Bowen's Disease of the Nail Bed and Periungual Area: A Clinicopathologic Analysis of Seven Cases

Background: This article describes the clinical and histologic features of seven cases of Bowen's disease (BD) of the nail bed, evaluates the role of human papillomavirus in the bowenoid change, and discusses optimal therapy. Observation: The patients presented with the clinical features of verruca vulgaris (n=3), nail dystrophy and onycholysis (n=2), paronychia (n=1), and acral melanoma (n=1). Histologically, the lesions demonstrated acanthosis, hyperkeratosis, and anaplasia, involving the full thickness of the epithelium. In four cases, human papillomavirus type 16 was demonstrated by in situ hybridization. Six lesions were treated by Mohs micrographic surgery, and one case was treated with topical 5% fluorouracil. In two cases, lesions recurred 1 and 2 years following surgery. In the case treated with topical 5% fluorouracil, residual BD was found 6 weeks after therapy. This case was then treated by Mohs surgery. Conclusions: Bowen's disease of the nail bed and periungual area may present clinically as various inflammatory and neoplastic conditions. An important clinical finding in differentiating BD of the nail bed from verruca is the presence of scaling and onycholysis that are out of proportion to the verrucous changes. Human papillomavirus type 16 may be etiologically related to BD of the nail bed and periungual area. Mohs micrographic surgery is recommended for adequate excision and maximal preservation of normal tissue and function.