BACKGROUND: Giant Bowenâ€™s disease is a rare and unusual clinical manifestation. Presenting as extensive scaly erythematous patch or plaque, it gives rise to a wide spectrum of dermatological differential diagnoses.
CASE PRESENTATION: We report a patient with giant Bowenâ€™s disease on the face that was successfully treated with topical 5 % imiquimod. A review of the literature was made with the aim to analyse and compare the findings in it with our observation.
CONCLUSION: We present this case to draw attention to the importance of the self skin examination in the elderly population. Also, to prevent development to invasive squamous cell carcinoma from Bowenâ€™s disease, we recommend mandatory dermoscopic examination on every long-standing erythemosquamous lesion

Arsovska-Bezhoska, Irina

Caca-Biljanovska, Nina

Vâ€™lckova-Laskoska, Marija

English

Open Access Macedonian Journal of Medical Sciences 

 _______________________________________________________________________________________________________________________________ 
606                                                                                                                                                                                                https://www.id-press.eu/mjms/index 
 
ID Design Press, Skopje, Republic of Macedonia 
Open Access Macedonian Journal of Medical Sciences. 2019 Feb 28; 7(4):606-609. 
https://doi.org/10.3889/oamjms.2019.190 
eISSN: 1857-9655 
Case Report 
 
 
  
 
Giant Bowen’s Disease on the Face: Case Report and Review of 
the Literature 
 
 
Nina Caca-Biljanovska, Irina Arsovska-Bezhoska
*
, Marija V’lckova-Laskoska 
 
University Clinic of Dermatology, Ss. Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia 
 
Citation: Caca-Biljanovska N, Arsovska-Bezhoska I, 
V’lckova-Laskoska M. Giant Bowen’s Disease on the 
Face: Case Report and Review of the Literature. Open 
Access Maced J Med Sci. 2019 Feb 28; 7(4):606-609. 
https://doi.org/10.3889/oamjms.2019.190 
Keywords: Giant Bowen’s disease; dermoscopy; 
histopathology 
*Correspondence: Irina Arsovska-Bezhoska. University 
Clinic of Dermatology, Ss. Cyril and Methodius University 
of Skopje, Skopje, Republic of Macedonia. E-mail: 
irina.arsovska@yahoo.com 
Received: 10-Feb-2019; Revised: 17-Feb-2019; 
Accepted: 18-Feb-2019; Online first: 22-Feb-2019 
Copyright: © 2019 Nina Caca-Biljanovska, Irina 
Arsovska-Bezhoska, Marija V’lckova-Laskoska. This is an 
open-access article distributed under the terms of the 
Creative Commons Attribution-NonCommercial 4.0 
International License (CC BY-NC 4.0) 
Funding: This research did not receive any financial 
support 
Competing Interests: The authors have declared that no 
competing interests exist 
 
 
 
Abstract 
BACKGROUND: Giant Bowen’s disease is a rare and unusual clinical manifestation. Presenting as extensive 
scaly erythematous patch or plaque, it gives rise to a wide spectrum of dermatological differential diagnoses.  
CASE PRESENTATION: We report a patient with giant Bowen’s disease on the face that was successfully 
treated with topical 5 % imiquimod. A review of the literature was made with the aim to analyse and compare the 
findings in it with our observation.  
CONCLUSION: We present this case to draw attention to the importance of the self skin examination in the 
elderly population. Also, to prevent development to invasive squamous cell carcinoma from Bowen’s disease, we 
recommend mandatory dermoscopic examination on every long-standing erythemosquamous lesion.  
 
 
 
 
 
 
 
 
 
Introduction 
 
Bowen’s disease is considered an 
intraepidermal/in situ squamous cell carcinoma (SCC) 
as long as it has not spread beyond the basal 
membrane. Spreading into the dermis is a time-
consuming process, and when it happens, it grows as 
an invasive SCC [1]. This precancerous nature of 
Bowen’s disease was first recognised by John 
Templeton Bowen in 1912 [2]. The risk of progression 
to invasive SCC is estimated to be 3-5 % for 
extragenital lesions and 10% for genital lesions [3]. 
Referring to these assertions, its potential lateral 
spreading through the epidermis is expected. By this 
gradual progress, with time, Bowen’s disease gets an 
unusual giant dimension.  
Clinical presentation as a large 
erythemosqamous patch or plaque can be mistaken 
with various other dermatological differential 
diagnoses [4], [5].  
Chronic UV irradiation exposure (solar, iatrogenic and 
sunbeds) is considered the most obvious trigger of 
Bowen’s disease. Etiological causes also inspected 
are age, genetic factors, arsenic exposure and other 
carcinogens, human papilloma viruses (HPV), 
immunosuppression, trauma, x-ray irradiation etc. [4].  
We present a case with giant Bowen’s 
disease on the face, a sun-exposed area, an elderly 
patient. Our observation prompted us to consult the 
literature concerning this unusual presentation of 
Bowen’s disease and compare the published findings 
with ours.  
 
 
Case Report 
 
An 85-year-old female was referred to our 
department with a history of slowly enlarging scaly 
erythematous lesion on the left cheek, developed over 
the last two years. Completely asymptomatic, it has 
 Caca-Biljanovska et al. Giant Bowen’s Disease on the Face: Case Report and Review of the Literature 
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Open Access Maced J Med Sci. 2019 Feb 28; 7(4):606-609.                                                                                                                                                        607 
 
caused an only cosmetic disturbance. Patient has 
reported unprotected exposition to the sun 5-6 months 
per year, in the last 30 years. She declined previous 
cutaneous carcinomas of any kind. The attempts to 
treat it with topical corticosteroids and antimycotic 
creams did not reveal any results. After careful clinical 
and dermoscopic examination of the total skin, no 
other suspected lesions were noticed.  
Dermatological status showed scaly, slightly 
elevated erythematous plaque with dimension 9 x 7.5 
centimetres and well-demarcated borders from the 
surrounding healthy skin (Fig. 1).  
 
Figure 1: Large scaly erythematous plaque on the left cheek 
 
Dermoscopic findings through the surface of 
the entire lesion showed glomerular or dotted vessels 
and yellow-white opaque scales on an erythematous 
background, suggestive for Bowen’s disease (Fig. 2).  
 
Figure 2: Dermoscopic findings: dotted vessels and yellow-white 
opaque scales on an erythematous background 
Histopathological examination revealed 
parakeratosis in stratum corneum with atypia in cells 
throughout the epidermis. Individual dyskeratotic cells 
and increased mitotic figures were evident in the 
spinous layer. So, the diagnosis of Bowen’s disease 
was confirmed (Fig. 3).  
 
Figure 3: Histopathology, H&E: Parakeratosis in stratum corneum, 
atypia, pleomorphism, dyskeratotic cells and some mitotic figures in 
the epidermis 
  
Treatment with 5% imiquimod cream was 
initiated 3 times weekly for 4 months. For the following 
2 months, the application was reduced to 2 times per 
week. Impressive healing of the skin lesion was 
achieved [Fig.4]. Ten months follow-up did not show 
recurrence of the lesion.  
 
Figure 4: Complete healing of the Bowen’s lesion after 6 months 
treatment with 5 % imiquimod 
 
We aimed to review the literature and hence a 
Medline search was undertaken for the terms “Giant 
Case Report  
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Bowen’s disease”, “Huge Bowen’s disease”, “Large 
Bowen’s disease” and “Extensive Bowen’s disease”. 
Additional articles were disclosed from the references 
given in the publications. All articles were methodically 
studied for the described clinical, dermoscopic and 
histopathological features. Clinical images and 
photomicrographs were reviewed and matched with 
those of our patient. All articles lacking any 
photomicrographs were excluded.  
Table 1: Data from the literature concerning giant Bowen’s 
disease, including our case 
Reference Sex Age Localisation Dimension Course 
Sotiriou E, et al.2011 [6] Male  79 Right fronto-
temporal area  
10 x 10 cm  2 years 
Park JY, et al. 2013 [7] Male 
Female 
55 
79 
Left Flank 
Right breast 
13 x 12 cm 
21 x 14 cm 
? 
40 years 
Bakardzhiev I, et al. 2015 [8] Male 56 Above right 
flank 
26 x 22 cm  More than 
15 years 
Shankar AA, et al.2015 [9] Male 68 Abdomen 11 x 5 cm  25 years 
Baykal C, et al. 2016 [10] Male 67 Abdomen 15 x 15 cm  Since 
childhood 
Akay BN, et al. 2016 [11] Male 44 Abdomen 32 x 25 cm 10 years 
Nagakeerthana S, et al. 2017 
[12] 
Male 73 Gluteal  15 x 16 cm 3 years 
Ozlu E, et al. 2017 [13] Male 62 Abdomen  13 x 13 cm  7 years 
Caca-Biljanovska N, et al. 
2019 [this paper] 
Female 85 Left cheek 9 x 7.5 cm 2 years 
 
 
 
Discussion 
 
Giant Bowen’s disease is rarely reported in 
the literature [8]. There is no consensus on an official 
definition of large, extensive or huge Bowen’s 
disease. Morton et al. made efforts in their study to 
define “large Bowen’s disease” as a lesion with a 
dimension more than 2 cm [14]. On the other hand, 
Lopez et al. used the term “extensive Bowen’s 
disease” for those lesions larger than 3 cm in diameter 
[15]. Our patient with 9 x 7.5 cm sized Bowen’s 
disease fulfilled the criteria proposed by Morton and 
Lopez [14], [15].  
Although the clinical presentation can argue 
about plentiful of dermatological diseases, 
dermoscopic findings strongly suggestive for Bowen’s 
disease were recently defined [16]. Anyway, 
histopathology remains the ‘gold standard’ for an 
accurate diagnosis of Bowen’s disease [17].  
The period for full expression of the Bowen’s 
lesion is variable, from 2 years to maximum 40 years, 
a finding which is strongly in favour of the slow, lateral 
spreading of Bowen’s disease.  
Opposite to our patient, the most common 
position of giant Bowen’s disease in other published 
cases is the abdomen, followed by flanks. These are 
covered parts of the body, non- sun exposed. We 
could assume that this observation and the fact that 
most of the patients with giant Bowen’s disease are 
old males are the reasons for ignoring the lesion or 
delaying the dermatological consultation.  
Only two of the patients from the literature, 
including our, have a lesion on the face, and both of 
them have the shortest history of 2 years duration of 
the disease. Upon that background, we can assume 
that cosmetically non-acceptance was the main 
motive to the patient to seek out dermatological help.  
Asymptomatic as it is, the early lesions of 
Bowen’s disease are very subtle and overlap with 
clinical features seen in many other dermatological 
conditions (seborrheic keratosis, superficial basal cell 
carcinoma, actinic keratosis, eczema, tinea, psoriasis 
vulgaris, seborrhoeic dermatitis etc.) [5].  
Although early dermatological consultation 
can be accessed by the patient, these clinically not 
specific changes of Bowen’s disease often mislead 
the dermatologist in making the correct diagnosis. 
Undiagnosed Bowen’s disease ultimately advances to 
invasive SCC [11].  
Treatment modalities for Bowen’s disease are 
topical immunosuppressive/immunostimulating 
creams, cryotherapy, curettage, photodynamic 
therapy, radiotherapy, laser and finally surgical 
excision [18]. The therapeutic choice can be 
influenced by the age group, number, size and 
localisation of the lesion, preferable and comfortable 
solution by the patient and affordability of the 
therapeutic modalities [1].  
In conclusion, the term “giant” is referred to 
clinical manifestation of the lesion, and it should not 
be used as a variant or distinctive form of Bowen’s 
disease. We suppose that giant manifestation of 
Bowen’s disease is due to neglecting the skin lesion 
by the patient, or not identifying it promptly by the 
dermatologist. Therefore, we strongly recommend self 
skin examination to be carried out, especially in older 
patients. Also, regular dermoscopy performed on 
every long-standing erythemosquamous skin lesion 
should be a rule. Early recognition of Bowen’s disease 
and prevention of its undeniable progression into an 
invasive SCC is very important.  
 
 
References  
 
1. Bath‐Hextall FJ, Matin RN, Wilkinson D, et al. Interventions for 
cutaneous Bowen's disease. Cochrane Database of Syst 
Rev.2013; 6:CD007281. 
https://doi.org/10.1002/14651858.CD007281.pub2 
2. Bowen JT. Precancerous dermatosis: a study of two cases of 
chronic atypical epithelial proliferation. J Cutan Dis Syph 1912; 
:241-55. In: Arch Dermatol. 1983; 119(3):243-60. 
https://doi.org/10.1001/archderm.1983.01650270061020 
PMid:6297414  
 
3. Kao GF. Carcinoma arising in Bowen's disease. Arch Dermatol 
1986; 122:1124–1126. 
https://doi.org/10.1001/archderm.1986.01660220042010 
PMid:3767398  
 
4. Kallini JR, Hamed N, Khachemoune A. Squamous cell 
 
 Caca-Biljanovska et al. Giant Bowen’s Disease on the Face: Case Report and Review of the Literature 
_______________________________________________________________________________________________________________________________ 
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Open Access Maced J Med Sci. 2019 Feb 28; 7(4):606-609.                                                                                                                                                        609 
 
carcinoma of the skin: epidemiology, classification, management, 
and novel trends. Int J Dermatol. 2015; 54(2):130-40. 
https://doi.org/10.1111/ijd.12553 PMid:25428226  
5. Wozniak Rito AM, Rudnicka L. Bowen's disease in dermoscopy. 
Acta Dermatovenerol Croat 2018; 26:157-161. 
https://doi.org./10.2340/00015555-1328 PMid:29989873  
 
6. Sotiriou E, Lallas A, Apalla Z, et al. Treatment of giant Bowen's 
disease with sequential use of photodynamic therapy and 
imiquimod cream. Photodermatology, Photoimmunology & 
Photomedicine. 2011; 27: 164–166. https://doi.org/10.1111/j.1600-
0781.2011.00586.x PMid:21535173  
 
7. Park JY, Kim SK, Cho KH, et al. Huge Bowen's disease: A pitfall 
of topical photodynamic therapy. Photodiagnosis and Photodyn 
Ther. 2013; 10(4):546-8. 
https://doi.org/10.1016/j.pdpdt.2013.05.001 PMid:24284109  
 
8. Bakardzhiev I, Chokoeva AA, Tchernev G. Giant extragenital 
Bowen's disease. Wien Med Wochenschr. 2015; 165(23-24):504-7. 
https://doi.org/10.1007/s10354-015-0396-z PMid:26542410  
 
9. Shankar AA, Pinto M, Shenoy MM, et al. Giant pigmented 
Bowen's disease: A rare variant at a rare site. Indian Dermatol 
Online J. 2015; 6:S63-4. https://doi.org/10.4103/2229-5178.171048 
PMid:26904458 PMCid:PMC4738524 
 
10. Baykal C, Buyukbabani N, Babuna G, et al. Giant Bowen's 
disease histologically showing Borst- Jadassohn phenomenon and 
complicated with squamous cell carcinoma development. J Eur 
Acad Dermatol Venerol. 2016; 30: 88-89. 
https://doi.org/10.1111/jdv.13335 PMid:26373350  
 
11. Akay BN, Maden A, Kocak O, et al. Development of poorly 
differentiated invasive squamous cell carcinoma in giant Bowen's 
disease: a case report with dermatoscopy. Dermatol Pract Concept 
 
2016; 6(2):2. 
12. Nagakeerthana S, Rajesh G, Madhavi S, et al. Bowen's 
disease: Two case reports of a giant and dwarf lesions. J Can Res 
Ther. 2017; 13:371-3. https://doi.org/10.4103/0973-1482.187237 
PMid:28643763  
 
13. Ozlu E, Ertas R, Ozyurt K, et al. Giant neglected Bowen's 
disease lesion treated successfully with topical 5-fluorouracil. North 
Clin Istnb. 2017; 10; 4:77. 
 
14. Morton CA, Whithurst C.,McColl J.H., et al. Photodynamic 
therapy for large or multiple patches of Bowen's disease and basal 
cell carcinoma. Arch Dermatol. 2001; 137: 319-324. 
PMid:11255332  
 
15. Lopez N, Meyer-Gonzales T, Herrera-Acosta E, et al. 
Photodynamic therapy in the treatment of extensive Bowen's 
disease. J Dermatol Treat 2012; 23:428-430. 
https://doi.org/10.3109/09546634.2011.590789 PMid:21787214  
 
16. Zalaudek I, Argenziano G, Leinweber B, et al. Dermoscopy of 
Bowen's disease. Br J Dermatol 2004; 150: 1112–1116. 
https://doi.org/10.1111/j.1365-2133.2004.05924.x PMid:15214896  
 
17. Neagu TP, Tiglis M, Botezatu D. et al. Clinical, histological and 
therapeutic features of Bowen's disease. Rom J Morphol Embryol. 
2017; 58: 33-40. PMid:28523295  
 
18. Morton CA, Birnie AJ, Eedy DJ. British Association of 
Dermatologists' guidelines for the management of squamous cell 
carcinoma in situ (Bowen's disease) 2014. British Journal of 
Dermatology. 2014; 170: 245-260. 
https://doi.org/10.1111/bjd.12766 PMid:24313974  
 
 


Giant Bowenâ€™s Disease on the Face: Case Report and Review of the Literature

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Giant Bowenâ€™s Disease on the Face: Case Report and Review of the Literature

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