| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Dermatology > VIRAL INFECTIONS
Bowenoid Papulosis
Article Last Updated: Jul 11, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Edward A DiPreta, MD, Department of Dermatology, Dermatology & Skin Cancer Center of Georgia
Edward A DiPreta is a member of the following medical societies: American Academy of Dermatology
Coauthor(s):
Kurt Maggio, MD, Director of Dermatologic Surgery and Cutaneous Oncology, Assistant Chief, Department of Dermatology, Walter Reed Army Medical Center
Editors: Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
viral keratosis, bowenoid papulosis of the penis, bowenoid papulosis of the genitalia, multifocal indolent pigmented penile papules
Background
Originally described in 1977 by Kopf and Bart as papules on the penis, bowenoid papulosis (BP) now is known to occur on the genitalia of both sexes in sexually active people. BP is manifested as papules that are induced virally by human papillomavirus (HPV) and demonstrate a distinctive histopathology (bowenoid dysplasia). Many of the lesions appear to run a benign course, although a number of case reports associate BP with malignant invasive transformation (2.6%).
BP may be considered to be a transitional state between a genital wart and Bowen disease. The rate of transformation is unknown. Clearly, lesions have some malignant potential, but they may be treated with locally destructive modalities, sparing the surrounding tissues. The lesions often are multifocal, and patients should be observed for recurrence and for the possibility of invasive or in situ malignancy.
Pathophysiology
BP is a focal epidermal hyperplasia and dysplasia induced by HPV infection (most commonly by HPV 16). The result is a papule demonstrating scattered atypical cells or full-thickness epidermal atypia that some view as analogous to squamous cell carcinoma in situ. This epidermal atypia is sometimes known as bowenoid dysplasia.
Frequency
United States
BP lesions are related clinically to genital warts. They share the same age of onset in patients and are transmitted sexually. Since BP lesions frequently are treated destructively as warts and without histopathologic examination, the true frequency of BP is unknown but is believed to be underestimated. With locally destructive therapy, the risk of invasive carcinoma appears to be low.
Mortality/Morbidity
Cervical lesions are associated with an increased incidence of abnormal cervical smears. Although BP has a low rate of developing invasive characteristics (2.6%), yearly serial examinations are recommended because of the possibility of recurrence.
Race
BP affects all races equally.
Sex
The male-to-female ratio is equal.
Age
The disease occurs primarily in young, sexually active adults, with a mean age of 31 years.
History
BP typically occurs in young sexually active persons. The disease tends to be benign with spontaneous regression occurring within several months. A more protracted course is believed to occur in older patients and, possibly, with lesions consistent with certain HPV types. These lesions may last as long as 5 years, or they may never regress completely. The lesions tend to be asymptomatic but can be inflamed, pruritic, or painful.
Physical
BP presents as solitary or multiple, small, pigmented (red, brown, or flesh-colored) papules with a flat-to-verrucous surface. The lesions can coalesce into larger plaques. Lesions occur most commonly on the shaft of the penis or the external genitalia of females, although they can occur anywhere on the genitalia and in the perianal region. Of note, 6 cases of nongenital BP have been reported.
Causes
HPV, particularly HPV 16, has been linked closely to BP. Other HPV types implicated include 18, 31, 32, 33, 34, 35, 39, 42, 48, 51, 52, 53, and 54. Consequently, the risk of acquiring BP is identical to that for other genital HPV-associated conditions via sexual contact or, possibly, via vertical transmission from mother to newborn.
Bowen Disease
Lichen Planus
Molluscum Contagiosum
Seborrheic Keratosis
Squamous Cell Carcinoma
Warts, Genital
Warts, Nongenital
Warty Dyskeratoma
Lab Studies
- Select a typical lesion for cutaneous biopsy, and send it for routine histologic evaluation.
-
- White vinegar (5% acetic acid) application may make subclinical lesions visible within 5-10 minutes.
-
Other Tests
- HPV subtyping is not performed routinely. If subtyping the lesion is considered necessary, this can be accomplished via Southern blot hybridization, dot blot hybridization, reverse blot hybridization, or polymerase chain reaction.
-
Histologic Findings
Histopathologic findings with routine hematoxylin and eosin stain vary from those of a genital wart with buckshot atypica to full-thickness epidermal atypia. This is characterized by a circumscribed epidermal proliferation composed of pleomorphic cells with clumped nuclei and numerous occasionally abnormal mitoses. The integrity of the dermal-epidermal border is preserved. The pattern occasionally has been described as windblown and may be identical to Bowen disease or squamous cell carcinoma in situ, occurring on nongenital skin.
Medical Care
- The most effective treatment is simple local destruction of the lesions. Various modalities have been used, although recurrences are common with all. The modalities include simple local excision, electrodesiccation, cryosurgery, laser surgery, and use of topical retinoic acid, podophyllum resin, and topical 5-fluorouracil.
- Immunomodulators have been reported as effective and may lengthen the remission period of lesions. Among immunomodulators, 2 of the agents include imiquimod 5% and interferon. Application of interferon beta may decrease the relapse rate by reducing transcription of viral RNA oncogenes E6 and E7.
Consultations
- Dermatologist: Reexamine lesional skin serially every 3-6 months because of the possibility of transformation to Bowen disease or invasive squamous cell carcinoma. The risk of transformation is higher in patients who are immunocompromised and in elderly patients.
-
- Gynecologist: Female patients and women who have had sexual relations with male patients should be seen for a thorough cervical examination because of the increased risk of malignancy.
-
- Urologist: Patients with urethral involvement should consider receiving an examination by a urologist.
-
- Proctologist: Patients with perianal involvement should consider scheduling an examination with a proctologist.
-
Activity
- Condom use may decrease the risk of transmission.
-
- Patients with HPV infection may be lifelong carriers of the virus. Partners should have regular evaluations. Female partners should be evaluated regularly using Papanicolaou smears.
-
- In male partners, periodic anogenital examination may be of benefit.
-
Destruction of the lesion is the treatment of choice. Most medications act to some degree as both destructive and immunomodulating agents.
Drug Category: Keratolytic agents
Inhibit cell proliferation by blocking the progression of the cell cycle at specific stages.
| Drug Name | Podophyllum resin (Pod-Ben, Podocon-25, Podofin) |
|---|
| Description | Topical treatment for benign growths including external genital and perianal warts, papillomas, and fibroids.
Arrests mitosis in metaphase; active agent is podophyllotoxin; type of podophyllum resin used determines strength. American podophyllum contains one fourth of the amount reported by an Indian source. |
|---|
| Adult Dose | Apply 10-25% concentration sparingly (1 drop at a time) onto lesions weekly (variations exist on frequency of treatment), allow drying between drops until area is covered
Treat only intact lesions; wash treatment area 1-2 h after first application; in subsequent treatments, patient can wait 4-6 h before washing off agent |
|---|
| Pediatric Dose | Apply as in adults |
|---|
| Contraindications | Documented hypersensitivity; diabetes; impaired peripheral circulation; avoid use on mucous membranes, eyes, bleeding warts, moles, birthmarks, or unusual warts with hair |
|---|
| Interactions | None reported |
|---|
| Pregnancy | X - Contraindicated in pregnancy
|
|---|
| Precautions | Powerful caustic and severe irritant; do not use if surrounding tissue is swollen or irritated; 25% solution should not be applied near mucous membranes; do not use large amounts; avoid contact with cornea; systemic absorption of large quantities has resulted in toxicity, particularly polyneuritis, paralytic ileus, thrombocytopenia, and leukopenia; histologic changes can be noted in squamous cells, which can be misread as squamous cell carcinoma |
|---|
| Drug Name | Trichloroacetic acid (Tri-Chlor) |
|---|
| Description | Cauterizes skin, keratin, and other tissues. Although caustic, causes less local irritation and systemic toxicity than others in the same class; however, response often is incomplete and recurrence occurs frequently. |
|---|
| Adult Dose | Apply 25-50% topical liquid to lesion, wash off in 1-2 h; avoid uninvolved skin; can be used in anal areas; repeat q1-2wk |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; premalignant or malignant lesions |
|---|
| Interactions | Topical medications that are irritants |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | External use only; restrict use to treatment areas only; may cause pain, burning, erythema, and erosion |
|---|
| Drug Name | Imiquimod (Aldara) |
|---|
| Description | Induces secretion of interferon alpha and other cytokines; mechanisms of action are unknown. |
|---|
| Adult Dose | Apply overnight for 3 nights per wk; wash off in 6-10 h |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Topical medications that are irritants |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal HPV infection; following surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed; may cause local irritation and erythema |
|---|
| Drug Name | 5-Fluorouracil cream (Efudex, Adrucil, Fluoroplex) |
|---|
| Description | For treatment-resistant BP. Interferes with DNA synthesis by blocking the methylation of deoxyuridylic acid, and inhibits thymidylate synthetase, which subsequently reduces cell proliferation. |
|---|
| Adult Dose | Apply 5% cream overnight qwk for up to 10 wk; adjust dose in patients tolerant to skin irritation |
|---|
| Pediatric Dose | Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; potentially serious infections |
|---|
| Interactions | None reported |
|---|
| Pregnancy | X - Contraindicated in pregnancy
|
|---|
| Precautions | Protect sensitive areas (eg, vulva, urethra, anus) using petroleum, zinc oxide, or 0.5% hydrocortisone as needed; inflammatory reactions may occur with occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction; may cause pain, burning, erythema, and erosions |
|---|
Further Inpatient Care
- BP may show malignant change; therefore, follow-up treatment is warranted every 3-6 months if the lesions recur or do not resolve.
-
Further Outpatient Care
- Perform serial examinations.
-
Deterrence/Prevention
- Advise patients to avoid direct contact with lesions.
-
- Advise patients to seek prompt treatment.
-
Complications
- BP has an increased potential to cause cervical neoplasia, vulvar neoplasia, Bowen disease, and invasive squamous cell carcinoma.
-
Prognosis
- Prognosis is variable. Younger patients tend to have a self-limiting course lasting months. Patients who are older or immunocompromised can have a protracted course lasting years and, possibly, no resolution.
-
Patient Education
- Educate patients regarding the malignant potential of BP and the avoidance of direct sexual contact to decrease transmission of the disease.
-
Medical/Legal Pitfalls
- Failure to refer female patients with BP for appropriate gynecologic examination
-
- Failure to counsel patients regarding the sexual transmission and malignant potential of this condition
-
| Media file 1:
Bowenoid papulosa histopathology (hematoxylin and eosin, magnification 40X). |
 |  View Full Size Image | |
Media type: Photo
|
| Media file 2:
Bowenoid papulosa histopathology (hematoxylin and eosin, magnification 400X). |
 | View Full Size Image | |
Media type: Photo
|
| Media file 3:
Typical appearance of bowenoid papulosis in the female. |
 | View Full Size Image | |
Media type: Photo
|
- Champion RH, Burton JL, Burns DA. Rook/Wilkinson/Ebling Textbook of Dermatology. Vols 1-2. 6th ed. London, UK: Blackwell Science; 1998:1047, 1676, 3197-8, 3233.
- de Belilovsky C, Lessana-Leibowitch M. [Bowen's disease and bowenoid papulosis: comparative clinical, viral, and disease progression aspects]. Contracept Fertil Sex. Mar 1993;21(3):231-6. [Medline].
- Elder D, Elenitsas R, Jaworsky C. Lever's Histopathology of the Skin. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997:579, 584-6.
- Goorney BP, Polori R. A Case of Bowenoid Papulosis of the Penis Successfully Treated with Topical Imiquimod Cream 5%. Int J STD AIDS. Dec 2004;15(12):833-5. [Medline].
- Grekin RC, Samlaska CP, Vin Christian K. Andrews Diseases of the Skin. 9th ed. Philadelphia, Pa: WB Saunders; 2000:515.
- Johnson TM, Saluja A, Fader D, Blum D, Cotton J, Wang TS, et al. Isolated extragenital bowenoid papulosis of the neck. J Am Acad Dermatol. Nov 1999;41(5 Pt 2):867-70. [Medline].
- Lucker GP, Speel EJ, Creytens DH, van Geest AJ, Peeters JH, Claessen SM, et al. Differences in imiquimod treatment outcome in two patients with bowenoid papulosis containing either episomal or integrated human papillomavirus 16. J Invest Dermatol. Mar 2007;127(3):727-9. [Medline].
- Lucker GP, Speel EJ, Creytens DH, van Geest AJ, Peeters JH, Claessen SM, et al. Differences in imiquimod treatment outcome in two patients with bowenoid papulosis containing either episomal or integrated human papillomavirus 16. J Invest Dermatol. Mar 2007;127(3):727-9. [Medline].
- Majewski S, Jablonska S. Human papillomavirus-associated tumors of the skin and mucosa. J Am Acad Dermatol. May 1997;36(5 Pt 1):659-85; quiz 686-8. [Medline].
- Orengo I, Rosen T, Guill CK. Treatment of squamous cell carcinoma in situ of the penis with 5% imiquimod cream: a case report. J Am Acad Dermatol. Oct 2002;47(4 Suppl):S225-8. [Medline].
- Patterson JW, Kao GF, Graham JH, Helwig EB. Bowenoid papulosis. A clinicopathologic study with ultrastructural observations. Cancer. Feb 1986;57(4):823-36. [Medline].
- Ricart JM, Cordoba J, Hernandez M, Esplugues I. Extensive genital bowenoid papulosis responding to imiquimod. J Eur Acad Dermatol Venereol. Jan 2007;21(1):113-5. [Medline].
- Schwartz RA, Janniger CK. Bowenoid papulosis. J Am Acad Dermatol. Feb 1991;24(2 Pt 1):261-4. [Medline].
- Schwartz RA, Stoll HL. Epithelial precancerous lesions. In: Freedberg IM, Fitzpatrick T, eds. Fitzpatrick's Dermatology in General Medicine. Vol 1. 5th ed. New York, NY: McGraw-Hill; 1999:831-2.
Bowenoid Papulosis excerpt Article Last Updated: Jul 11, 2007
|
