You are in: eMedicine Specialties > Dermatology > MALIGNANT NEOPLASMS Erythroplasia of Queyrat (Bowen Disease of the Glans Penis)Article Last Updated: Jan 15, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Joseph L Wilde, MD, Mohs Micrographic Surgery, Chief, Department of Dermatology, Brooke Army Medical Center Joseph L Wilde is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology Editors: Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates; Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA; Mary Farley, MD, Dermatologic Surgeon/Mohs Surgeon, Department of Dermatology, The Skin Surgery Center; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: carcinoma in situ of the penis, Bowen disease, penile carcinoma, penile neoplasia, EQ, erythroplasia of the glans penis, uncircumcised men, erythematous plaques, penile Bowen disease, papillomavirus-induced carcinoma in situ INTRODUCTIONSection 2 of 11
  BackgroundErythroplasia of Queyrat (EQ) originally was described by Tarnovsky in 1891 and subsequently was appreciated as a penile disease by Fournier and Darier in 1893. More intensive studies by Queyrat in 1911 allowed this condition to be accepted as a distinct entity. He described erythroplasia of the glans penis and concluded that the disease represented a precancerous process. PathophysiologyEQ arises from the squamous epithelial cells of the glans penis or inner lining of the prepuce. It is seen almost exclusively in uncircumcised men and represents an in situ form of squamous cell carcinoma. Progression to invasive carcinoma may occur after a variable period of time. FrequencyUnited StatesEQ is a rare disorder in the United States. The exact prevalence is not well documented in the medical literature. Mortality/MorbidityEQ is treatable if underlying invasive carcinoma does not exist; however, as many as 10% of patients with EQ may have invasive squamous cell carcinoma in the primary lesion. Extension of cancerous cells into the submucosa is associated with a 20% incidence of regional lymph node metastases. SexEQ occurs only in men. AgeMedian age of onset is 51 years. EQ has been described in men aged 20-80 years.1 CLINICALSection 3 of 11
HistoryCharacteristic lesions of EQ are solitary or multiple erythematous plaques. The texture can be smooth, velvety, scaly, or verrucous. The condition almost always involves the glans penis or adjacent mucosal surfaces or both. EQ lesions may be regarded as synonymous with penile Bowen disease or as representative of one end of a spectrum of in situ penile carcinoma. Both may represent forms of papillomavirus-induced carcinoma in situ.
PhysicalSolitary or multiple cutaneous lesions may be present. Typically, minimally raised, erythematous plaques with variable texture are seen. The plaques may be smooth, velvety, scaly, crusty, or verrucous. Ulceration or distinct papillomatous papules within a plaque may indicate progression to invasive squamous cell carcinoma. CausesEQ most often occurs in uncircumcised men. Multiple factors have been implicated as causative agents in this process.
DIFFERENTIALSSection 4 of 11
Balanitis Circumscripta Plasmacellularis Balanitis Xerotica Obliterans Balanoposthitis Candidiasis, Mucosal Contact Dermatitis, Allergic Contact Dermatitis, Irritant Drug-Induced Bullous Disorders Psoriasis, Plaque Squamous Cell Carcinoma
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| Drug Name | Fluorouracil (Efudex) |
|---|---|
| Description | Disrupts DNA synthesis by stopping the methylation of deoxyuridylic acid and inhibiting thymidylate synthetase, thereby halting cell proliferation. |
| Adult Dose | Apply cream to affected areas bid for minimum of 4 wk; longer treatment schedules may be required depending on depth and diameter of individual lesions |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; potentially serious infections |
| Interactions | None reported |
| Pregnancy | X - Contraindicated; benefit does not outweigh risk |
| Precautions | Avoid exposing treated area to UV radiation; incidence of inflammatory reactions may occur with occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction; patients should expect inflammatory reaction with crusting |
Several case reports and series describe successful treatment of non-invasive EQ with topical imiquimod 5% cream.
| Drug Name | Imiquimod (Aldara) |
|---|---|
| Description | Immune response modifier that induces local activity of cytokines to include interferon alpha. Specific mechanism of action unknown. |
| Adult Dose | Various topical dosing regimens have been used in reported cases; duration of treatment should be long enough to induce some degree of local response clinically, as indicated by erythema, crusting, or superficial erosion Reported cases achieved local response after 3-12 wk of treatment dosed qod or 3 times per wk; rest period of 3-7 d may be needed mid cycle to allow healing of erosions or decrease local pain/pruritus Optimum dosing schedule and length of treatment have not yet been determined by large-scale studies |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Genital use: Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal human papilloma infection; following surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed Actinic keratosis: Avoid exposure to sunlight or artificial tanning; regular use of sunscreen is encouraged; avoid contact with lips, eyes, or nostrils; common adverse effects include erythema, edema, vesicles, erosion or ulceration, weeping, exudate, flaking, scaling, dryness, and scabbing or crusting Basal cell carcinoma: Medical follow-up is essential to assure cancer has responded adequately to treatment; may cause redness, swelling, and sore development at application site; may cause itching or burning |
Close follow-up monitoring is required for patients treated medically or surgically for EQ. Local recurrence rates range from 3-10%.
Uncircumcised men are at greatest risk of developing EQ; however, adult circumcision has not proven to decrease the risk. Concomitant chronic inflammatory dermatoses of the penis also can increase the potential for developing EQ.
All transplantation patients or any patients on immunosuppressive medications should undergo a thorough cutaneous examination to include genital skin as part of the initial workup and any subsequent visits.
Effective treatment and minimization of the inflammation from any infectious or inflammatory process is important.
Early diagnosis and treatment provide patients with an excellent chance of cure. Most studies show the cure rate to be greater than 90%.
Instruct patients concerning personal hygiene and the importance of cleansing beneath the foreskin to minimize the irritant effects of urine and smegma. Additionally, emphasize the importance of preventing sexually transmitted diseases such as genital herpes, human papillomavirus, and bacterial infections.
For excellent patient education resources, visit eMedicine's Men's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer: What You Need to Know.
Failure to carefully evaluate any patient, especially uncircumcised patients, presenting with a subacute or chronic balanitis. The threshold for performing skin biopsy of any lesion should be very low.10 In addition, failure to diagnose EQ expediently can easily result in disease that progresses to frank squamous cell carcinoma of the penis.
| Media file 1: Erythroplasia of Queyrat. Courtesy of Hon Pak, MD. | |
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Erythroplasia of Queyrat (Bowen Disease of the Glans Penis) excerpt
Article Last Updated: Jan 15, 2008
