Abstract

Multifocal Bowen’s disease (BD) with high-risk Human papillomavirus (HPV) infection involving the anogenital area is not uncommon. However, the occurrence of multifocal BD in non-anogenital areas is rare. We report a case of a 43-year-old male with BD of the left palm diagnosed 5 years ago, treated for several years with Imiquimod without incident until a recent flare. Additional new red, painful lesions were reported around the fingertips on the same hand. On examination, a 4.8 cm x 2.5 cm pink hyperkeratotic plaque was noted on the left palm as well as pink plaques with keratotic scale and scattered yellow crusting on the proximal cuticle of 1^st, 2^nd, 3^rd, and 4^th left fingers. Biopsies from the palm and 1^st finger showed hyperkeratotic and acanthotic epidermis with hypergranulosis and an atypical basaloid proliferation with abundant mitoses and dying keratinocytes in stratum spongiosum. Variable degree of lymphohistiocytic infiltrate was seen in the papillary dermis. In contrast, biopsies from 2^nd, 3^rd and 4^th fingers showed spongiotic dermatitis with a perivascular infiltrate. High-risk HPV in situ hybridization (ISH)(16/18/31/33 cocktail) was positive in the lesional cells from the 1^st finger biopsy while negative on 2^nd finger. Low-risk HPV ISH (6/11 cocktail) was negative in both biopsies. This case strongly suggests that high-risk HPV plays an important role in the development of multifocal BD in non-anogenital areas.