A woman with hyperkeratotic, verrucous plaques on her back
Hertel D, Jiang A, Lim H. A woman with hyperkeratotic, verrucous plaques on her back. Journal of the American Academy of Dermatology 2017; 76(6 Suppl 1):AB30.
Journal of the American Academy of Dermatology
Case Report: A 33-year-old woman with a history of Down syndrome presented for further evaluation and management of growths on her back and arms. The lesions developed over the preceding year and progressively enlarged. She has a history of similar lesions on her lower extremities and occiput that were previously treated with liquid nitrogen at an outside hospital with no improvement and subsequently surgical debridement with split thickness skin grafts. Physical examination revealed well-demarcated erythematous plaques with overlying scale on the bilateral forearms and right elbow in addition to hyperkeratotic, verrucous-appearing plaques over her mid and upper back. Biopsy of a lesion on her back was performed which revealed marked psoriasiform epidermal hyperplasia with papillomatosis, a diminished granular layer, parakeratosis and Munro’s microabscesses. Edema and vascular dilation in the papillary dermis were also noted. There was no viral cytopathic change and HPV immunostaining was negative.
Discussion: Verrucous psoriasis (VP) is a rare variant of psoriasis that presents with a mix of psoriasiform and wart-like changes both clinically and histologically. Symmetric, hypertrophic, verrucous plaques on an erythematous base clinically characterize VP. Subtypes exist including dome-shaped or crater-like papules, annular and erythrodermic forms. There appears to be an association between VP and diabetes mellitus, pulmonary disease, and phlebitis. It is theorized that resulting local anoxia can lead to hyperkeratosis in these lesions. VP could also represent a response to repeated trauma and irritation in a patient with psoriasis. Histopathologically, classic psoriasiform changes are observed in addition to verrucoid features; however, they lack koilocytic changes and have negative HPV studies. Reported treatment options include both topical and systemic agents that are typically used to treat psoriasis, though an ideal regimen specifically for VP has not been established. Our patient had significant improvement using superpotent topical corticosteroids.
Conclusion: Atypical presentations of psoriasis can lead to delayed diagnoses and unnecessary interventions. Knowledge of these variants combined with histopathological confirmation can help guide appropriate therapy.
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