Strength of recommendations (A-D) and quality of evidence (I-IV) and are defined at the end of the Major Recommendations field.
Summary of the Main Management Recommendations
- Routine investigation for internal malignancy in patients with Bowen's disease (BD) is not justified (E, I).
- The risk of progression to invasive cancer is about 3%. This risk is greater in genital BD, and particularly in perianal BD. A high risk of recurrence, including late recurrence, is a particular feature of perianal BD and prolonged follow up is recommended for this variant (A, II-ii).
- There is reasonable evidence to support use of 5-fluorouracil (5-FU) (B, II-i) but its use may be limited by irritancy and it was less effective than photodynamic therapy (PDT) in a randomized controlled trial (RCT). It is more practical than surgery for large lesions, especially at potentially poor healing sites, and has been used for 'control' rather than cure in some patients with multiple lesions.
- Topical imiquimod is likely to be used for BD (B, I), especially for larger lesions or difficult/poor healing sites. However, it is costly, currently unlicensed for this indication, and the optimum regimen has yet to be determined.
- Topical PDT has been shown to be equivalent or superior to cryotherapy and 5-FU, either in efficacy and/or in healing, in randomized controlled trials (A, I). It may be of particular benefit for lesions that are large, on the lower leg or at otherwise difficult sites, but it is costly. Photodynamic therapy for nonmelanoma skin cancer (NMSC) and premalignant skin lesions has now been approved as an interventional procedure by the National Institute for Health and Clinical Excellence in the United Kingdom, and methyl aminolaevulinate photodynamic therapy (MAL-PDT) has been approved by the European Medicines Authority for treatment of BD.
- Curettage has good evidence of efficacy, and time to healing is faster than with cryotherapy (A, II-ii).
- Cryotherapy has good evidence of efficacy (B, II-i), but discomfort and time to healing are inferior to photodynamic therapy (A, I) or curettage (A, II-ii).
- Excision should be an effective treatment with low recurrence rates, but the evidence base is limited and for the most part does not allow comment on specific sites of lesions (A, II-iii). Lower leg excision may be limited by lack of skin mobility. For perianal BD treated surgically, wide excision is recommended rather than narrow excision or laser treatment (A, II-iii). Micrographic surgery is logical at sites such as digits or penis where it is important to limit removal of unaffected skin (B, III) and is useful for poorly defined or recurrent head and neck BD (B, II-iii).
- Radiotherapy has good evidence of efficacy but poor healing on the lower leg suggests that it should be avoided at this site (B, II-iii; for lower leg lesions D, II-III).
- There is limited evidence on laser treatment, suggesting that it is a reasonable option for digital or genital lesions (B, II-iii) but probably not for other sites (mostly C or D, II-iii to IV); specifically, results for perianal BD are worse than those using wide surgical excision.
Table. Summary of the main treatment options for Bowen's disease. The suggested scoring of the treatments listed takes into account the evidence for benefit, ease of application or time required for the procedure, wound healing, cosmetic result and current availability/costs of the method or facilities required. Evidence for interventions based on single studies or purely anecdotal cases is not included.
| Lesion Characteristics |
Topical 5-FU |
Topical Imiqumoda |
Cryotherapy |
Curettage |
Excision |
PDT |
Radiotherapy |
Laserb |
| Small, single/few, good healing sitec |
4 |
3 |
2 |
1 |
3 |
3 |
5 |
4 |
| Large, single, good healing sitec |
3 |
3 |
3 |
5 |
5 |
2 |
4 |
7 |
| Multiple, good healing sitec |
3 |
4 |
2 |
3 |
5 |
3 |
4 |
4 |
| Small, single/few, poor healing sitec |
2 |
3 |
3 |
2 |
2 |
1-2 |
5 |
7 |
| Large, single, poor healing sitec |
3 |
2-3 |
5 |
4 |
5 |
1 |
6 |
7 |
| Facial |
4 |
7 |
2 |
2 |
4d |
3 |
4 |
7 |
| Digital |
3 |
7 |
3 |
5 |
2d |
3 |
3 |
3 |
| Perianal |
6 |
6 |
6 |
6 |
1e |
7 |
2-3 |
6 |
| Penile |
3 |
3 |
3 |
5 |
4d |
3 |
2-3 |
3 |
1, probably treatment of choice; 2, generally good choice; 3, generally fair choice; 4, reasonable but not usually required; 5, generally poor choice; 6, probably should not be used; 7, insufficient evidence available.
aDoes not have a product licence for Bowen's disease.
bDepends on site.
cRefers to the clinician's perceived potential for good or poor healing at the affected site.
dConsider micrographic surgery for tissue sparing or if poorly defined/recurrent.
eWide excision recommended.
Definitions:
Strength of Recommendations
- There is good evidence to support the use of the procedure
- There is fair evidence to support the use of the procedure
- There is poor evidence to support the use of the procedure
- There is fair evidence to support the rejection of the use of the procedure
- There is good evidence to support the rejection of the use of the procedure
Quality of Evidence
I: Evidence obtained from at least one properly designed, randomized controlled trial
II-i: Evidence obtained from well-designed controlled trials without randomization
II-ii: Evidence obtained from well-designed cohort or case–control analytical studies, preferably from more than one centre or research group
II-iii: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence
III: Opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees
IV: Evidence inadequate owing to problems of methodology (e.g., sample size, or length of comprehensiveness of follow up, or conflicts in evidence)
