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CORRESPONDENCE
Year : 2023 | Volume
: 41
| Issue : 1 | Page : 36-37
Verrucous inverse psoriasis: A novel variant of psoriasis
Hsuan-An Su, Ya-Chu Tsai
Department of Dermatology, Far Eastern Memorial Hospital, New Taipei, Taiwan
Correspondence Address:
Dr. Ya-Chu Tsai
No. 21, Section 2, Nanya South Road, Banciao, New Taipei 220
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/1027-8117.363837
Dear Editor,
A 95-year-old male presented with painful and pruritic skin lesions that had developed over several months. Multiple verrucous brownish nodules and papules on erythematous to dusky red moist patches with peripheral satellite papules were located on bilateral inguinal areas [Figure 1]a. The clinical impression and differential diagnoses included inflamed seborrheic keratosis, inflamed verruca vulgaris, inverse psoriasis, and extramammary Paget's disease. Hyphae were identified on a KOH stands for potassium hydroxide examination. Dermoscopy of the verrucous nodules demonstrated multiple irregular whitish finger-like projections with red globules and glomerular vessels [Figure 1]b.
Figure 1: Clinical presentation of the verrucous inverse psoriasis on the right inguinal fold. (a) Initial presentation as brownish verrucous nodules on dusky red patches. (b) The dermoscopy of VIP revealed overlapping features of verruca and psoriasis, including irregular whitish finger-like projections, dotted vessels, glomerular vessels, clotted hemorrhages, and white scales. (c) After 4 weeks of topical miconazole treatment. (d) Week 2 posttopical corticosteroid/calcipotriol monotherapy. (e) Week 8 posttopical corticosteroid/calcipotriol treatment. (f) Week 20 posttopical corticosteroid/calcipotriol treatment. VIP: Verrucous inverse psoriasisTwo skin biopsies were performed on one of the verrucous nodules and the erythematous patches. The pathology of the patch revealed marked regular psoriasiform epidermal hyperplasia with suprapapillary thinning, parakeratosis, hyperkeratosis, mild spongiosis, dilated papillary vessels, neutrophilic and lymphocytic infiltrates, and Munro's microabscess [Figure 2]a. The pathology of the verrucous nodules demonstrated exaggerated papillomatosis, acanthosis, hyperkeratosis, parakeratosis, dilated vessels in the papillary dermis, Munro's microabscess, and a spongiform pustule of Kogoj [Figure 2]b and [Figure 2]c. Periodic acid-Schiff staining highlighted several scattered hyphae in the stratum corneum. Neither koilocytic changes nor a horn cyst was noted. CK7 and CK20 staining was negative, while p63 staining was positive. The patient was treated with topical miconazole cream twice daily under the impression of inverse psoriasis plus verrucous psoriasis, complicated with a mild superficial fungal infection.
Figure 2: Pathology of verrucous inverse psoriasis. (a) The pathology of the erythematous patch of VIP revealed typical psoriasiform dermatitis, including regular psoriasiform epidermal hyperplasia with suprapapillary thinning, parakeratosis, hyperkeratosis, mild spongiosis, dilated papillary vessels, neutrophilic and lymphocytic infiltrates, and Munro's microabscess (H and E, ×100 magnification). (b) Pathology of the verrucous nodules of VIP showed overlapping features of verruca and psoriasis (H and E, ×40). (c) Marked hyperkeratosis, parakeratosis, acanthosis, dilated vessels in the papillary dermis with erythrocyte extravasation, Munro's microabscess, and spongiform pustules of Kogoj on a mammillated nodule shaped like a “verrucous nodule of psoriasis” (H and E, ×100). VIP: Verrucous inverse psoriasisThe erythematous patches improved partially after 4 weeks, but the superimposed verrucous lesions did not change [Figure 1]c. The follow-up KOH examination yielded negative findings. Thus, the treatment was focused on psoriasis and shifted to topical monotherapy with betamethasone dipropionate plus calcipotriol ointment once daily. The patient was followed up at week 2 [Figure 1]d, week 8 [Figure 1]e, and week 20 [Figure 1]f as the lesions gradually improved with the topical corticosteroid/calcipotriol treatment. The erythematous patches were almost clear at week 20, and the verrucous nodules decreased significantly in size. Verrucous inverse psoriasis (VIP) was the final diagnosis based on the clinical presentation, pathology, and treatment response.
Verrucous psoriasis arising from inverse psoriasis, or VIP, has not been reported before, but variants of verrucous psoriasis have been suggested.[1] The first description of verrucous psoriasis, or psoriasis verrucosa, was traced to 1952.[2] Only a few cases of verrucous psoriasis have been reported in the literature, and all verrucous lesions were derived from plaque-type psoriasis, except for one case described by Sezer et al. demonstrating verrucous lesions in a background of genital psoriasis.[3] Another case reported by Scavo et al. had a history of inverse psoriasis, but his verrucous lesions arose from plaque-type psoriasis afterward.[4]
Inverse psoriasis generally appears as moist and scaly patches, while verrucous psoriasis reveals a more hyperkeratotic and rupioid surface compared to psoriasis vulgaris.[1],[5] These two opposite subtypes rarely emerge in the same area or the same person. Interestingly, dermoscopic findings of the verrucous psoriasis nodule, which have not been reported in the literature, indicated overlapping features of verruca and psoriasis.[6],[7] Although human papillomavirus immunostaining was not performed in our case, koilocytic changes were absent and the nodules improved after the topical corticosteroid/calcipotriol treatment. Seborrheic keratosis typically presents as hyperkeratotic papillomatosis with horn cysts microscopically and does not resolve with topical steroids. The resemblance to seborrheic keratosis in appearance may have caused the incidence of VIP to be underestimated in the same way as verrucous psoriasis.[1] The lack of cytological atypia ruled out malignancy.
The pathology of verrucous psoriasis is overlapping features of verruca and psoriasis,[1] while the pathology of inverse psoriasis demonstrates similar features of psoriasis vulgaris with less pronounced epidermal hyperplasia and more spongiosis.[5] In the present case, the pathology of the erythematous patches featured inverse psoriasis, while the pathology of the verrucous nodules paralleled verrucous psoriasis, forming a “verrucous nodule of psoriasis.” Psoriasis can vary greatly in its clinical manifestations, but it retains consistent histological characteristics. A biopsy is warranted in suspicious cases, particularly in those with an unusual presentation.
The present case was complicated by a superficial fungal infection, which is a common scenario in inverse psoriasis.[5] Miconazole has served as an off-label drug to treat plaque psoriasis due to its anti-inflammatory properties and ability to suppress the expression of several pro-inflammatory mediators.[8] Our patient was successfully treated with topical betamethasone dipropionate plus calcipotriol ointment; however, more cases are required to confirm a satisfactory response to treatment and a good prognosis for VIP.
Declaration of patient consent
The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for the images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Acknowledgment
The authors would like to thank Enago (www.enago.com) for the English language review.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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