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Periungual Bowen disease mimicking chronic paronychia and diagnosed by dermoscopy
Periungual Bowen disease mimicking chronic paronychia and diagnosed by dermoscopy Jason Giacomel, MBBS,a Aimilios Lallas, MD,b Iris Zalaudek, MD,c and Giuseppe Argenziano, MDb Como, Australia; Graz, Austria; and Reggio Emilia, Italy
CLINICAL PRESENTATION A 75-year-old woman, with Fitzpatrick skin phototype I/II and a history of nonmelanoma skin cancer presented with a scaly, fissured, erythematous, fairly well demarcated patch involving the periungual skin of the left index finger (Fig 1). The lesion had persisted for [1 year despite the use of antibiotic and corticosteroid ointments. The patient was immunocompetent, an exsmoker, with no reported history of arsenic ingestion, trauma, burns, or ionizing radiation to the site.
Fig 1. Clinical image. Squamous cell carcinoma in situ presenting as a fairly well demarcated, scaly, erythematous patch involving the periungual skin of the patient’s left index finger. No onycholysis or nail plate destruction can be seen.
DERMOSCOPIC APPEARANCE The dermoscopic images are shown in Fig 2.
From Skin Spectrum Medical Services,a Como, Western Australia; the Skin Cancer Unit,b Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia; and the Department of Dermatology,c Medical University of Graz. Funding sources: None. Conflicts of interest: None declared.
Correspondence to: Jason Giacomel, MBBS, Skin Spectrum Medical Services, Como 6152, Western Australia, Australia. E-mail: [email protected]. J Am Acad Dermatol 2014;71:e65-7. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.01.894
e65
e66 Giacomel et al
J AM ACAD DERMATOL
SEPTEMBER 2014
Fig 2. Dermoscopic images (using polarized light). Periungual squamous cell carcinoma in situ featuring islands of whitish scale and numerous, diffusely distributed red dotted vessels. The vessels have whitish haloes and occur on a whitish-pink background. Note the absence of normal dermatoglyphs (A). An additional finding is hyperkeratotic targetoid structures at the proximal nail fold (rectangle), comprising central white-to-yellowish scale surrounded by an outer white rim, the latter in turn surrounded by linear, dotted, and/or hairpin vessels (B).
HISTOLOGIC DIAGNOSIS The histopathologic examination confirmed the diagnosis of squamous cell carcinoma in situ (SCCIS; Fig 3).
Fig 3. Histopathologic images. Periungual squamous cell carcinoma in situ revealing irregular acanthosis, hyperkeratosis, parakeratosis, elongated rete ridges, and full-thickness squamous cell atypia (A). P16 stain highlighting full-thickness squamous cell atypia (B).
J AM ACAD DERMATOL VOLUME 71, NUMBER 3
Giacomel et al e67
KEY MESSAGE Periungual SCCIS (Bowen disease) is an uncommon but distinctive subtype of SCCIS that may be associated with radiodermatitis, chronic trauma, oral exposure to arsenic, and human papillomavirus infection (notably type 16).1 It can clinically mimic benign conditions, such as chronic paronychia, periungual dermatitis, psoriasis, and verruca vulgaris,1 potentially leading to a diagnostic delay and an adverse outcome (including progression to invasive SCC). Dermoscopy assists in the diagnosis of nonpigmented SCCIS on other body sites by revealing clusters of coiled (glomerular) vessels and islands of scale.2 As shown in the present case, dermoscopy of periungual SCCIS may reveal overlapping criteria with classical SCCIS; however, the vessels were generally of small diameter (predominantly dotted rather than glomerular) and mostly diffusely distributed rather than clustered. In addition, periungual SCCIS can show hyperkeratotic, targetoid structures. These dermoscopic features may potentially assist in the early recognition and biopsy of periungual SCCIS, and in monitoring the response to topical treatment.
The authors gratefully acknowledge the contribution of Lawrence Yu, MBBS FRCPA, in interpreting the histopathologic findings. REFERENCES 1. Thomas L, Zook EG, Haneke E, Drape JL, Baran R. Tumors of the nail apparatus and adjacent tissues. In: Baran R, de Berker DAR, Holzberg M, Thomas L, editors. Baran and Dawber’s diseases of the nails and their management. 4th ed. Chichester, UK: Wiley-Blackwell; 2012. pp. 657-61. 2. Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: Part II. Nonmelanocytic skin tumors. J Am Acad Dermatol 2010;63:377-86.
CLINICAL PRESENTATION A 75-year-old woman, with Fitzpatrick skin phototype I/II and a history of nonmelanoma skin cancer presented with a scaly, fissured, erythematous, fairly well demarcated patch involving the periungual skin of the left index finger (Fig 1). The lesion had persisted for [1 year despite the use of antibiotic and corticosteroid ointments. The patient was immunocompetent, an exsmoker, with no reported history of arsenic ingestion, trauma, burns, or ionizing radiation to the site.
Fig 1. Clinical image. Squamous cell carcinoma in situ presenting as a fairly well demarcated, scaly, erythematous patch involving the periungual skin of the patient’s left index finger. No onycholysis or nail plate destruction can be seen.
DERMOSCOPIC APPEARANCE The dermoscopic images are shown in Fig 2.
From Skin Spectrum Medical Services,a Como, Western Australia; the Skin Cancer Unit,b Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia; and the Department of Dermatology,c Medical University of Graz. Funding sources: None. Conflicts of interest: None declared.
Correspondence to: Jason Giacomel, MBBS, Skin Spectrum Medical Services, Como 6152, Western Australia, Australia. E-mail: [email protected]. J Am Acad Dermatol 2014;71:e65-7. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.01.894
e65
e66 Giacomel et al
J AM ACAD DERMATOL
SEPTEMBER 2014
Fig 2. Dermoscopic images (using polarized light). Periungual squamous cell carcinoma in situ featuring islands of whitish scale and numerous, diffusely distributed red dotted vessels. The vessels have whitish haloes and occur on a whitish-pink background. Note the absence of normal dermatoglyphs (A). An additional finding is hyperkeratotic targetoid structures at the proximal nail fold (rectangle), comprising central white-to-yellowish scale surrounded by an outer white rim, the latter in turn surrounded by linear, dotted, and/or hairpin vessels (B).
HISTOLOGIC DIAGNOSIS The histopathologic examination confirmed the diagnosis of squamous cell carcinoma in situ (SCCIS; Fig 3).
Fig 3. Histopathologic images. Periungual squamous cell carcinoma in situ revealing irregular acanthosis, hyperkeratosis, parakeratosis, elongated rete ridges, and full-thickness squamous cell atypia (A). P16 stain highlighting full-thickness squamous cell atypia (B).
J AM ACAD DERMATOL VOLUME 71, NUMBER 3
Giacomel et al e67
KEY MESSAGE Periungual SCCIS (Bowen disease) is an uncommon but distinctive subtype of SCCIS that may be associated with radiodermatitis, chronic trauma, oral exposure to arsenic, and human papillomavirus infection (notably type 16).1 It can clinically mimic benign conditions, such as chronic paronychia, periungual dermatitis, psoriasis, and verruca vulgaris,1 potentially leading to a diagnostic delay and an adverse outcome (including progression to invasive SCC). Dermoscopy assists in the diagnosis of nonpigmented SCCIS on other body sites by revealing clusters of coiled (glomerular) vessels and islands of scale.2 As shown in the present case, dermoscopy of periungual SCCIS may reveal overlapping criteria with classical SCCIS; however, the vessels were generally of small diameter (predominantly dotted rather than glomerular) and mostly diffusely distributed rather than clustered. In addition, periungual SCCIS can show hyperkeratotic, targetoid structures. These dermoscopic features may potentially assist in the early recognition and biopsy of periungual SCCIS, and in monitoring the response to topical treatment.
The authors gratefully acknowledge the contribution of Lawrence Yu, MBBS FRCPA, in interpreting the histopathologic findings. REFERENCES 1. Thomas L, Zook EG, Haneke E, Drape JL, Baran R. Tumors of the nail apparatus and adjacent tissues. In: Baran R, de Berker DAR, Holzberg M, Thomas L, editors. Baran and Dawber’s diseases of the nails and their management. 4th ed. Chichester, UK: Wiley-Blackwell; 2012. pp. 657-61. 2. Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: Part II. Nonmelanocytic skin tumors. J Am Acad Dermatol 2010;63:377-86.