What is Bowen’s disease?

Bowen’s disease is a growth of cancerous cells in the outer layer of the skin (epidermis). It is a very early form of slow-growing skin cancer. It often appears as a red, scaly area on the skin. Bowen’s disease is sometimes called squamous cell carcinoma in situ. This means the cancerous cells are in the outer layer of the skin. They grow very slowly and are unlikely to cause a problem in most people.

Bowen’s disease is sometimes called squamous cell carcinoma in situ. If it is not treated, it can occasionally develop into squamous cell carcinoma (SCC). This happens in a small number of people (about 3 to 5 out of every 100 who have Bowen’s disease). SCC 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, SCC can spread to other parts of the body.

Causes and risk factors of Bowen’s disease

Bowen’s disease is more common in women. It usually affects people in their 60s and 70s.

Bowen’s disease has most often been linked to long-term sun exposure. This risk factor is higher if you have fair skin or tend to burn easily in the sun. It has also been linked to having a weakened immune system or having had radiotherapy in the past.

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). HPV may also be linked with Bowen’s disease on the hands or feet. There are different types of HPV. Some are linked with other cancers, such as cervical cancer

Rarely, long-term exposure to a chemical called arsenic can cause Bowen’s disease.

Bowen’s disease is not contagious.

Signs and symptoms of Bowen's disease

Bowen’s disease can occur anywhere on the body. But it is usually found on areas that have been regularly exposed to the sun. These include the:

  • face
  • scalp
  • neck
  • hands
  • lower legs.

Bowen’s disease often starts by looking like a red, scaly patch on the skin. Sometimes it can look like raised spots or warts. The affected area may become itchy or sore and may bleed. Bowen’s disease can look like other skin conditions, such as eczema or psoriasis. It is always important to get any skin problems checked by a doctor to be sure of the cause.

How Bowen’s disease is diagnosed

If your GP thinks you might have Bowen’s disease, you will be referred to a doctor who specialises in skin problems (dermatologist). They will examine your skin and may be able to diagnose it from the way it looks. They may also take a sample of skin to confirm the diagnosis. This is called a biopsy.

Before you have a biopsy, a doctor will numb the area with a local anaesthetic. They will remove a small piece of the affected skin and examine it under a microscope.

Treatment for Bowen’s disease

There are many different treatments for Bowen’s disease. The treatment you have will depend on:

  • where the area of Bowen’s disease is on your body
  • its size and thickness
  • the number of affected areas you have
  • any previous treatment you may have had for Bowen’s disease.

The treatment you have depends on how well the skin is likely to heal afterwards. For example, skin on the lower legs tends to be more fragile, especially in older people. This means it may not heal well. Some treatments may be more suitable than others, depending on your situation. Your doctor will discuss with you which treatment might be best.

Chemotherapy cream

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. A chemotherapy cream called fluorouracil (Efudix®) may be used to treat Bowen’s disease. Fluorouracil is also called 5FU.

You put the cream onto the affected area of skin. Your nurse or doctor will tell you:

  • how to put the cream on the affected area
  • how often you need to use it
  • how long you need to use it for.

The area can usually be left uncovered. But your doctor or nurse may advise you to cover the area with a waterproof dressing after putting on the cream. Follow the instructions they give you.

The treatment should make the skin red and inflamed and cause it to scab before the Bowen’s disease gets better. During this time, the area may become sore and leak fluid. If the skin reaction is particularly severe, treatment may be paused or sometimes stopped.

Your doctor may also prescribe a steroid cream to help. The skin usually takes about 2 weeks to fully heal after you finish the treatment. But it can take longer.

Try to protect the treated area from the sun, as it can make the inflammation worse. Usually there are no other side effects with this type of chemotherapy.

Immunotherapy cream

A cream called imiquimod (Aldara®) can also be used. It is a type of immunotherapy. This means that it works with body’s immune system to attack the cancerous cells. You put the cream onto the affected area of skin. Your nurse or doctor will tell you how to apply the cream, how often and for how long. It causes some redness and a scab before the Bowen’s disease improves.

You may feel a burning or tender feeling in the area being treated. This is most common at the start of treatment. If the skin reaction is very strong, your doctor may give you a steroid cream to help. It is normal for redness and some crusting to continue for about 2 weeks after the treatment has finished.

Occasionally, the immunotherapy cream may cause shivers and other flu-like symptoms. If this happens, tell your doctor or specialist nurse. They may advise you to stop using it.

Your doctor or specialist nurse can give you more detailed instructions on how to use your immunotherapy cream. They can also help manage any side effects.

Photodynamic therapy (PDT)

Photodynamic therapy destroys cancer cells by using a laser or light source combined with a light-sensitive drug. It may be used to treat different types of cancer, including some types of skin cancer. If you have large areas of Bowen’s disease, it may be a treatment option.

During PDT, the doctor or nurse puts light-sensitive cream on the affected area. They then usually cover the area with a dressing. After about 3 to 4 hours, they shine a special light onto the area for about 10 to 15 minutes. The light destroys cells that have absorbed the cream.

You may have a stinging or burning feeling in the treatment area. Tell your doctor or nurse if you are uncomfortable. They can give you something to help.

After the treatment session, the doctor or nurse will cover the area with a dressing to protect it from any light. You may need to have more than one treatment. Your doctor will tell you how many treatments you are likely to need.

Cryotherapy

If the affected area is very small, it may be possible to treat Bowen’s disease by freezing it. This is called cryotherapy or cryosurgery. A dermatologist will carefully spray liquid nitrogen onto the area to freeze and destroy the abnormal cells. Cryotherapy can be painful, and some people describe it as feeling like a bee sting.

After treatment, the area may ache or throb for a few minutes. After 1 hour or so, it is common for the area to blister. The blister may become filled with blood and may be painful. Your doctor or nurse may need to drain the fluid from the blister. They will use a sterile needle, leaving the top of the blister intact. About 2 weeks after your treatment, the scab drops off. You may have a white scar in the area.

Curettage and electrocautery

Curettage is when a dermatologist (skin specialist doctor) scrapes away the affected area. They then use heat or electricity to stop any bleeding (electrocautery).

Before treatment, the doctor will give you a local anaesthetic to numb the area. Then they scrape away the area, using a spoon-shaped instrument called a curette. They use an electrically heated loop or needle to stop the bleeding from the wound and destroy any remaining abnormal cells. The wound usually heals within a few weeks and leaves a small scar.

This treatment may be suitable for small patches of Bowen’s disease.

Surgery

Doctors may use surgery to remove areas of Bowen’s disease, using a local anaesthetic. Surgery may be used to remove deeper areas, or if other treatments have not been successful.

Laser treatment

Laser treatment uses intense light energy to remove tissue. It is sometimes used to treat Bowen's disease that affects the fingers or genitals. Doctors are carrying out research trials to find out how effective this treatment is in the long term.

Radiotherapy

Radiotherapy uses high energy x-rays to treat abnormal cells. It is sometimes used if you have Bowen’s disease that is causing symptoms, such as pain or bleeding. Doctors may also use it on areas that come back after treatment. It is not usually used on areas where the skin takes longer to heal, such as the lower legs.

Observation and monitoring

Bowen’s disease often grows very slowly, over a period of months or years. Sometimes a thin patch of Bowen’s that does not change will never cause a problem. In this case, your dermatologist may advise you to keep checking it for changes instead of giving you treatment. You may also have regular check-ups with your doctor to monitor it carefully.

Monitoring can be a good option if you are likely to have problems with skin healing after treatment.

Tell your dermatologist if you notice any changes or develop an ulcer (sore) on the area of Bowen’s disease.

Follow-up after treatment for Bowen’s disease

After treatment, you may only need to see your GP for a check-up. If any new skin changes develop, you may need to have these checked by your dermatologist.

If you have had treatment at hospital, you may have regular follow-up appointments at the hospital where you were treated. Your doctor will check your skin for any further changes that may need treating. Contact your doctor or nurse at the hospital if:

  • you notice any changes to a patch of Bowen’s disease
  • a new patch develops between appointments.

If you are not being seen regularly by a dermatologist, it is important to keep checking your skin yourself. Tell your GP if you develop new patches or have any other skin symptoms.

Ways to help prevent skin cancers

If you have had Bowen’s disease, it is even more important to protect yourself from the sun and avoid sunburn. We have more information about how to stay safe in the sun.

Your feelings

You may feel anxious about being diagnosed with Bowen’s disease or having treatment and its impact on your appearance. Everyone’s reactions are different, and you might have a mixture of emotions. You may find it helpful to talk things over with family and friends or your doctor or nurse.

Talking about your feelings can be helpful. Sometimes it is easier to talk to someone like a professional counsellor. If you are finding it difficult to cope, your specialist doctor or GP can usually refer you to a counsellor who can help.

You may have some minor scarring from the treatment. Although this usually improves with time, you may feel self-conscious about how you look. We have more information if the Bowen’s disease has made you feel self-conscious about the way you look (body image).

About our information

  • References

    Below is a sample of the sources used in our skin cancer information. If you would like more information about the sources we use, please contact us at cancerinformationteam@macmillan.org.uk

    National Institute for Health and Care Excellence (NICE) NICE pathways: Skin Cancer Treatment overview. (updated 2020) 

    Institute for Health and Care Excellence (NICE). Sunlight exposure: risks and benefits. NICE guideline [NG34] Published:2016.

    British Journal of Dermatology. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma. 2020.

    National Institute for Health and Care Excellence (NICE) Cemiplimab for treating metastatic or locally advanced cutaneous squamous cell carcinoma [TA592] Published: 07 August 2019. 

    BMJ Best Practice. Overview of Skin Cancer. (updated 2019)

    British Association of Dermatologists. Service Guidance and Standards for Mohs Micrographic Surgery (MMS). 2020.


  • Reviewers

    This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Senior Medical Editor, Dr Samra Turajlic, Consultant Medical Oncologist.

    Our cancer information has been awarded the PIF TICK. Created by the Patient Information Forum, this quality mark shows we meet PIF’s 10 criteria for trustworthy health information.

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