Bowen Disease and Erythroplasia of Queyrat
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Direct answer
Bowen disease is squamous cell carcinoma in situ, a full-thickness keratinocyte atypia confined to the epidermis that presents as a sharply demarcated, scaly red plaque. Erythroplasia of Queyrat is the same process affecting the glans penis or prepuce, where it appears as a velvety red plaque. Both carry a risk of progression to invasive squamous cell carcinoma, so excision or another destructive treatment with histological confirmation is the standard approach.
What you must remember
- Histology: full-thickness keratinocyte atypia with dyskeratotic cells and abnormal mitoses, but no invasion across the basement membrane.
- Clinical picture: a well-demarcated, erythematous and scaly plaque, often on sun-exposed skin of older adults.
- Erythroplasia of Queyrat: a velvety red plaque on the glans or prepuce, classically in uncircumcised men.
- Arsenic: multiple Bowen lesions on the trunk, palms or soles raise the question of arsenical exposure from contaminated water or medicines.
- Internal malignancy: an association of arsenic-related Bowen disease with internal cancers is reported, though the evidence is debated, so a targeted screen is reasonable.
- HPV: human papillomavirus, particularly type 16, is implicated in genital Bowen-type disease and is found in some cases of erythroplasia of Queyrat.
- Treatment: surgical excision with histological margin control is standard, while cryotherapy, curettage and cautery, topical 5-fluorouracil, imiquimod and photodynamic therapy are alternatives for selected lesions.
- Bowenoid papulosis: multiple HPV-related pigmented papules in sexually active young adults, usually benign or in situ, and distinct from Bowen disease.
Comparing three HPV and sun-linked lesions
Bowen disease, erythroplasia of Queyrat and bowenoid papulosis look alike to a quick observer, so site and morphology guide the first diagnosis. The table summarises the differences that exam stems most often use.
| Feature | Bowen disease | Erythroplasia of Queyrat | Bowenoid papulosis |
|---|---|---|---|
| Site | Sun-exposed skin, trunk, limbs or other skin | Glans penis or prepuce | Genital and anogenital skin |
| Morphology | Scaly, sharply demarcated red plaque | Velvety, sharply demarcated red plaque | Multiple pigmented or red papules |
| Typical patient | Older adults | Older, often uncircumcised men | Sexually active young adults |
| Main risk | Invasive squamous cell carcinoma | Invasive squamous cell carcinoma | Usually benign, occasionally in situ |
| Treatment focus | Excision, cryotherapy or topical therapy | Excision, often with circumcision | Topical or destructive therapy |
Histology confirms the diagnosis in every case, because the clinical picture alone cannot separate in situ disease from benign mimics. A persistent, sharply demarcated lesion should always prompt a biopsy. Bowenoid papulosis is the entity most often regarded as benign, so a lesion that fails to respond to treatment still needs histology.
Where the exam tries to catch you
Stems on Bowen disease test whether you see a persistent, demarcated plaque as malignant until proven otherwise.
- Trap: diagnosing Bowen disease as eczema or psoriasis because of scale and redness. Correct: Bowen disease is persistent and sharply demarcated, and it needs biopsy, whereas eczema responds to steroids and resolves.
- Trap: treating a red velvety patch on the glans as simple balanitis. Correct: a persistent velvety, sharply demarcated red plaque in an uncircumcised man is erythroplasia of Queyrat until biopsy shows otherwise.
- Trap: ignoring arsenic exposure when multiple Bowen lesions appear on the trunk, palms or soles. Correct: multiple lesions in these sites prompt an exposure history and consideration of screening for internal cancers.
Frequently asked questions
What is the main difference between Bowen disease and actinic keratosis?
Bowen disease is squamous cell carcinoma in situ, with full-thickness epidermal atypia, while actinic keratosis is an early lesion with partial-thickness atypia. Bowen disease is larger, more sharply demarcated and carries a greater risk of progression.
Why is HPV relevant in erythroplasia of Queyrat?
Human papillomavirus, particularly type 16, is found in some cases of erythroplasia of Queyrat and other genital Bowen-type disease. Its presence matters for counselling and for the assessment of sexual contacts.
Why is arsenic exposure important in Bowen disease?
Arsenic exposure, from contaminated groundwater or arsenical medicines, is linked to multiple Bowen lesions on the trunk, palms and soles. Such patients need a careful exposure history and consideration of screening for internal malignancy, because an association with internal cancers has been reported, although its strength is debated.
Which treatments are used for Bowen disease?
Surgical excision with histological margin assessment is the standard treatment for Bowen disease. Cryotherapy, curettage with cautery, topical 5-fluorouracil and photodynamic therapy are alternatives for selected lesions, chosen by size, site and patient factors.