BRIEF REPORT
Pigmented Bowen Disease in the Acral Region: A Diagnostic
Challenge
Rita Fernanda Cortez de Almeida, MD,* Ariane Sponchiado Assoni, MD,*
João Pedro Cabrera Pereira, MD,* Luiza Erthal de Britto Pereira Kassuga Roisman, MD, MSc,*,†
and Thiago Jeunon, MD*,‡
Key Words: pigmented Bowen disease, Bowen disease, dermoscopy,
pigmented lesions, acral region
(Am J Dermatopathol 2023;45:235–236)
INTRODUCTION
Bowen disease (BD) is a type of squamous cell
carcinoma in situ that presents itself mostly as flattish
erythematous scaly lesions on thin skin over the body.1 BD
seldom presents itself as a pigmented lesion, when it is char-
acterized by a nonuniform hyperpigmented patch or plaque
with a smooth, velvety, or verrucous surface.1 Pigmented BD
should be clinically distinguished from a variety of differen-
tial diagnoses, including melanoma, atypical nevus, sebor-
rheic keratosis, pigmented solar keratosis, and pigmented
basal cell carcinoma.2,3
Dermoscopy enhances the ability to specifically diag-
nose pigmented BD due to the recognition of some well-
stablished criteria, such as keratotic/scaly surface, glomerular
vessels, hypopigmented structureless zones, and brown or
grey dots arranged in a linear fashion.4
However, BD rarely occurs on the volar skin.1
Pigmented BD on palms and soles is even rarer, representing
an exceptional occurrence. Dermoscopic criteria for the diag-
nosis of pigmented BD on these topographies have not been
set forth.5
Herein, we report a case of pigmented BD on the palm
in which classic dermoscopic patterns usually found in
pigmented lesions located on nonvolar skin were absent.
CASE REPORT
A 66-year-old man, Fitzpatrick phototype V, presented with
an 0,3 · 0.7 cm irregular brownish macule, in the right palm with 1
year of evolution and progressive growth (Fig. 1A). His medical
history was remarkable for lichen simplex chronicus in the lower
limbs. Dermoscopic examination revealed structureless light brown
to dark pigmented areas with irregular contours, occupying furrows
and ridges (Fig. 1B). After 3 months of follow-up, the lesion re-
mained unchanged. Because of the lack of any specific finding and
From the *Department of Dermatology, Hospital Federal de Bonsucesso, Rio
de Janeiro, Brazil; †Brazilian National Cancer Institute, Rio de Janeiro,
Brazil; and ‡ID, Investigação em Dermatologia, Rio de Janeiro, Brazil.
The authors declare no conflicts of interest.
Correspondence: Thiago Jeunon, MD, Rua General Roca 778/1005 Tijuca,
Rio de Janeiro—RJ, Brasil (e-mail: thiago.jeunon@gmail.com).
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
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uncertainty about the diagnosis, an excisional biopsy was performed.
Histopathology depicted hyperkeratosis and acanthosis, with pleo-
morphic squamous keratinocytes occupying the role thickness of the
Malpighian layer. Numerous dyskeratotic cells were found (Fig. 2).
No evidence of relapse was found on follow-up.
DISCUSSION
The volar skin has a thicker epidermis with a more
compact stratum corneum when compared with the other
regions.6 The surface also presents an alternation of parallel
ridges and furrows. Histologic features of volar skin are
known to be responsible for the distinct dermoscopic presen-
tation of pigmented lesions in these topographies, for exam-
ple, parallel furrows pigmentation pattern of acral
melanocytic nevi and parallel ridge pigmentation pattern of
acral melanomas. It might also explain the lack of specific
dermoscopic features of pigmented BD in our case, contrib-
uting to the atypical presentation.
The differential diagnosis included verruca vulgaris,
thermal or mechanical injury resulting in intracorneal hem-
orrhage and/or epidermal necrosis, and melanoma. When
facing pigmented acral lesions, a method to avoid missing
malignant lesions, particularly acral melanoma should be
applied. Our group followed the revised 2-step dermoscopy
algorithm for the classification of pigmented lesions of the
skin.7 The lesion was considered structureless because of a
lack of any discernible structures and could not be categorized
as melanocytic or nonmelanocytic. In such cases, a skin
biopsy is needed to rule out melanoma.7
The diagnosis of pigmented BD is often missed or
delayed because of the scarce and variable clinical/
dermoscopic findings in volar skin. Despite the lack of
well-established criteria for this region, dermoscopy remains
an auxiliary tool for the early diagnosis of cutaneous lesions.
It might also be useful to guide incisional biopsies. The
possibility of malignancy should always be considered in
lesions that did not fit well in established dermoscopic crite-
ria, and histopathology is essential for the definitive
diagnosis.8
In conclusion, typical dermoscopic criteria used for the
diagnosis of PBD in nonvolar skin may not typically be
visualized in the acral region. The relevance of this case is to
highlight the importance to follow the 2-step dermoscopy
algorithm for the classification of pigmented lesions to avoid
missing malignant lesions and to include PBD in the
differential diagnosis of pigmented skin lesions.
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Cortez de Almeida et al Am J Dermatopathol  Volume 45, Number 4, April 2023

FIGURE 1. Clinical and dermoscopic findings.

A, Light brown to dark, irregular, pigmented
macule on the right palm. B, Light brown to
dark pigmented areas, with irregular contours,
occupying furrows and ridges (20· magnifica-
tion, nonpolarized light).

FIGURE 2. Histopathology. A, Parakeratosis,

slight acanthosis, and cell crowding
within the epidermis. Hematoxylin and
eosin, 40·. B, Proliferation of pleo-
morphic squamous keratinocytes and
dyskeratosis. Hematoxylin and eosin,
400·.

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