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

Bowen's disease (BD) is an intraepidermal malignancy that may progress to skin cancer, yet no study has compared interventions from randomized controlled trials (RCT). We synthesized RCT data to calculate lesion-specific initial clearance rates, long-term clearance rates, and cosmetic outcomes relative to placebo. We searched MEDLINE, EMBASE, CENTRAL and trial registers up to September 30, 2024, and included nine studies (672 patients, 844 lesions). Interventions compared to placebo and ranked via network meta-analysis included surgery, imiquimod, photodynamic therapy (PDT), laser ablation (LA), laser-assisted PDT (LA-PDT), cryotherapy and 5-fluoruracil (5-FU). Bias was assessed using the revised Cochrane risk-of-bias tool. The study was registered in PROSPERO prior to data extraction (CRD42024583966). All interventions showed higher lesion-specific clearance rates than placebo. Regarding initial clearance, LA-PDT ranked first, followed by surgery and LA. Surgery ranked first for long-term clearance, followed by LA-PDT and PDT. Cryotherapy and imiquimod ranked lowest for initial clearance and long-term clearance. PDT, LA-PDT, and 5-FU showed the best cosmetic outcome, while surgery had the worst. Limitations included moderate to high bias and study heterogeneity. Our findings support clinical decision-making for BD, identifying LA-PDT and PDT as effective options balancing efficacy and cosmetic results, and surgery as optimal for long-term clearance.