Bowen's disease (BD) is an in-situ squamous cell carcinoma of epidermis. The etiology of BD is multifactorial with high incidence among Caucasians. BD is common in photo-exposed areas of skin, but other sites can also be involved. Lesions are usually solitary. The morphology of BD differs based on age of the lesion, site of origin, and the degree of keratinization. BD is considered as the “lull before the storm,” which precedes an overt squamous cell carcinoma. Histopathology is the gold standard diagnostic modality to confirm the diagnosis. Immunohistochemistry, dermoscopy, and reflectance confocal microscopy are the adjuvant modalities used in the diagnosis of BD. The treatment depends on various factors like site, size, immune status, patient's age, esthetic outcome, etc. The available therapeutic modalities include topical chemotherapy, surgical modalities, light-based modalities, and destructive therapies. It requires a combined effort of dermatologist, oncosurgeon, and plastic surgeon to plan and execute the management in various presentations of BD.

This is an open-access article distributed under the terms of the Creative Commons Attribution (CC-BY) License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. FIGURE 1. Multiple erythematous hyperkeratotic crusted plaques over the gluteal region and lateral aspect of thighs.

A 30-year-old man presented with a 6 year history of recurrent, multiple asymptomatic raised lesions over his back and bilateral upper limbs. He had been treated repeatedly for a case of recurrent boils with oral and topical antibiotics. Some of the lesions had healed spontaneously leaving behind unsightly scars. The patient denied any history of associated fever, chronic cough, weight loss, and drug intake prior to the onset of lesions. There was no recognized contact with tuberculosis patients. General and systemic examination was essentially normal. Dermatological examination revealed the presence of multiple, well-defined, hyperpigmented crusted papules of 0.5-1.0 cm in size, distributed symmetrically over his entire back, extensor surface of bilateral forearm, arm, and bilateral dorsum of foot, interspersed with atrophic varioliform scarring (Figures 1 and 2). Routine laboratory workup was normal. Tuberculin (Mantoux) was strongly positive at 72 hours (23 × 23 mm) with central necrosis (Figure 3). Sputum for acid fast bacilli culture, chest radiograph, ultrasound abdomen, and pelvis did not reveal any abnormality. A biopsy specimen taken from a crusted papule over his forearm (Figure 4) showed fibrinoid necrosis, surrounded by mixed inflammatory infiltrate filling the entire dermis along with a few ill-defined epitheloid granulomas and lymphocytoclastic vasculitis. These are consistent with papulonecrotic tuberculid.The patient was started on a four drug combination therapy of rifampicin, isoniazid, pyrazinamide, and ethambutol for two months initially followed by a combination of rifampicin and isoniazid to complete a total of 6 months of standard antitubercular therapy. The patient responded well and all of the lesions eventually healed.