This information is about a skin condition called Bowen’s disease. In a small number of people, Bowen’s disease that hasn't been 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 in the outer layer of the skin (epidermis). These cells don’t spread into the deeper layers of the skin. Bowen’s disease is sometimes called squamous cell carcinoma in-situ.
Untreated cases of Bowen’s disease may develop into squamous cell cancer in a small number of people (about 3-5 out of every 100 who have it). This is a common, curable type of skin cancer which affects the outermost cells of the skin but can spread to deeper layers of skin.
If left untreated for a long time, squamous cell cancer can spread to other parts of the body. Bowen’s disease is more common in women and it usually affects people in their 60s and 70s.
Long-term overexposure to the sun 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, as is exposure to a chemical called arsenic, although this is rare.
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 and some are linked with 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 out 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). You will usually be referred to a dermatologist (specialist in skin diseases) to have this done.
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 to be looked at under a microscope.
Treatment for Bowen’s disease
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There are a number of different treatments available for Bowen’s disease. Your treatment will depend on where it is on your body, the size, thickness and the number of patches.
How well the skin is likely to heal afterwards is an important factor when making decisions about treatment. The skin on the lower legs tends to be more fragile (especially in older people) and, as a result, there may be problems with it healing.
Bowen’s disease often grows very slowly, over a period of months or years. So, if you have a thin patch of affected skin which isn't changing, then keeping a close eye on it (observation) may be all that your dermatologist advises. You may have regular check-ups to monitor it carefully.
This can sometimes 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 on to the affected area to freeze it. 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 (anti-cancer treatment) cream called 5-fluorouracil (Efudix®), also known as 5FU, may be used. The cream is applied to 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®), which works by using the immune system to attack the abnormal cells, can also be used. You will be asked to apply it 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 applied 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 is a newer treatment that is used for different conditions. It can be a useful option for people with large areas of Bowen’s disease. It uses laser, or other light sources, combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy abnormal cells. A photosensitising cream is applied to the affected area. This is usually done 4-6 hours before treatment with the light, which lasts about 20-45 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. But it’s 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 of the finger or the 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 follow-up appointments, the doctors will check for any further changes that may need to be treated. However, if you notice changes in a patch, or a new patch developing in between appointments, contact your doctor or nurse for advice.
If you aren’t being seen regularly by a skin specialist, it’s important to keep a close eye on your own skin. Let your GP know if you develop new patches or have any other skin symptoms. Many people with Bowen’s disease are looked after by their GPs when their treatment is over.
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, resentment, guilt, anxiety and fear. These are all normal reactions, and are part of the process many people go through in trying to come 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, while others prefer to seek help from people outside their situation. 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 information about counselling in your area.
This section has been compiled using information from a number of reliable sources, including:
Cox, et al. Guidelines for management of Bowen’s disease. British Journal of Dermatology. 2006 (updated 2007).
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. 2010. Wiley-Blackwell.
UpToDate. Clinical features and diagnosis of cutaneous squamous cell carcinoma (SCC). www.uptodate.com/contents/clinical-features-and-diagnosis-of-cutaneous-squamous-cell-carcinoma.com (accessed Aug 2012)
With thanks to Professor Rona Mackie, Consultant Dermatologist, and the people affected by cancer who reviewed this edition. Reviewing information is just one of the ways you could help when you join our Cancer Voices network.