Wolf in Sheep’s Clothing—Malignant Degeneration of an HPV-16 Verruca to Bowen’s Disease

A healthy 25-year-old woman had had a swiftly growing, refractory verrucous skin lesion on the left heel for 3 years.(Figure a) Analysis of a cutaneous biopsy sample from the lesion revealed human papilloma virus (HPV)-16-induced verruciform epidermal hyperplasia, rarely found at this site. High-risk HPV-16 (prevalence 20%) is sexually transmitted and oncogenic. The patient was treated unsuccessfully with imiquimod, 5-fluorouracil, and MMR vaccine and lived for a decade with a painful, highly erosive, and bleeding skin lesion, until repeat biopsy revealed that the HPV-16-infected cells had progressed to Bowen’s disease—a clinically polymorphous obligate precancerous condition (Figure b). Most cases of this form of skin cancer are induced by UV light in the elderly. Bowen’s disease often develops into squamous cell carcinoma and may metastasize lymphogenically. The dysplasia was excised with a margin of healthy tissue, and the wound healed without complications, leaving a defect with extensive scarring (Figure c). The incidence of associated oncogenic infections has decreased significantly since the introduction of HPV vaccines in 2006.

Figure

Dr. Dr. univ. Jasmin Schießl, Dr. med. Andreas H. Dietrich, Hautarztpraxis, Oberland, Holzkirchen, [e-mail]

Conflict of interest statement: JS has received lecture fees from Boehringer Ingelheim, Endocare Derma Enzinger, and Sanofi. AHD declares that no conflict of interest exists.

Translated from the original German by David Roseveare.

Cite this as: Schießl J, Dietrich AH: Wolf in sheep’s clothing—malignant degeneration of an HPV-16 verruca to Bowen’s disease. Dtsch Arztebl Int 2023; 120: 862. DOI: 10.3238/arztebl.m2023.0121