Photodiagnosis and Photodynamic Therapy (2013) 10, 546—548

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CASE REPORT/RESEARCH LETTER

Huge Bowen’s disease: A pitfall of topical

photodynamic therapy
Ji-Youn Park a, Sue Kyung Kim a, Kwang Hyun Cho b,
You Chan Kim MD, PhD a,∗

a
Department of Dermatology, Ajou University School of Medicine, Suwon, Republic of Korea
b
Department of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea
Available online 15 June 2013

KEYWORDS Summary Bowen’s disease (BD) is one of the major histological types of nonmelanoma skin
Bowen’s disease; cancer. With challengeable ‘‘multiple and large’’ patches of BD, topical photodynamic therapy
Photodynamic (PDT) has been considered as a first-line effective modality for decades. However, there was
therapy no general consensus among authors about the definition of ‘‘large BD’’. Herein, we have
experienced two cases of huge BD which has over 10 cm in diameter with resistance to topical
PDT. Our cases suggest that topical PDT is likely to show a much less satisfactory effect for huge
BD than we have expected, and the previously specified indication of topical PDT (‘‘multiple,
larger lesion’’) seems the fallacy of hasty generalization. Therefore, it is required that further
cut-off value of size for suitable candidate for topical PDT would be clarified.
© 2013 Elsevier B.V. All rights reserved.

Bowen’s disease (BD) is one of the major non-melanoma skin
cancers [1]. For large or multiple patches of BD, photody-
namic therapy (PDT) has been considered to be an effective
modality for decades [1—3]. However, the ‘‘multiple and
large’’ lesions mean still vague so far, and there was no gen-
eral consensus among authors about the definition of ‘‘large
BD’’.
Case 1. A 79-year-old woman presented with a 40-year
history of a well-defined erythematous plaque, measur-
ing 21 cm × 14 cm with nodular lesions on her right breast
(Fig. 1A). Multiple skin biopsies showed BD for plaque
lesion, accompanying squamous cell carcinoma (SCC) for
the nodular appearance. The lesion was unsuitable for
∗ Corresponding author at: Department of Dermatology, Ajou
University School of Medicine, 5 Woncheon Dong, Yeongtong-Gu,
Suwon-si, Gyeonggi-do 443-721, Republic of Korea.
Tel.: +82 31 219 5190; fax: +82 31 219 5189.
E-mail address: maychan@ajou.ac.kr (Y.C. Kim).
surgical management because of its huge size; there-
fore, the local excision for SCC with following topical
5-aminolevulinic acid (ALA)-PDT was attempted. After 4 h
of occlusive dressing, the lesion was illuminated with
Waldman PDT 1200® (Waldmann-Medizin-Technik, Villingen-
Schwenningen, Germany) at a dose of 110—180 J/cm2 and an
irradiance of 100 mW/cm2 . During topical PDT treatment,
the lesion became smaller and the roughness of lesion was
improved; therefore the patient wanted to undergo addi-
tional sessions. After 18 sessions of PDT, the lesion was
smaller, but remained persistently (Fig. 1B). Radiotherapy
was recommended; however, the patient was lost to follow-
up.
Case 2. A 55-year-old man presented with a well-defined
erythematous patch, measuring 13 cm × 12.5 cm, on his left
flank (Fig. 2A). Multiple skin biopsies revealed BD, and top-
ical 5-ALA-PDT was started. With an identical incubation
time and light source to those of Case 1, the lesion was
illuminated at a dose of 120 J/cm2 and an irradiance of
100 mW/cm2 . After 15 sessions of PDT and the additional

1572-1000/$ — see front matter © 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.pdpdt.2013.05.001
Huge Bowen’s disease 547

Figure 1 Case 1, a well-defined erythematous round plaque measuring 21 cm × 14 cm with an erythematous nodule on her right
breast. Skin biopsy from the erythematous plaque showed the proliferation of atypical squamous cells through the entire thickness
of the epidermis, diagnosed as BD and from the nodular lesion showed SCC (original magnification, hematoxylin—eosin stain, left:
100×, right: 40×), after 18 sessions of PDT, the lesion was smaller in size and much improved, but the residual lesion still showed
clinically.

Figure 2 Case 2, a well-defined erythematous to brownish patch measuring 13 cm × 12.5 cm was observed on his left flank. With
skin biopsy, the lesion confirmed as BD. (original magnification; hematoxylin—eosin stain, 100×), After 15 sessions of PDT, the lesion
still remained clinically and histologically (original magnification; hematoxylin—eosin stain, 100×).
548
application of imiquimod 5% cream three times a week,
the post-treatment biopsy still showed residual tumor cells
(Fig. 2B).
The treatment options for BD include surgery, electrodis-
section, cryotherapy, immune modulating topical creams
(5-fluorouracil and imiquimod), PDT, laser ablation, and
radiotherapy [4]. The choice of therapy depends on patient
suitability, location of lesion, and number of lesions. Topi-
cal PDT is a well-tolerated treatment modality, widely used
for treating BD. Also, it is considered as a first-line therapy
for larger or multiple BD [1—3]. According to Calzavara-
Pinton et al. [5], the maximal diameter of a lesion was
not a predictor of treatment outcome, but only an asso-
ciative factor of relapse. Unlike this result, topical PDT
showed little effect in our cases. The distinguishing feature
of our cases was the huge size of the lesions, compared to
lesions reported by Calzavara-Pinton et al. [5], which was
20 mm. Other reports have determined a ‘‘large’’ lesion
to be a lesion greater than 30 mm [1] or 20 mm [2] in
diameter. Only one report has mentioned a much larger
lesion with 8 cm of maximal diameter [3]. It is postu-
lated that clinically larger lesions may be correlated with
a larger tumor burden and deeper maximal invasion depth
[1]. Radiotherapy, another treatment modality for huge BD,
also showed an unsatisfactory outcome with failure of heal-
ing in 12 (20%) of 59 lesions up to 10 cm in diameter [6].
Although topical PDT is the recommended first-line treat-
ment for ‘‘large’’ BD, the definition of ‘‘large’’ is still
vague. Therefore, it is premature to conclude that topi-
cal PDT is the most suitable treatment modality for these
lesions. In terms of systemic PDT, there have been only
3 reports, which mentioned systemic PDT on treating BD
patients [7—9]. With those articles, we have found that
systemic PDT seems also quite beneficial for treating BD.
However, it is unsatisfactory for conclude because of the
small number of patients who underwent systemic PDT so
far. For huge BD like our cases, there was a paucity of report
with systemic PDT. Although the patients were refractory to
topical PDT, it does not imply additional refractoriness with
systemic PDT. There might be a possibility to response sys-
temic PDT, though they showed poor response with topical
PDT.
In conclusion, our cases suggest that topical PDT is likely
to show a much less satisfactory effect for huge BD than
we have expected, and the previously specified indication
of topical PDT (‘‘multiple, larger lesion’’) seems the fal-
lacy of hasty generalization. Therefore, the huge diameter
of BD should be considered as a poor prognostic factor for
using topical PDT, and it is required that further cut-off
J.-Y. Park et al.
value of size for suitable candidate for topical PDT would
be clarified.
Conflict of interest
None.
Acknowledgment
Funding support — This research was supported by the Basic
Science Research Program through the National Research
Foundation of Korea (NRK), funded by grant 2010-0022412
from the Ministry of Education, Science, and Technology.
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