Bowen's Disease at a Periocular or Nail Unit Site — When First-Line Surgery Has Not Achieved Clearance
This protocol addresses immunocompetent patients with Bowen's disease (squamous cell carcinoma in situ) at a challenging anatomical site — the periocular region or nail unit — where tissue conservation is a clinical priority and first-line surgical treatment has not resulted in complete clearance of the lesion.
Clinical scenario
Squamous cell carcinoma in situ at a tissue-critical site (periocular region or nail unit) in a non-immunosuppressed patient. These locations are regarded as high-risk sites for Bowen's disease, where sparing healthy tissue is a guiding principle that constrains the choice of approach.
Previous treatment — failure condition
First-line treatment with Mohs micrographic surgery, standard surgical excision, or curettage with cautery did not achieve complete clearance of the SCC in situ lesion within six months. This protocol describes the next step taken after that failure.
What comes next (partial overview)
When primary surgical approaches are unavailable, have not succeeded, or are not appropriate at these tissue-sensitive sites, guidelines support considering alternative active treatment on an individual basis — the full structured options and their selection criteria are in the protocol.
References
DOI: 10.1093/bjd/ljac042
- Consider Mohs micrographic surgery in people with SCC in situ when tissue conservation is important, such as around the eyes and the nail unit.
- Lesions are considered large if > 2 cm and are considered high risk at periocular and digital (and penile) sites.
- Where Mohs micrographic surgery is not available or not appropriate, consider active treatment with any suitable alternative, on an individual basis. This includes standard surgical excision, curettage with cautery, PDT, 5-fluorouracil (5%), imiquimod (5%), laser and cryotherapy.
- Where this service is available, consider laser treatment in people with SCC in situ where other treatments have failed or are not suitable. Ablative CO2 laser may be more effective than nonablative neodymium:YAG.
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