BOWENOID PAPULOSIS

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.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. 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. 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.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

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. 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.

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.

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.