Mild:  

• Advise all patients on use of sun protection and emollients.  

Active treatment options include: 

• Topical Fluorouracil 5% (Efudix) cream apply 1-2 times daily for up to 4 weeks. Review 3 to 6 months after treatment to ensure healing has occurred. 
• Cryotherapy – N.B.  use with caution on lower legs; consider shorter freeze time and repeat 4 weeks later, if required, to reduce risk of ulceration.  
• Imiquimod 5% can be used as an alternative, on consultant advice.  

Moderate: 

• Skin surgery: shave curettage and cautery, for solitary especially thicker or hyperkeratotic lesions or multiple lesions. 
• Conventional PDT successful for solitary lesions. Consider daylight PDT for multiple lesions.   

Severe:  

Refer to a dermatologist if suspicious of invasive squamous cell carcinoma. Signs of this include a lesion that is growing rapidly, becoming thickened or raised and possibly tender to touch. Refer genital and perianal lesions suspicious of Bowen’s and periungual Bowen’s.  

Mild:  

Manage in primary care. Seek advice and guidance if there is diagnostic uncertainty. If confirmation is required before proceeding with a certain type of treatment, a punch biopsy can be performed.  This is preferable to a curette biopsy, as the full thickness of the epidermis and dermis can be viewed to establish whether there is any invasive disease amounting to a cutaneous SCC.

Moderate: 

Manage by those with training in primary care or refer to secondary care. Seek advice and guidance if there is diagnostic uncertainty.  If confirmation is required before proceeding with a certain type of treatment, a punch biopsy can be performed.  This is preferable to a curette biopsy, as the full thickness of the epidermis and dermis can be viewed to establish whether there is any invasive disease amounting to a cutaneous SCC. 

Severe:  

Refer to dermatology urgently. Many Dermatology services accept these under the USOC category. 

BNF – Imiquimod cream: 

BAD guidelines for the management of squamous cell carcinoma in situ (Bowen's disease) 2014 

BNF – Imiquimod cream: 

NICE guidance, Patient.Info: 

PCDS - Bowen's Disease 

DermNet NZ - Intraepidermal Squamous Cell Carcinoma 

• For diagnostic purposes punch biopsy as opposed to curette to ensure full thickness evaluation. 
• Bowen’s in genital and periungual sites higher risk for transformation to SCC. 
• If any pigmentation, use two week wait referral guidance to exclude a melanoma. 

1. British Association of Dermatologists (bad.org.uk)  
2. Patient.co.uk Patient information leaflet - Bowen’s:  
3. BAD Patient information leaflet - 5-Fluorouracil cream:  
4. BAD patient information leaflet – Imiquimod:  
5. NHS patient information - Bowen’s Disease:  

Benign 

ICD11 code - 2E64