Summary: Bowenoid papulosis is a pre-malignant condition affecting the ano-genital area. Pathogenesis may be associated with high-risk human papillomavirus genotypes, and sexual transmission is the most likely mode of acquisition. Risk of progression to invasive disease is low. Treatment usually involves locally destructive or ablative therapies. We report well-tolerated, successful clearance of bowenoid papulosis of the penis in a 25-year-old male, using topical Aldara (imiquimod) cream 5%, once every other day for two months.
Keywords: bowenoid papulosis, penis, imiquimod, immunocompetent
Introduction
Bowenoid papulosis exhibits histological features of carcinoma in situ, with similarities to other genital dermatoses such as Bowen’s disease. It presents clinically with macular or papular lesions in the ano-genital area which are typically pink or flesh coloured, and may be mistaken for condyloma accuminata, seborrhoeic keratosis or other common dermatoses such as lichen planus. Human papillomavirus (HPV) types 16 and 18 have been associated with the disease and patients are often young and sexually active. Distribution shares similarities with condylomata accuminata. Histological confirmation of diagnosis is usually followed by appropriate treatment, for which invasive and non-invasive modalities are available.
We describe a case in a young White male who responded to treatment with the immune response modifier imiquimod.
Case history
A 25-year-old British male presented to a university dermatology department whilst on a backpacking holiday in Australia and Southeast Asia. He expressed concern about an intermittent, nonitchy penile rash which had been present for the previous 12 months. His general health was good, other than asthma and flexural eczema. He had no history of sexually transmitted infection (but never tested for HIV) and was a non-smoker. There had been several casual female partners during his travels but no unprotected sex. His current regular female partner of 12 months had no history of genital warts or abnormal cervical cytology. This was also true of his previous regular partners. The only treatment prior to presentation was over- thecounter Canesten (clotrimazole) cream with some improvement of the rash.
Clinical examination at the time of diagnosis (September 2003) revealed an erythematous macular eruption on the glans penis (uncircumcised), with no signs of general dermatoses and no inguinal lymphadenopathy (Figure 1). Differential diagnosis included lichen planus, seborrhoiec balanitis, and atypical warts. Penile biopsy and histology revealed parakeratosis, abnormal cellular atypia and hyperchromatism, which, combined with preservation of the dermo- epidermal junction were suggestive of carcinoma in situ changes (Figure 2), and consistent with the diagnosis of bowenoid papulosis. The patient was offered surgical excision of his disease but declined, preferring to wait until his return to the UK, upon which he was seen by a dermatologist and promptly referred to the sexual health clinic for management.
Various treatment options were discussed but he was concerned about destructive therapies such as laser and electrodessication. After a negative HIV test result, topical imiquimod cream 5% was initiated, once a day on alternative days for one month. Follow-up at the end of treatment revealed a 75% reduction in lesion area, with no adverse effects. After a further month of imiquimod, the lesion had completely cleared (Figure 3) and treatment was discontinued. One month later a penile biopsy showed absence of both disease (Figure 4) and high risk HPV DNA. To date the patient remains clear of his bowenoid papulosis.
Figure 1. Bowenoid papulosis on glans penis before treatment
Figure 2a. Histological changes of carcinoma in situ with cellular atypia and parakeratosis of epithelium
Figure 2b. Showing preservation of dermo-epidermal junction
Figure 3. After treatment showing clearance of lesion on glans
Figure 4. Normal histological appearance, with hyperkeratosis and absence of atypia
Discussion
This case illustrates the importance of considering a diagnosis of bowenoid papulosis in sexually active young persons presenting with atypical macular papular or warty lesions on the anogenital area. Similar appearance to other pre-malignant conditions such as Bowen’s disease means that clinical diagnosis should be confirmed by histology. HPV-16, 18 and other genotypes are frequently found in bowenoid papulosis1 and sexual transmission is thought to be the main mode of transmission2. There have also been reports of vertical transmission of HPV-16 and development of bowenoid papulosis in a child3. Although classified as a carcinoma in situ, the risk for progression to invasive disease is low4, though a more aggressive course is found in older and immunosuppressed5 patients.
Current treatment is by ablative or destructive therapies, including surgical excision, CO2 laser and cryotherapy. Since recurrence is common, there has been increased interest in non- invasive methods such as intralesional β-interferon, cidovofir and 5FU. However, none of these are specific for HPV infection6.
Imiquimod, licensed for the treatment of external condyloma accuminata, acts via stimulation of the innate and cell-mediated immune systems to eliminate virally infected cells and reduce HPV viral load7. Concomitant induction of memory lymphocytes potentially reduces disease recurrence7. Reports in the literature suggest that imiquimod may be a well-tolerated and useful adjunct to managing bowenoid papulosis8. Our results concur with this view, although long-term follow-up for signs of disease recurrence will be required and his sexual partner will also need regular cytological screening.
References
1 De-Villiers EM. Papillomavirus and HPV typing. Clin Derm 1997;15:199-206
2 Obacks S, Jadlonska S, Beaudenon S, Walzczak L, Orth G. Bowenoid papulosis of male and female genitalia: risk of cervical neoplasia. J Am Acad Dermatol 1985;3:104-13
3 Godfrey JC, Vaughan MC, Williams JV, et al. Successful treatment of bowenoid papulosis in a 9 year-old girl with vertically acquired HIV. Paediatrics 2003;112(1):73-6
4 De-Belilosky C, Lessana-Leibovitch M. Bowen’s disease and bowenoid papulosis, comparison of clinical viral and disease progression aspects. Contraception Fertilitie Sexualitie 1993;21:231- 6
5 Redondo P, Lionet P. Topical imiquimod for bowenoid papulosis in an HIV positive women. Acta Derm Venereal 2002;82:212-13
6 Zanoti KM, Belinson J. Update on the diagnosis and treatment of HPV infection. Cleveland Clinic J Med 2002;69:948-61
7 Stanley MA. Mechanism of action of imiquimod. Papillomavirus Report 1999;10:23-9
8 Wigbels B, Luger T, Metze D. Imiquimod – a new possible treatment for bowenoid papulosis? Hautarzt 2001;52:128-31
(Accepted 3 June 2004)
B P Goorney FRCP and R Polori DipGUM
Department of Genito-Urinary Medicine, Hope Hospital, Stott Lane, Manchester M6 8HD, UK
Correspondence to: Dr B P Goorney
E-mail: [email protected]
Copyright Royal Society of Medicine Press Ltd. Dec 2004
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