Bowen's disease: An unusual clinical presentation

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Figure 3: The same patient after 6 months of follow-up with clearance of lesions over the sun exposed areas (a). Lesions on the thighs and perineum (b), and the back, buttocks and posterior aspect of thighs healed with residual hyperpigmentation

protein deficiency, and vitamin A and zinc deficiency.[5] Low urinary levels of N-methylnicotinamide and pyridone of less than 1.5 mg in 24 h indicate severe Niacin deficiency and can be used whenever in doubt.[1] Treatment of pellagra includes exogenous Niacin, multivitamin and zinc supplementation and a diet rich in calories along with topical emollients and sunscreen for skin lesions.[1] The prevention of pellagra is based on nutritional advice that includes avoidance foods such as jowar, ragi, maize and alcohol and inclusion of diet rich in niacin such as eggs, bran, meat, poultry, fish, legumes and seeds.[1,4]

Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab, India. E-mail: [email protected]

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Sunil Kumar Gupta, Amanjot Kaur Arora, Neena Sood1, Sukhjot Kaur Departments of Dermatology and Venereology, and 1Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India Address for correspondence: Dr. Sunil Kumar Gupta, Department of Dermatology and Venereology,

Bowen’s disease: An unusual clinical presentation Sir, Bowen’s disease is an intra-epidermal squamous cell carcinoma that is carcinoma in situ. It usually affects the fair skinned individuals with a peak incidence in sixth to eighth decade of life. Most common sites are the head and neck followed by the extremities. The etiological causes

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Pitche PT. Pellagra. Sante 2005;15:205-8. Stratigos JD, Katsambas A. Pellagra: A still existing disease. Br J Dermatol 1977;96:99-106. Wan P, Moat S, Anstey A. Pellagra: A review with emphasis on photosensitivity. Br J Dermatol 2011;164:1188-200. Park K, editor. Nutrition. In: Park’s Textbook of Preventive and Social Medicine. 22nd ed. Jabalpur, India: M/S Banarsidas, Bhanot Publishers; 2013. p. 574. Vannucchi H, Fávaro RM, Cunha DF, Marchini JS. Assessment of zinc nutritional status of pellagra patients. Alcohol Alcohol 1995;30:297-302. Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.142544

known are chronic ultraviolet radiation exposure, human papillomavirus infection, arsenic exposure, previous radiation, immunosuppression, trauma and genetic factors.[1] The risk of development of invasive carcinoma is 3-5% in extra-genital lesions and 10% in genital lesions.[2] A 57-year-old man presented with a painless raised lesion over the shaft of penis since five years, which was gradually increasing in size. There was no history of prior raw areas or trauma at the site of lesion, topical application or unsafe sexual exposure. Systemic symptoms such as fever, malaise, Indian Dermatology Online Journal - October-December 2014 - Volume 5 - Issue 4


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or weight loss were absent. There was no history of any other major medical or surgical illness. On clinical examination, a single painless, minimally scaly, slightly erythematous plaque with a hyperpigmented border of size 2 cm × 0.5 cm was seen on the dorsolateral aspect of the shaft of the penis [Figure 1]. No regional lymphadenopathy was noted and no similar lesion was present elsewhere on the body. Enzyme-linked immunosorbent assay for human immunodeficiency virus and Venereal Disease Research Laboratory Test were negative/non-reactive. A differential diagnosis of discoid lupus erythematosus, lichen sclerosus et atrophicus and extramammary Paget’s (EPD) disease was considered. A biopsy was drawn from the lesion. On histopathological examination, the epidermis showed acanthosis, and elongation and thickening of the rete ridges with crowding of keratinocytes. Throughout the epidermis, the cells were in complete disarray, reflecting a “wind-blown” appearance [Figure 2]. Anisocytosis, loss of polarity and few mitotic figures were seen. The dyskeratotic cells were large, round and had homogeneous, strongly eosinophilic cytoplasm with hyperchromatic nuclei. Basal cell layer and basement membrane were intact [Figure 3]. Dermis showed an inflammatory infiltrate of lymphocytes [Figure 3]. These findings were consistent with Bowen’s disease. Surgical excision with a wide margin was done and patient was followed-up for one year with no recurrence til date. The usual clinical presentation of Bowen’s disease is a single erythematous, infiltrated, scaly, crusted, fissured plaque that may be commonly confused with psoriasis, nummular eczema and actinic keratosis. Sometimes, the lesion can be pigmented

Figure 1: Single painless minimally scaly hypo pigmented plaque with a hyper pigmented border of 2 cm × 0.5 cm was seen on the dorsolateral aspect of the shaft of penis Indian Dermatology Online Journal - October-December 2014 - Volume 5 - Issue 4

and have a variable presentation. Bowen’s disease presenting as a slightly erythematous plaque, as in our case, mimicking discoid lupus erythematosus and Lichen sclerosus et atrophicus is rare. As per our knowledge there is only one such case report in the literature.[3] Hence, histopathological examination should be done in all doubtful lesions on the penis to rule out carcinoma in situ. It is difficult to distinguish between Pagetoid variant of Bowen’s disease and EPD. The differentiating histopathological features are involvement of whole thickness of the epidermis in Bowen’s disease in contrast to lower layers in Paget’s disease. Flattening of the basal layer by nests of cells, Pagetoid cells within the stratum corneum and acinar structures within epidermis are present in Paget’s disease while intercellular bridges are visible between cells in Bowen’s disease.[4] Immunohistochemistry stains help in distinguishing the two diseases. The neoplastic cells in pagetoid variant of Bowen’s disease are negative for cytokeratin 7, carcinoembryonic antigen and gross cystic disease fluid protein 15, whereas the neoplastic cells (Paget’s cells) in EPD are positive for them.[5] In a dermoscopic study of Bowen’s disease, the characteristic dermoscopic features found were glomerular vessels (90.5%) and a scaly surface (90.5%).[6] Various treatment modalities used are topical imiquimod cream, topical 5-fluorouracil cream, cryotherapy, surgical excision, curettage and electrocautery and photodynamic therapy (PDT), lasers and topical diclofenac.[7] PDT has been shown to be an effective treatment option for Bowen’s disease with 80-95% complete response rates and an excellent cosmetic outcome especially for large lesions.[8]

Figure 2: Epidermis shows acanthosis with elongation and thickening of the rete ridges with crowding of keratinocyte. Throughout the epidermis, the cells lie in complete disorder, resulting in a “wind-blown” appearance (H and E, ×40)

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Figure 3: Basement membrane was intact. Anisocytosis, loss of polarity and few mitotic figures were seen. The dyskeratotic cells were large, round and had a homogeneous, strongly eosinophilic cytoplasm and a hyperchromatic nucleus (H and E, ×400)

Ameet Dandale, Meeta Dipak Mantri, Viral Thakkar, Rachita S. Dhurat, Smita Ghate Department of Dermatology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India Address for correspondence: Dr. Meeta Dipak Mantri, Department of Dermatology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai - 400 022, Maharashtra, India. E-mail: [email protected]

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Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.142546

Clavel CE, Huu VP, Durlach AP, Birembaut PL, Bernard PM, Derancourt CG. Mucosal oncogenic human papillomaviruses and

Unilateral pityriasis rosea Sir, Pityriasis rosea (PR) is an acute, self-limited disease, characterized by erythematous and squamous lesions and demonstrates minimal constitutional symptoms. Typical distribution of the lesions is the sudden onset of a squamous plaque, followed by a number of smaller, symmetrical squamous plaques, which are generalized on the trunk and proximal part of the extremities. Although PR usually occurs in a typical distribution and morphology, rarely, distinctive clinical and morphological variants may be observed. Still, unilateral PR is a very rarely encountered variant.[1] A 20-year-old female presented with erythema over the left leg. Patient claimed that the redness started 10 days ago. Patient had no distinctive personal and family history. Dermatological examination revealed a well-demarcated squamous plaques with peripheral erythema over the proximal part of the left leg, some with a collarette of scale at the margin [Figure 1]. Histopathological evaluation of the biopsy specimen demonstrated hyperkeratosis, focal

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extragenital Bowen disease. Cancer 1999;86:282-7. Cox NH, Eedy DJ, Morton CA. Guidelines for management of Bowen’s disease. British Association of Dermatologists. Br J Dermatol 1999;141:633-41. Yahya H, Mohammed A. Bowen’s disease: Report of a case in a Nigerian man. West Afr J Med 2005;24:350-1. Williamson JD, Colome MI, Sahin A, Ayala AG, Medeiros LJ. Pagetoid bowen disease: A report of 2 cases that express cytokeratin 7. Arch Pathol Lab Med 2000;124:427-30. Memezawa A, Okuyama R, Tagami H, Aiba S. p63 constitutes a useful histochemical marker for differentiation of pagetoid Bowen’s disease from extramammary Paget’s disease. Acta Derm Venereol 2008;88:619-20. Z a l a u d e k I , A rg e n z i a n o G , L e i n w e b e r B , C i t a r e l l a L , Hofmann-Wellenhof R, Malvehy J, et al. Dermoscopy of Bowen’s disease. Br J Dermatol 2004;150:1112-6. Cox NH, Eedy DJ, Morton CA, Therapy Guidelines and Audit Subcommittee, British Association of Dermatologists. Guidelines for management of Bowen’s disease: 2006 update. Br J Dermatol 2007;156:11-21. Clayton TH, Tait J, Whitehurst C, Yates VM. Photodynamic therapy for superficial basal cell carcinoma and Bowen’s disease. Eur J Dermatol 2006;16:39-41.

parakeratosis, irregular acanthosis, exocytosis, spongiosis, extravasated erythrocytes and perivascular mononuclear cell infiltration in dermis [Figure 2]. The total blood count, blood chemistry and erythrocyte sedimentation rate were within normal limits. KOH mount did not reveal any fungal elements. The patient was diagnosed as PR on clinical and

Figure 1: Well demarcated, some with a collarette of scale at the margin, squamous plaques with peripheral erythema on the proximal part of the left leg Indian Dermatology Online Journal - October-December 2014 - Volume 5 - Issue 4