|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 97-98
Multiple Bowen's disease over the right gluteal region in a middle-aged male
Mukunda Ranga Swaroop1, Shravandanahalli N Manas1, Kuchangi C Nischal2, Belagola D Sathyanarayana1, Haleuoor B Basavaraj1
1 Department of Dermatology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, India
2 Consultant Dermatologist, Nirmal Skin and Hair Clinic, Vijaynagar, Bangalore, Karnataka, India
|Date of Web Publication||18-Dec-2014|
Mukunda Ranga Swaroop
Department of Dermatology, Adichunchanagiri Institute of Medical Sciences, BG Nagara
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Swaroop MR, Manas SN, Nischal KC, Sathyanarayana BD, Basavaraj HB. Multiple Bowen's disease over the right gluteal region in a middle-aged male. Indian J Dermatopathol Diagn Dermatol 2014;1:97-8
|How to cite this URL:|
Swaroop MR, Manas SN, Nischal KC, Sathyanarayana BD, Basavaraj HB. Multiple Bowen's disease over the right gluteal region in a middle-aged male. Indian J Dermatopathol Diagn Dermatol [serial online] 2014 [cited 2020 Oct 28];1:97-8. Available from: https://www.ijdpdd.com/text.asp?2014/1/2/97/147318
Bowen's disease (BD) is a rare, progressive, intraepithelial carcinoma, first described by John Bowen in 1912.  The risk of transformation to squamous cell carcinoma is about 8%.
A 45-year-old male farmer presented with multiple painful raised lesions over the right lower back and right buttock since 1 year. There was no history of contact with fungicides, weed killers, or pesticides. Cutaneous examination revealed four tender, well-defined plaques with irregular erythematous margins distributed over the right gluteal region. There was thick adherent scale and crusting over these plaques [Figure 1]. There was no regional lymphadenopathy.
|Figure 1: Four well-defined, indurated, tender plaques with irregular erythematous margins seen over the right gluteal region. There was thick adherent scale and crusting over these plaques|
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Routine investigations were within normal limits and patient was seronegative for HIV. Punch biopsy from the center of the largest plaque revealed an irregularly acanthotic epidermis with mild nuclear pleomorphism, loss of normal architecture, scattered dyskeratotic keratinocytes, and multinucleated giant cells with varying degree of mitoses with intact basement membrane. Diagnosis of BD was confirmed. Patient was referred to a surgeon who performed complete excision with wide margin and skin grafting for the largest plaques. Excision biopsy revealed marked acanthosis of epidermis, atypical cells with hyperchromatic nuclei, loss of polarity, and focal area of invasion of these pleomorphic cells into the dermis [Figure 2] and [Figure 3], suggesting progression to squamous cell carcinoma.
|Figure 2: Excisional biopsy reveals parakeratosis, irregular acanthosis, atypia, and dysplasia. There is moderately dense lymphohistiocytic infiltrate|
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|Figure 3: Large atypical cells, multinucleate giant cells, and atypical mitotic figures can be seen within the epidermal islands present in upper dermis|
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BD is a rare, premalignant progressive intraepidermal carcinoma affecting the skin and/or mucus membrane with the potential to progress to squamous cell carcinoma.  The incidence is around 1.42 per 1000 population.  It can occur at any age, but is mostly seen in elderly individuals with equal sex preponderance. Although the exact etiology is unknown, chronic sun exposure plays a major role. When lesions are seen over palms, soles, mucosae, and unexposed areas, arsenic exposure and human papilloma virus (2, 16, 18, 34, and 35) are implicated. , Clinically, it presents as a solitary, erythematous, well-demarcated, crusted, or scaly plaque.  Multiple lesions are seen in 10-20% of cases with history of arsenic exposure.  The other uncommon clinical variants are pigmented, intertriginous, verrucous, hyperkeratotic, atrophic, palmar, plantar, genital, periungal, and subungal types.  Histological examination of BD reveals hyperkeratotic epidermis with variable degree of parakeratosis. There is elongation and thickening of rete ridges. The cells throughout the epidermis lie in complete disorder resulting in a 'windblown appearance' showing atypia with large hyperchromatic nuclei. Numerous vacuolated atypical cells are especially seen in arsenical BD. The basement membrane is intact. The upper dermis shows a moderate amount of chronic inflammatory infiltrate.  Other histological variants, namely, psoriasiform, atrophic, acantholytic, epidermolytic, and pagetoid types, have also been reported. In our case, the histological findings were similar; however, excision biopsy revealed focal area of invasion of the pleomorphic cells to the dermis, thereby indicating progression toward squamous cell carcinoma. On dermoscopy, BD reveals glomerular vessels (coiled vessels), scaly surface, and linear arrangement of brown or gray dots (pigmented variant).  Based on the above-discussed clinical and histopathological findings, we arrived at the diagnosis and thereby excluded conditions like herpetic granuloma, botryomycosis, psoriasis, seborrheic keratosis, dermatophytic granuloma, and lupus vulgaris. The progression of Bowen's to squamous cell carcinoma is 3-10% and the average duration is 3-6 years. However, in our patient, it had progressed within 1 year.  Various treatment modalities are surgical excision, Moh's micrographic surgery, cryotherapy, curettage, cautery, chemotherapy with topical 5-fluorouracil, 5% imiquimod cream, lasers (CO 2 laser, Er: YAG ablative fractional laser), radiotherapy, and more recently, photodynamic therapy with a topical photosensitizer d-aminolevulinic acid. In our patient, surgical excision with wide margin was performed. It has a recurrence rate of 10-15%. 
We hereby are reporting this case for multiplicity of lesions, presence in sun-protected area, unusual site, and rapid progression to squamous cell carcinoma, with no evidence of immunosuppression and arsenic exposure.
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[Figure 1], [Figure 2], [Figure 3]