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CASE REPORT
Year : 2009  |  Volume : 54  |  Issue : 3  |  Page : 283-286
Bowenoid papulosis of the genitalia successfully treated with topical tazarotene : Areport of two cases


Department of Skin and STD, J.S.S Hospital, Mysore, Karnataka, India

Date of Web Publication10-Sep-2009

Correspondence Address:
Veeranna Shastry
Department of Skin and STD, J.S.S Hospital, Ramanuja Road, Mysore, Karnataka
India
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DOI: 10.4103/0019-5154.55643

PMID: 20161865

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   Abstract 

Bowenoid papulosis is a rare condition of the genital area caused by human papilloma virus. Clinically, it resembles viral wart and histopathologically Bowen's disease. We herein report two male patients presenting with multiple flat papules on the penis and scrotum. The second patient was HIV-positive. Histopathology showed features of bowenoid papulosis. Both the patients were treated with topical tazarotene gel 0.05%. Lesions cleared within 2 weeks in both the patients.Second patient had recurrences that cleared after retreatment with tazarotene.


Keywords: Bowenoid papulosis, human papilloma virus, tazarotene


How to cite this article:
Shastry V, Betkerur J, Kushalappa. Bowenoid papulosis of the genitalia successfully treated with topical tazarotene : Areport of two cases. Indian J Dermatol 2009;54:283-6

How to cite this URL:
Shastry V, Betkerur J, Kushalappa. Bowenoid papulosis of the genitalia successfully treated with topical tazarotene : Areport of two cases. Indian J Dermatol [serial online] 2009 [cited 2014 Oct 30];54:283-6. Available from: http://www.e-ijd.org/text.asp?2009/54/3/283/55643



   Introduction Top


Bowenoid papulosis (BP) is a distinct clinicopathologic entity characterized by multiple, small skin colored to reddish brown papules, primarily occurring on the genitalia of young adults. BP is strongly associated with human papilloma virus (HPV) infection and is difficult to differentiate clinically and histopathologically from squamous cell carcinoma in situ . [1] It is often considered as low grade in situ carcinoma. [2]

We herein report two cases of BP of genitalia successfully treated with topical tazarotene.


   Case Reports Top


Case 1

A 31-year-old, unmarried male presented with asymptomatic lesions over the scrotum for the past one year. Earlier treatment with topical steroids and antifungal agents had not shown any improvement. On examination, there was a large, well-defined, pigmented plaque with velvety surface over the scrotum [Figure 1]a. There were similar smaller papules present on the adjacent area and over the prepuce. Blood VDRL and HIV screening test were nonreactive. Skin biopsy from the lesion over the scrotum showed irregular acanthosis, disordered maturation of the epidermis, crowding of the nuclei, focal hypergranulosis, dyskeratosis, hyperchromatic, and multinucleated keratinocytes with increased mitosis [Figure 2] and [Figure 3].

On the basis of the clinical and histological features, the case was diagnosed as bowenoid papulosis and the patient was treated with tazarotene gel 0.05% once daily. After one week, lesion became erythematous and scaly with mild irritation and the treatment was stopped. The lesions completely cleared in the next week [Figure 1]b. The patient is under follow up for one year and there is no relapse.

Case 2

A 40-year-old male presented with asymptomatic lesions of three months duration over the penis. Previous treatment with topical antibiotics and antifungal agents failed to clear the lesions. Examination revealed multiple, well-defined, flat pigmented papules with velvety surface [Figure 4]a. The lesions were situated over the prepuce. Hemogram and urine analysis was within normal limits. ELISA test for HIV antibodies was positive. Skin biopsy from the lesion showed irregular acanthosis, vacuolated cells, pleomorphic cells, and dysmaturation [Figure 5] and [Figure 6].

The patient was treated with topical tazarotene 0.05% once daily. Although he had mild irritation initially, he continued the treatment and the lesions resolved within two weeks [Figure 2]b. After one month, few fresh lesions reappeared, which were again cleared with tazarotene.

Discussion

Bowenoid papulosis was first described by Kopf and Bart in 1977. [2] Some authors prefer to use the term penile intraepithelial neoplasia, but there is no formal consensus on the clinicopathological classification. An alternative expression of squamous intraepithelial lesion (SIL) has been proposed. [3] BP is probably a virus-induced epithelial dysplasia mainly associated with Human papilloma virus type 16 but other types have also been found. [3] HIV- infected individuals are at increased risk for persistent HPV infection and HPV-associated anogenital SIL. [1] It usually affects sexually active adults with slight female predominance and is more common in smokers. It presents as asymptomatic, flat, hyperpigmented, or violaceous papules, few millimeters to several centimeters in size, occurring over the penis, vulva, or perianally. [2] Lesions are also reported in the oral cavity and lower abdomen. [4]

Histopathology shows features resembling Bowen's disease. There is crowding and an irregular windblown arrangement of nuclei, many of which are large, hyper chromatic, and pleomorphic. Dyskeratosis atypical mitosis and multinucleated keratinocytes are also present. [5]

Over time, these lesions can regress, persists, recur, or progress to invasive squamous cell carcinoma in some cases. Female partners of men with BP and women with BP have a risk of cervical dysplasia. The condition has to be differentiated from genital warts, melanocytic nevi, seborrheic keratosis, lichen planus, Zoon's balanitis, squamous cell carcinoma, basal cell carcinoma, and anogenital Bowen's disease. [2]

Treatment of this condition is mainly by local agents such as 5 fluorouracil, imiquimod, podophylin, and cidofovir. Other modalities include excision, electrocautery, CO2 laser, cryosurgery, photodynamic therapy, and Interferon. [2],[3] Retinoid either topically or systemically is also effective in treating this condition. [6],[7] Therapeutic vaccination has also been tried. [8]

Tazarotene is a polyaromatic retinoid that influences epithelial cell proliferation and differentiation. It is mainly indicated in the management of acne vulgaris and psoriasis. It is also found to be useful in congenital icthyosis, [9] icthyosis bullosa of siemens, [10] nevus comedonicus, [11] linear Darier's disease, [12] elephantiasis verrucosa nostra, [13] basal cell carcinoma, [14] and in situ squamous cell carcinoma. [15]

Both of our patients had clinical and histological features of BP. The lesions completely regressed in both the patients after treatment with tazarotene. Mild burning sensation and erythema at the site of application were the only adverse effects observed in our cases. The rapid clinical response was more likely to be due to the effect of the drug rather than due to natural course of disease. Absence of recurrence in first case and successful retreatment in the second case also support the effectiveness of topical tazarotene in BP.

BP being asymptomatic often goes unnoticed. Though this condition is considered as a low grade in situ carcinoma, the prognosis is good in majority of the patients. Many drugs have been used to treat BP. Topical tazarotene has never been tried in this condition to the best of our knowledge. Our results suggest that topical tazarotene is an effective treatment for BP. It also offers faster and longer remissions. However, multicentric studies on a large number of patients are warranted to substantiate our results.

 
   References Top

1.Toro JR, Sanchez S, Turiansky G Blauvelt A. Topical cidofovir for the treatment of dermatologic conditions: Verruca, condyloma, intraepithelial neoplasis, herpes simplex and its potential use in smallpox. Dermatol Clin 2003;21:303-4.  Back to cited text no. 1      
2.Duncan KO, Geisse JK, Leffell DJ. Epithelial precancerous lesions. In: Wolff K, Goldsmith lA, Katz SI, et al . editors. Fitzpatrick's dermatology in general medicine. 7th ed. vol 1. New York: McGraw Hill Medical; 2008. p. 1007-27.  Back to cited text no. 2      
3.Bunker CB, Neil SM. The genital, perianal and umbilical regions In: Burns T, Breathnach S, Cox N, Griffith C, editors. Rook's Textbook of dermatology. 7 th ed. Oxford: Blackwell Science; 2004. p. 68.35-68.36.  Back to cited text no. 3      
4.Shwartz RA, Janniger CK. Bowenoid papulosis. J Am Acad Dermatol 1991;24:261.  Back to cited text no. 4      
5.Xu X, Erickson L, Chen L, Elder DE. Diseases caused by viruses. In: Elder DE, Elenitsas R, Murphy GF, Johnson B Jr, Xu X, editors, Lever's histopathology of skin. 10 th ed. Philadelphia: Lippincott-Williams and Wilkins; 2009. p. 65-7.  Back to cited text no. 5      
6.Weitzner JM, Fields KW, Robinson MJ. Pediatric bowenoid papulosis: Risks and management. Pediatr Dermatol 1987;6:303.  Back to cited text no. 6      
7.Gimeno E, Vilata JJ, Sanchez JL, Lloreta A, Fortea JM. Bowenoid papulosis: Clinical and histological study of 8 cases. Genitourin Med 1987;63:109-13.  Back to cited text no. 7      
8.Baldwin PJ, Vanden Burg SH, Boswell CM. Vaccinia expressed HPV 16 and 18 E6 and E7 as a therapeutic vaccination for vulval and vaginal intraepithelial neoplasis. Clin Cancer Res 2003;9:5205-13.  Back to cited text no. 8      
9.Barbarot S, Acher-Chenebaux A, Stalder JF. Topical tazarotene for severe congenital icthyosis. Ann Dermatol Venereol 2006;133:66-7.  Back to cited text no. 9      
10.Rajiv S, Rakesh SV. Icthyosis bullosa of Siemens: Response to topical tazarotene. Indian J Dermatol Venereal Leprol 2006;72:43-6.  Back to cited text no. 10      
11.Deliduka SB, Kwong PC. Treatment of nevus comedonicus with topical tazarotene and calcipotrien. J Drugs Dermatol 2004;3:674-6.  Back to cited text no. 11      
12.Brazzelli V, Prestinari F, Barbagallo T, Vasallo C, Agozzino M. Linear Darrier's disease successfully treated with 0.1% tazarotene gel 'short contact' treatment. Eur J Dermatol 2006;16:59-61.  Back to cited text no. 12      
13.Boyd J, Sloan S, Meffer T. Elephentiasis nostrum verrucosa of the abdomen: Clinical results with tazarotene. J Drugs Dermatol 2004;3:446-8.  Back to cited text no. 13      
14.Peris K, Fargnoli MC, Chimenti S. Preliminary observation on the use of topical tazarotene to treat BCC. N Engl J Med 1999;341:1707-8.  Back to cited text no. 14      
15.Bardazzi F, Bianchi F, Parente G. A pilot study on the use of topical tazarotena to treat squamous cell carcinoma in situ . J Am Acad Dermatol 2005;52:1102-4.  Back to cited text no. 15      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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