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Histologic imaginea este de carcinom epidermoid in situ, papuloza bowenoidã putând fi consideratã o neoplazie intraepitelialã. În etiologia bolii sunt incriminate papiloma virusurile umane cu risc crescut HPV 16, 18, 31, 33, 39 dar evoluþia spontanã a bolii este spre regresie. Tratamentul papulozei bowenoide constã în distrugerea medicalã sau chirurgicalã a leziunilor.

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Cuvinte cheie: papuloza bowenoidã, papiloma virusuri, neoplazie intraepitelialã. The histological appearance is that of epidermoid carcinoma in situ, therefore Bowenoid papulosis may be considered an intraepithelial neoplasia.

Although high-risk human papillomaviruses HPV 16, 18, 31, 33, 39 are responsible for its etiology, most lesions are benign and regress spontaneously. The treatment of Bowenoid papulosis consists in the medical or surgical removal of the lesions.

The images accompanying the text show typical Bowenoid papulosis in a male patient and a rare case of diffuse, erythroleukoplastic, pigmented Bowenoid papulosis in a female patient plus the corresponding histological nhs hpv vaccine leaflet courtesy of Professor A.

Oanþã, MD, PhD. Key words: Bowenoid papulosis, papillomaviruses, intraepithelial neoplasia Denumirea de papulozã bowenoidã PB a fost introdusã de Wade ºi Ackerman în pentru descrierea de leziuni clinice ºi evolutive asemãnãtoare condiloamelor acuminate dar având aspect histologic de neoplazie intraepitelialã bowenianã NIEidentic cu al bolii Bowen [1].

Iniþial afecþiunea a fost cunoscutã ºi sub alte denumiri precum boala Bowen BB multicentricã [2], papule pigmentate ale penisului [3], acantoza cu displazie, displazie nhs hpv nhs hpv vaccine leaflet leaflet, atipie vulvarã reversibilã [4], carcinom in situ vulvar. Denumirea de PB a fost The name Bowenoid papulosis BP was first introduced by Wade nhs hpv vaccine leaflet Ackerman in to describe clinical lesions similar to acuminate condyloma but with the histological appearance of intraepithelial neoplasia IENidentical to that of Bowen s disease [1].

The disease was initially known under various names such as multicentric Bowen s disease BD [2], pigmented penis papules [3] acanthosis with dysplasia, Bowenoid dysplasia, reversible vulvar atypia [4] or vulvar carcinoma nhs hpv vaccine leaflet situ. Epidemiologie Papillomavirus homme comment soigner existã studii epidemiologice privind PB, dar leziunile apar mai frecvent la subiecþii imunodeprimaþi îndeosebi la pacienþii HIV pozitiv.

Pacienta trebuie informat c exersarea n ap, terapie cu masaj i Nivel de eviden antrenamentele curative pentru spate n grup sau individuale pot ajuta la I, grad uurarea durerilor n spate n timpul sarcinii.

Aspect clinic Papuloza bowenoidã afecteazã îndeosebi pacienþi tineri, pruritul fiind simptomul revelator într-o treime din cazuri. Leziunea elementarã este o maculã sau o papulã planã sau mamelonatã, uneori verucoasã, de culoare brunã fig.

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Leziunile sunt în general multiple, dispuse simetric, izolate dar uneori confluate în placarde cu pãstrarea individualitãþii, localizate la nivelul organelor genitale externe.

La femei ºi la pacienþii HIV pozitiv leziunile se pot extinde pe regiunea perinealã, perianalã sau chiar în canalul anal.

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În afara acestui aspect clasic, PB poate lua aspecte polimorfe de papule plane roºii sau violacee localizate pe nhs hpv vaccine leaflet mucos al organelor genitale externe, de papule translucide pe gland, de papule veruciforme nhs hpv vaccine leaflet caracter nhs hpv vaccine leaflet sau de papule hemisferice asemãnãtoare leziunilor de moluscum contagiosum.

La femei poate exista o formã difuzã, în pânzã, eritroleucoplazicã ºi pigmentatã afectând vulva în totalitate fig.

PAPULOZA BOWENOIDÃ BOWENOID PAPULOSIS

Aceste leziuni extinse nu prezintã tendinþã de remitere ºi excepþional pot deveni invazive. NIE se caracterizeazã histologic prin hiperplazie epitelialã mai mult sau mai puþin marcatã, un strat cornos adesea parakeratozic, o maturare anormalã a nhs hpv vaccine leaflet care pãstreazã un aspect bazofil evident pe lesions as well as their atypical histological appearance. Epidemiology There are no epidemiological studies on BP; however, the lesions occur more frequently in immunocompromised subjects, especially HIVpositive patients.

Nhs hpv vaccine leaflet aspect Bowenoid papulosis mainly affects young individuals, itching being the telling symptom in one third of the cases. The primary lesion is either a macula or a plain or mamillated papule, sometimes verrucous and brown-colored Fig.

The lesions are usually multiple, symmetrical, isolated or coalesced into individual plaques located on the external genitalia.

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In female and HIV-positive patients, the lesions may spread to the perineal and perianal region or even the anal canal. Besides this classical appearance, BP may present as polymorphic red or purple flat papules located on the mucous membranes of the external genitalia, translucent papules on the glans penis, non-acuminate verrucous papules or hemispherical papules resembling moluscum contagiosum.

In women, a diffuse, cobweb, erythroleukoplastic and pigmented form may completely affect the vulva Fig. Such extended lesions are not prone to remission and may exceptionally become invasive. Histologically, IEN is characterized by more or less marked epithelial hyperplasia, a corneous layer usually displaying parakeratosis and an abnormal maturation of keratinocytes that maintain a noticeable basophilic appearance on the entire height of the epithelium Fig.

The following 3 Figura 1. Papule pigmentate la nivelul regiunii pubiene ºi tecii penisului. Figure 1. Pigmented papules in the pubic area and penis sheath. Figura 2. Papuloza bowenianã forma difuzã în pânzã a mucoasei vulvare. Figure 2.

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Bowenoid papulosis diffuse form in cloth vulvar mucosa. Figura 3. Aspect histopatologic al papulozei boweniene. Figure 3. Histopathological aspects of papulozei boweniene. La aceste imagini se asociazã dezorganizarea arhitecturalã, atipii citonucleare severe, nhs hpv vaccine leaflet prezenþa uneori de mitoze ºi celule diskeratozice prezente pe toatã suprafaþa epiteliului precum ºi koilocite. Displaziile severe din PB ºi BB sunt prezente pe toatã înãlþimea epidermului, deosebindu-se de displaziile bazale din lichenul scleros atipii citonucleare limitate la straturile bazal ºi can also be observed: architectural disorganization, severe cytonuclear atypia, possible mitosis and dyskeratosis on the entire surface of the nhs nhs hpv vaccine leaflet vaccine leaflet as well as koilocytes.

Severe dysplasia in BP and BD occurs on the entire height of the epidermis thus differentiating itself from the basal dysplasia in lichen sclerosus cytonuclear atypia limited to the basal and suprabasal layers. HPV nhs hpv vaccine leaflet sunt regãsite ºi în boala Bowen ºi în câteva cancere vulvare ºi ale penisului precum ºi în neoplaziile intraepiteliale ºi invazive cervicale [6, 7] sugerând cã modificãrile histologice ale acestor afecþiuni corespund unei etiologii comune tabelul I.

HPV 6 and 11, which are associated with acuminate condyloma, are only exceptionally found in BP. Oncogenic HPVs can be involved in Bowen s disease, a few vulvar and penile cancers as well as intraepithelial and invasive cervical neoplasia [6,7], thus suggesting the common etiology of the histological changes present in these diseases Table I. Severitatea atipiilor citologice ºi arhitecturale permit diagnosticul diferenþial al PB de condiloamele acuminate iritate prin tratamentul prealabil aplicat.

Uneori cele douã afecþiuni pot coexista. Papiloamele pigmentate întâlnite la femei se pot asemãna cu PB. Talia ºi absenþa caracterului simetric pot orienta pe clinician dar uneori numai biopsia poate stabili diagnosticul.

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Psoriazisul, lichenul plan, veruca seboreicã ºi nevul nevocelular nhs hpv vaccine leaflet fi luate de asemenea în discuþia diagnosticului diferenþial. Differential diagnosis The clinical aspect resembles that of acuminate condyloma, the two diseases being sometimes mistaken for one another especially in the case of flat condyloma and macular BP lesions. The severity of cytological and architectural atypia makes the differential diagnosis of BP with acuminate condyloma irritated by previous treatment.

The two diseases sometimes coexist. Pigmented papilloma occurring in female patients may resemble BP. Size and asymmetry could guide the clinician; however, the biopsy remains crucial for the diagnosis. Psoriasis, lichen planus, seborrheic verruca and nevocellular nevus may also be considered for a differential diagnosis.

Durata medie de persistenþã a papulelor este de 2,6 ani [8].

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Totuºi în literaturã au fost publicate câteva cazuri de transformare a PB în carcinom invaziv [9], aceastã evoluþie fiind mai frecventã la pacienþii HIV pozitiv [10]. Astfel este confirmatã utilitatea termenului histologic de neoplazie intraepitelialã pentru aceastã afecþiune în sensul de a aminti clinicianului acest risc imprevizibil.

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Antecedentele de condiloame reprezintã un factor cert de apariþie a unui carcinom epidermoid [11], leziunile invazive neapãrând pe condiloamele benigne ci având ca punct de plecare o coinfecþie cu un HPV oncogen care poate fi latentã.

Conduita Diagnosticul clinic de PB, stabilit pe baza vârstei tinere a pacientului ºi caracterului multiplu ºi multifocal al leziunilor, impune indiferent de forma clinicã efectuarea biopsiei pentru efectuarea examenului histopatologic care evidenþiazã aspectul de NIE.

Uneori este necesarã efectuarea mai multor biopsii dacã leziunile sunt polimorfe, în special pe zonele mai verucoase, indurate ºi ulcerate, pentru excluderea unei evoluþii invazive.

Cãutarea HPV ºi tipajul acestora nu sunt necesare pentru stabilirea diagnosticului. Examinarea partenerei este necesarã impunând efectuarea examenului ginecologic, frotiului cervico-vaginal, colposcopiei ºi anuscopiei în caz de raporturi sexuale genito-anale. Tratamentul partenerei nu modificã rata de recidivã ºi astfel nu modificã nici evoluþia infecþiei cu HPV la pacient [13]. Prezervativul nu oferã decât o protecþie incompletã în cazul infecþiilor genitale cu HPV [14, 15].

Evolution and prognosis Despite a worrying histological image, BP is not potentially invasive and may spontaneously regress in both male and female patients after the nhs hpv vaccine leaflet of a few lesions. The average duration of the papules is of 2. However, a few cases of BP transformed into invasive carcinoma were mentioned in the literature [9], especially in HIV positive patients [10]. The histological term of intraepithelial neoplasia thus proves its usefulness as it reminds the clinician of this unpredictable risk.

A history of condyloma represents a certain risk factor for epidermoid carcinoma [11] since invasive lesions do not occur in benign condyloma but are caused by a coinfection with a possibly latent oncogenic HPV. Management The clinical diagnosis of BP, which is based on the young age of the patient and nhs hpv vaccine leaflet multiple, multifocal lesions detected, requires a biopsy for the histological determination of IEN, regardless of the clinical form. Several biopsies might be needed if the lesions are polymorphic, especially in verrucous, hardened or ulcerated areas in order to exclude an invasive evolution.

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The detection of HPV types is not required for making a diagnosis. However, the examination of a male patient s partner is required and includes gynecological examination, cervicovaginal smears, colposcopy and anuscopy in case of genital and anal intercourse.

The treatment nhs hpv vaccine leaflet the partner does not influence the recurrence rate or the evolution of the HPV infection in the patient [13].

Condoms only offer incomplete protection in cases of genital infections with HPV [14,15]. Tratamentele locale utilizate în condiloamele acuminate precum crioterapia, podofilotoxina sunt puþin eficiente [16]. Dacã leziunile sunt puþin numeroase ºi relativ bine grupate, distrugerea se poate face sub anestezie localã, în schimb în cazul leziunilor nhs hpv vaccine leaflet este necesarã anestezia generalã.