Bowen Disease and Erythroplasia of Queyrat

Bowen disease and erythroplasia of Queyrat are 2 related entities that describe squamous cell carcinoma (SCC) in situ of the skin. Bowen disease usually presents in sun-exposed areas (e.g., face and forearms) as a red, scaly skin lesion. The lesion can occur in other areas as well. The genital region, particularly the penile shaft, is also affected. When the glans penis is involved, the lesion is called erythroplasia of Queyrat, with uncircumcised males being at high risk. Both genital lesions have HPV infection as a risk factor. Pathologic findings show full-thickness atypia without basement membrane invasion. Both entities may progress to invasive SCC. Thus, local destruction via surgical excision or topical chemotherapy should be performed.

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Bowen Disease

  • Squamous cell carcinoma (SCC) in situ affecting any area of the body:
    • Represents a thin skin cancer that is localized to the epidermis
    • 3%–5% of cases progress to invasive SCC.
  • Annual incidence among white individuals is 14.9 cases per 100,000.
  • Risk factors: 
    • Sun exposure
    • Immunosuppression
    • Fair complexion
    • Smoking
    • Arsenic exposure 
    • HPV infection (type 16 is the most common)
  • Clinical presentation: 
    • Erythematous, scaly, well-demarcated patch/plaque 
    • +/- Ulcerations
    • +/- Crusting
    • Sun-exposed areas (e.g., face, neck, and forearms)
    • Can affect genital region (e.g., penile shaft)
    • Grows slowly but can present as invasive SCC
    • Usually asymptomatic
  • Diagnosis: 
    • Skin biopsy: gold standard test
    • Pathology:
      • Shows full-thickness atypia without basement membrane invasion
      • Large hyperchromatic nuclei with numerous mitoses
  • Treatment: 
    • Local excision
    • Topical chemotherapy creams: 
      • Fluorouracil
      • Imiquimod

Erythroplasia of Queyrat

  • SCC in situ (Bowen disease) of the glans penis
  • Incidence is < 1 per 100,000 males.
  • Risk factors:
    • Lack of circumcision
    • Chronic irritation (e.g., urine)
    • HPV infection: specifically high-risk HPV subtypes 16 and 18
    • Smoking
    • Immunosuppression
  • Clinical presentation: 
    • Red, well-defined velvety plaque over the glans or foreskin
    • +/- Ulcerations
    • +/- Bleeding
    • +/- Pruritus
  • Diagnosis: skin biopsy (similar to Bowen disease)
  • Treatment: 
    • Local excision
    • Topical chemotherapy creams: 
      • Fluorouracil
      • Imiquimod
Erythroplasia of Queyrat

Erythroplasia of Queyrat

Image: “Figure 1” by João Roberto Antônio et al. License: Public Domain

Differential Diagnosis

  • Cutaneous squamous cell carcinoma (cSCC): the 2nd most common skin malignancy, caused by malignant proliferation of atypical keratinocytes. This condition usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Histopathologic examination provides the diagnosis. Surgical excision is the mainstay of treatment.
  • Penile cancer: malignant lesions of the penis arise from the squamous epithelium of the glans, prepuce, or penile shaft. The most common histologic subtype is SCC. Both Bowen disease and erythroplasia of Queyrat are considered thin, noninvasive skin cancers, but these conditions can progress to invasive SCC. Uncircumcised men are at highest risk, along with those with HPV infections. Diagnosis is a combination of clinical findings and tissue biopsy. Treatment approach depends on cancer stage and can include local topical therapy and multimodal surgical/radiation/chemotherapy.
  • Bowenoid papulosis: a sexually transmitted condition induced by HPV infection, which facilitates keratinocyte neoplastic transformation. On skin biopsy, Bowenoid papulosis manifests as low-grade dysplasia. Presenting features include genital papules of a red to brown color that are often asymptomatic. Most cases resolve spontaneously. Lesions should be followed up due to the risk of transformation to invasive SCC. Cryosurgery, excision, or topical therapy may be used for persistent bowenoid papulosis.

References

  1. Bolognia, JL, Schaffer, JV, Cerroni, L. (2018). Actinic Keratosis, Basal Cell Carcinoma, and Squamous Cell Carcinoma. Dermatology, 4e. Edinburgh Elsevier.
  2. Curti, BD, Leachman, S, Urba, WJ. (2018). Cancer of the skin. In Jameson, J, et al. (Eds.). Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill.
  3. Porten, SP, Presti, Jr., J.C. (2020). Genital tumors. In McAninch, JW, Lue, TF (Eds.). Smith & Tanagho’s General Urology, 19e. McGraw-Hill.

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