Clinical Challenge: Asymptomatic Lesion on the Forearm - MPR

Clinical Challenge: Asymptomatic Lesion on the Forearm

Slideshow

  • Slide

A 52-year-old man presents with a lesion on his right forearm that has been growing for the past year. He is an avid fisherman and admits to ample sun exposure. The lesion is asymptomatic without itching, burning, or bleeding. The patient’s medical history is significant for basal cell carcinoma on the neck. Physical examination reveals a 1.0cm x 2.0cm erythematous, slightly indurated, circumscribed patch on the right forearm. Moderate actinic damage of both arms is also observed.

Biopsy of the lesion revealed Bowen disease, an intraepithelial squamous cell carcinoma.  Major risk factors contributing to the development of this condition are chronic outdoor sun exposure and sun-damaged skin. The sex ratio is approximately equal in men and women;...

Submit your diagnosis to see full explanation.

Biopsy of the lesion revealed Bowen disease, an intraepithelial squamous cell carcinoma.  Major risk factors contributing to the development of this condition are chronic outdoor sun exposure and sun-damaged skin. The sex ratio is approximately equal in men and women; the majority of cases occur in individuals older than age 60.1,2 The most common areas of occurrence are the head, neck, and extremities; less common locations include palmar, genital, and perianal regions.

Bowen disease characteristically presents as slow-growing, well-demarcated, erythematous scaly plaques of variable size and pigmentation. Lesions in women occur most frequently on the cheeks and lower extremities, and in men on the head and neck.3 This neoplasm may resemble other benign dermatologic conditions such as psoriasis, chronic eczema, and seborrheic keratosis, leading to a delay in diagnosis. It may also mimic actinic keratosis, superficial basal cell carcinoma, and malignant melanoma. Clinical recognition of Bowen disease is important since it carries a 3% to 5% risk of developing into invasive carcinoma.4

Bowen disease can be treated with a variety of surgical and nonsurgical modalities, with the former generally regarded as the first-choice option for well-defined lesions.5 Mohs micrographic surgery is recommended for recurrent, more extensive, or poorly defined neoplasms.6 Curettage with electrodesiccation and cryosurgery are relatively easy to perform; these procedures offer acceptable cure rates and are cost-effective.7 Topical therapy with either 5-fluorouracil (an antineoplastic agent) or imiquimod (an immune-response modifier) offers variable cure rates and may be used to treat sites not amenable to surgery such as the glans, penis, and rectal canal.

Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.

References

  1. 1. Eedy DJ, Gavin AT. Thirteen-year retrospective study of Bowen’s disease in Northern IrelandBr J Dermatol. 1987;117(6):715-720.
  2. 2. Hansen JP, Drake AL, Walling HW. Bowen’s disease: a four-year retrospective review of epidemiology and treatment at a university centerDermatol Surg. 2008;34(7):878-883.
  3. 3. Kossard S, Rosen R. Cutaneous Bowen’s disease. An analysis of 1001 cases according to age, sex, and siteJ Am Acad Dermatol. 1992;27(3):406-410.
  4. 4. Kao GF. Carcinoma arising in Bowen’s disease. Arch Dermatol. 1986 Oct;122(10):1124-6
  5. 5. Ferrandiz L, Ruiz-de-Casas A, Trakatelli M, et al. Assessing physicians’ preferences on skin cancer treatment in EuropeBr J Dermatol. 2012;167(Suppl 2):29-35.
  6. 6. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Cutaneous squamous carcinoma in situ (Bowen’s disease): treatment with Mohs micrographic surgeryJ Am Acad Dermatol. 2005;52(6):997-1002.
  7. 7. Moreno G, Chia ALK, Lim A, Shumack S. Therapeutic options for Bowen’s diseaseAustralas J Dermatol. 2007;48(1):1-10.