Bowen's disease

Bowen's disease is a very common mild form of skin cancer, affecting only upper layers of the skin. It tends to grow slowly progression is unusual.

Also known as

Superficial squamous cell carcinoma, intraepithelial carcinoma, IEC, squamous cell carcinoma in situ, intraepidermal squamous cell carcinoma

Symptoms and signs

  • Scaly plaque, usually red or pink but sometimes brown, up to several centimetres in diameter
  • Usually located on areas that have received long term sun exposure, such as the face, ears, forearms and lower legs

Risk factors

  • Long term sun exposure
  • Exposure to arsenic
  • Infection with human papillomavirus
  • Immune suppression due to disease (e.g. chronic lymphocytic leukaemia) or medications (e.g. methotrexate)

Prognosis / outcome

Progression

About 5 per cent of Bowen's disease lesions progress to invasive squamous cell carcinoma

Medications for

 

Bowen's disease

Prevention of

 

Bowen's disease

  • Avoid unnecessary ultraviolet exposure
  • Nicotinamide (vitamin B3) 500mg tablets taken twice daily reduce the risk of future Bowen's disease

More information

Recommended web links

Clinical images of
Bowen's disease
Click on an image to view it in greater detail.

Treatment options for Bowen's disease

Surgical removal of Bowen's disease is considered the “gold standard” treatment for superficial basal cell carcinoma because:

  • it has the highest success rate
  • it allows a skin pathologist to examine the removed skin and conform that the basal cell carcinoma has been completely removed.

However, since Bowen's disease is relatively minor, for some people there are other considerations:

  • Cosmetic appearance (i.e. minimal scarring after treatment)
  • Cost
  • Convenience and duration of treatment
  • Wish to avoid side effects such as pain, bleeding, bruising and infection

The table below summarises treatment options for Bowen's disease and may be helpful in reaching a decision on the most appropriate form of treatment.

  Excision (surgical removal) Cryotherapy (freezing) Topical treatment (fluorouracil or fluorouracil / calcipotriol cream) Photodynamic therapy

How well does it work?

98.6% cure rate (Liebovitch 2005)

97-98% cure rate (Holt 1988, Kuflik 1991)

Fluorouracil: up to 92% cure rate for Bowen's disease (superficial squamous cell carcinoma) (Moreno 2007)

Combination fluorouracil/calcipotriol treatment has been shown to reduce the risk of squamous cell carcinoma in the treated area for up to three years (Rosenberg 2019). This benefit has not been shown with other treatments for superficial skin cancers.

Studies have demonstrated higher cure rates for photodynamic therapy when compared with topical treatments or cryotherapy. (Morton 2006, Basset-Seguin 2008).

Note that in these studies, success rates for cryotherapy treatment were generally less than in trials where cryotherapy was not compared with PDT.

What are the side effects?

Short term: bleeding, bruising, swelling, pain, infection

Long term: scarring in almost all cases, wound breakdown, nerve damage

Short term: pain, blistering (including blood-filled blisters), swelling

Long term: changes in skin pigmentation. The treated area is commonly lighter or darker than the surrounding skin.

 

Short term: irritation of the treated area: redness, pain, blistering, crusts and pustules

Long-term: side effects are uncommon. Scarring sometimes occurs after severe reactions during treatment.

Short term: pain during and soon after treatment. irritation , redness, blistering and crusts of the the treated area.

Long term: side effects are uncommon. Scarring sometimes occurs after severe skin reactions.

Side effects are less common and the long term cosmetic outcome is superior to treatment with either cryotherapy or topical treatments. (Morton 2006)


How much does it cost?

The cost of excision varies, according to the size and the anatomical location of the skin cancer.

Spot Check Clinic generally charges at least $200 for surgical removal. The fee varies according to the size of the skin cancer and the location on the body. This fee is usually discounted for pensioners and Health Care Card holders so that there is minimal or no out of-pocket expense.

If the procedure is performed by a plastic surgeon and/or more complicated techniques such as Moh's surgery or skin flaps or grafts are used, the cost can be thousands of dollars.

Approximately $40.

In most cases, the cost is completely covered by Medicare, but only if the diagnosis has previously been confirmed by a biopsy.

The PBS subsidises the cost of fluorouracil only for Department of Veterans' Affairs cardholders. For others, the out-of-pocket expense is about $80.

Combination fluorouraci/calcipotriol is not commercially available at pharmacies and is not covered by the PBS. It must be prepared by a compounding pharmacy. Typically, the cost of a course of treatment is about $120.

 

Treatment costs are variable and are influenced by:

  • whether skin preparation treatment (e.g. microneedling) is performed on the day of treatment
  • amount of ALA cream used
  • type of light used to activate the ALA (i.e. LED red light phototherapy vs intense pulsed light)
  • whether post-treatment LED phototherapy sessions are used to speed wound healing.

Costs generally vary between $500 to $1000 for treatment of a single skin cancer.

How convenient is it?

Surgical removal must be performed by a doctor. it usually takes 30-60 minutes.

After the procedure, there is a period of aftercare lasting several weeks. Activities and exercise may be restricted during this period.

 

Cryotherapy is performed by a doctor and takes a few minutes.

Cryotherapy aftercare is relatively simple and the wound is usually healed in about three weeks.

Fluorouracil cream must be applied twice daily to the affected area and surrounding region for four weeks.

Combination fluorouracil/calcipotriol cream is applied to the cancer twice daily for 6 days, followed by a break of 14 days and a further course of 6 days. In some cases a further 6 day course must be applied 2 weeks later. (Bricknell 2021)

During treatment, the area usually becomes red, irritated and painful. Direct sunlight must be avoided during the treatment period.

Treatment can usually be completed in a single visit to the skin cancer clinic, lasting several hours.

Due to inflammation and pain after treatment, it may be necessary to limit work and other activities for several days after treatment.

References

Leibovitch I, Huilgol S, Selva D et al
Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up.
Journal of the American Academy of Dermatology, 2005 Sep; 53(3): 452-7
2005
https://doi.org/10.1016/j.jaad.2005.04.087
Date accessed:
July 24, 2021
Holt P.
Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery
British Journal of Dermatology, volume 119, issue 2, August 1988, pages 231-240
1988
https://doi.org/10.1111/j.1365-2133.1988.tb03205.x
Date accessed:
July 24, 2021
Kuflik E, Gage A
The five-year cure rate achieved by cryosurgery for skin cancer
J Am Acad Dermatol, 1991 Jun; 24(6 Pt 1): 1002-4
1991
https://doi.org/10.1016/0190-9622(91)70160-4
Date accessed:
July 24, 2021
Moreno G, Chia A, Lim A et al
Therapeutic options for Bowen’s disease
Australasian Journal of Dermatology, volume 48, issue 1, February 2007, pages 1-10
2007
https://doi.org/10.1111/j.1440-0960.2007.00317.x
Date accessed:
July 24, 2021
Rosenberg A R, Tabacchi M, Ngo K H et al
Skin cancer precursor immunotherapy for squamous cell carcinoma prevention
JCI Insight. 4(6):e125476
2019
https://doi.org/10.1172/jci.insight.125476
Date accessed:
January 26, 2021
Morton C, Horn M, Leman J et al
Comparison of topical methyl aminolevulinate photodynamic therapy with cryotherapy or Fluorouracil for treatment of squamous cell carcinoma in situ: Results of a multicenter randomized trial
Arch Dermatol 2006 Jun; 142(6): 729-35.
2006
https://doi.org/10.1001/archderm.142.6.729
Date accessed:
July 24, 2021