Presurgical, neoadjuvant treatment of Bowens’ disease with 0.5% 5-fluorouracil in 10% salicylic acid

Roberta Giuffrida,1 Beatrice Bova,2 Maximilian Uranitsch,2 Bernd Feuerstein,3 Teresa Deinlein,4 Iris Zalaudek4

1Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, Italy

2Visiting fellow of the Department of Dermatology and Venereology, Medical University of Graz, Austria

3Department of Dermatology and Venereology, Paracelsus Medical University of Salzburg, Austria

4Department of Dermatology and Venereology, Medical University of Graz, Austria

Case presentation

A 94-year-old woman with multiple actinic keratosis was referred to our skin cancer unit because of large, partially nodular-ulcerated and hyperkeratotic plaques on her right front (Figure 1). Her medical history a highly differentiated squamous cell carcinoma (SCC) on her forehead, which had been completely excised ten years before. In addition she received oral anticoagulant treatment for a deep vein thrombosis of the left lower extremity one year before.

Diagnostic work up:

A punch biopsy was taken from the ulcerated nodule and histopathology revealed a Bowens’ disease.

Treatment and outcome:

Based on the age of the patient and the large extend of the lesion requiring major surgery and hospitalization, radiotherapy was offered as second treatment option. However, because the patient refused both, surgery and radiotherapy, topical treatment with 0.5% 5-fluorouracil in 10% salicylic acid  (5-FU/SA) once daily for 4 weeks was started. This decision was based on the combined keratolytic and cytotoxic components of the solution and the clinical features of thick hyperkeratotic plaques.

The patient was scheduled for a follow up 4 weeks later. At this visit, a marked erythema, erosions and hemorrhagic crusts were observed and the treatment was stopped (Figure 2). Re-evaluation 4 weeks later revealed a marked reduction of the tumor size (Figure 3). At this stage, the patient agreed to perform a simple excisional biopsy of the residual tumor. Histopathology of the excisional biopsy confirmed Bowens’ disease with clear margins. At latest follow up, 15 months after treatment start, she was free of recurrence.  

Figure 2

Figure 3


Key message

Bowen’s disease (BD), also named intraepidermal carcinoma (IED), represents an early form of cutaneous squamous cell carcinoma (SCC). It is estimated that about 3–5% of lesions may develop into invasive SCC1. For this reason, treatment of BD is generally recommended. Various treatment options are available and include surgical interventions, destructive therapies (liquid nitrogen), radiotherapy, light-based therapies, and topical therapies.2

Although a recent systematic review suggested similar or slightly better results in terms of outcomes between photodynamic compared to 5-FU,2 our decision to use low dose 5-FU/SA was based on the marked hyperkeratosis, requiring both a keratolytic and a cytotoxic treatment. In fact, 5-FU/SA been shown to be effective in the treatment of grad I and II, but also grad III (hyperkeratotic) actinic keratoses.3

In our patient, topical treatment with 5-FU/SA offered two benefits: First, we achieved a sufficient tumor reduction allowing for a simple excision. Second, it resulted in a field clearance of the surrounding damaged skin with a good cosmetic outcome despite the cutaneous local side effects after the treatment cycle.

In conclusion, our case suggests that low dose 5-FU/SA may be considered a neoadjuvant or palliative treatment option for BD in a selected group of patients.

Figure legends:

Figure 1: Bowens’ disease presenting as large, hyperkeratotic and partially ulcerated plaque on the forehead

Figure 2: Local cutaneous reactions of erythema, erosions and hemorrhagic crusts after application of topical low dose 5-FU/SA once daily.

Figure 3: Clinical picture 4 weeks after treatment continuation. Only a small part of the BD remained. This was removed by simple surgical excision.

References

  1. Morton CA, Birnie AJ, Eedy DJ. British Association of Dermatologists’ guidelines for the management of squamous cell carcinoma in situ (Bowen’s disease) 2014. British Journal of Dermatology. 2014;170(2):245–60.
  2. Bath-Hextall FJ, Matin RN, Wilkinson D, Leonardi-Bee J. Interventions for cutaneous Bowen's disease. Cochrane Database Syst Rev. 2013 Jun 24;(6): CD007281. doi: 10.1002/14651858.
  3. Herranz P, Morton C, Dirschka T, Azeredo RR, Roldán-Marín R. Low-Dose 0.5% 5-Fluorouracil/10% Salicylic Acid Topical Solution in the Treatment of Actinic Keratoses. J Cutan Med Surg. 2016;20(6):555-561.