Cox et al

Title: Guidelines for management of Bowen's disease: 2006 update.

Author: Cox NH, Eedy DJ, Morton CA on behalf of the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee.

Journal Reference: Brit J  Dermatol 2007;156:11-21. (by clicking on this link you will be leaving this site - Galderma is not responsible for the content)

Objective: to update the previous British Association of Dermatologists (BAD) guidelines for management of Bowen's disease (BD). They comprise evidence-based guidance for treatment, primarily for dermatologists, with identification of the strength of evidence available at the time of preparation of the guidelines.

Methods: The latest evidence on available treatments for BD was graded on the basis of:

  • Quality (from grade I to IV, where I represents the highest quality of evidence - evidence from at least one properly designed, randomised controlled trial, down to IV - where there are inadequate studies in terms of methodology).
  • Strength (from grade A to E, where A represents the highest strength of evidence - good evidence to support the treatment, down to E - where there is there is good evidence to reject the treatment).

The treatment recommendations also take into account simplicity, cost and healing. Additionally, updated information on BD epidemiology, predisposing factors, disease associations and risk of malignancy was analysed.

Key Recommendations:

  1. Routine investigation for internal malignancy in patients with BD is not justified - E I rating.
  2. The risk of progression to invasive cancer is about 3%. A high risk of recurrence occurs with perianal BD and prolonged follow up is recommended - AII-ii rating.
  3. 5-FU - reasonable evidence to support use but may be limited by irritancy and it was less effective than PDT - BII-I rating
  4. Topical imiquimod - used for BD but is costly, currently unlicensed for this indication, and the optimal regimen is unclear - BI rating
  5. Topical PDT - equivalent or superior to cryotherapy and 5-FU, either for efficacy and/or healing. Of particular benefit for lesions that are large, or on the lower leg but it is costly - AI rating
  6. Curettage - good evidence of efficacy, and time to healing - AII-ii rating
  7. Cryotherapy - good evidence of efficacy  but discomfort and time to healing are inferior to PDT or curettage -  BII-I rating 
  8. Excision - considered an effective treatment with low recurrence rates, but limited evidence - AII-iii rating. Micrographic surgery is useful at sites such as digits or penis - BIII rating; useful for poorly defined or recurrent head and neck BD - BII-iii rating.
  9. Radiotherapy - efficacious but with poor healing on the lower leg - generally B II-iii rating, but for lower leg lesions - D II-iii rating
  10. Laser treatment - limited evidence but may be a reasonable option for digital or genital lesions - B II-iii rating, but not for other sites.

Conclusion: no treatment is  superior for all clinical situations, although PDT gained the highest overall rating. For individual patients, factors such as treatment-related morbidity and the ease and availability of the treatment options may be more important than absolute cure rate. Choice exists for patients between clinic-based and home-administered treatments. The BAD guidelines emphasise that treatment is patient- and situation-specific.