Bowen's Disease

[Black&White]

Hi all, just had the results back from a biopsy with a diagnoses of Bowen's disease. I was wondering if anyone has experience with this and could provide better info than what my vet provided - they really didn't know anything about it. My cat (she's 12) is prescribed Imiquimod 5% Cream (Aldara), she has two warty patches on her throat area, and lesions on her ears, and a wart on her lip. I wanted to ask if anyone might be able to suggest a pharmacy, or possibly an online pharmacy, in Canada where we could order it. We were quoted about $500 so we are hoping to find a better price for it! It is suggested she could take oral anti-inflammatory drugs and/or analgesics to be used for discomfort associated with the lesions. I am also wondering about diet, she has lost muscle mass and is somewhat 'gaunt' Her energy, mood, and appetite is good, although I can see she is tired inside sometimes. Thank you!

Here is some info the vet sent me via email:

Bowen disease affects cats older than age 10 years and is triggered by papillomavirus. This slowly progressive disease causes eroded crusted papules and plaques that are frequently found on the head and neck but can also appear on the shoulders and forelegs. This disease is not solar induced and does not metastasize.

Disease description:
Definition
Bowenoid carcinoma is an uncommon disease that is characterized by multifocal squamous cell carcinoma (SCC) in situ lesions in the skin. In situ refers to the histologic finding that lesions do not cross the epithelial basement membrane.1-3
Etiology and Pathophysiology
Bowenoid carcinoma has been fairly well described in humans and cats but only one case report has been published in the dog.4 Immunosuppression and papillomaviruses have been implicated as causative factors for in situ SCC, and DNA from multiple feline papillomaviruses has been isolated from a high percentage of feline BISC tissue samples.5-8,18-23 Bowenoid carcinoma has not been associated with feline leukemia or feline immunodeficiency virus infection.
Sun exposure and degree of pigmentation in the skin do not appear to play a role in the development of Bowen’s disease, which makes it clinically and histopathologically distinct from actinic (ultraviolet light-induced) SCC in situ. This latter condition more commonly develops as localized lesions on the face (especially nonhaired) of lightly pigmented or white areas on cats (See the Associate chapter on Feline Cutaneous Squamous Cell Carcinoma).1,8-11

Imiquimod 5% Cream (Aldara): This agent is an immune response modifier that is licensed to treat actinic keratosis, superficial basal cell carcinoma, and viral papillomas in humans. Imiquimod enhances both innate and cell-mediated immunity via the induction of cytokines. The cream is applied (after hair is clipped) in a thin film to lesions q 24-72 hours. Treatments are continued until resolution or stabilization of the lesion. A high response rate (including multiple complete responses) has been reported for cats with Bowenoid carcinoma.11 Treatment can be used long term and for any subsequent lesions that develop.11 Reported side effects include localized erythema, anorexia, and increased liver enzymes. Side effects are thought to result from patient ingestion (via licking) of the cream.

SUPPORTIVE THERAPY
An Elizabethan collar can be applied immediately after application of Aldara cream to prevent ingestion and systemic exposure. Oral anti-inflammatory drugs and/or analgesics can be used for discomfort associated with the lesions.
MONITORING and PROGNOSIS
Effective local therapy is often curative for individual in situ lesions; however, new lesions usually develop at other sites over time and require ongoing treatment. Untreated in situ lesions can progress to invasive SCC. Patients with Bowenoid lesions can also have invasive SCC concurrently; therefore, prompt treatment is recommended for all lesions documented or suspected to be in situ SCC. One case report exists of a cat with SCC in situ progressing to invasive SCC, with subsequent distant metastasis.7

• Cause: Felis catus papillomavirus type 2.
• While this papillomavirus commonly infects cats, Bowenoid in situ carcinomas are thought to be rare.
• Viral plaques and Bowenoid in situ carcinomas probably represent a continuum depending on the presence or absence of dysplasia within the sample.
• Signs: multiple, irregular, raised, keratinized or ulcerated up to 3 cm diameter skin lesions.
• Disease usually in middle-aged to older cats.
• Lesions can develop in pigmented or non-pigmented skin.
• Diagnosis: histopathology possibly with immunohistochemistry or molecular diagnostics.
• Treatment: surgical excision if necessary.
• Cryotherapy may also be appropriate as lesion superficial.
• Some evidence that imiquimod cream may be beneficial, although no controlled studies.
• Prognosis: some lesions will remain stable for a long period of time without causing significant illness in the cat. However, up to 15% of Bowenoid in situ carcinomas may progress to squamous cell carcinoma. Bowenoidin situcarcinomas can also become extensive necessitating euthanasia due to repeated skin infections.

Pathogenesis
Etiology

• Felis catus papillomavirus type 2.
• This virus is detectible on the skin of a high proportion of cats.
• Therefore, host factors are more important than the presence of the papillomavirus in determining which cats will develop disease.

 

[babiesmom5]

Hi,
I am sorry your cat has been diagnosed with Bowens, but as someone who has a cat with Bowens and has been dealing with this issue for a while, I hope I can give you some information and positive encouragement.

My cat is now 19 years old. She was (officially) diagnosed with Bowens in June 2019. Prior to this, I had taken her to my local vet as well as her Internal Medicine Vet for crusting lesions on the head and neck for about a year. Various things were tried, antibiotic creams, topical corticosteroid cremes, but to no avail. In an attempt to get to the bottom of this, I took her to a very good Vet Dermatologist at a specialty hospital. They removed the lesion on the head, biopsied it and the results came back as "Bowenoid Squamous Cell Carcinoma in Situ". This is a very rare, slow growing skin cancer few vets ever see. As long as it can be treated on the skin, it usually does not progress to squamous cell carcinoma or go internal.

I was advised to apply Imiquimod cream to the head lesion area as well as the neck lesion every other day.
So each evening, I applied a very thin film of Imiquimod to these lesions. I had to watch her carefully after applying it to ensure she did not lick it off for about an hour till it was fully absorbed. I was told to wipe it off next morning. Despite doing this, my cat's appetite decreased and she was slightly nauseous next day. So I was then advised to decrease applications to three times a week. Decreased appetite and nausea were still a problem, but less so with giving Cerenia the night of the Imiquimod treatment. Then we went down to Imiquimod twice a week leaving it on 30 minutes prior to wiping it off. Still appetite/nausea issues as the Imiquimod cream, despite being wiped off, is still absorbed internally.

My cat also has IBD and CKD, so we are dealing with multiple issues here. Keeping her eating and keeping her hydrated are #1 priority.

The Imiquimod cream did resolve the neck lesion as well as another lesion on her back, but the lesion on the head remained. Last month, rather than continue Imiquimod, the Vet began Cyrotheraphy treatment to the head. Basically a local anesthetic is given and they freeze the lesion off using passes of a pen. She has had two treatments which have been successful. We will take for follow up tomorrow where the Dermatologist will evaluate the lesion to determine if another treatment is required or not.

Knowing what I now know, I wish I had gone with the Cryrotherapy treatment from the beginning rather than deal with the side effects of the Imiquimod. I am not saying that every cat will have these side effects, but I believe the underlying IBD and CKD were definitely contributing factors.

Cost wise, your quote of $500 sounds outrageous! I bought a package of 24 premeasured Imiquimod packets (each packet is enough for 1-2 treatments) for $45 at my local pharmacy.

So I hope my insights have been helpful. If you have any questions, please do not hesitate to ask.
I wish your cat a successful resolution of the Bowens!

 

[fionasmom]

Years ago I got meds from Canada for my dog at AmeriCana Pharmacy. I don't know if they are still in business; they were in British Columbia.

 

[Black&White]

Thank you very much for your suggestions, I was very glad to see your post and appreciate everything you mentioned. Thank you also for telling me about Chryotherapy, I would never have known about it otherwise.
I called the Vet hospital in Victoria and they have someone who comes once per month from Vancouver. I had my vet write a referral so I can get on the waiting list.
From what you describe it seems my cat has similar areas affected. She has a couple of big patches on her throat, which may be better for using Aldara, then a wart on her lip, head, and base of the ear which I assume may be better with freezing. I would not have known about the nausea and vomiting, so thank you for mentioning about Cerenia. How long did you have to use Imiquimod? I have already been thinking how difficult this will be to apply. She will hate it. I was told to put a collar on her after applying the cream for about 2 hours to prevent licking.
One question I have is when the lesions begin to clear up, does she begin to feel better overall? Or do other lesions continue to appear? I don't know how simply having this disease affects her mood, muscle mass, fatigue, and if it is making her look more gaunt and causing her to sleep more?

The hospital said that $500 for Imiquimod may be the normal price in Canada and is often covered by insurance in part. I dont have insurance. $45 is unbelievable, I will need to check around but I have a feeling that will not be available in Canada, unfortunately.

Thank you again for your suggestions and support that is deeply appreciated!

 

[babiesmom5]

I am glad my insights have been helpful. You posed some interesting questions I will try to answer. First, I tend to think that the physical symptoms your cat is experiencing (fatigue,looking more gaunt, loss of muscle mass, sleeping more etc) is unrelated to the Bowen's disease. Bowen's disease in of itself does not usually cause any physical symptoms such as you describe. It is a form of skin cancer that, other than what is visible on the cat's skin, dark, crusty, sometimes ulcerated patches, should not cause any physical symptoms other than perhaps itching or irritation that the cat wants to scratch. Despite my cat having multiple lesions, (neck, head, back), she had no symptoms; in fact she never even knew they were there. It was only me who could see and feel them.

I would discuss the physical symptoms your cat is having with your vet. Some further tests may be needed to determine if there are any underlying conditions your cat may be having.

The Imiquimod was applied to my cat's lesions for about 6 months because I had to stretch out her treatments due to side effects. Had she been able to tolerate it every other day as originally prescribed, the lesions could have been resolved much quicker. The neck and back lesions resolved fairly quickly as they were mild. The head lesion, (the first one she got) was more resistant; hence the Cryotherapy

The vet had recommended the "cone" and I tried this, but it was too stressful for her. So I applied the Imiquimod cream to the lesions with gloved finger, then sat with her on my lap for an hour ensuring that she wouldn't scratch or rub with paw and try to lick it off. Then absorbed, I wiped it off. Ideally you would leave the cream on overnight and rub it off next morning if nausea, decreased appetite is not an issue. I think you will have to see how your cat tolerates it and work with your vet re application protocol.

I would recommend you seek out a good Vet Dermatologist who has had some experience with Bowen's. .
Since your cat has multiple lesions in multiple spots, the Dermatologist may want to use Cryotherapy on some, Imiquimod on others and maybe surgery on others. For sure you would not want to use Imiquimod around the lips. Your vet can best determine the correct approach.

As for cost, I would check around. Imiquimod is used for Bowen's in humans also. We Americans normally think we pay more for drugs here than in Canada, but maybe not so with this drug.

My cat saw the Dermatologist today for follow-up. Vet was most pleased with the healing of the head lesion. Originally there was a 2cm x 1 cm lesion and another 1cm x 1cm lesion but today she only saw a tiny less than 1 mm spot, so did a light Cryotherapy pass over it which she says should resolve it completely. She will check her again in 6 weeks.

So although Bowen's at first seems like a daunting challenge, it is definitely treatable. If I can be of further help or if you have more questions as you go along, please do not hesitate to ask.

 

[Black&White]

I'm very glad to hear that you are at the 'tail' end of your treatment, it is giving me a sense of hope that we can beat this. I applied Aldara yesterday for the first time, at about 3pm. It was fine and no issues or resistance.

By 10pm, though, it was clear that she was feeling discomfort, she appeared 'spooked'. When she sat on my lap, after a while she suddenly jumped up like she had been stung. This happened twice, she then went to sit by herself. I comforted her, stroked her, brushed her, gave her cream and so forth, and sat with her for a long time. She had settled down by the time I went to bed at 2am.

I am wondering if I should just apply the cream to the large sores on her chest first? She has small ulcers on both ears as well, a lump at the base of one ear, a small one on her head, and a warty growth above one lip that is very hard - which I picked off a bit.

She seemed fine this morning, but she had the 'stung' reaction when she sat on my lap again. I wondered if she was having a bad memory, or if there is something going on inside. I can see her mood is more introspective, but she seems to be doing much better today.

I re-read your messages and see that you apply it at night. I will do that next time, perhaps an hour or two before bed.
Did you give her any other meds aside from cerenia to help ease her discomfort? Did you change her diet at all? Our vet has said nothing about that, but they have indicated that they really know nothing about it.

We are booked to see a dermatologist vet in Vancouver at the end of August, that will be quite a journey for her...

Blessings!

 

[babiesmom5]

The most common adverse reactions (>28%) are localized skin reactions like burning, stinging, itching, flaking, scaling, irritation etc. My cat did not experience any type of local skin reaction, only decreased appetite and nausea next day. But as you know, different cats have different reactions.

I don't know what instructions your vet gave, but mine told me to apply the Imiquimod twice a week for first two weeks to see how tolerated. She did fine, so then was advanced to every other day.

You might try this twice a week routine. See how it goes first. Of course, you are applying it THINLY with a gloved finger. Applied thinly, you should see no film residue on the skin. Do you think perhaps you were applying the Imiquimod too thick? This stuff is pretty potent, so doesn't take much to be effective.

I trust the hair has been shaved off the lesions? If not, hair needs to be shaved in those spots. This helps you see what you are doing and also helps for better medication penetration. Yes my cat looked raggedy!

Make sure you are getting Imiquimod not just in the center, but also along the edges or the margins.

You might want to apply the Imiquimod on the largest, most troublesome spots for now. Obviously that limits the amount of irritation, burning she experiences. Fortunately, Bowen's is a slow growing type of carcinoma, so the smaller lesions in more sensitive areas may be treated differently by the Dermatologist you are seeing next month.

My cat's diet stayed as normal. It did not change due to Bowen's and Imiquimod. To my knowledge no dietary changes need be made, only if the cat has gastrointestinal adverse reactions. My cat gets an all wet diet of high quality protein, grain free, low phosphorus food good for CKD and IBD.

As I said previously, my cat had IBD and CKD prior to the Bowen's, so her GI tract was already sensitive. For these issues, she was already on a low dose of Prednisolone (for the IBD) and also got Cerenia as needed on rare occasion for nausea. She also was getting Mirataz transdermal ointment (an appetite enhancer) for both of these issues. Prior to Bowen's, the IBD and CKD were both stable.

But when she began Imiquimod, it caused a decrease in appetite and nausea the day after application. So on the "application nights", per my vet's advice, I added Cerenia which helped offset the nausea and keep her eating more normally. With CKD and IBD, my cat absolutely has to eat and stay hydrated. She was, and still is, getting daily fluids for the CKD.

My best advice is to give the Imiquimod best you can, beat back the larger lesions, until you see the Dermatologist next month who may be able to advise further on surgeries, and or Cryotheraphy.

 

[Black&White]

Thank you, that's much appreciated. We are on the third week now. The first two weeks have gone well, I can see the two big lesions on her chest are already clearing up. We have stuck to every two days, and I do not see any adverse reactions or nausea so far.

She never ceases to amaze me, she knows when it's application night, and reminds me and waits for it. She keeps very still and bears it without a fuss (or just a little bit). After it's done she wears her little collar for an hour without the slightest issue.

The only thing is that her hair is growing back enough now that I was wondering if I should buy some clippers to keep it trimmed myself? I will also ask my vet to see where I can buy them.

Thank you again

 

[babiesmom5]

That's wonderful news! Yes, the lesions do respond to the Imiquimod fairly quickly. Cats have an amazing way of sensing when someone is trying to help them; reason she is being so cooperative with treatment. I would try to keep the hair around the lesion trimmed as much as possible for efficacy of the Imiquimod. I kept my girl trimmed with sharp scissors here at home, but the vet can trim closer with clippers...they just don't like the noise it makes. Thanks for sharing the update and picture. Give your girl some love from me.

 

[Black&White]

We have been doing applications for about a month now, and yesterday we had an unusual incident. She was obviously not feeling well, and I had to go out for a few hours. I felt that she didn't want me to go, so I sat with her for as long as I could to comfort her. When I came home she was not there to greet me in the car port, she was unusually absent. After a while I went back to the front of the house and there she was siting in the garden where she often sits, clearly very upset. She just sat there, even when I went up to her. looking despondent. I picked her up and carried her inside. No purring. I felt that she was not well and was upset that I had left her. After a few hours she came back to semi normal, and today she seems ok, but is really wanting attention. I'm wondering if the Imiquimod is having a cumulative effect on the way she feels? I am going to skip her application tonight and do it tomorrow which would be 72 hours. I'm wondering, though, about the lesions on her chest for example, when is it time to stop treatment and see if the remaining bit of scabbies fall away? Perhaps its already better, but needs some time to heal?

 

[babiesmom5]

I am sorry your baby was not feeling well, but glad to hear she is ok now. Actually, I have not noticed a cumulative effect...just a "post application effect" for 1-3 days following an application. Now that you have given her a break for 72 hrs, watch and see how she does afterwards again.

I would not stop the treatments prior to examination by the Dermatologist you will be seeing this month.
Only the Dermatologist can determine whether a lesion has been sufficiently healed. Mine looks carefully with a special light and under magnification, sometimes taking slight scrapings and looking under the microscope. What YOU think might be healed, might NOT be what the Dermatologist thinks and vice versa.
For instance, with my cat, I was unsure whether her back and neck lesions were healed, but under close examination the vet said that they were and I could stop the treatment in those spots.

I caution you not to discontinue the treatment before getting the "green light" from the Dermatologist, because if the lesions are not completely healed, they return and may even spread. Hope this helps.

 

[Black&White]

Thanks that's good to hear. She seems to be back to her usual self now, but I will do a lighter treatment tomorrow and continue until we see the dermatologist. Thank you!

 

[Black&White]

Another question has come up, I could smell some bad odor between her shoulder blades today, although when I felt around the area there does not seem to be anything. I recognize the odor, because about 2 months ago she had an abscess break on her left cheek, white creamy gook on her fur that smelled worse than this but similar. At the time there wasn't much to feel there either, but now it has grown a bit and I just snipped the fur on her cheek to start treating it. So, I'm just wondering if there might be something just beginning between her shoulder blades possibly?

 

[Black&White]

I just cleaned her fur in the area on her shoulders with some self-cleaning shampoo, and I feel certain about the smell. Which means it is spreading, perhaps. I did notice last week on the ones on her chest that the radius had increased a bit to the surrounding fur. I had to snip some more of the fur to treat it. We see the dermatologist on the 1st Sept. Did your cat have a bad odor with some of the affected areas?

 

[babiesmom5]

My cat did not have a bad odor on any of the lesions, but the one on the head (the worst one) became ulcerated and infected. The Dermatologist cleaned it out well, then she was on an antibiotic for a while. This procedure cleared it up.

From your description, it does sound infected. Sept 1 is just around the corner, but you might want to have your local vet check this area, clean it out meanwhile.

You are a good cat mom to be so observant as these lesions can pop up anywhere.

 

[Black&White]

Thank you!

 

[Black&White]

Amazing that a month has passed since I last posted - our appointment with the dermatologist was postponed and we did a 'remote' consultation instead, where the dermatologist in Vancouver called and spoke to my Vet and I followed up with an appointment with my vet last Monday. She took some pictures to send to the dermatologist, and we found that she had lost 300 ounces. The vet also said that she may have a slight heart murmur - type 1.

So my vet set up an appointment next week for Xrays ($500) to check the heart murmur, and blood-work ($350) to review what might be causing the weight loss. My cat did have bloodwork 2 months ago, and it appears the weight-loss has occurred since treatment with the Aldara. Strangely, I would say her appetite has increased in the last two months. She has been eating a lot, so my assumption at this point, is that the weight-loss may be related to the Aldara treatment? I have to say I wasn't very happy with how the vet conducted the appointment, and I am tempted to go to another vet for a second opinion - I wonder if she really does have a heart murmur...

There are two stubborn scabs on her chest that I see now have been preventing the aldara from penetrating those spots. So the vet suggested soaking them - dabbing warm water - and trying to flake them off. This has worked somewhat, and the softening may be allowing more of the cream to get through. Did you have this issue? I am wondering if there might be another way to remove the scabs...

The aldara has been working, it seems, the lesion on her ear is gone for the most part, her left cheek also, and the ones on her head are dissipating. Which just leaves her chest and right cheek. But I have noted what you said about needing the derm to verify that first.

 

[Black&White]

I realized I must have made a mistake, not 300 ounces, she lost a very small amount of weight, maybe 3 ounces, but I was sure she said 300 something...

 

[babiesmom5]

Thanks for the update. I've been thinking of you knowing you had the Dermatology appointment this month and wondered how you made out. I'm not a vet, but think a "remote" dermatological consultation is not optimal. These lesions need to be seen up close with the eye and under magnification. Pictures in my opinion do not do justice, nor do they substitute for physical dermatological examination.

As for the low grade heart murmur, my girl has a heart murmur also. I had her evaluated by a cardiologist using an echocardiogram. It revealed that she has a "dynamic right ventricular outflow tract obstruction". This means that the right side of the heart contracts forcefully on itself when she is excited. The cardiologist explained that this is common in cats that are anxious at a vet. This leads to a heart murmur, but is usually of no clinical significance to the cat. Nontheless, my cat is periodically re-evaluated by her cardiologist.

Rather than X-rays, for the same amount of money or less, I would recommend you have your cat evaluated by a cardiologist with an echocardiogram. X-rays can detect enlargement of the heart, but cannot tell the full picture of what is going on inside the heart. I would ask your vet for a cardiology referral.

Now as for the weight loss despite good appetite and eating more, I do not think this is related to the Imiquimod. A potential side effect of Imiquimod is loss of appetite and nausea. Your girl has not had this; in fact just the opposite. So I think the weight loss is due to something else and it is good you are getting bloodwork done soon.

Those scabs you see on the lesions are best removed by a dermatologist after they closely shave the hair. Bowens does manifest itself as scabs, crusting and flaking lesions. Yes, you can try dabbing them with warm water to flake them off a bit so the Imiquimod penetrates more effectively.

It is good that the lesions on your cats ear, left cheek and head seem to be responding to Imiquimod therapy, but yes a dermatologist needs to evaluate and make that determination. Even so, careful close monitoring by you is essential. Case in point: last month I took my cat to her dermatologist for follow up to the Cryotheraphy treatments on the head. I mentioned to the vet that I thought the lesions on her neck and back may be coming back. Vet rechecked, but said it was an enlarged hair follicle or something. Well, a couple of weeks later, I feel and see scabs on those lesions...sure enough it came back! So we are back to the Imiquimod treatments twice a week until I can get her to the dermatologist next month, (or sooner) to hopefully be treated by Cryotheraphy. Constant vigilance is a must!

I do hope you will be able to somehow get an "in person" consultation with a dermatologist as well as a cardiology consult as well as answers to why your cat is losing weight. I hope it is nothing serious. Please do keep us posted. We are all wishing you and your girl the best!

 

[Black&White]

Wonderful! Thank you for your feedback and continued support, this has really helped! I am sorry to hear your cat's lesions have returned, does it ever go away completely?

The remote consult was a way for the derm to pre-screen any issues so we could save time when I go to Vancouver. They want to do Co2 laser treatment, 'ablation', which is a half day treatment under anesthetic, here it is: North West Veterinary Dermatology Services Ltd. - Veterinarian in Vancouver, BC

It is a bit expensive, they want me to prepay $1000 cdn, then pay the difference if it is more than that after the treatment.

I originally thought this was Cryotheraphy, but I don't think they even offer it. I have seen Cryotheraphy at another clinic in Vancouver, though. They also suggested I see an oncologist in Vancouver as well.

I sent a note to my vet for a referral to see a cardiologist for an echocardiogram. Why wouldn't they have suggested this in the first place?

Thank you again, always a pleasure to read your responses!