nodule can indicate progression into an invasive SCC. Bowen’s disease occurs in aging skin. It may be caused by ultraviolet irradiation or human papillomavirus (HPV) infection. HPV-induced Bowen’s disease occurs mostly in the genital sites but may also appear periungally. Differential diagnoses include discoid eczema, psoriasis, viral warts, seborrhoeic keratoses, actinic keratoses, superficial basal cell carcinoma and extramammary Paget’s disease. Histolopathology shows full-thickness change of the epidermis with loss of the normal maturation keratinocytes. Treatments include topical chemotherapy with 5-fluorouracil cream and imiquimod. Cryotherapy with liquid nitrogen is very effective. Photodynamic therapy (PDT) refers to treatment with a photosensitizer that is applied topically to the affected area prior to exposing it to a strong source of visible light. Other destructive methods include curet-tage and cautery.
KEY POINTS
• Bowen’s disease occurs on sun-exposed skin sites in the elderly.
• Patches are well demarcated, erythematous and hyperkeratotic.
• Bowen’s disease is squamous cell carcinoma in situ.
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