Clinical Challenge: Enlarging Lesion on the Forearm


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A patient, aged 52 years, presented with a lesion on his right forearm that had been enlarging in size over the past year. The patient reported that he was an avid fisherman and admitted to ample sun exposure. The lesion was asymptomatic with no itching, burning or bleeding.

The patient’s medical history was significant for a previous basal cell carcinoma on the neck. Physical examination revealed a 1cm x 2cm erythematous, slightly indurated, circumscribed patch on the right forearm. Moderate actinic damage of both arms was also observed.

Biopsy of the lesion revealed Bowen disease, an intraepithelial squamous cell carcinoma. The major risk factors in the development of this condition are chronic outdoor sun exposure and sun damaged skin.The sex ratio is approximately equal in males and females,...

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Biopsy of the lesion revealed Bowen disease, an intraepithelial squamous cell carcinoma. The major risk factors in the development of this condition are chronic outdoor sun exposure and sun damaged skin.

The sex ratio is approximately equal in males and females, although some studies point to either a male or female predominance.1,2 The majority of cases occur in individuals aged ≥60 years.3 The most common sites of involvement are the head, neck and extremities.2 Less common locations include palmar, genital, and perianal regions.4

Bowen disease characteristically presents as slow growing, well demarcated, erythematous scaly plaques with variable scale and pigmentation. Lesions in women occur most commonly on the cheeks and lower extremities, and in men on the head and neck.5 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 3-5% risk of developing into invasive carcinoma.6,7

Definitive diagnosis is invariably through biopsy of the lesion. Histology reveals cellular disarray throughout the epidermis creating a “windblown” appearance.8 Many cells are atypical and manifest keratinization. Additional features include hyperkeratosis, parakeratosis, and acanthosis as well as an inflammatory dermal infiltrate.

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.9 Mohs micrographic surgery is recommended for recurrent, more extensive, or poorly defined neoplasms.10

Curettage with electrodesiccation and cryosurgery are relatively easy to perform, offer acceptable cure rates, and are cost-effective.11

Topical therapy with either an antineoplastic agent such as 5-fluorouracil or an immune response modifier such as imiquimod, offer variable cure rates and are of particular value for sites not amenable to surgery such as the glans penis and rectal canal, as is radiation therapy.11

Megha D. Patel, is a student at the Commonwealth Medical College, Scranton, Pennsylvania.

Stephen Schleicher, MD, is an associate professor of Medicine at the Commonwealth Medical College and an Adjunct Assistant Professor of Dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, Pennsylvania.


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  2. Hansen JP, Drake AL, Walling HW. Dermatol Surg.2008; 34(7): 878-883.
  3. Kovács A, Yonemoto K, Katsuoka K, Nishiyama S, Harhai I. J Dermatol. Apr 1996;23(4):267-74. 
  4. Habif TP. (2010.) Bowen’s Disease. Clinical Dermatology. (5th ed.) Philadelphia, PA: Elsevier.
  5. Kossard S, Rosen R. J Am Acad Dermatol. 1992;27(3):406-10.
  6. Peterka ES, Lynch FW, Goltz RW. Arch Dermatol.1961; 84:623-9.
  7. Kao GF. Arch Dermatol. 1986; 122:1124-6.
  8. Elder D. (1997.) Lever’s Histopathology of Skin. (8thed.) Philadelphia, PA: Lipponcott.
  9. Ferrandiz L, Ruiz-de-Casas A, Trakatelli M, et al. Br J Dermatol. 2012;167 Suppl 2:29-35.
  10. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R.J Am Acad Dermatol. 2005;52(6):997-1002.
  11. Moreno G, Chia AL, Lim A, Shumack S. Australas J Dermatol. 2007;48(1):1-8.