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JAAD Case Rep
JAAD Case Rep
JAAD Case Reports
2352-5126
Elsevier

S2352-5126(24)00285-6
10.1016/j.jdcr.2024.07.012
Case Report
Multiple pigmented squamous cell carcinoma in situ on the volar hands after chronic use of topical tacrolimus
Konisky Hailey BS hailey.konisky@einsteinmed.edu
a∗
Kortz Alison PA-C b
Huho Albert MD b
Gregory A. Neal MD b
a Albert Einstein College of Medicine, Bronx, New York
b Upstate Dermatology, Castleton-on-Hudson, New York
∗ Correspondence to: Hailey Konisky, BS, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461. hailey.konisky@einsteinmed.edu
03 8 2024
10 2024
03 8 2024
52 6667
© 2024 by the American Academy of Dermatology, Inc. Published by Elsevier Inc.
2024
American Academy of Dermatology, Inc.
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Key words

Bowen’s disease
immunomodulator
squamous cell carcinoma in situ
tacrolimus
Abbreviations used

AD atopic dermatitis

SCC squamous cell carcinoma
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pmcIntroduction

Bowen’s disease (squamous cell carcinoma in situ) is a condition that typically presents as scaly erythematous lesions on sun-exposed areas, most often in Caucasians over the age of 60.1 In less than 2% of cases, these lesions are pigmented. Pigmented Bowen’s disease is most common in Black men; however, to our knowledge, there are only 2 other cases reported on volar surfaces.1, 2, 3 Herein, we describe a novel case of multiple pigmented Bowen’s disease lesions on the volar hands of a man after chronic topical tacrolimus use.

Report of a case

A 55-year-old man with Fitzpatrick Skin Type V presented with 3 irregular pigmented macules on his right distal volar first and fourth digits and his left distal volar fourth digit for less than 6 months, concerning for acral melanoma (Fig 1). He had a long-standing history of asthma and chronic lichenified atopic dermatitis (AD) affecting over 90% of body surface area, with improvement after 4 years of daily topical tacrolimus 0.1% to the hands and 3 years of twice-monthly dupilumab 300 mg. The patient previously failed trials of narrow-band ultraviolet B therapy. Dermoscopy showed irregular streaks of pigment not following either a ridge or furrow pattern. Punch biopsies of all 3 lesions noted atypical keratinocytes present throughout the entire thickness of a pigmented epidermis, consistent with squamous cell carcinoma in situ, or Bowen’s disease (Fig 2). The patient denied known exposure to arsenic, human papilloma virus, or extensive sun exposure. Biopsies were all negative for human papilloma virus 16 and 18 by in situ hybridization, and he had no history or evidence of verruca clinically. Treatment options (including 5-fluorouracil, cryotherapy, photodynamic therapy, and surgical excision) and risk of recurrence were discussed with the patient and he opted for a 6-week course of imiquimod.Fig 1 A, Photo of all 3 lesions (A, B, arrow) prior to biopsy. B, Zoomed in view of lesion on the right distal fourth digit prior to biopsy.

Fig 2 Pathology of one of the pigmented macules showing atypical keratinocytes present throughout the entire thickness of a pigmented epidermis.

Discussion

Pigmented Bowen’s disease of the volar hands is an exceedingly rare condition with risk factors including exposure to sunlight, chronic arsenic exposure, radiotherapy, Human papilloma virus infection, and trauma.3 In the case of our patient, he had an extensive history of AD on his hands treated with topical tacrolimus and remote history of ultraviolet B therapy. Given the patient’s skin type and the lack of squamous cell carcinoma (SCC) elsewhere on his skin, we do not think the ultraviolet B therapy is implicated. Furthermore, the tacrolimus was exclusively used on his hands as his AD was not responsive to dupilumab in this area. Generally, SCC is the most common skin cancer in skin of color patients, often arising in areas of chronic inflammation.4 Tacrolimus is an Food & Drug Administration-approved calcineurin inhibitor that locally suppresses the immune system to treat AD. It has been associated with an increased risk of SCC in some reports. Two case reports noted SCC at the site of topical tacrolimus use: one in a patient with oral lichen planus and the second in a man with balanoposthitis. The authors hypothesized that tacrolimus may have allowed for the growth of pre-existing malignant cells, which may have been present in our patient after years of inflammation on his volar hands.5,6

To date, there have been no other published cases of multiple Bowen’s disease lesions associated with chronic topical tacrolimus use. This case highlights the importance of considering this diagnosis in patients with new pigmented lesions in areas of chronic topical tacrolimus use, especially in patients with skin of color.

Conflicts of interest

None disclosed.

Funding sources: None.

Patient consent: The authors obtained written consent from the patient for their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available. Patient consent forms were not provided to the journal but are retained by the authors.

IRB approval status: Not applicable.
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References

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