Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(2):e2024086 1 Dermoscopic Features of Pigmented Bowen Disease: A Multicenter Study on Behalf of the Ibero-Latin American College of Dermatology (CILAD) Horacio Cabo1, Gabriel Salerni2, Emilia Cohen Sabban3, Agustín Bollea Garlatti4, Nicole Orendain5, Sonia Rodríguez-Saa6, Renato Marchiori Bakos7, Flavia Carolina Pozzobon8, Virginia M González9, Rosario Peralta10, Cristian Navarrete-Dechent11, 12, Dominga Peirano12, Elia Pérez-Fernández13, Susana Puig14 1 Head Professor of Dermatology, Universidad de Buenos Aires, Argentina 2 Dermatology Department, Hospital Provincial del Centenario de Rosario - Universidad Nacional de Rosario, Rosario, Argentina 3 Head of Dermatology Service, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, Argentina 4 Private practice, San Miguel de Tucumán, Tucumán, Argentina 5 Private practice, Guadalajara, Mexico 6 Department of Dermatology, Hospital Nuestra Señora del Carmen, Obra Social de Empleados Públicos (OSEP), Godoy Cruz, Mendoza, Argentina 7 Department of Dermatology, Hospital de Clınicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil 8 Centro de Diagnostico Dermatológico, Bogotá, Colombia; Instituto Nacional de Cancerología, Bogotá, Colombia 9 Dermatology Department, Hospital Alemán, Buenos Aires, Argentina 10 Dermatology Department, Instituto de Investigaciones Médicas “A. Lanari”, University of Buenos Aires, Buenos Aires, Argentina 11 Melanoma and Skin Cancer Unit, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile 12 Department of Dermatology Pontificia Universidad Católica de Chile, Santiago, Chile 13 Unidad de Investigación. Hospital Universitario Fundación Alcorcón, Madrid, Spain 14 Melanoma Unit, Hospital Clinic Barcelona, University of Barcelona, Barcelona, Spain. CIBER de enfermedades raras, Instituto de Salud Carlos III, Barcelona, Spain Key words: Bowen disease, dermoscopy, pigmented Bowen disease, skin cancer, diagnosis Citation: Cabo H, Salerni G, Sabban EC, et al. Intralesional Quadrivalent Human Papillomavirus (HPV) Vaccine Versus Candida Antigen in the Treatment of Multiple Recalcitrant Non-Genital Warts. Dermatol Pract Concept. 2024;14(2):e2024086. DOI: https://doi.org/10.5826/dpc.1402a86 Accepted: October 2, 2023; Published: April 2024 Copyright: ©2024 Cabo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Gabriel Salerni, Salta 2391. CP 2000. Rosario. Argentina. Phone: +54 341 4398586 Email: gabrielsalerni@hotmail.com 2 Original Article | Dermatol Pract Concept. 2024;14(2):e2024086 Introduction Bowen disease (BD) is a form of squamous cell carcinoma in situ that shows full-thickness involvement of the epidermis, and the pilosebaceous units. In the case of pigmented Bowen disease (pBD), the distinguishing feature is the presence of pigmentation or dark coloration within the lesion [1]. Clinically, pBD appears as a well-defined, dark brown or black patch on the skin, often resembling melanoma or other pigmented skin lesions. It typically occurs on sun-exposed areas of the body, such as the face, scalp, neck, and hands, although it can appear elsewhere as well. The lesion may be flat or slightly raised, and it can be associated with symp- toms like itching or tenderness [1]. Dermoscopy has shown to be a valuable tool in the di- agnosis of skin cancer, by providing enhanced visualization, improving diagnostic accuracy, and enabling early detection of both melanoma and non-melanoma skin cancer [2-6]. The dermoscopic features of pBD have been already described in Caucasian European population [7]; however, studies fo- cused on Latin American population are scarce and limited to case reports or small series. Herein, we report dermoscopic findings in a large series of pBD in Latin American population with mostly skin pho- totype 3 and 4. To the best of our knowledge this is the first study focused on this specific population. Objectives To report dermoscopic findings in a large series of 147 pBD diagnosed in Ibero-Latin American population. Methods We conducted a retrospective analysis of clinical and der- moscopic characteristics of 147 histologically proven pBD retrieved from the database of 22 institutions (private and academic centers), planned as a project of the Dermoscopy Chapter of Ibero-Latin American College of Dermatol- ogy (CILAD). All active CILAD members were invited to participate in the study, the call was made through periodic mails/reminders through the CILAD mailing list for a period of 3 months. We included cases of biopsy-proven pBD with clinical and dermoscopic pictures. We excluded patients were either clinical or dermoscopic photos were missing or if the images were of poor quality. Clinical data such as age, gender, previous history of skin cancer and skin phototype of the patients and the evolu- tion, localization and diameter of the lesions were recorded. The clinical and dermoscopic images were included into a PowerPoint presentation (Microsoft Corp) and images were evaluated by 2 experts dermoscopists (G.S. and H.C.) who performed both clinical and dermoscopic evaluation. Der- moscopic images were assessed for the presence or absence of criteria for pBD as previously described [7-10]. If the two observers did not agree on any point of the clinical and dermoscopic evaluation, a consensus ruling was applied to reach agreement. Statistical Analysis The data was analyzed with the SPSS 22 program. The dis- tribution of the qualitative data is presented by means of absolute and relative frequencies and the distribution of the Introduction: Studies focused on dermoscopic aspects of pigmented Bowen disease (pBD) in Latin American population are scarce and limited to only case reports or small series. Objectives: To report dermoscopic findings in a large series of 147 pBD diagnosed in Ibero-Latin American population. Methods: We conducted a multicentric, retrospective study on 147 histologically proven pBD under the auspices of the Dermoscopy Chapter of the Ibero-Latin American College of Dermatology. Results: The study population consisted of 77 females (52%) and 70 males (48%) with a mean age of 68.6 years. 70.1% of patients had skin phototype 3, 15.6% to skin phototype 2, and 14.3% to skin phototype 4. On clinical examination, near 60% of pBD were flat, 70% presented with scales, and 90% were asymmetric. Under dermoscopy, structureless hypopigmented areas, dots brown and pink color were the most frequently observed. Regarding specific dermoscopic clues to pBD, the most prevalent were structureless hypopigmented areas, vessels arranged in linear fashion at the periphery, and pigmented lines or pigmented dots distributed in a linear fashion. Clustered, coiled, and dotted vessels were observed in 55.8%, 45.6%, and 45.6% of the cases, respectively. Conclusions: We report a large series of cases of pBD in Latin American patients, with most patients being skin phototype 3 and 4. Distinctively in our study, the pigmented structures and the clues derived from the presence of melanin were much more frequent than in previous reports in fair skin. ABSTRACT Original Article | Dermatol Pract Concept. 2024;14(2):e2024086 3 quantitative data by mean and standard deviation or median and interquartile range, depending on the distribution of the data. The estimates of the dermoscopic findings are pre- sented, accompanied by the corresponding 95% confidence intervals calculated by the exact method. Results Population A total of 147 pBD analyzed. The study population con- sisted of 77 females (52%) and 70 males (48%) with mean age of 68.6 (range 40-94) years. Regarding skin phototype, 103 (70.1%) corresponded to skin phototype 3, 23 (15.6%) phototype 2, and 21 (14.3%) phototype 4. A total of 40 pa- tients had previous history of basal cell carcinoma (27.2%), 26 of squamous cell carcinoma (17.7%), and 9 (6.1%) of melanoma. Clinical Evaluation Median size of the lesions was 13 mm (interquartile range [IQR] 10-19). Fifty lesions (34%) were located on lower extremities, 28 (19%) in upper extremities, 23 (15.6%) on head and neck, 22 (15%) on anterior trunk, 14 (9.5%) on posterior trunk, and 10 (6.8%) on other localizations. The median time to diagnosis was 18 months (IQR 12-24) and it was unknown in 34 cases (23.1%). On clinical examination, near 60% of pBD were flat (N = 87), 70% (N = 104) presented with scales, and 90% (N = 133) were asymmetric. Dermoscopic Evaluation Dermoscopy evaluation is shown in Table 1. Regarding dermoscopic features, structureless areas were observed in most cases (92.5%, N = 136), followed by dots in more than 70% of cases (N = 105); circles were observed only in 8.2% of the cases (N = 12). Brown and pink colors were the most frequent, observed in 98 and 94.6% respectively; white color was observed in 52.7% and gray color in 36.7%. Blue and black colors were observed both in only 3.4% of cases. The most prevalent dermoscopic clues to pBD ob- served were: structureless hypopigmented areas in 91.8% (N = 135), vessels arranged in linear fashion at the periph- ery in 62.6% (N = 92), and pigmented lines or pigmented dots in linear arrangement in 59.2% (N = 87). Clustered, coiled, and dotted vessels were observed in 55.8% (N = 83), 45.6% (N  =  77), and 45.6% (N = 67), respectively. Only 9.5% (N = 14) displayed no specific dermoscopic clues upon examination (Figure 1). Table 1. Dermoscopic characteristics Total N = 147 N Percentage CI95% Features Structureless 136 92.5% 87% 96% Dots 105 71.4% 63% 79% Circles 12 8.2% 4% 14% Color Brown 144 98.0% 94% 100% Pink 139 94.6% 90% 98% White 77 52.4% 44% 61% Gray 54 36.7% 29% 45% Black 5 3.4% 1% 8% Blue 5 3.4% 1% 8% Dermoscopic clues Hypopigmented structureless areas (white, pink, or skin colored) 135 91.8% 86% 96% Vessels distributed in a linear fashion 92 62.6% 54% 70% Vessels distributed in a linear fashion at the periphery 90 61.2% 53% 69% Pigmented lines or dots distributed in a linear fashion 87 59.2% 51% 67% Clustered vessels 82 55.8% 47% 64% Coiled vessels 77 52.4% 44% 61% Dotted vessels 67 45.6% 37% 54% CI = confidence interval. 4 Original Article | Dermatol Pract Concept. 2024;14(2):e2024086 Figure 1. Examples of pBD, clinic (top row) and dermoscopic images (bottom row). Dermoscopic clues observed are as follows: (A) Dotted vessels arranged in a linear fashion at the periphery, (B) Clustered glomerular vessels, (C) Hypopigmented structureless areas and dotted vessels, and (D) Hypopigmented structureless areas, glomerular and dotted vessels. Conclusions It has been almost 30 years since the first descriptions of the dermoscopic features of pBD, evidence suggest that der- moscopy has been shown to be useful in improving its diag- nostic accuracy. Early in 2004, Zalaudek et al reported the presence of glomerular vessels in combination with a scaly surface as the most frequent criteria in both pigmented and non- pigmented BD; the authors additionally reported the presence of small brown globules and/or homogeneous pig- mentation in the pigmented variety [7]. Also in 2004, Bugatti et al reported that pigmented structures could be detected by dermoscopy in many cases of their series including 14 cases, such as the presence of pseudo-network, irregular diffuse pigmentation, and irreg- ular dots / globules [8]. Shortly after, Stante et al reported a lesion of pBD clinically mimicking a superficial spread- ing melanoma; they describe a reticular, heterogenous ar- rangement of the melanin pigment, which might resemble therefore remnants of atypical pigment network, and irreg- ular, brown globular structures at the periphery and wide regression- like areas [9]. In 2010, Cameron et al. described the dermoscopic pat- terns of pBD in a series of 52 cases. They characterized two archetypical dermoscopic patterns of pBD, namely a struc- tureless brown pattern and a combination of dots and struc- tureless pattern. They also identified a linear arrangement of brown and/or gray dots and/or coiled vessels that have not been described previously in other lesions and represented a specific clue to pBD [10]. Few data exist about the characteristics of the popu- lation corresponding to the first cases describing dermo- scopic findings in pBD. In 2009, Mun et al described the dermoscopic features of 26 BD in Asians, of which 10 were pigmented, they reported the presence of small brown glob- ules, small black globules, and structureless (homogenous) pigmentation as the most frequent findings [11]. In 2010, Gutierrez-Mendoza et al reported two cases of pBD in skin phototypes 3 and 4. Both cases displayed irregular dotted vessels and pigment remnants upon dermoscopy [12]. Our study provides novel and useful information on the dermoscopic characteristics of pBD in a specific population. Since it is a study on behalf of CILAD, it is the first study that includes mostly Latin American patients:142 out of 147 corresponded to patients from Argentina, Brazil, Chile, Colombia, and Mexico. The remaining 5 cases corresponded to patients from Spain. In line with this, we found 70% of patients with skin phototype 3 and almost 15% with skin phototype 4. Similar to the findings from Cameron et al [10], the most frequently observed feature in our study were structureless areas in more than 90% of the cases and dots in 70%. Re- garding color, brown and pink were the most frequent ob- served in more than 90% of the cases. Regarding dermoscopic features, hypopigmented (pink, skin colored, or white) structureless areas were the most Original Article | Dermatol Pract Concept. 2024;14(2):e2024086 5 3. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic ac- curacy of dermoscopy. Lancet Oncol. 2002;3(3):159-165. DOI: 10.1016/s1470-2045(02)00679-4. PMID: 11902502. 4. Vestergaard ME, Macaskill P, Holt PE, Menzies SW. Dermos- copy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008;159(3):669-676. DOI: 10.1111/j.1365-2133.2008.08713.x. PMID: 18616769. 5. Reiter O, Mimouni I, Gdalevich M, et al. The diagnostic accuracy of dermoscopy for basal cell carcinoma: A systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(5):1380-1388. DOI: 10.1016/j.jaad.2018.12.026. PMID: 30582991. 6. Dinnes J, Deeks JJ, Chuchu N, et al. Visual inspection and dermoscopy, alone or in combination, for diagnosing kerat- inocyte skin cancers in adults.  Cochrane Database Syst Rev. 2018;12(12):CD011901. DOI: 10.1002/14651858.CD011901. pub2. PMID: 30521688. PMCID: PMC6516870. 7. Zalaudek I, Argenziano G, Leinweber B, et al Dermoscopy of Bowen’s disease. Br J Dermatol. 2004;150(6):1112-1116. DOI: 10.1111/j.1365-2133.2004.05924.x. PMID: 15214896. 8. Bugatti L, Filosa G, De Angelis R. Dermoscopic observa- tion of Bowen’s disease. J Eur Acad Dermatol Venereol. 2004;18(5):572-574. DOI: 10.1111/j.1468-3083.2004.01008.x. PMID: 15324396. 9. Stante M, de Giorgi V, Massi D, Chiarugi A, Carli P. Pigmented Bowen’s disease mimicking cutaneous melanoma: clinical and dermoscopic aspects. Dermatol Surg. 2004;30(4 Pt 1):541-544. DOI: 10.1111/j.1524-4725.2004.30173.x. PMID: 15056147. 10. Cameron A, Rosendahl C, Tschandl P, Riedl E, Kittler H. Der- matoscopy of pigmented Bowen’s disease. J Am Acad Dermatol. 2010;62(4):597-604. DOI: 10.1016/j.jaad.2009.06.008. PMID: 20079953. 11. Mun JH, Kim SH, Jung DS, Ko HC, Kwon KS, Kim MB. Der- moscopic features of Bowen’s disease in Asians. J Eur Acad Dermatol Venereol. 2010;24(7):805-810. DOI: 10.1111/j.1468- 3083.2009.03529.x. PMID: 20015173. 12. Gutiérrez-Mendoza D, Narro-Llorente R, Karam-Orantes M, et al. Dermoscopy Clues in Pigmented Bowen’s Disease. Derma- tol Res Pract. 2010;2010:464821. DOI: 10.1155/2010/464821. PMID: 20886019. PMCID: PMC2945663. frequent structure followed by vascular structures and pig- mented lines or dots arranged in linear fashion. In our se- ries, dermoscopic clues concerning melanin structures were more frequent than in the series from Cameron et al [10]. Although the latter study did not describe skin types, as this was a study from Australia and Austria, it could be assumed that the majority were patients with fair skin phototypes, and this could explain the lesser frequency of pigmented structures. Our study does not lack of limitations since it was a retrospective study and evaluators were not blinded to the diagnoses. We report a large series of cases of pBD in Latin Amer- ican patients, with most patients having skin phototype 3 and 4. In this population, the pigmented structures and the clues derived from the presence of melanin are much more frequent than in previous reports in fair skin patients. Acknowledgments: We would like to thank the collabora- tion of the following colleagues for providing cases for the study: Blanca Carlos, Consuelo Mosquera, Dianely García- Hernández, Diana Guerrero Hernández, Sofía André, Cinthia López Kot, Rocío Muñiz, Ivonne Arellano, Malynahi Tapia Juárez, Luis Carlos Morales Godínez, Luisa Polo Silveira, Mayra Reyes Soto References 1. Ragi G, Turner MS, Klein LE, Stoll HL Jr. Pigmented Bowen’s dis- ease and review of 420 Bowen’s disease lesions. J Dermatol Surg Oncol. 1988;14(7):765-769. DOI: 10.1111/j.1524-4725.1988. tb01161.x. PMID: 3292613. 2. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy (epi- luminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the eval- uation of diagnostic tests. Arch Dermatol. 2001;137(10):1343- 1350. DOI: 10.1001/archderm.137.10.1343. PMID: 11594860.