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230 Part I Disorders Presenting in the Skin and Mucous Membranes Etiology UVR, HPV, arsenic, tar, chronic heat exposure, and chronic radiation dermatitis. Clinical Manifestation Lesions are most often asymptomatic but may bleed. Nodule formation or onset of pain or tenderness within SCCIS suggests progression to invasive SCC. Skin Findings. Appears as a sharply demarcated, scaling, or hyperkeratotic macule, papule, or plaque (Fig. 11-4). Pink or red in color, slightly scaling surface or erosions, and can be crusted. Solitary or multiple. Such lesions are called Bowen disease (Fig. 11-4). Red, sharply demarcated, glistening macular or plaque-like SCCIS on the glans penis or labia minora are called erythroplasia of Queyrat (see Section 36). Anogenital HPV-induced SCCIS may be red, tan, brown, or black in color and are referred to as Bowenoid papulosis (see Section 36). Eroded lesions may have areas of crusting. SCCIS may go undiagnosed for years, resulting in large lesions with annular or polycyclic borders (Fig. 11-5). Once invasion occurs, nodular lesions appear within the plaque and the lesion is then commonly called Bowen carcinoma (Fig. 11-5). Distribution. UVR-induced SCCIS commonly arises within a solar keratosis in the setting of photoaging (dermatoheliosis); HPVinduced SCCIS, mostly in the genital area but also periungually, most commonly on the thumb or in the nail bed (see Fig. 10-33 and 34-16). Laboratory Examination Dermatopathology. Carcinoma in situ with loss of epidermal architecture and regular differen- tiation; keratinocyte polymorphism, single cell dyskeratosis, increased mitotic rate, and multinuclear cells. Epidermis may be thickened but basement membrane intact. Diagnosis and Differential Diagnosis Clinical diagnosis confirmed by dermatopathologic findings. Differential diagnosis includes all well-demarcated pink-red plaque(s): Nummular eczema, psoriasis, seborrheic keratosis, solar keratoses, verruca vulgaris, verruca plana, condyloma acuminatum, superficial BCC, amelanotic melanoma, and Paget disease. Course and Prognosis Untreated SCCIS will progress to invasive SCC (Fig. 11-5). In HIV/AIDS, resolves with successful antiretroviral therapy (ART). Lymph node metastasis can occur without demonstrable invasion. Metastatic dissemination from lymph nodes. Management Topical Chemotherapy. 5-Fluorouracil cream applied every day or twice daily, with or without tape occlusion, is effective. So is imiquimod, but both require considerable time. Cryosurgery. Highly effective. Lesions are usually treated more aggressively than solar keratoses, and superficial scarring will result. Photodynamic Therapy. Effective but still cumbersome and painful. Surgical Excision Including Mohs Micrographic Surgery. Has the highest cure rate but the greatest chance of causing cosmetically disfiguring scars. It should be done in all lesions where invasion cannot be excluded by biopsy.
Section 11 Precancerous Lesions and Cutaneous Carcinomas 231 A B Figure 11-4. Squamous cell carcinoma in situ: Bowen disease (A) A large, sharply demarcated, scaly, and erythematous plaque simulating a psoriatic lesion. (B) A similar psoriasiform plaque with a mix of scales, hyperkeratosis, and hemorrhagic crusts on the surface.
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