Dermatology: Practical and Conceptual


Case Report  |  Dermatol Pract Concept 2016;6(2):2 5

DERMATOLOGY PRACTICAL & CONCEPTUAL
www.derm101.com

Introduction
Bowen’s disease (BD) is an in situ variant of cutaneous squa-

mous cell carcinoma (SCC). Etiological factors for BD include 

ultraviolet radiation (solar, iatrogenic and sunbeds) [1,2], 

radiotherapy, carcinogens (arsenic), immunosuppression 

[3,4], and infection with human papillomavirus [5-7]. Histo-

pathologically it is characterized by abnormal and pleomor-

phic keratinocytes that in the precursor stages involve only 

the lower part of the epidermis and, in time, with progression 

to BD, the full thickness of it. Dermatoscopic criteria have 

been described for pigmented and non-pigmented BD, actinic 

keratosis (AK) and superficial forms of SCC [8-10]. A recent 

study has focused on a progression model of actinic keratosis 

and intraepidermal carcinomas to invasive carcinoma but was 

limited to facial cases [10].

Case report

A 44-year-old male presented with a 10-year history of a 

35x25 cm erythematous hyperkeratotic, crusted, and ulcer-

Development of poorly differentiated invasive 
squamous cell carcinoma in giant Bowen’s disease: 

a case report with dermatoscopy
Bengu Nisa Akay1, Aysenur Maden1, Oguzhan Kocak2, Seher Bostanci1, Ayşe Boyvat1, 

Pelin Kocyigit1, Aylin Okcu Heper3

1 Ankara University Faculty of Medicine, Department of Dermatology, Ankara, Turkey

2 Kutahya Evliya Celebi State Hospital, Department of Dermatology, Kutahya, Turkey

3 Ankara University Faculty of Medicine, Department of Pathology, Ankara, Turkey

Key words: Bowen’s disease squamous cell carcinoma, dermatoscopy, dermoscopy

Citation: Akay BN, Maden A, Kocak O, Bostanci S, Boyvat A, Kocyigit P, Okcu Heper A. Development of poorly differentiated invasive 
squamous cell carcinoma in giant Bowen’s disease: a case report with dermatoscopy. Dermatol Pract Concept 2016;6(2):2. doi: 10.5826/
dpc.0602a02

Received: August 24, 2015; Accepted: January 12, 2016; Published: April 30, 2016

Copyright: ©2016 Akay et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

All authors have contributed significantly to this publication.

Corresponding author: Aysenur Maden, MD, Ankara University Faculty of Medicine, Department of Dermatology, Ankara, Turkey. Tel. 
+90 (312) 5082231; Fax. +90 (312) 3108636. E-mail: abotsali@hotmail.com

Bowen’s disease (BD) is an in situ form of squamous cell carcinoma (SCC), often occurring in the 
chronically UV-damaged skin of elderly people. The risk of progression of BD to invasive SCC var-
ies between 3% and 5%, and one-third of invasive tumors may metastasize. Herein we discuss the 
dermatoscopic findings of a case of giant Bowen’s disease, which progressed to poorly differentiated 
invasive SCC.

ABSTRACT

mailto:abotsali@hotmail.com


6 Case Report  |  Dermatol Pract Concept 2016;6(2):2

whole lesion. Multiple skin biopsies from the peripheral and 

central parts were taken. Central parts were histopathologi-

cally consistent with poorly differentiated invasive SCC, while 

peripheral parts were compatible with BD (Figure 4). There 

were no cytopathic changes compatible with human papil-

lomavirus infection. The patient’s arsenic level was found to 

be elevated on blood analysis.

Thoracic-abdominal-pelvic computed tomography did 

not show any metastasis. The lesion was totally excised with 

safe surgical margins and split-thickness skin grafting was 

performed in the plastic surgery department.

Discussion

Bowen’s disease (BD) can be considered a low-grade form of 

SCC, with the majority of studies reporting the risk of pro-

gression to SCC at 3-5% [12,13]. Despite the low incidence of 

malignant progression, BD has significant consequences since 

ated plaque on his abdominal region (Figure 1). The patient 

did not report previous history of trauma, immunosuppres-

sion or radiotherapy to the lesion site.

Dermatoscopic examination of the central part of the 

lesion with DermLite Pro HR (3Gen, LLC, San Juan Capist-

rano, CA, USA) mounted on an iPhone 5S®, revealed white 

circles and a vascular pattern, observed as large coiled ves-

sels in linear arrangement intermingled with ulcerations and 

adherent fibrin crusts (Figure 2).

The peripheral parts showed a linear arrangement of gray 

dots and coiled vessels without prominent white circles and 

ulceration (Figure 3).

The diameter of the coiled vessels on the central part was 

larger in size than seen in the periphery. In addition, red and 

white structureless areas were distributed throughout the 

Figure 1. Clinical image of the patient showed a 35x25 cm ery-

thematous hyperkeratotic, crusted, and ulcerated plaque on the ab-

dominal region. [Copyright: ©2016 Akay et al.]

Figure 2. Dermatoscopy of the 

central region. (A) Linear arrange-

ment of coiled vessels becoming 

convoluted and larger in size (blue 

arrows) intermingled with ulcer-

ation and adherent fibrin crusts. 

(B) White circles (blue arrows). 

[Copyright: ©2016 Akay et al.]

Figure 3. Dermatoscopy the peripheral region. (A, B) White and 

pink structureless areas, white lines (green circle) and a linear ar-

rangement of gray dots and coiled vessels (blue arrows). No ulcer-

ation or white circles are seen. [Copyright: ©2016 Akay et al.]

Figure 4. (A) Histopathology of 

the peripheral part which is con-

sistent with BD: An acanthotic 

epidermis shows full-thickness 

epidermal replacement by crowd-

ed keratinocytes that demonstrate 

disordered dyspolarity, lack of 

maturation, atypical mitotic fig-

ures and nuclear pleomorphism 

with hyperchromasia. A band-like 

lymphocytic infiltrate is appar-

ent in the papillary dermis. (B) 

Histopathology of the central re-

gion shows invasive part of tumor 

which extends as invasive broad 

tongues into the dermis. This part 

of the tumor composed of pleo-

morphic atypical epithelioid cells 

with high nucleocytoplasmic ratio 

and frequent mitosis. Squamous 

differentiation features, such as squamous pearls or single cell kera-

tinization, are not obvious. Foci of necrosis can be noted at the right 

part of the figure. [Copyright: ©2016 Akay et al.]



Case Report  |  Dermatol Pract Concept 2016;6(2):2 7

in the infundibular epidermis, which in effect is invasion of 

adnexa and can be a feature of well-differentiated SCC. The 

white circles observed in our case were poorly formed and 

sparse which may be associated with the poor differentiation 

status. In the present case, the periphery of the lesion cor-

responding to BD showed gray to brownish dots and coiled 

vessels arranged in lines, while the central part corresponding 

to invasive SCC revealed white circles, large coiled vessels 

arranged in lines and ulceration. The diameter of the coiled 

vessels on the central part was larger in size than seen on 

the periphery, similar to the progression model of Zalaudek 

et al [10]. In addition, white circles and ulceration were not 

observed on the parts where there was BD. Rosendahl et al., 

found the positive predictive value of white circles as 92% in 

SCC when compared with BD [14].

In conclusion, we have presented the first description 

of dermatoscopic findings of poorly differentiated invasive 

SCC developing on a huge BD. Dermatoscopy may help to 

differentiate intraepidermal carcinoma from invasive SCC, 

especially when confronted with white circles and coiled 

vessels with large diameter. This in turn may help clinicians 

not only to diagnose in situ or invasive lesions but also to 

improve the selection of lesions requiring biopsy or excision 

for definitive histopathologic diagnosis.

References
 1. Kossard S, Rosen R. Cutaneous Bowen’s disease. An analysis of 

1001 cases according to age, sex, and site. J Am Acad Dermatol 

1992; 27:406–10. PMID: 1401276.

 2. Reizner GT, Chuang TY, Elpern DJ, Stone JL, Farmer ER. Bowen’s 

disease (squamous cell carcinoma in situ) in Kauai, Hawaii. A 

population-based incidence report. J Am Acad Dermatol 1994; 

31:596–600. PMID: 8089285

 3. Drake AL, Walling HW. Variations in presentation of squamous 

cell carcinoma in situ (Bowen’s disease) in immunocompromised 

patients. J Am Acad Dermatol 2008; 59:68–71. PMID: 18440666. 

DOI: 10.1016/j.jaad.2008.03.028

 4. Moloney FJ, Comber H, O’Lorcain P, et al. A population-based 

study of skin cancer incidence and prevalence in renal transplant 

recipients. Br J Dermatol 2006; 154:498–504. PMID: 16445782. 

DOI: 10.1111/j.1365-2133.2005.07021.x

 5. Kettler AH, Rutledge M, Tschen JA, Buffone G. Detection of 

human papillomavirus in nongenital Bowen’s disease by in situ 

DNA hybridization. Arch Dermatol 1990; 126:777–81. PMID: 

2161202. DOI: 10.1001/archderm.1990.01670300077011

 6. Collina G, Rossi E, Bettelli S et al. Detection of human papillo-

mavirus in extragenital Bowen’s disease using in situ hybridiza-

tion and polymerase chain reaction. Am J Dermatopathol 1995; 

17:236–41. PMID: 8599431.

 7. Hama N, Ohtsuka T, Yamazaki S. Detection of mucosal human 

papilloma virus DNA in bowenoid papulosis, Bowen’s disease and 

squamous cell carcinoma of the skin. J Dermatol 2006; 33:331–7. 

PMID: 16700665. DOI: 10.1111/j.1346-8138.2006.00078.x

 8. Zalaudek I, Argenziano G, Leinweber B, et al. Dermoscopy 

of Bowen’s disease. Br J Dermatol 2004; 150:1112–6. PMID: 

15214896. DOI: 10.1111/j.1365-2133.2004.05924.x

approximately 20% of the tumors that develop into SCC will 

eventually become metastatic [12]. Therefore, patients with 

BD should be diagnosed and treated as early as possible.

Dermatoscopy is considered a helpful and non-invasive 

tool for increasing the diagnostic accuracy of BD. In 2004, 

Zalaudek et al., described dermatoscopic features of BD in 21 

cases [8]. They observed a particular type of vascular pattern 

in BD, named glomerular vessels, a variant form of dotted 

vessels that are large in size and often grouped and regularly 

arranged in clusters, mimicking the glomerular apparatus of 

the kidney. They emphasized that the “glomerular” vessels 

together with a scaly surface and, in cases of pigmented BD, 

the additional presence of pigmented small globules and/or 

homogeneous pigmentation, represent specific dermatoscopic 

criteria for the diagnosis of BD. In their study glomerular 

vessels were observed in 100% of the non-pigmented and 

80% of the pigmented BD. This special type of tortuous cap-

illary was histopathologically correlated to a convolution of 

grouped, frequently dilated capillaries in the dermal papillae 

and papillary dermis [8]. In 2010, Cameron et al., described 

dermatoscopic findings of pigmented BD, and they found 

that the linear arrangement of brown and/or gray dots and/or 

coiled vessels were specific clues to pigmented BD [9]. Pink, 

white or skin-colored structureless areas were found to be the 

most common finding in their study. Histopathologically, the 

brown to gray dots in BD may correspond to the presence of 

melanophages arranged in clusters and diffusely situated in 

the superficial dermis, and/or to a slightly increased number 

of pigmented keratinocytes in the basal layer and less fre-

quently in suprabasal locations. Dermatoscopy of SCC has 

been the subject of very recent studies.

Zalaudek et al., proposed a progression model of facial 

AK developing into BD and invasive SCC based on dermato-

scopic findings [10]. In this model, those AK that progress to 

increasing atypia tend to display vessels around follicles that 

become dotted (or coiled on higher magnification), then as 

the lesion develops into SCC in situ the dotted/coiled vessels 

appear to enlarge, become more convoluted and clustered, 

and the follicles in that area appear to miniaturize and dis-

appear eventually forming the discrete whitish, opaque scaly 

areas. With progression of BD to invasive SCC, looped and/

or linear irregular vessels will appear, and a central mass of 

keratin forms and ulceration may occur [10]. White circles, 

keratin, and blood spots were the strongest features associ-

ated with the diagnosis of SCC in a recent study by Rosendahl 

et al [14]. Especially, white circles were useful clues to dif-

ferentiate SCC and keratoacanthoma from other raised non-

pigmented skin lesions by dermatoscopy. White circle is a new 

dermatoscopic criterion, represented by white circles centered 

around a dilated infundibulum filled with a keratin plug that 

is visible as a yellow or an orange clod on dermatoscopy. 

White circles correspond to acanthosis and hypergranulosis 



8 Case Report  |  Dermatol Pract Concept 2016;6(2):2

12. Peterka ES, Lynch FW, Goltz RW. An association between Bowen’s 

disease and internal cancer. Arch Dermatol 1961; 84:623–9. PMID: 

14485715. DOI: 10.1001/archderm.1961.01580160087015

13. Kao GF. Carcinoma arising in Bowen’s disease. Arch Derma-

tol 1986; 122:1124-26. PMID: 3767398. DOI: 10.1001/arch-

derm.1986.01660220042010

14. Rosendahl C, Cameron A, Argenziano G, et al. Dermoscopy of 

squamous cell carcinoma and keratoacanthoma. Arch Dermatol 

2012; 148:1386-92. PMID: 22986634. DOI: 10.1001/archder-

matol.2012.2974

 9. Cameron A, Rosendahl C, Tschandl P, et al. Dermatoscopy of 

pigmented Bowen’s disease. J Am Acad Dermatol 2010; 62:597-

604. PMID: 20079953. DOI: 10.1016/j.jaad.2009.06.008

10. Zalaudek I, Giacomel J, Schhmid K, et al. Dermatoscopy of 

facial actinic keratosis, intraepidermal carcinoma and invasive 

squamous cell carcinoma: A progression model. J Am Acad 

Dermatol 2012; 66:589-97. PMID: 21839538. DOI: 10.1016/j.

jaad.2011.02.011

11. Cox NH, Eedy DJ, Morton CA. Guidelines for management of 

Bowen’s disease: 2006 update. Br J Dermatol 2007; 156:11-21. 

PMID: 17199561. DOI: 10.1111/j.1365-2133.2006.07610.x