Bowenoid Papulosis

Bowenoid papulosis is a sexually transmitted condition induced by HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infection, which facilitates keratinocyte neoplastic transformation. On skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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 Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. 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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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

  • Low-grade squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC) in situ of the genitalia (although extragenital lesions have been reported)
  • Induced by human HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infection:
    • Oncogenic genotypes (e.g., HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: 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 HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infection ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV 16 is the most common associated agent)
  • Immunocompromised status
  • Smoking

Clinical Presentation

Table: Clinical presentation
Number and morphology Multiple papules
Color Red-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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • ♀ (usually bilateral)
    • Labia majora
    • Labia minora
    • Clitoris
    • Vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor
    • Inguinal folds
    • Perianal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
Symptoms
  • Usually asymptomatic
  • Pruritus
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: 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 HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. 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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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 Genital Warts Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts) ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV): common sexually transmitted condition induced by HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infection. Lesions present as exophytic cauliflower-like growths that can be seen on the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis, vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor, vagina, or cervix.
  • Bowen disease Bowen Disease 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. When the glans penis is involved, the lesion is called erythroplasia of Queyrat, with uncircumcised males being at high risk. Bowen Disease and Erythroplasia of Queyrat: synonymous with SCC in situ of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function 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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of 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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