PHOTO QUIZ

What Is Your Diagnosis?

CUTIS

The patient noticed the development of pigmented papules in the genital Doregion over severalNot months. He thought the Copyfirst papule was a mole but expressed concern that other lesions had developed. His girlfriend recently was told that she had an abnormal Papanicolaou test.

PLEASE TURN TO PAGE 295 FOR DISCUSSION

Dirk M. Elston, MD, Departments of Dermatology and Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania. The author reports no conflict of interest.

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The Diagnosis: Bowenoid Papulosis

owenoid papulosis is CUTISa human papilloma- HPV-induced lesions. They require a high index of (HPV)–related lesion with strong histologic suspicion, as they display little atypia. Because atypia Bresemblance to in situ.1 Without is minimal, they may be misdiagnosed as benign even appropriate clinical correlation, a pathologist is likely when biopsies are obtained. Because of their bland to render a diagnosis of appearance, they were once considered a pseudo- in situ and the patient may be subjected to overly malignancy2 but are really in aggressiveDo treatment. Notsheep’s Copyclothing. &OLQLFDO'LDJQRVLV 3DWKRJHQHVLV Lesions of bowenoid papulosis often resemble con- Bowenoid papulosis is related to HPV infection, dylomata acuminatum but are more likely to be specifically HPV-16,3 in contrast to common con- smooth, sessile, and hyperpigmented. They may be dylomata acuminatum, which is associated most misdiagnosed as nevi or atypical moles by healthcare commonly with HPV-6. As both lesions are related providers who are unfamiliar with bowenoid papulo- to HPV infection, it is not surprising that lesions of sis. Lesions frequently are multiple and may be long- bowenoid papulosis clinically resemble genital . standing or of recent onset. The diagnosis requires Lesions of bowenoid papulosis more often are smooth, a biopsy for confirmation. A lesion that clinically sessile, and hyperpigmented, all features that suggest resembles a venereal but is reported as squamous the need for biopsy. Individual lesions present a his- cell carcinoma in situ when biopsied most likely rep- tologic spectrum that ranges from lesions resembling resents bowenoid papulosis. warts with only scattered atypical cells to lesions All pigmented papules and plaques of the genital histologically indistinguishable from Bowen disease.4 region should be carefully examined. Carcinoma Active communication between the clinician and in situ also is frequently pigmented in the genital pathologist is essential to avoid misdiagnosis. region. When in doubt, a biopsy is always appropriate Loss of S-100 protein–positive dendritic in the setting of a pigmented genital lesion. (Langerhans) cells is seen in both bowenoid papulosis Giant lesions suggestive of venereal warts should and penile Bowen disease and may result in a dimin- be biopsied to rule out verrucous carcinoma, so- ished immune response to the tumor cells.5 This loss called giant condyloma or Buschke-Löwenstein of immune surveillance may be involved in tumor. These may evolve from other tumor spreading.

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7UHDWPHQW 2. Mikhail GR. Cancers, precancers, and pseudocancers Destructive modalities that ensure removal of on the male genitalia. a review of clinical appearances, the lesion but preserve surrounding tissue are appro- histopathology, and management. J Dermatol Surg priate for lesions of bowenoid papulosis. Many lesions Oncol. 1980;6:1027-1035. can be treated with liquid nitrogen cryosurgery. Laser 3. Gimeno E, Vilata JJ, Sanchez JL, et al. Bowenoid vaporization, shave biopsy, and simple excision also papulosis: clinical and histological study of eight cases. may be appropriate. Surgical procedure for bowenoid Genitourin Med. 1987;63:109-113. papulosis is complicated by the multicentric nature of 4. Peters MS, Perry HO. Bowenoid papules of the penis. J the lesions.6 Urol. 1981;126:482-484. Some lesions of bowenoid papulosis have 5. Hahn A, Löning T, Hoos A, et al. Immunohisto- responded to subcutaneous injections of interferon chemistry (S 100, KL 1) and human papillomavirus alfa.7 Topical imiquimod also has been used with DNA hybridization on morbus Bowen and bowenoid some success, though it is not indicated for use in papulosis. Virchows Arch A Pathol Anat Histopathol. bowenoid papulosis. Oral retinoid therapy shows 1988;413:113-122. some promise as an off-label adjunctive treatment.8 6. Guillet GY, Braun L, Massé R, et al. Bowenoid papulosis. Normal-appearing tissue often harbors the virus demonstration of human papilloma virus (HPV) with and patients must be followed for recurrence. The risk anti-HPV immune serum. Arch Dermatol. 1984;120: for conversion to carcinoma is low but presents a real 514-516. risk if lesions are not destroyed. Both the patient and 7. Gross G, Roussaki A, Schöpf E, et al. Successful sexual partners should be regularly examined for signs treatment of condylomata acuminata and bowenoid of HPV infection or genital cancer. papulosis with subcutaneous injections of low- dose recombinant interferon-alpha. Arch Dermatol. 5()(5(1&(6 1986;122:749-750. 1. Schwartz RA, Janniger CK. Bowenoid papulosis. J Am 8. de Mari F, Rampen FH, van Everdingen JJ. Etretinate in Acad Dermatol. 1991;24(2, ptCUTIS 1):261-264. bowenoid papulosis. Lancet. 1982;1:1027. Do Not Copy

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