• There is reasonable evidence to support use of 5-fluorouracil (5-FU).⁴ It is more practical than surgery for large lesions, especially at potentially poor healing sites, and has been used for “control” rather than cure in some patients with multiple lesions.

• Topical imiquimod is likely to be used for BD especially for larger lesions or difficult/poor healing sites. However, it is costly and the optimum regimen has yet to be determined.⁵

• One prospective study suggests that a curettage and electrodesiccation treatment is superior to cryotherapy in treating BD, especially for lesions on the lower leg.⁶ Curettage was associated with a significantly shorter healing time, less pain, fewer complications, and a lower recurrence rate when compared with cryotherapy.⁶

• Cryotherapy has good evidence of efficacy but discomfort and time to healing are inferior to photodynamic therapy (PDT) or curettage. With discretion, SCC in situ can be treated by cryotherapy with liquid nitrogen spray by a 30-second freeze, thaw and refreeze 30 seconds (see Chapter 15, Cryosurgery).

• Photodynamic therapy has been shown to be equivalent to cryotherapy and 5-FU, either in efficacy and/or in healing.⁴ PDT may be of particular benefit for lesions that are large, on the lower leg, or at otherwise difficult sites, but it is costly.

• Excision should be an effective treatment with low recurrence rates, but the evidence base is limited and for the most part does not allow comment on specific sites of lesions. Lower leg excision may be limited by lack of skin mobility. Although elliptical excision with clear margins is an effective and acceptable treatment for Bowen’s disease, it is too aggressive for actinic keratoses.

• Mohs surgery is recommended for BD at sites such as the digits or penis where it is important to limit removal of unaffected skin (Figure 34-5). It is useful for poorly defined or recurrent head and neck BD.

• See Table 34-1 for a summary of all recommended treatments for Bowen’s disease based on location and other characteristics.

FIGURE 34-5 Bowen’s disease on the finger secondary to human papilloma virus. Evidence for HPV was seen in the biopsy specimen performed with a shave.

(Copyright Richard P. Usatine, MD.)

TABLE 34-1 Summary of the Main Treatment Options for Bowen’s Disease ⁴

Basal Cell Carcinoma

Diagnoses

• Frequent on the face, hands, upper chest, and sun-exposed skin.

• Nodular is the most common form (Figure 34-6):

• Raised, waxy, translucent, or pearly border.

• Central erosion, telangiectasias, and bleeding are common.

• Usually flesh colored or pale, but may be pigmented, confusing it with melanoma.

• Superficial BCC (Figure 34-7)

• Flat or slightly raised, often red to brown.

• Look for a thready border that may be pearly.

• More often on the trunk and arms than face.

• Morpheaform (also called sclerosing) (Figure 34-8)

• Usually has nondiscrete margins.

• More aggressively infiltrating.

• Higher recurrence rate.

• Shave biopsy can confirm diagnosis.

FIGURE 34-6 Typical nodular BCC on the face of a 53-year-old man. Note the pearly borders and telangiectasias.

(Copyright Richard P. Usatine, MD.)

FIGURE 34-7 Superficial BCC on the back with erythema, scale, and a thready border.

(Copyright Richard P. Usatine, MD.)

FIGURE 34-8 Sclerosing BCC that turned out to be widely invasive when removed with Mohs surgery.

(Courtesy of Ryan O’Quinn, MD.)

Removal

(See Table 34-2 for cure rates of BCC treatment modalities.)

Elliptical Excision (Fusiform) (Figure 34-9)

• Remove with 3-mm surgical margin if discrete border and clinically feasible, 4 to 5 mm if indiscrete border.⁷

• Consider using a skin curette to define the margins of the BCC and redraw the ellipse as needed (Figure 34-10).

• Heals with linear scars, which can be hidden in skin lines.

• Provides immediate closure.

• Provides tissue for pathology and assurance of removal.

• If you find evidence of the BCC at the base or edges (Figure 34-11) of the removed specimen, take another piece of skin or fascia at a deeper and/or wider level and put it in a second formalin container with a stitch used to mark its orientation in the body.

Electrodesiccation and Curettage

• BCC tissue is softer than the surrounding normal tissue so a skin curette can remove the BCC without taking too much normal tissue around it (Figure 34-12).

• Firmly curette in all directions then electrodesiccate and repeat to a total of three cycles at one visit (see Chapter 14, Electrosurgery, pages 177–178).

• Useful for smaller lesions or where closure of a full-thickness excision would be difficult.

Mohs Micrographic Surgery (Figure 34-13)

• The most effective in achieving cure with clean margins—99%.

• Specialized skin surgeon examines pathology at time of excision.

• Further resection as needed at time of surgery.

• Can minimize impact on adjacent structures.

• Useful for uncertain borders or aggressive forms of BCC (i.e., sclerosing or morpheaform).⁷

• Consider for H-zone on face (See Figure 37-12 on page 461), especially for recurrent BCC.⁸

• Consider referral for Mohs micrographic surgery if lesions affect sensitive structures including the eyelids, ala of the nose, and the ear canal.