Interventions for Bowen's disease: A systematic review and network meta-analysis of randomized controlled trials.

Summary

Across nine RCTs, laser-assisted photodynamic therapy ranked highest for initial clearance, surgery for long-term clearance, and PDT/LA-PDT/5-FU achieved the most favorable cosmetic outcomes. Cryotherapy and imiquimod ranked lowest for both initial and long-term clearance. The review was PROSPERO-registered and used Cochrane risk-of-bias assessments, though heterogeneity and bias were noted.

Key Findings

• LA-PDT ranked first for initial lesion clearance; surgery and laser ablation followed.
• Surgery ranked first for long-term clearance; LA-PDT and PDT followed.
• PDT, LA-PDT, and 5-FU had the best cosmetic outcomes; surgery had the worst.
• Cryotherapy and imiquimod ranked lowest for both initial and long-term clearance.

Clinical Implications

For lesions where cosmesis matters, PDT or LA-PDT can be prioritized; if durable long-term clearance is paramount, surgery remains preferred. Counseling should address the trade-offs, particularly the lower clearance with cryotherapy or imiquimod.

Limitations

• Moderate-to-high risk of bias and heterogeneity across included trials
• Limited number of head-to-head comparisons and variable outcome definitions

Future Directions

Conduct adequately powered head-to-head RCTs (e.g., LA-PDT vs surgery vs PDT) with standardized cosmetic outcome measures and long-term follow-up.