Bowenoid Papulosis

Bowenoid papulosis is a sexually transmitted condition induced by HPV infection, which facilitates keratinocyte neoplastic transformation. On skin biopsy, Bowenoid papulosis manifests as low-grade dysplasia. Affected individuals present with genital papules of a red-to-brown color that are often asymptomatic. Although most cases resolve spontaneously, lesions should be followed up because there is a risk of transformation to invasive squamous cell carcinoma (SCC). Cryosurgery, excision, or topical therapy may be used to hasten the resolution of persistent cases of Bowenoid papulosis.

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Overview

Definition

  • Low-grade squamous cell carcinoma (SCC) in situ of the genitalia (although extragenital lesions have been reported)
  • Induced by human HPV infection:
    • Oncogenic genotypes (e.g., HPV 16, 18, and 31)
    • Sexually transmitted condition
  • Overall course of disease:
    • Generally regresses spontaneously
    • In rare cases, may transform into invasive SCC (< 1 %)

Epidemiology

  • The condition most often affects individuals in their 3rd to 5th decade of life (mean age: 31 years).
  • Both sexes are affected, with slight male predominance.
  • No racial predilection

Risk factors

  • HPV infection (HPV 16 is the most common associated agent)
  • Immunocompromised status
  • Smoking

Clinical Presentation

Table: Clinical presentation
Number and morphologyMultiple papules
ColorRed-brown to violaceous
Surface
  • Smooth/flat
  • Papillomatous/verrucous
Size< 1 cm
Distribution
  • Discrete lesions (most common)
  • Annular
  • Linear
Location
    • Penile shaft (most common site)
    • Foreskin
    • Glans
    • Scrotum
    • Perianal skin
  • ♀ (usually bilateral)
    • Labia majora
    • Labia minora
    • Clitoris
    • Vagina
    • Inguinal folds
    • Perianal skin
Symptoms
  • Usually asymptomatic
  • Pruritus
  • Pain
Penile shaft bowenoid papulosis

Penile shaft Bowenoid papulosis (small gray-brown papules)

Image: “Figure 1” by Carolina Marcucci et al. License: Public Domain

Diagnosis and Management

Diagnosis

  • Skin biopsy: 
    • Focal epidermal hyperplasia
    • Partial-/full-thickness epidermal dysplasia
  • HPV subtyping
  • Evaluation of other sites: oral, genital, and anal areas
  • Sexual-partner evaluation 

Management

  • Conservative, with close follow-up
  • Most cases regress in an average of 8 months.
  • Persistent or cosmetically bothersome lesions can be treated with locally ablative therapies (e.g., cryotherapy, excision, or fluorouracil).
  • Prevention: HPV vaccination
  • Recurrence is common regardless of the treatment method.
Bowenoid papulosis skin biopsy

Bowenoid papulosis
Skin biopsy showing epidermal dysplasia

Image: “Bowenoid papulosis of the genitalia successfully treated with topical tazarotene: a report of two cases” by Shastry V, Betkerur J. License: CC BY 2.0

Differential Diagnosis

  • Squamous cell carcinoma (SCC): the 2nd most common skin cancer and usually presents as a firm, erythematous, keratotic plaque or papule. Diagnosis should be suspected on a clinical basis, and histopathologic examination confirms the diagnosis, with pathognomonic features such as keratin pearls.
  • Genital warts (HPV): common sexually transmitted condition induced by HPV infection. Lesions present as exophytic cauliflower-like growths that can be seen on the penis, vulva, vagina, or cervix.
  • Bowen disease: synonymous with SCC in situ of the skin and presents as a scaly, red, well-demarcated papule or plaque. Biopsy is necessary to confirm the diagnosis and rule out invasive carcinoma. Then the skin cancer should be definitively treated with excision or topical chemotherapy.

References

  1. Bolognia, JL, Schaffer, JV, Cerroni, L. (2018). Anogenital Disease. Dermatology, 4e. Edinburgh Elsevier.
  2. Lim, JL, Asgari, M. (2021). Cutaneous squamous cell carcinoma (cSCC): Clinical features and diagnosis. UpToDate. Retrieved April 20, 2021, from https://www.uptodate.com/contents/cutaneous-squamous-cell-carcinoma-cscc-clinical-features-and-diagnosis

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