ArticlePDF Available

Psoriasis with verrucous appearance: a case report

Authors:
Sarra Ben Rejeb at Security Forces Hospital Tunisia
Sarra Ben Rejeb
  • Security Forces Hospital Tunisia
Amen Dhaoui
Amen Dhaoui
Amen Dhaoui
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Dorra Ben Ghachem
Dorra Ben Ghachem
Dorra Ben Ghachem
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Asmahane Souissi
Asmahane Souissi
Asmahane Souissi
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Show all 5 authorsHide
Download full-text PDF
Read full-text
Download citation

Abstract and Figures

Psoriasis verrucosa is a rare clinical variant of psoriasis with peculiar histologic features. Only few cases have been reported in the literature. We herein report a rare case of psoriasis with verrucous appearance occurring in a 63 year-old woman who presented with verrucous and scaly erythematous plaque of the legs which was developed thirty years ago. The biopsy specimen showed regular psoriasiform epidermal hyperplasia with acanthosis, hyperkeratosis, and focal spongiosis with a superficial perivascular infiltrate. The patient was diagnosed with verrucous psoriasis. Recognition of this entity should preempt confusion with verruca vulgaris or other entities capable of producing wart-like epidermal changes.
Figures - available via license: Creative Commons Attribution 4.0 International
Content may be subject to copyright.
Available via license: CC BY 4.0
Content may be subject to copyright.
© Our Dermatol Online 1.2017 63
Our Dermatology Online
How to cite this article: Ben Rejeb S, Dhaoui A, Ben Ghachem D, Souissi A, Bellil K. Psoriasis with verrucous appearance: A case report. Our Dermatol Online.
2017;8(1):63-65.
Submission: 05.04.2016; Acceptance: 07.07.2016
DOI: 10.7241/ourd.20171.17
Psoriasis with verrucous appearance: A case report
Psoriasis with verrucous appearance: A case report
Sarra Ben Rejeb1, Amen Dhaoui1, Dorra Ben Ghachem1, Asmahane Souissi2,
Khadija Bellil1
1Department of Pathology, FSI Hospital, La Marsa, Tunisia, 2Department of Dermatology, FSI Hospital, La Marsa, Tunisia
Corresponding author: Dr. Sarra Ben Rejeb, E-mail: sarrabenrejeb88@yahoo.fr
INTRODUCTION
Psoriasis is an inflammatory disorder characterized
by peculiar skin and joint manifestations. The most
common clinical presentation is a scaly erythematous
plaque with thick silvery white scale. Psoriasis with
verrucous appearance is a rare variant of the disease
with characteristic clinical and pathological features; it
might be confused with many other lesions including
warts, epidermal nevus, contact dermatitis, eczema and
fungal infection [1,2].
We herein describe another case of this rare entity.
The clinicopathological features of this disease are
discussed.
CASE REPORT
A 63 year-old woman with no past medical history
presented with erythematous, scaly lesions of the
lowers extremities developed thirty years ago. They
were painless but were progressively growing, causing
significant physical dis-figurement and discomfort on
wearing shoes. Physical examination revealed verrucous
plaques of the legs (Fig. 1). A skin biopsy of these
lesions has been performed.
Pathologic examination revealed psoriasiform epidermal
hyperplasia of rete ridges with prominent papillomatosis,
marked parakeratosis and hyperkeratosis. It also showed
epidermal hypogranulosis, thin suprapapillary epidermal
plates, focal spongiosis of the Malpighi mucous body
and a superficial perivascular inflammatory infiltrate.
No inflammatory collection has been noted within the
epidermal layers (Figs. 2 and 3). Koilocytic changes
were not observed.
Clinical and pathological findings were consistent with
verrucous psoriasis (VP). The patient was treated with
local dermocorticoid. The patient has not been seen
since the beginning of the treatment.
Prior to the study, patient gave written consent to the
examination and biopsy after having been informed
about the procedure.
DISCUSSION
Verrucous psoriasis is a rare variant of the disease with
less than thirty cases reported in the literature [3].
It is mostly occurring on men with a sex ratio of 1.6
and a mean age of 53 year old [1,4]. Clinically, VP
is characterized by a scaly erythematous plaque with
ABSTRACT
Psoriasis verrucosa is a rare clinical variant of psoriasis with peculiar histologic features. Only few cases have been reported
in the literature. We herein report a rare case of psoriasis with verrucous appearance occurring in a 63 year-old woman
who presented with verrucous and scaly erythematous plaque of the legs which was developed thirty years ago. The
biopsy specimen showed regular psoriasiform epidermal hyperplasia with acanthosis, hyperkeratosis, and focal spongiosis
with a superficial perivascular infiltrate. The patient was diagnosed with verrucous psoriasis. Recognition of this entity
should preempt confusion with verruca vulgaris or other entities capable of producing wart-like epidermal changes.
Key words: Psoriasis; Verrucous; Histology
Case Report
www.odermatol.com
© Our Dermatol Online 1.2017 64
verruca vulgaris, epidermal nevus, contact dermatitis,
eczema and fungal infection [1]. However, a verrucous
carcinoma must be ruled out on biopsy. Microscopically,
the lesion has a characteristic feature of psoriasis with
wart-changes, it is typically showing parakeratosis,
epidermal psoriasiform hyperplasia with elongation
of rete ridges, thin suprapapillary epidermal plates,
thinning of the granular layer, and dilated, tortuous
capillaries with an inflammatory infiltrate, which may
contain admixed neutrophils in the papillary dermis.
Munro abscesses and spongiform pustules are frequently
noted. In our case, despite the absence of characteristic
neutrophils collection’s of psoriasis within the epidermal
layer, the correlation of clinical and other histologic
features including papillomatosis and epithelial
buttressing suggested the diagnosis. Moreover, Munro
abscesses might be absent in 35% of authentic psoriasis.
Classically, absence of koilocytic changes and Human
papilloma virus (HPV) immunostaining support the
diagnosis of verrucous psoriasis.
The etiology of verrucous psoriasis remains unclear. It has
been associated in some cases to lymphatic obstruction,
microangiopathy, diabetes and obesity [5,6]. Other
authors consider it as a progressive form of vulgaris
psoriasis [1,5]. The verrucous changes in this case have
been related to repeated trauma.
However, although it is considered to be a variant from
psoriasis, little is known about its adequate treatment
because of poor response to classic local therapy
(dermocorticosteroid, vitamine D, puvatherapy). Some
authors reported the efficacy of etretinate, adalimumab
and methotrexate. However, further investigations are
required to determine an optimal treatment for this
rare entity.
CONCLUSION
Verrucous psoriasis is a rare variant of psoriasis that
might prompt consideration of verruca vulgaris.
Combination of clinical and pathological findings is
required for precise diagnosis. Because of its rarity, no
codified therapy has been established yet.
Consent
The examination of the patient was conducted
according to the Declaration of Helsinki principles.
Written informed consent was obtained from the
patient for publication of this article.
Figure 1: Warty plaques of the foot.
Figure 2: Wart-like appearance of the epidermis (HEx400).
Figure 3: Epidermal hyperplasia with parakeratosis and prominent
papillomatosis (HE x200).
wart-like changes. It is commonly occurring on frictions
area such as elbows, hands, knees and feet. VP may be
confused with many other benign lesions, including
www.odermatol.com
© Our Dermatol Online 1.2017 65
REFERENCES
1. Khalil FK, Keehn CA, Saeed S, Morgan MB. Verrucous
psoriasis: a distinctive clinicopathologic variant of psoriasis. Am J
Dermatopathol. 2005;27:204-7.
2. Monroe HR, Hillman JD, Chiu MW. A case of verrucous psoriasis.
Dermatol Online J. 2011;17:10.
3. Kawtar I, Mariame M, Siham L, Fatimazahra M, Hassania A,
Taoufi q H. Verrucous Psoriasis and Verrucous Lichen Associated
With an Autoimmune Hepatitis. J Clin Diagn Res. 2014;2:2.
4. Curtis AR, Yosipovitch G. Erythrodermic verrucous psoriasis.
J Dermatolog Treat. 2012;23:215-8.
5. Okuyama R, Tagami H. Psoriasis verrucosa in an obese Japanese
man; A prompt clinical response observed with oral etretinate.
J Europ Acad Dermatol Venereol. 2006;20:1359-61.
6. Zouboulis CC, Biczó S, Gollnick H, Reupke HJ, Rinck G, Szabó M,
et al. Elephantiasis nostras verrucosa: benefi cial effect of oral
etretinate therapy. Br J Dermatol. 1992;127:411-6.
Copyright by Sarra Ben Rejeb, et al. This is an open access article
distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Source of Support: Nil, Confl ict of Interest: None declared.
... Verrucous psoriasis (VP) is a rare variant of psoriasis that typically arises in patients with established psoriasis but can occur de novo [1]. There is a higher prevalence in men [2]. The disease usually appears in areas of friction, and is associated with obesity, diabetes mellitus, and peripheral circulatory failure [3]. ...
... The diagnosis of VP can be challenging because of its similarity to other entities, including verruca vulgaris; epidermal nevus; contact dermatitis, eczema, fungal infection and squamous cell carcinoma [4,5]. Histopathologically, overlapping features of verruca vulgaris and psoriasis have been described [2,4]. ...
View
... In addition to the clinical picture of the lesion, and although history was going with verrucous psoriasis (VP), we went to surgery due to atypical presentation. It is well-known that, VP is rare, could occur de novo, highly prevalent in men, appears in friction areas in obese, diabetic patients (16,17) . Also, the diagnosis was challenging due to similarity to other lesions including verruca vulgaris, epidermal nevi, fungal infection and squamous cell carcinoma (SCC). ...
Epidermal Verrucal Lesion with Velvety-Like Granular Surface at Female External Genitalia and Medial Aspect of the Thigh Compatible with Previous History of Longstanding Psoriasis : A Case Report
Article
Full-text available
  • Jul 2020
Psoriasiform dermatoses are a wide spectrum of inflammatory diseases, with several major forms represented by different clinical entities. Psoriasis is the prototype of psoriasiform dermatoses. Other conditions include pustular psoriasis, Reiter’s syndrome, pityriasis rubra pilaris, lichen simplex chronicus and large-plaques parapsoriasis. These lesions represent a diagnostic challenge, both on clinical and histopathological basis. This could be attributed to overlapping clinical and histopathological features. All of them share the hyperactivity of keratinocytes leading to extensive hyperkeratosis, orthokeratosis, congestion and perivascular lymphocytic infiltration. We presented a 25 years old female patient. She complained of epidermal verrucal lesion at the external genitalia and medial aspect of the thigh and pubic region. The surface of the skin was rough with variable velvety like granular surface from one area to another. The cut section showed marked thickening of the epidermis with upper dermal congested vessels. This lesion was compatible with the previous history of long-standing psoriasis. A wide local excision was performed with closure of the wide area with minimal scar. The specimen was sent for histopathological examination and it revealed a picture of psoriasiform dermatitis.
View
DIVERGENT VERRUCOUS PRESENTATIONS – UNANTICIPATED HISTOPATHOLOGICAL DISCOVERY
Article
  • Feb 2021
Verrucous presentation of common dermatological disorders is a rare entity. Herein we report three such presentations. One is a verrucous variant of disseminated DLE, the second is verrucous psoriasis, and the other is prurigo nodularis, rare clinico-histopathological variants. They can be misdiagnosed for other closely mimicking conditions like Keratoacanthoma, Tuberculosis verrucosa cutis, and deep fungal infections.
View
Verrucous Psoriasis and Verrucous Lichen Associated With an Autoimmune Hepatitis
Article
Full-text available
  • Jan 2014
Verrucous psoriasis is a rare form of Psoriasis which has a clinical characteristic and histological appearance. Only few cases have been reported in the literature. We report a rare case of verrucous psoriasis associated with verrucous lichen appeared in a patient with an autoimmune hepatitis.
View
Erythrodermic verrucous psoriasis
Article
Verrucous psoriasis is characterized clinically by symmetric hypertrophic verrucous plaques on an erythematous base and histologically by overlapping features of both verrucae and psoriasis with negative human papilloma virus (HPV) studies. A 46-year-old African-American male presented with an 8-year history of extensive malodorous, symmetric, verrucous plaques manifesting as erythroderma. Biopsies showed epidermal hyperplasia and papillomatosis, parakeratosis with neutrophils, and dilated vessels in the dermal papillae. The polymerase chain reaction of lesional skin was negative for HPV DNA, and T-cell gene rearrangement was negative. The patient was diagnosed with erythrodermic verrucous psoriasis. Verrucous psoriasis is a rare presentation of psoriasis and has only been reported as a localized variant. To the authors' knowledge, erythrodermic verrucous psoriasis has not been reported. This presentation was a diagnostic and therapeutic challenge and serves to heighten the awareness of a unique variant of psoriasis.
View
A case of verrucous psoriasis
Article
  • May 2011
  • Dermatol Online J
Psoriasis is a common inflammatory disease with a range of clinical presentations and a chronic relapsing course. There have been few reports of verrucous psoriasis, which is distinguished by its warty appearance and characteristic histology. We report a case of this rare form of psoriasis in an elderly woman with a history of plaque-type psoriasis and and discuss the histopathologic findings.
View
Elephantiasis nostras verrucosa: Beneficial effect of oral etretinate therapy
Article
  • Nov 1992
Elephantiasis nostras verrucosa is characterized by chronic secondary, non-filarial lymphoedema due to recurrent lymphangitis, dermal fibrosis, and epidermal changes consisting of hyperkeratotic, verrucous and papillomatous lesions. Histologically, there is pseudoepitheliomatous hyperplasia. Therapeutic efforts should aim to reduce lymph stasis, which will also lead to improvement of the cutaneous changes. In this study, rapid disappearance of the hyperkeratotic and verrucous lesions, remarkable flattening of the papillomatous nodules and improvement of lymphoedema occurred in three obese patients treated with etretinate in an initial dose of 0.6-0.75 mg/kg/day for 4-6 weeks. Monitoring of plasma concentrations of etretinate, acitretin and 13-cis-acitretin by HPLC revealed sufficient short-time absorption (4 h) and bioavailability of the drug (30 days; two out of three patients). Long-term maintenance therapy in one patient produced a remarkable improvement in the lymphoedema; another patient relapsed after discontinuation of the etretinate and responded again after this was reintroduced. In the third patient treatment was withdrawn because of an increase in triglycerides, but improvement persisted 6 months later. The clinical side-effects of oral retinoid therapy were moderate and well tolerated.
View
Verrucous Psoriasis: A Distinctive Clinicopathologic Variant of Psoriasis
Article
  • Jul 2005
  • AM J DERMATOPATH
Psoriasis is capable of presenting in a variety of clinical and pathologic guises including a rarely described variant variably termed hypertrophic or verrucous psoriasis. Herein, we describe the clinical and pathologic attributes of a large series of patients with this unusual variant of psoriasis and distinguish it from other entities in the differential diagnosis. The histopathologic features and clinical and demographic attributes of a series of 12 cases from 12 patients were reviewed by a single dermatopathologist (MM). The 12 patients consisted of 7 males and 5 females with an average age of 61.8 years (males 38-93 years, females 41-71 years). Eight of the patients were Caucasian, 3 Hispanic and 1 African-American. Six of the lesions were located on the knees, 4 involved the elbows, and 2 were seen on the dorsum of the hands (metacarpal-phalangeal joint). The clinical appearance of the lesions consisted of flesh-toned to white mammillated plaques (8 cases) and coalesced papules (4 cases). Each of the biopsies showed regular psoriasiform epidermal hyperplasia with acanthosis, hyperkeratosis, and either spongiform neutrophilic or Munro micro-abscesses. In addition, each showed papillomatosis with bowing of the peripheral rete ridges toward the center of the lesion (buttressing). At high power, epidermal neutrophils were seen in particular surmounting the tips of the suprapapillary plates with accompanying serum. Hypergranulosis and koilocytic change were not observed in any of the lesions. Human papilloma virus (HPV) immunostaining and periodic acid Schiff (PAS) special staining for fungi were negative. Verrucous psoriasis is a distinctive variant of psoriasis with overlapping clinical and pathologic features that might prompt consideration of verruca vulgaris. The presence of epidermal papillomatosis and epidermal buttressing seen in these lesions is reminiscent of the histologic features of verruca vulgaris. Similarly, the presence of coalesced papules might prompt clinical consideration of verruca vulgaris as well. It is likely that this under recognized clinicopathologic entity represents a patterned response of the epithelium to repeated trauma/irritation typical of the anatomic locations that were encountered in this series. Recognition of this entity should preempt confusion with verruca vulgaris or other entities capable of producing wart-like epidermal changes.
View
View