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CASE REPORT |
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| Year : 2023 | Volume
: 44
| Issue : 1 | Page : 69-70 |
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An unusual presentation of perianal Bowen's disease in an immunocompromised patient – Excised and grafted
Hari Pathave, Omkar Warang, Chitra Nayak
Department of Dermatology, BYL Nair Charitable Hospital and TNMC, Mumbai, Maharashtra, India
| Date of Submission | 29-Nov-2021 |
| Date of Decision | 25-Jul-2022 |
| Date of Acceptance | 19-Oct-2022 |
| Date of Web Publication | 09-Dec-2022 |
Correspondence Address:
Dr. Hari Pathave
Department of Dermatology, BYL Nair Charitable Hospital and TNMC, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijstd.ijstd_106_21
 Abstract | | |
Bowen's disease also known as bowenoid keratoses, presents as a clinically persistent, progressive red scaly, or crusted plaque which is due to intraepithelial carcinoma and is potentially malignant. Lesions are typically asymptomatic but may be associated with bleeding. We are reporting perianal Bowen's disease in a 30-year-old married HIV-infected male which is excised and underlying healthy ulcer grafted.
Keywords: Excision and grafting, immunocompromised patient, perianal Bowen's disease
How to cite this article:
Pathave H, Warang O, Nayak C. An unusual presentation of perianal Bowen's disease in an immunocompromised patient – Excised and grafted. Indian J Sex Transm Dis 2023;44:69-70 |
How to cite this URL:
Pathave H, Warang O, Nayak C. An unusual presentation of perianal Bowen's disease in an immunocompromised patient – Excised and grafted. Indian J Sex Transm Dis [serial online] 2023 [cited 2023 Sep 30];44:69-70. Available from: https://ijstd.org/text.asp?2023/44/1/69/363114 |
| Introduction | |  |
Nonmelanoma skin cancer (NMSC) is the most common human cancer. Patients at risk for NMSC are also predisposed to the development of Bowen's disease. The majority of studies report that squamous cell carcinoma (SCC) in situ occurs mainly on sun-exposed sites, and the head and neck being the most common, but lower limbs seem to be afflicted more in women.[1],[2] Here, we report a case of Bowen's disease in an HIV-positive male in an uncommon site, namely, the perianal region which was treated by excision and grafting.
| Case Report | | |
A 30-year-old married, HIV-infected male with a CD4 count of 332, on antiretroviral therapy (tenofovir, lamivudine, and efavirenz regimen) presented with a growth on the perianal region for 2 years. The lesion was initially present on the perianal region and then gradually involved the upper medial aspect of the left buttock. There was a history of high-risk behavior present with unprotected sexual exposures with unknown male and female partners 4–5 years ago. Cutaneous examination revealed a single large ulcerated plaque of size 2 cm × 3 cm present over the perianal region [Figure 1]a. The surrounding skin of the gluteal region showed multiple asymptomatic discrete, rounded, hyperpigmented verrucous papules and plaques. Scalp, oral mucosae, palms, and soles were normal. Systemic examination did not reveal any abnormality. | Figure 1: (a) An ulcerated plaque with surrounding multiple asymptomatic discrete, rounded, hyperpigmented verrucous papules and plaques over the perianal region. (b) Skin biopsy shows papillomatosis, epithelial hyperplasia, and loss of polarity of epithelium with the pathognomonic “windblown” appearance of atypical keratinocytes (H and E, ×10). (c) Atypical keratinocytes and multiple atypical mitotic figures (H and E, ×40). (d) Excisional removal of the lesion with skin grafting
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A skin biopsy from the plaque showed papillomatosis, epithelial hyperplasia, and loss of polarity of the epithelium [Figure 1]b. Adnexal/acrotrichial/acrosyringial involvement was seen but it was not suggestive of invasion. Cells had larger, and oval shaped more corrugated nuclei.
The pathognomonic “windblown” appearance of atypical keratinocytes and multiple atypical mitotic figures were better appreciated on high power [Figure 1]c. Based on clinical features and histopathology, we made a diagnosis of Bowen's disease.
After consultation with surgeons, excisional removal of the lesion with skin grafting was planned. An inferior gluteal artery-based muscle pedicle flap was carried out and the ulcerative growth was removed en masse [Figure 1]d.
| Discussion | | |
Bowen's disease was first described in medical literature by a physician named John T. Bowen, a Boston dermatologist in the year 1912. It more commonly affects females in the age group of 20–45 years. It is associated with cervical and vulvar intraepithelial neoplasia with Human Papillomavirus (HPV) serotypes 16 and 18 being the most commonly implicated. Sunlight and arsenical exposure are important predisposing factors. It is typically seen over the sun-exposed sites and lower limbs. Psoriasiform, atrophic, verrucous,[3] hypertrophic, pigmented,[4] and irregular variants have been reported.
The prognosis of Bowen's disease is favorable. The majority of studies found the risk of progression to invasive SCC to be 5% and of those that become invasive, one-third may metastasize.
Multiple therapeutic options are available for the treatment of BD, which include medical and surgical. Medical treatment includes topical chemotherapy with 5-fluorouracil and imiquimod 5% cream,[5] curettage, cryotherapy, and photodynamic therapy.
Surgical options include simple excision with a minimum 4 mm margin around well-defined tumors of <2 cm in diameter and wide excision with at least 6 mm margin for larger or less-differentiated tumors or tumors in high-risk locations (e.g., scalp, ears, eyelids, nose, and lips).[6] Other surgical modalities include Mohs micrographic surgery, curettage and electrodesiccation, cryotherapy, and laser ablation.
Surgical excision of Bowen's disease is one of the standard treatment protocols, especially in small and single, digital, and perianal Bowen's. Recurrences in Bowen's disease depend on viral etiology, body site, size of the wound defect, and size of the lesion. In two retrospective studies, recurrence rates for perianal Bowen's disease were as follows: 23% for wide excision, 53% for local excision, and 80% for local therapy. Mohs micrographic surgery is specially performed in sites such as fingers, nail unit, and penis where tissue-sparing surgery is necessary. The main advantage of wide excision is the securing of histologically free excision margins. Drawbacks are delayed or complicated wound healing in some areas and adverse cosmetic and functional outcome.[7]
| Conclusion | | |
Our case has not reported recurrence after 3 months of excision and grafting. Postoperatively, the wound healed without any complications and the patient reported no difficulty in defecation. This case is presented due to its rare site of involvement and functionally and cosmetically good response.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Hansen JP, Drake AL, Walling HW. Bowen's disease: A four-year retrospective review of epidemiology and treatment at a university center. Dermatol Surg 2008;34:878-83.  |
| 2. | Kossard 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. |
| 3. | Grekin RC, Swanson NA. Verrucous Bowen's disease of the plantar foot. J Dermatol Surg Oncol 1984;10:734-6. |
| 4. | Ragi G, Turner MS, Klein LE, Stoll HL Jr. Pigmented Bowen's disease and review of 420 Bowen's disease lesions. J Dermatol Surg Oncol 1988;14:765-9. |
| 5. | Barad P, Fernandes J, Shukla P. Bowen's disease: A favorable response to imiquimod. Indian Dermatol Online J 2014;5:546-7. [Full text] |
| 6. | Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992;27:241-8. |
| 7. | Neubert T, Lehmann P. Bowen's disease – A review of newer treatment options. Ther Clin Risk Manag 2008;4:1085-95. |
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