Indian Dermatology Online Journal

: 2016  |  Volume : 7  |  Issue : 6  |  Page : 536--537

Dermatopathology quiz: Keratotic papules of the palms

Alex Flamm1, Qiang Xie1, Dennis C Polley2, Lana Vanstory2, Dirk M Elston3,  
1 Department of Dermatology, Downstate Medical Center, Brooklyn, NewYork, USA
2 The Polly Clinic, Wilson, North Carolina, USA
3 Department of Dermatology, The Medical University of South Carolina, Charleston, South Carolina, USA

Correspondence Address:
Dirk M Elston
Ackerman Academy of Dermatopathology, 145 East 32nd Street, 10th Floor, New York, NY 10016

How to cite this article:
Flamm A, Xie Q, Polley DC, Vanstory L, Elston DM. Dermatopathology quiz: Keratotic papules of the palms.Indian Dermatol Online J 2016;7:536-537

How to cite this URL:
Flamm A, Xie Q, Polley DC, Vanstory L, Elston DM. Dermatopathology quiz: Keratotic papules of the palms. Indian Dermatol Online J [serial online] 2016 [cited 2019 Sep 16 ];7:536-537
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Full Text

A 65-year-old woman presented with a 1 cm × 1 cm erythematous keratotic plaque on the palmar aspect of the left hand [Figure 1]. Physical examination was otherwise unremarkable. The lateral edge of the lesion was biopsied for further evaluation [Figure 2].{Figure 1}{Figure 2}

The lesion most likely represents?

Bowen's disease Psoriasis Seborrheic keratosis Allergic contact dermatitis Verruca vulgaris.

Answer: Bowen's disease

Histopathological exam [Figure 2] and [Figure 3] showed hyperkeratosis, parakeratosis, and full thickness atypia of the epidermis. No invasion beyond the basement membrane was noted.{Figure 2}{Figure 3}

Bowen's disease, or squamous cell carcinoma (SCC) in situ, is an intraepithelial neoplasm with an up to 8% chance of progression to SCC.[1] It is most often located in sun-exposed areas. Head and neck are most commonly involved followed by the lower and the upper extremities. While the dorsal aspects of the hands are commonly affected, occurrence on the palms is rare. In a study of 1001 cases of Bowen's disease, there were no cases noted on the palms.[2]

Bowen's disease of the palm is generally described as presenting as a long-standing erythematous scaly plaque, similar to Bowen's disease of other cutaneous surfaces. Some have been pigmented.[3],[4] Excessive exposure of the palms to ultraviolet radiation, arsenic exposure, and human papilloma virus (HPV) infection have all been noted as predisposing factors in these cases.[1],[5] In particular, arsenic exposure needs to be ruled out in cases of suspected Bowen's disease of non-sun exposed areas.[4],[6] Two cases of palmar SCC discussed in the literature noted previous exposure to arsenic, one of which eventually progressed to metastatic SCC.[1],[7] HPV infection was detected in two additional cases through use of PCR, one of which was positive for HPV 52, a high-risk, mucosal strain of HPV.[4],[5]

Palmar lesions of Bowen's are often difficult to recognize without biopsy due to their unusual location. A few were initially misdiagnosed as other entities such as seborrheic keratoses [3] or psoriasis,[6] which are also included in the differential diagnosis. Other entities to be considered include lichen planus, contact dermatitis, tinea manuum, subcutaneous mycoses, cutaneous tuberculosis, and lichen simplex chronicus.[1],[6] Histopathologic exam showing full-thickness atypia of the epidermis with loss of normal maturation of the keratinocytes will differentiate palmar Bowen's disease from the other entities.

Excision is generally curative with few recurrences.[3],[6],[7] These lesions also respond well to topical 5-fluorouracil [1],[6] and intralesional bleomycin treatment.[8]

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Conflicts of interest

There are no conflicts of interest.


1Harnalikar M, Dongre A, Khopkar U. Bowen's disease on palm: A rare presentation. Indian J Dermatol 2011;56:353-4.
2Kossard S, Rosen R. Cutaneous Bowen's disease. An analysis of 1001 cases according to age, sex, and site. J Am Acad Dermatol 1992;27:406-10.
3Wilmer EM, Lee KC, Higgins W 2nd, Cruz AP. Hyperpigmented palmar plaque: An unexpected diagnosis of Bowen disease. Dermatol Online J 2013;19:18573.
4Cavicchini S, Tourlaki A, Ghislanzoni M, Alberizzi P, Alessi E. Pigmented Bowen disease of the palm: An atypical case diagnosed by dermoscopy. J Am Acad Dermatol 2010;62:356-7.
5Murao K, Tetsutani M, Ishigami T, Kubo Y, Arase S. Bowen disease of the palm associated with human papillomavirus 52. Clin Exp Dermatol 2013;38:489-91.
6Sarveswari KN. Bowen's disease of the palm. Int J Dermatol 1998;37:157-8.
7González-Pérez R, Gardeazábal J, Eizaguirre X, Diaz-Pérez JL. Metastatic squamous cell carcinoma arising in Bowen's disease of the palm. J Am Acad Dermatol 1997;36:635-6.
8Dyall-Smith D. Intralesional bleomycin. Australas J Dermatol 1998;39:123-4.