Bowen’s disease is a skin condition. In a small number of people, Bowen’s disease that isn’t treated may develop into a skin cancer called squamous cell cancer (SCC).
Bowen’s disease looks like a red, scaly patch on the skin. It is caused by the abnormal growth of cells called keratinocytes. These are cells in the outer layer of the skin (epidermis). They don’t spread into the deeper layers of the skin. Bowen’s disease is sometimes called squamous cell carcinoma in situ. Bowen’s disease is more common in women. It usually affects people in their 60s and 70s.
If not treated, Bowen’s disease can develop into squamous cell cancer. This happens in a small number of people (about 3–5 out of every 100 who have Bowen’s disease). Squamous cell cancer is a common, curable type of skin cancer. It affects the outer layer of the skin, but can spread to deeper layers. If left untreated for a long time, squamous cell cancer can spread to other parts of the body.
Causes of Bowen’s disease
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Too much sun exposure over a long time is probably the most important risk factor for Bowen’s disease. But it can occur in areas that haven’t been exposed to the sun, so this isn’t the only cause.
Previous radiotherapy in the affected area is another risk factor. Rarely, exposure to a chemical called arsenic can be the cause.
People who have to take drugs that lower their immunity (for example, after a kidney transplant) are more at risk of getting Bowen’s disease.
Occasionally, Bowen’s disease can affect the genital area. This is usually linked with a common type of virus called the human papilloma virus (HPV). There are different types of this virus. Some are linked with other cancers, such as cervical cancer.
Signs and symptoms of Bowen’s disease
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Bowen’s disease can occur anywhere on the body but it's usually found on the lower legs. To begin with, it often looks like a red, scaly patch, or sometimes like raised spots or warts. The affected skin may become itchy, sore and may bleed. As Bowen’s disease can look like other skin conditions such as eczema or psoriasis, it’s important to get any skin problems checked by a doctor.
How Bowen’s disease is diagnosed
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Bowen’s disease is diagnosed by taking a sample of skin (biopsy). A dermatologist (specialist in skin diseases) will usually do this.
A local anaesthetic is given to numb the area and a small part of the affected skin is removed. The sample is then sent to the laboratory and looked at under a microscope.
Treatment for Bowen’s disease
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There are a number of different treatments. Which treatment you have will depend on where the patch of Bowen’s disease is on your body, its size and thickness, and the number of patches there are.
How well the skin is likely to heal afterwards is an important factor when making decisions about treatment. For example, the skin on the lower legs tends to be more fragile, especially in older people. This means it may not heal as well, so certain treatments may not be suitable.
Bowen’s disease often grows very slowly, over a period of months or years. So, if you have a thin patch of affected skin that isn't changing, your dermatologist may advise you to just keep checking it for changes. You may also have regular check-ups to monitor it carefully.
Observation can be a good option for people who are more likely to have problems with skin healing after treatment.
It may be possible to treat the area by freezing it. This is called cryotherapy or cryosurgery. Liquid nitrogen is sprayed onto the affected area. At the time, this feels very cold and a bit uncomfortable. Afterwards, you will have a scab, which usually falls off within a few weeks. This removes the affected skin.
Creams (topical therapy)
A chemotherapy cream called 5-fluorouracil (Efudix ®) may be used. It’s also called 5FU. Chemotherapy is the use of anti-cancer drugs.
You put the cream onto the skin regularly over a period of time. It can make the skin in the area red and inflamed before the Bowen’s disease gets better. Usually there are no other side effects.
A cream called Imiquimod (Aldara ®) can also be used. This works by using the immune system to attack the abnormal cells. You put it on the skin regularly over a period of time. It will cause some redness and skin irritation before the Bowen’s disease improves.
Curettage and electrocautery
Scraping away the affected area (curettage) and using heat or electricity to stop any bleeding (electrocautery) are suitable for small patches of Bowen’s disease. A local anaesthetic is given before the doctor scrapes away the area using a spoon-shaped instrument called a curette.
An electrically heated loop or needle is then used to stop the bleeding from the wound (cauterise it) and destroy any remaining abnormal cells. After this treatment, a scar may develop.
Photodynamic therapy (PDT)
Photodynamic therapy (PDT) is a treatment that is used for different conditions. It can be a useful option for people with large areas of Bowen’s disease. It uses light combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy abnormal cells.
A photosensitising cream is put on the affected area. About 3–4 hours later, special light is shone onto the area for about 10–15 minutes. Afterwards, a dressing is put on to cover the area and protect it from light. Usually, more than one treatment is needed.
Surgery may be used for small areas of Bowen’s disease that can be removed under local anaesthetic. This is not always the best option for large patches of Bowen’s disease.
Laser treatment uses intense light energy to remove tissue. It's sometimes used as a treatment for Bowen's disease affecting the finger or genitals. Doctors are carrying out research trials to find out how effective this treatment is in the long term.
Follow-up after treatment for Bowen’s disease
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You may have regular check-ups after treatment. At these follow-up appointments, the doctor will check your skin for any further changes that may need treating.
If you notice any changes to a patch of Bowen’s disease, or a new patch develops in between appointments, contact your doctor or nurse.
If you aren’t being seen regularly by a skin specialist, it’s important to keep checking your own skin. Let your GP know if you develop new patches or have any other skin symptoms. After treatment, many people with Bowen’s disease are just seen by their GP, unless any new skin changes develop.
Protecting yourself from the sun is even more important when you’ve had Bowen’s disease. This means wearing clothing that protects you from the sun and using a high-factor sunscreen (SPF 30 or above).
You may have many different emotions including anger and resentment, guilt, anxiety and fear. These are all normal reactions. They are part of the process many people go through when coming to terms with their condition.
Everyone has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends. Others prefer to seek help from people outside of their situation, such as a counsellor. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is there if you need it. Our cancer support specialists can give you support and information about counselling in your area.
This section has been compiled using information from a number of reliable sources, including:
Morton, et al. Guidelines for management of Bowen’s disease. British Journal of Dermatology. 2014.
National Institute for Health and Clinical Excellence (NICE). Photodynamic Therapy for Non-Melanoma Skin Tumours (Including Premalignant and Primary Non-Metastatic Skin Lesions). 2006.
Tobias J, Hochhauser D. Cancer and its management. 6th edition. Wiley-Blackwell. 2010.
Chartier T K et al. Treatment and prognosis of cutaneous squamous cell carcinoma. www.uptodate.com. January 2014. (Accessed March 2014).
With thanks to Dr Colin Morton, Consultant Dermatologist, who reviewed this edition.
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