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2</a>&#41;&#46; Overexpression of the tumor suppressor protein p16 was also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Based on a diagnosis of extragenital bowenoid papulosis&#44; the patient was re-questioned&#44; but he reported that neither he nor his current partner had had genital or anal warts&#46; Lymphocyte counts &#40;including CD4 and CD8 counts&#41; were normal and serologic testing for human immunodeficiency virus &#40;HIV&#41; was negative&#46; Human papillomavirus &#40;HPV&#41; DNA testing using the hybrid capture assay detected HPV 42&#46; It was decided to excise the entire lesion and schedule periodic follow-up visits for the patient and his partner&#46; The patient was asymptomatic a year after diagnosis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">bowenoid papulosis</span> was introduced to describe multiple wart-like papules in the genital region that are histologically similar to Bowen disease and clinically similar to genital warts&#46; The condition typically affects young&#44; sexually active individuals and mainly involves the genital&#44; crural&#44; and perianal regions&#46; However&#44; there have also been reports of extragenital bowenoid papulosis with or without concomitant genital lesions in both immunocompetent and immunodeficient patients&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Bowenoid papulosis is associated with HPV infection&#46; While there is a close link with HPV 16 infection&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> types 18&#44; 31-35&#44; 39&#44; 42&#44; 48&#44; and 51-54 have also been implicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> HPV 16&#44; 18&#44; and 33 are considered to have the greatest oncogenic potential&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Bowenoid papulosis is considered to be a squamous cell carcinoma in situ and has an estimated risk of malignant transformation of 2&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The oncogenic mechanism is probably initiated by HPV-induced genetic changes in infected cells&#46; High-risk serotypes produce HPV oncoproteins E6 and E7&#44; which are capable of inactivating the Rb and p53 tumor suppressor proteins&#44; respectively&#44; giving rise to uncontrolled cell proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> HPV has been detected in bowenoid papulosis lesions and adjacent healthy skin&#44; indicating that HPV infection is a necessary but not sufficient factor in the development of bowenoid papulosis&#46; Other alterations&#44; such as additional genetic mutations in the host cell&#44; may be necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Bowen papulosis is histologically similar to Bowen disease&#44; but exhibits more focal and less intense changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;6</span></a> To distinguish between the 2 entities&#44; it is always necessary to correlate clinical and histologic findings&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The prevalence of Bowenoid papulosis is unknown&#44; as the lesions are commonly confused with other wart-like lesions and are frequently destroyed without histological examination&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Since the lesions tend to recur and have malignant potential&#44; patients and their sexual partners should be referred for periodic follow-up and an immunological study in the case of persistent or recurrent lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The clinical course is variable&#44; with some lesions progressing to chronic or malignant forms and others spontaneously regressing&#46; Conservative treatment involving destruction of the lesions by simple excision&#44; electrocoagulation&#44; or cryosurgery is the most effective therapeutic approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Bowenoid papulosis generally occurs with concomitant genital lesions or in patients with a history of HPV-induced lesions<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;Transmission is believed to occur through direct contact&#44; autoinoculation&#44; or fomites&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;7&#44;9</span></a> These transmission mechanisms would explain the involvement of different parts of the body&#46; Reports in the literature describe lesions affecting the neck&#44; the abdomen&#44; the shoulder&#44; the chin&#44; and the periungual area&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">We have reported a new case of bowenoid papulosis affecting the periungual area of a finger in a patient with no past or present history of genital lesions&#46; Two similar cases of extragenital bowenoid papulosis have been reported in the literature&#46; One of the patients had bowenoid papulosis lesions in the perianal area that were detected on diagnosis of the nail lesion<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the other patient had HIV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We believe that lesions in young sexually active patients should be examined histologically&#44; 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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Red-grayish exophytic periungual lesion with a hyperkeratotic surface&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hypoplastic epidermis with loss of normal cell architecture&#44; moderate cellular atypia&#44; dyskeratosis&#44; and koilocytes &#40;hematoxylin-eosin&#44; original magnification &#215;40&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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            "Tamanyo" => 345751
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Overexpression of tumor suppressor protein p16&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; HIV&#44; human immunodeficiency virus&#59; HPV&#44; human papillomavirus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Immunodeficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">HPV Detected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Transmission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Genital Lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bart<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not tested&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Grussendorg-Conen<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HPV 16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#252;dlinger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Periungual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HPV 35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Direct contact&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Grob et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HPV 16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Razor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Johnson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Razor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fader et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HPV 31&#44; 33&#44; 35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Razor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes &#40;in the past&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Baron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Purnell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic CD4<span class="elsevierStyleSup">&#43;</span> lymphocytopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Finger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Papadopoulos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NoHIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ShoulderAbdomen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44; 1&#44; 42&#44; 43&#44; 44Not identified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NoNo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Toe webs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tinea pedis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Journal Information
Vol. 104. Issue 10.
Pages 932-934 (December 2013)
Vol. 104. Issue 10.
Pages 932-934 (December 2013)
Case and Research Letter
Full text access
Periungual Bowenoid Papulosis Due to Human Papillomavirus Type 42
Papulosis bowenoide periungueal por virus del papiloma humano 42
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M. Gómez Vázquez
Corresponding author
mergova@terra.es

Corresponding author.
, R. Navarra Amayuelas
Servicio de Dermatología, Hospital Municipal de Badalona, Badalona Serveis Assistencials, Barcelona, Spain
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Table 1. A Selection of Published Cases of Extragenital Bowenoid Papulosis.
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To the Editor:

A 28-year-old man with no relevant past medical history consulted for a progressive, slow-growing exophytic lesion at the edge of the nail of the middle finger on the left hand. The lesion had been present for 2 years. The patient reported that he had had multiple sexual partners up to 6 years earlier.

Physical examination revealed a red-grayish exophytic periungual lesion measuring 0.7cm in diameter with a hyperkeratotic surface (Fig. 1). Histopathologic examination showed a hyperplastic epidermis with loss of normal cell architecture, moderate cellular atypia, dyskeratosis, and koilocytes in the epidermis (Fig. 2). Overexpression of the tumor suppressor protein p16 was also observed (Fig. 3). Based on a diagnosis of extragenital bowenoid papulosis, the patient was re-questioned, but he reported that neither he nor his current partner had had genital or anal warts. Lymphocyte counts (including CD4 and CD8 counts) were normal and serologic testing for human immunodeficiency virus (HIV) was negative. Human papillomavirus (HPV) DNA testing using the hybrid capture assay detected HPV 42. It was decided to excise the entire lesion and schedule periodic follow-up visits for the patient and his partner. The patient was asymptomatic a year after diagnosis.

Figure 1.

Red-grayish exophytic periungual lesion with a hyperkeratotic surface.

(0.04MB).
Figure 2.

Hypoplastic epidermis with loss of normal cell architecture, moderate cellular atypia, dyskeratosis, and koilocytes (hematoxylin-eosin, original magnification ×40).

(0.47MB).
Figure 3.

Overexpression of tumor suppressor protein p16.

(0.33MB).

The term bowenoid papulosis was introduced to describe multiple wart-like papules in the genital region that are histologically similar to Bowen disease and clinically similar to genital warts. The condition typically affects young, sexually active individuals and mainly involves the genital, crural, and perianal regions. However, there have also been reports of extragenital bowenoid papulosis with or without concomitant genital lesions in both immunocompetent and immunodeficient patients.1

Bowenoid papulosis is associated with HPV infection. While there is a close link with HPV 16 infection,1,2 types 18, 31-35, 39, 42, 48, and 51-54 have also been implicated.1–4 HPV 16, 18, and 33 are considered to have the greatest oncogenic potential.

Bowenoid papulosis is considered to be a squamous cell carcinoma in situ and has an estimated risk of malignant transformation of 2.6%.2 The oncogenic mechanism is probably initiated by HPV-induced genetic changes in infected cells. High-risk serotypes produce HPV oncoproteins E6 and E7, which are capable of inactivating the Rb and p53 tumor suppressor proteins, respectively, giving rise to uncontrolled cell proliferation.4 HPV has been detected in bowenoid papulosis lesions and adjacent healthy skin, indicating that HPV infection is a necessary but not sufficient factor in the development of bowenoid papulosis. Other alterations, such as additional genetic mutations in the host cell, may be necessary.3,4

Bowen papulosis is histologically similar to Bowen disease, but exhibits more focal and less intense changes.1,5,6 To distinguish between the 2 entities, it is always necessary to correlate clinical and histologic findings.

The prevalence of Bowenoid papulosis is unknown, as the lesions are commonly confused with other wart-like lesions and are frequently destroyed without histological examination.7 Since the lesions tend to recur and have malignant potential, patients and their sexual partners should be referred for periodic follow-up and an immunological study in the case of persistent or recurrent lesions.7 The clinical course is variable, with some lesions progressing to chronic or malignant forms and others spontaneously regressing. Conservative treatment involving destruction of the lesions by simple excision, electrocoagulation, or cryosurgery is the most effective therapeutic approach.6,8

Bowenoid papulosis generally occurs with concomitant genital lesions or in patients with a history of HPV-induced lesions8–10 (Table 1).Transmission is believed to occur through direct contact, autoinoculation, or fomites.1,2,7,9 These transmission mechanisms would explain the involvement of different parts of the body. Reports in the literature describe lesions affecting the neck, the abdomen, the shoulder, the chin, and the periungual area, among others.1–10

Table 1.

A Selection of Published Cases of Extragenital Bowenoid Papulosis.

Cases  Immunodeficiency  Site  HPV Detected  Transmission  Genital Lesions 
Bart5  Not known  Chin  Not tested    Not known 
Grussendorg-Conen6    Neck  HPV 16    No 
Rüdlinger et al.3  No  Periungual  HPV 35  Direct contact  Yes 
Grob et al.7  No  Neck  HPV 16  Razor  No 
Johnson et al.1  No  Neck  42  Razor  No 
Fader et al.2  HIV  Neck  HPV 31, 33, 35  Razor  Yes (in the past) 
Baron et al.9    Neck  18     
Purnell et al.10  Idiopathic CD4+ lymphocytopenia  Finger  18    No 
Papadopoulos et al.4  NoHIV  ShoulderAbdomen  6, 1, 42, 43, 44Not identified    NoNo 
Oh et al.8  No  Toe webs  16  Tinea pedis  No 
Our case  No  Periungual  42    No 

Abbreviation: HIV, human immunodeficiency virus; HPV, human papillomavirus.

We have reported a new case of bowenoid papulosis affecting the periungual area of a finger in a patient with no past or present history of genital lesions. Two similar cases of extragenital bowenoid papulosis have been reported in the literature. One of the patients had bowenoid papulosis lesions in the perianal area that were detected on diagnosis of the nail lesion10 and the other patient had HIV infection.4 We believe that lesions in young sexually active patients should be examined histologically, even when they are located at a distance from the genital region. The possibility of immunosuppressive conditions should be investigated, as should the presence of genital lesions in the patients and their partners.

References
[1]
T.M. Johnson, A. Saluja, D. Fader, D. Blum, J. Cotton, T.S. Wang, et al.
Isolated extragenital bowenoid papulosis of the neck.
J Am Acad Dermatol, 41 (1999), pp. 867-870
[2]
D.J. Fader, M.H. Stoler, T.F. Anderson.
Isolated extragenital HPV-thirties-group-positive bowenoid papulosis in an AIDS patient.
Br J Dermatol, 131 (1994), pp. 577-580
[3]
R. Rüdlinger, R. Grob, X.Y. Yuan, W.S. Rus.
Human papillomavirus-35-positive bowenoid papulosis of the anogenital area and concurrent human papillomavirus-35-positive verruca with bowenoid dysplasia of the periungual area.
Arch Dermatol, 125 (1989), pp. 655-659
[4]
A.J. Papadopoulos, R.A. Schwartz, A. Lefkowitz, L.L. Tinkle, C.K. Jänniger, W.C. Lambert.
Extragenital bowenoid papulosis associated with atypical human papillomavirus genotypes.
J Cutan Med Surg, 6 (2002), pp. 1117-1119
[5]
R. Bart.
Bowenoid papulosis of the chin.
J Dermatol Sug Oncol, 10 (1984), pp. 821-823
[6]
E.I. Grussendorg-Conen.
HPV-16 induzierte pigmentierte bowenoid papulosis am hals.
Akt Dermatol, 14 (1988), pp. 317-319
[7]
J.J. Grob, H. Zarour, J. Jacquemier, J. Hassoun, J.J. Bonerandi.
Extra-anogenital HPV16-related bowenoid papulosis.
Genitourin Med, 67 (1991), pp. 18-20
[8]
S.H. Oh, J.H. Lee, K.Y. Lee, K.H. Lee.
Isolated extragenital bowenoid papulosis of the toe-webs.
Acta Dermatol Venereol, 89 (2009), pp. 212-213
[9]
J.M. Baron, A. Rübben, E.I. Grussendorf-Conen.
HPV-18 induced pigmented papulosis of the neck.
J Am Acad Dermatol, 40 (1999), pp. 633-634
[10]
D. Purnel, A. Illchyshyn, D. Jenkins, A. Salim, R. Seth, D. Snead.
Isolated human papillomavirus 18-positive extragenital bowenoid papulosis and idiopathic CD4+ lymphocytopenia.
Br J Dermatol, 144 (2001), pp. 619-621

Please cite this article as: Gómez Vázquez M, Navarra Amayuelas R. Papulosis bowenoide periungueal por virus del papiloma humano 42. Actas Dermosifiliogr. 2013;104:932–934.

Copyright © 2012. Elsevier España, S.L. and AEDV
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