How to spot skin cancers

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07/11/23

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DVA skin cancer management
There are many types of skin cancers including BCCs or basal cell cancers, SCC or squamous cell cancers as well as melanomas. Todays review is on Bowen disease or Intraepidermal Squamous Cell Carcinoma. This is a common non-invasive cancer of the skin affecting the epidermal layers of skin. IECs most frequently occur on sun-exposed areas and present as red, scaly and persistent patches. IECs may arise de-novo, or from lesions of solar keratosis. If left untreated, Bowen disease may progress to an invasive Squamous Cell Carcinoma. This is one of the most common skin cancers I see in DVA or Department of Defence patients in Australia, and is due to the high UV radiation we have in cities like Brisbane.

Clinical Features
Bowen disease most frequently presents as a persistent red scaly patch that slow grows over time. The most commonly affect areas include the legs, arms, and face- areas of sun exposure. Bowen disease or IECs can also affect the lips, oral mucosa, or even genital areas. As Bowen Disease is asymptomatic there is often a delay in the diagnosis, as it may mimic conditions such as dermatitis, psoriasis, tinea, and sun-spots.

Associations
Most cases of Bowen disease arise from sun-damaged skin, including areas of actinic keratosis. The most common associations include-

UV radiation. This plays a major contributing factor in the development of IECs.
Immunosuppression. Patients on certain immunosuppressive medications are more likely to develop IECs.
Arsenic exposure. This was a common cause of Bowen Disease in the past, as arsenic was frequently used in medicines during the 60s and 70s including Bells Asthma Mixture, sheep dip, and as pesticides. Arsenic induced IECs-Bowen disease is a rare event today, as occupational safety has increased. A time lag of 10-20 years is seen between exposure and cancer.
Human Papilloma virus infections.
Other associations include genetic diseases, radiotherapy and skin lesions such as porokeratosis, and solar keratosis.

Investigations
Bowen’s Disease can be suspected clinically, however in the majority of cases, a biopsy should be performed to confirm the diagnosis.

Treatment
There are multiple ways to manage Bowens/IECs. Treatment modalities will depend on the location and size of the cancer, the number of lesions, the degree of functional impairment. Each modality has both advantages and disadvantages.

Cryotherapy or liquid nitrogen
Liquid nitrogen can be an excellent method of treating IECs. Most cases will require a double –freeze cycle of cryotherapy. This treatment is not recommended for IECs below the knee, as poor healing may occur.

Creams
Imiquimod, or 5-fluorouracil are effective in the treatment of Bowen disease. Clinical studies have shown cure rates approaching 80-90%. Treatment appears to be most successful when these creams are applied for 6-16 weeks.

Curettage and Electrocautery
When small patches of IECs are present they may be treated via curettage and cautery. A local anaesthetic is given prior to the procedure to prevent pain and discomfort.

Photodynamic therapy
Photodynamic therapy or PDT can be an excellent non-surgical method of treating skin cancers such as Bowen’s/ IEC’s. PDT uses a photosensitive cream called 5-aminolevulinic acid or methyl aminolevulinate, that is applied to the skin cancer. The cancerous cells of Bowens/ IEC take up this chemical over a period of 3 hours. A low-level laser light then activates the chemical, and destroys the skin cancer cells. Patients will require two treatments spaced a week or two apart. DVA or the Department of Veteran Affairs in Brisbane, covers PDT for both sunspots on the face and also IECs on all areas. PDT can also be used for multiple or large IECs. The benefit of PDT is that it selectively targets neoplastic cells without affecting the surrounding epidermis. This results in improved cosmetic outcomes, and faster healing times.

Surgery
Surgery is the ideal method of treating IECs in certain areas including recurrent IEC or ones that dwell in hair follicles. Surgery has the highest cure rate for Bowens/ IECs.

For the majority of patients, especially DVA patients in Australia, non surgical methods, including the use of photodynamic therapy, is the future. Dr Davin Lim, Dermatologist. Brisbane Australia.

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