Bowenoid Papulosis


Article Author:
Amal Chamli


Article Editor:
Anissa Zaouak


Editors In Chief:
Amanda Oakley
Jules Lipoff
Shyam Verma


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/10/2019 11:29:22 AM

Introduction

Bowenoid papulosis (BP) is an uncommon sexually transmitted condition. It was first described in 1977 by Kopf and Bart as penile papules. However, it occurs at both sexes. It tends to affect young sexually active people. This condition was also termed “vulvar intraepithelial neoplasia (VIN)” in the vulva and termed penile intraepithelial neoplasia (PIN) in the penis.[1] The classification of this disease was confusing and including three clinical entities: BP, Bowen’s disease, and erythroplasia of Queyrat. Now it is recommended that these three entities not be used to describe lesions in the anogenital area.[2] But, dermatologists still recognize BP as a distinct clinical variant. In fact, BP is induced virally by human papillomavirus (HPV) and presents as solitary or multiple skin-colored papules in the anogenital area. It can last from two weeks to several years. Clinically BP is assimilated to genital warts while histologically it has a close resemblance to squamous cell carcinoma in situ (Bowen’s disease). Treatment is generally conservative. BP lesions are generally considered benign with a spontaneous regress leaving no sequelae in immunocompetent persons, although a small number may transform into invasive squamous cell carcinoma.

Etiology

BP is a sexually transmitted condition associated with HPV infection. Most lesions are associated with oncogenic HPV types mainly the HPV 16 genotype but occasionally HPV 18, 31, 33, 34, 35, 39, 42, 48, 51, 52, 53 and 54 are detected.[2] BP may also occur in immunocompromised individuals such as in organ transplant recipients. Smoking has recognition as a recurrence factor.

Epidemiology

BP occurs commonly in sexually active individuals and predominantly in their third to the mid-fifth decade with a mean age of 31 years.  However, BP can appear at any age and ranges from 3 to 80 years. Both sexes are affected, although recent data showed an increased number in women. There are an estimated 5 cases per 100000 women.[3] The exact prevalence is unknown because BP lesions are related clinically to genital warts. There is no racial predilection for BP.

Pathophysiology

Detection of papillomavirus common antigen in cases of BP supports the hypothesis that BP results from HPV. In fact, E6 and E7 viral oncoproteins of oncogenic HPV types contribute to oncogenesis by inducing over-expression of p16 protein and human telomerase reverse transcription (hTERT).

Histopathology

Histologically, BP is characterized by acanthosis with full thickness epidermal atypia, known as Bowenoid dysplasia. Multiple metaphase mitoses are usually visible above the basal layer as well as scattered dyskeratotic and multinucleated keratinocytes with pleiomorphism. Histopathologic findings may also show parakeratosis and hypergranulosis. The integrity of the basement membrane is preserved. The dermis contains superficial infiltrate of lymphocytes with perivascular accentuation. Induction of the focal epidermal hyperplasia and dysplasia is viral. Moreover, immunohistochemistry for p16 protein reveals strong in BP. Staining with an antibody to p16 protein has high specificity and sensitivity to detect this disease.

History and Physical

BP is a rare transmitted condition and typically occurs in sexually active people. It is clinically characterized by multiple well-demarcated red-brown to violaceous papules, usually less than 1 cm in size. The surface of the lesion can be flat, smooth, papillomatous or verrucous. Some papules may coalesce into large plaques. Sometimes, BP presents as warty white plaques. The distribution of lesions is commonly discrete; sometimes BP can have an annular or linear exhibition. In men, BP lesions primarily involve the penile shaft, but may also involve foreskin, glans, scrotum as well as the anus. Whereas in women, the lesions are usually bilateral and affect labia major, labia minor, clitoris, inside the vagina, inguinal folds, and perianal area. The lesions are generally darker in women than in men. They are usually asymptomatic; occasionally, patients may complain from pruritus and soreness of the affected area. Extragenital BP is a very rare condition, and it may involve the face, fingers or neck, with or without concomitant genital lesions.[4]

Evaluation

Because of its potential malignant transformation, the diagnosis is usually by a skin biopsy. HPV subtyping may also be a recommended next step. Microscopic findings show typical a feature of Bowen’s disease with only a few differentiating features. The distinction rests in the circumscribed plaque-like pattern, the multiplicity of lesions, the age of the patient, and less dyskeratosis and atypia and more dilated vessels in the dermis in pathology.[4] Hence the diagnosis of BP is based on clinical grounds and histopathological correlation. Furthermore, a skin biopsy is recommended in case of recalcitrant lesions to standards therapies to rule out malignancy.

An extensional assessment of HPV infection is mandatory, including examination of the oral, genital, and anal area. Besides, anoscopy should be performed in the case of receptive anal sex. All this must be performed for the patient as well as the partner.

Treatment / Management

The treatment aims to prevent malignancy transformation and to preserve the normal tissue and function. Since the disease commonly occurs in young people and it frequently remits spontaneously, the management of BP is generally conservative. Without treatment, BP lesions may regress in an average of 8 months. Treatment modalities include locally ablative or destructive therapies such as carbon dioxide (CO2) laser vaporization, cryotherapy, electrocoagulation, 5-aminolevulinic acid-mediated photodynamic therapy (ALA-PDT), excisional surgery, and 5 fluorouracil (5FU). Moreover, topical imiquimod cream 5% once a day on an alternate day for one month has proven good results on limited lesions of BP with viral clearance in some cases. However, relapse often occurs with all treatment modalities.[3][5][6]

Furthermore, there are prophylactic vaccines to prevent infection with oncologic HPV subtypes. Moreover, prevention from recurrence correlates with cessation of cigarette smoking.

Differential Diagnosis

  • Genital warts
  • Psoriasis
  • Lichen planus
  • Condylomata acuminate
  • Seborrheic keratosis
  • Pigmented Bowen’s disease
  • Melanocytic Nevus
  • cutaneous squamous cell carcinoma
  • Warty dyskeratoma

Prognosis

BP has a variable course. Lesions may regress spontaneously or persist for several years with older persons or immunocompromised patients. It may rarely transform into Bowen’s disease or invasive squamous cell carcinoma.[7]

Complications

Transformation into invasive squamous cell carcinoma is rare and occurs in less than 1 % of cases, especially in immunocompromised individuals. Females with BP lesions and sexual partners of male patients are at high risk of cervical or vulvar carcinomas because of the infection with a potentially oncogenic HPV.

Deterrence and Patient Education

BP rarely evolves into invasive squamous cell carcinoma; however, it is essential to educate patients regarding the risk of the potential malignant transformation. The patient should receive thorough education regarding HPV infections which spread via sexual contact. Therefore, the avoidance of direct sexual contact should be strongly advocated to decrease transmission of the disease.[8] Additionally, female partners of men should receive a close follow-up.

Enhancing Healthcare Team Outcomes

The management of BP is best with a multidisciplinary approach including a team of dermatologist, gynecologist, urologist, primary care provider, nurse practitioner, and a GI specialist. BP may develop malignant characteristics; therefore a long term evaluation is recommended by a dermatologist, every 3 to 6 months. Thus, the gynecologist should perform a careful cervical and anal cytologic screening of female patients as well as of sexual partners of the male patient. The urologist should examine patients with urethral involvement. And patients with perianal involvement should be examined by a GI specialist. Furthermore, smoking cessation is strongly advised.


  • Image 8731 Not availableImage 8731 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Bowenoid Papulosis - References

References

McCalmont TH, Whither bowenoid papulosis? Journal of cutaneous pathology. 2013 Feb;     [PubMed]
Deen K,Burdon-Jones D, Imiquimod in the treatment of penile intraepithelial neoplasia: An update. The Australasian journal of dermatology. 2017 May;     [PubMed]
Wang XL,Wang HW,Guo MX,Huang Z, Combination of immunotherapy and photodynamic therapy in the treatment of Bowenoid papulosis. Photodiagnosis and photodynamic therapy. 2007 Jun;     [PubMed]
Hoverson AR,Lundell RB,Cooper VL,Bridges AG, Oral bowenoid papulosis. Cutis. 2018 Nov;     [PubMed]
Richter ON,Petrow W,Wardelmann E,Dorn C,Kupka M,Ulrich U, Bowenoid papulosis of the vulva-immunotherapeutical approach with topical imiquimod. Archives of gynecology and obstetrics. 2003 Oct;     [PubMed]
Ricart JM,Cordoba J,Hernandez M,Esplugues I, Extensive genital bowenoid papulosis responding to imiquimod. Journal of the European Academy of Dermatology and Venereology : JEADV. 2007 Jan;     [PubMed]
Takayama A,Ishiguro N,Kawashima M, Coexistence of Bowenoid papulosis and Bowen's disease in a patient with systemic lupus erythematosus. The Journal of dermatology. 2012 Jul;     [PubMed]
Smith SM,Peters S,Blumenfeld ML,Chen W, Vulvar Bowenoid Papulosis: Histologically High-Grade Squamous Intraepithelial Lesion Known to Spontaneously Regress. Journal of lower genital tract disease. 2017 Jul;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Dermatology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Dermatology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Dermatology, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Dermatology. When it is time for the Dermatology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Dermatology.