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LETTER TO THE EDITOR
Year : 2015  |  Volume : 6  |  Issue : 7  |  Page : 63-64  

Giant pigmented Bowen's disease: A rare variant at a rare site


Department of Dermatology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India

Date of Web Publication4-Dec-2015

Correspondence Address:
Manjunath M Shenoy
Department of Dermatology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.171048

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How to cite this article:
Shankar AA, Pinto M, Shenoy MM, Krishna S. Giant pigmented Bowen's disease: A rare variant at a rare site. Indian Dermatol Online J 2015;6, Suppl S1:63-4

How to cite this URL:
Shankar AA, Pinto M, Shenoy MM, Krishna S. Giant pigmented Bowen's disease: A rare variant at a rare site. Indian Dermatol Online J [serial online] 2015 [cited 2019 Dec 6];6, Suppl S1:63-4. Available from: http://www.idoj.in/text.asp?2015/6/7/63/171048

Sir,

Bowen's disease (BD) is an intraepithelial squamous cell carcinoma (SCC) in situ with a potential for invasive malignancy. Although it has a propensity to occur in sun-exposed areas, other unusual sites are also described.[1] BD is unusual in the pigmented skin and the pigmented variant of BD occurs in less than 2% of cases.[2] Etiology of BD is not clearly understood but various strains of human papilloma viruses, arsenic exposure, and immune suppression have been considered as the risk factors.[3],[4] Lesions arising in scars have been described.[5] Three to five percent cases of BD have a risk of developing SCC; metastasis may occur in 1/3 of these invasive tumors.[6] We describe an unusual case of giant pigmented BD over an atypical site.

A 68-year-old male presented with a gradually progressing, asymptomatic plaque over the left lower abdomen of 25 years duration. He had applied topical herbal medications with no improvement. There were no medical co-morbidities or excessive sunlight exposure or exposure to arsenic, radiation or underlying immunosuppression. There was history of constant friction at the waistline due to tying of dhoti, a traditional outfit of south India. Cutaneous examination revealed a well defined, hyperpigmented, scaly, verrucous, irregular plaque with a central area of depigmentation measuring about 11 × 5 cm [Figure 1]. Differential diagnoses of Bowen's disease, basal cell carcinoma, and lupus vulgaris were considered. An edge biopsy sent for histopathological examination revealed hyperkeratosis, acanthosis, and irregular elongation of rete ridges with thinned out papillae. Scattered dyskeratotic cells having homogenous eosinophilic cytoplasm and hyperchromatic nuclei were noted imparting a windblown appearance [Figure 2]. Focal areas of dysplasia were noted with a few atypical cells having hyperchromatic nuclei with an intact basement membrane. Scattered melanin pigment was observed within the cytoplasm of the atypical keratinocytes. [Figure 3]. The deeper dermis revealed mild to moderate perivascular chronic inflammatory infiltrate. Multiple sections did not reveal features of SCC. A final diagnosis of pigmented type of Bowen's disease was thus confirmed.
Figure 1: Well-defined, hyperpigmented, scaly, verrucous, irregular plaque with a central area of depigmentation measuring about 11 × 5 cm

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Figure 2: Scattered dyskeratotic cells having homogenous eosinophilic cytoplasm and hyperchromatic nuclei giving a windblown appearance (H and E ×400)

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Figure 3: Scattered melanin pigment seen within the cytoplasm of the atypical keratinocytes (H and E ×400)

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In 1912, John T. Bowen described Bowen's disease as a form of in situ SCC, with a potential to progress to invasive carcinoma.[7] Histopathologically, it is characterized by the "windblown" pattern of the epidermis, with loss of polarity and presence of nuclear atypia and mitotic figures.[7] Various treatments including topical imiquimod or 5-fluorouracil, cryotherapy, surgical excision, electrocautery, photodynamic therapy, lasers, and Mohs micrographic surgery have been attempted.[1],[2] Excision and primary closure was relatively easy in our patient as a rapid treatment. Cosmetic outcome was not a major consideration for the patient because the lesion was situated in a covered area. Surgical excision was hence chosen ahead of other options such as cryotherapy and topical 5-fluorouracil.[8]

BD in sun protected areas of the body is a rare occurrence. It was also a giant lesion (11 × 5 cm) that did not progress to malignancy despite its chronicity. It also occurred at the friction prone site of the waistline due wearing of the dhoti, a traditional garment of south India, hence making it a possible cultural dermatosis. Many waistline dermatoses due to wearing of tight garments such as saree/petticoat have been reported but not Bowen's disease,[9] making our case unique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Dandale A, Mantri MD, Thakkar V, Dhurat RS, Ghate S. Bowen's disease: An unusual clinical presentation. Indian Dermatol Online J 2014;5:5268.  Back to cited text no. 1
    
2.
Duncan KO, Geisse JK, Leffell DJ. Epithelial precancerous lesions. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine, 8th ed. New York: McgrawHill; 2012. p. 127376.  Back to cited text no. 2
    
3.
Clavel CE, Huu VP, Durlach AP, Birembaut PL, Bernard PM, Derancourt CG. Mucosal oncogenic human papillomaviruses and extragenital Bowen disease. Cancer 1999;86:282–7.  Back to cited text no. 3
    
4.
Drake AL, Walling HW. Variations in presentation of squamous cell carcinoma in situ (Bowen's disease) in immunocompromised patients. J Am Acad Dermatol 2008;59:68–71.  Back to cited text no. 4
    
5.
Keefe M, Smith GD. Bowen's disease arising in a scar--a case report and review of the relationship between trauma and malignancy. Clin Exp Dermatol 1991;16:47880.  Back to cited text no. 5
    
6.
Kao GF. Carcinoma arising in Bowen's disease. Arch Dermatol 1986;122:1124-6.  Back to cited text no. 6
    
7.
Kirkham N. Tumours and cysts of the Epidermis In In: Elder DE, Elenitsas R, Johnson Jr BL, Murphy GF, Xu X, editors. Lever's Histopathology of the skin. 8th ed. Philadelphia: Lippincott Raven Publishers, 1997. p. 708-10.  Back to cited text no. 7
    
8.
Morton CA, Birnie AJ, Eedy DJ. British association of dermatologists' guidelines for the management of squamous cell carcinoma in situ (Bowen's disease) 2014. Br J Dermatol 2014;170:245-60.  Back to cited text no. 8
    
9.
Verma SB. Dermatological signs in South Asian women induced by sari and petticoat drawstrings. Clin Exp Dermatol 2010;35:45961.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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