Bowen's disease of the nail bed: A case presentation and review of the literature

Since 1919, when Bowenfirst described intraepidermal squamous cell carcinoma of the nail bed, only II cases of this rare disease have been reported in the literature. The 12th case of Bowen's disease, presented here, offers an alternative method of treatment using 5-fluorouracil combined with a keratolytic ointment.

Bruce K. Defiebre, Jr., CPT, MC, USN, San Diego, Calif.

IntraePidermal squamous cell carcinoma, first de­scribed by Bowen] in 1919, added a new facet of inter­est with the report of Bowen's disease of the nail by Coskei in 1972. His search of the previous 20 years' world literature revealed only one reported example of Bowen's disease of the nail bed.3

In the past 2 years six more cases have been re­ported.4 .6 The purpose of this paper is to report the 12th case of Bowen's disease of the nail bed and to offer an alternative method of treatment.

Case report.

H. T . B. , a 54-year-old Caucasian man, presented with a 4-year history of onycholysis and subungual hyperkeratosis of the radial third of the fingernail of the left long finger.

Fungal cultures were negative, and a punch biopsy was performed, revealing intraepidermal carcinoma of the nail bed. Upon referral from his dermatologist, the nail was avulsed and biopsies of both sides of the nail bed obtained. The radial side of the nail bed was involved with Bowen's disease, and the ulnar side was unaffected (Fig. I).

Following healing of the nail bed, the patient was treated for I month with twice daily application of a keratolytic oint­ment (Lasan pomade) and 5% 5-fluorouracil (Efudex) . There was considerable local reaction (Fig. 2). Healing occurred rapidly after cessation of treatment, and at 6 months after

From the Department of Surgery and the Clinical Investigation Cen­ter, Naval Regional Medical Center, San Diego, Calif.

Supported in part by the Bureau of Medicine and Surgery Clinical In­vestigation Program.

Received for publication Feb. 17 , 1977 .

Reprint requests: Bruce K. Defiebre, Jr., M.D., Plastic and Recon­structive Surgery , 900 Kiely Blvd . , Santa Clara , Calif. 95051.

The opinions or assertions expressed herein are those of the author and are not to be construed as official or as reflecting the views of the Navy Department or the naval service at large.

184 THE JOURNAL OF HAND SURGERY

treatment (Fig. 3), he had regrown three-quarters of the ulnar side of the nail.

Because of the residual deformity at I year following treat­

ment, a portion of the radial nail bed and distal ulnar nail bed were excised, resulting in an acceptable appearance (Fig. 4) . Histological examination of the resected nail bed showed it to be free of Bowen's disease .

Because 15% of the patients with Bowen's disease will have a malignancy elsewhere,1 a thorough evaluation was performed. This included a proctosigmoidoscopy, barium enema, upper gastrointestinal and small-bowel series , chest x-ray, and intravenous pylogram, in addition to a physicial examination and the usual associated blood and urine studies . The patient had no evidence of malignancy elsewhere .

Comment

Mikhail6 reviewed all of the previously published cases and believed, " ... the growth usually has its or­igin in the lateral nail fold and spreads from there into the nail bed."

The clinical picture presented requires differentiating Bowen's disease from onychomycosis, subungual ex­ostosis, eczema, verrucae, pyogenic granuloma, kera­toacanthoma, squamous cell carcinoma, and malignant melanoma. Since the diagnosis only can be made histo­logically, it is necessary to biopsy suspected lesions at the initial examination. The histopathology includes the intraepidermal subtypes of squamous cell car­cinoma. This group encompasses Bowen's disease, ar­senical carcinoma, erythroplasia of Queyrat, and the intraepidermal epithelioma of Jadassohn.

Recently, Albom8 reviewed the literature and found that 46 cases of squamous cell carcinoma of the nail bed had been reported . These cases fell into the cat­egory of invasive squamous cell carcinoma. The term "invasive" indicates that malignant epidermal cells

Vol. 3 No.2 March, 1978

Fig. 1. Preoperative appearance of the fingernail involved with Bowen's disease.

Fig. 2. Nail bed after 30 days of treatment with Lasan po­made and Efudex.

have invaded the dermis. The case presented here and those reviewed are histologically intraepidermal squa­mous cell carcinomas and thus are classified as Bo­wen's disease of the nail bed.

Treatment of Bowen's disease of the nail bed, as in all cancer, requires total destruction of the lesion. Am-

Bowen's disease of nail bed 185

Fig. 3. The fingernail 6 months after treatment with Lasan pomade and Efudex.

Fig. 4. The fingernail 3 months after surgical revision of the scarred nail bed.

putation is a definitive method of treatment and may not affect hand function seriously if only a distal pha­lanx is removed. Amputation of the distal phalanx of the thumb, however, results in a 75% impairment of the thumb. Since the thumb accounts for 40% of the function of the hand, a 30% disability of the hand will

186 Defiebre

result.9 In addition, an aesthetic deformity is produced by any amputation. The use of Mohs'lo chemosurgery technique is an effective method of treating this tumor but is not widely available. Mikhail6 states, "Because of removal of part of the phalanx, permanent absence of the nail plate, and wound contraction after healing of the chemosurgery wounds, the terminal phalanx be­came shorter."

Graham and Helwig7 report a disease recurrence of 72 % after curettement and desiccation and 87 % failure after radiation therapy in treatment of Bowen's disease in a location other than the nail bed. Jansen and co­workersll have experienced prompt clearing of Bo­wen's disease in areas other than the nail bed after I month's treatment with 5% 5-fluorouracil applied twice daily and without occlusion. Because a controlled study by Zala12 showed that effective penetration of fluorouracil was limited to the upper two-thirds of the corium, it was believed advisable to combine the use of 5-fluorouracil with a keratolytic ointment.

Conclusion

It is appreciated that the I-year follow-up observa­tion of the patient described in the foregoing case report is insufficient to determine his cure; however, the evi­dence of the effectiveness of 5-fluorouracil in the treat­ment of Bowen's disease is valid. The location of the lesion and low metastatic potential of Bowen's disease allow for prolonged and close observation and early treatment if the disease recurs. The aesthetic result ob­tained by applying 5% 5-fluorouracil and a keratolytic

The Journal of HAND SURGERY

agent makes this a valuable method of treatment for Bowen's disease of the nail bed.

REFERENCES

I. Bowen JT: Precancerous dermatoses. Cutaneous Dis 30:241-255, 1912

2. Cos key RJ: Bowen's disease of the nail bed. Arch Der­matol 106:79-80, 1972

3. Pardo-Castello V, Pardo OA: Diseases of the nail. Springfield, 1960, Charles C Thomas, Publisher, p 80

4. Dieteman DF: Bowen disease of the nail bed (letter to the editor). Arch Dermatol 108:577-578, 1973

5. Waller JD, et al: Bowen's disease of the nail bed. Bull Assoc Mil. Dermatologists 22:59-60, 1974

6. Mikhail GR: Bowen disease and squamous cell car­cinoma of the nail bed. Arch Dermatol 110:267-270, 1974

7. Graham JH, Helwig EB: Dermal pathology. Hagers­town, 1972, Harper & Row, Publishers, p 581

8. Alborn, AJ: Squamous cell carcinoma of the finger and nail bed. A review of the literature and treatment by the Mohs' surgical technique. J Dermatol Surg 1(2):43-48, 1975

9. Guides to the evaluation of permanent impairment. Chi­cago, 1971, AMA, P 4

10. Mohs FE: Chemosurgery in cancer, gangrene, and infec­tions. Springfield, 1956, Charles C Thomas, Publisher

II. Jansen, GT, et al: Bowenoid conditions of the skin; treat­ment with topical five-flurouracil. South Med J 60:185-188, 1967

12. Zala, L: Histologische befunde bei behandlung von haut­neoplasm mt 5-fluorouracil-salbe. Dermatol Monatsschr 145:326-333, 1972