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LETTER TO EDITOR
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 260-262

Co-localization of verruca vulgaris with verrucous epidermal nevus: Role of dermoscopy in diagnosis


epartment of Dermatology, Sexually Transmitted Diseases and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Submission10-Jun-2020
Date of Decision08-Sep-2020
Date of Acceptance18-Jun-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Sumaya Zeerak
Department of Dermatology, Sexually Transmitted Diseases and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_93_20

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How to cite this article:
Bhat YJ, Zeerak S, Devi R, Shah IH. Co-localization of verruca vulgaris with verrucous epidermal nevus: Role of dermoscopy in diagnosis. Clin Dermatol Rev 2021;5:260-2

How to cite this URL:
Bhat YJ, Zeerak S, Devi R, Shah IH. Co-localization of verruca vulgaris with verrucous epidermal nevus: Role of dermoscopy in diagnosis. Clin Dermatol Rev [serial online] 2021 [cited 2021 Dec 1];5:260-2. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/260/324582



Sir,

Verrucous epidermal nevus (VEN) is one of the multiple variants of epidermal nevi, arising as a result of epidermal hyperplasia. VEN is characterized by well-demarcated verrucous papules or plaques with a papillomatous surface. The lesions are usually skin colored to brown and can occur anywhere on the body.[1] They occur in circumscribed, linear, zosteriform, unilateral, or systematized patterns as streaks or whorls and often follow Blaschko's lines.[2]

A close clinical mimic of VEN is verruca vulgaris, which is a viral epidermal proliferation caused by human papillomavirus (HPV), usually by the low-risk types 6 and 11.[3] These two contrasting lesions also share some histological features, especially parakeratosis and papillomatosis, thus causing diagnostic difficulty in some cases even on histopathology.[4] Such cases can be eased through specialized tools like dermoscope.

It is very rare to encounter these two conditions together. We encountered four such cases wherein VEN and verrucae co-existed and the delineation was done using dermoscopy in all cases and histopathology (histopathological examinations) in cases wherever found necessary.

The first case was an 8-year-old female child who was brought to our outpatient department with the complaint of a warty lesion on her right cheek. The lesion had appeared a few weeks after her birth and had increased in size over a few months. It had then remained static till a month before reporting to the hospital when the mother had noticed an increase in the size of the lesion on one side. On examination, we noticed a verrucous plaque, composed of several verrucous papules on the right cheek of the child (near the malar eminence). The plaque was 4 by 3.7 cm in size, almost circular in shape, and light brown in color (especially on the medial side and along the margins). However, a segment of the plaque appeared dark brown superiorly and whitish inferiorly on the lateral side and the surface of this part looked different (more filiform) than the rest of the lesion [Figure 1]. Owing to this, we decided to perform a dermoscopy of the plaque to confirm the nature of the lesion, before proceeding to its ablative reduction.
Figure 1: (a) Verrucous epidermal nevus on the medial aspect and verruca vulgaris on the lateral aspect of the right cheek of a child. (b and c) Dermoscopy of the same patient depicting cerebriform pattern and brown circles medially and superiorly verrucous epidermal nevus, while the lateral and inferior aspect depicts reddish-brown hemorrhages (verruca vulgaris)

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The second case was a 13-year-old female who also presented to us with a warty lesion on her right leg (similarly present since birth). However, it showed the appearance of new warty projections toward the upper end for the last few weeks. On examination, we noticed the presence of a flat brownish-black serpiginous plaque with a slight verrucous surface on the posterior aspect of the thigh and leg extending from the buttock up to the insertion of the Achilles tendon. A similar plaque was also present on the anterior surface of the foot and the toes. The upper end of the thigh lesion showed the presence of few discrete skin-colored filiform projections distinct from the primary lesion [Figure 2].
Figure 2: (a) Clinical image showing serpentine verrucous epidermal nevus on the buttock, thigh, and leg with a few filiform verrucae superiorly. (b) Histopathological examination of the upper filiform portion showing hyperkeratosis, papillomatosis, and the presence of koilocytes, consistent with verruca. (c) Histopathological examination of the basal brownish-black portion of the plaque showing hyperkeratosis, parakeratosis, prominent granular layer, papillomatosis with a chronic inflammatory infiltrate in the dermis, and the absence of koilocytes, consistent with verrucous epidermal nevus

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On dermoscopy, the lesions exhibited two different patterns. In the first patient, the margins and the medial aspect exhibited a cerebriform appearance and brown circles at places, consistent with the classical dermoscopy of VEN [Figure 1]a and [Figure 1]b. Similarly, the primary flat brownish-black lesion in the second patient also depicted a similar pattern, again consistent with the diagnosis of VEN. However, in the first patient on the lateral side, we noticed irregularly distributed reddish-brown to brown and black hemorrhagic dots on a whitish keratotic background, consistent with the dermoscopy of verruca vulgaris [Figure 1]a and [Figure 1]b. Again, the filiform projections in the second patient depicted a similar picture, consistent with the dermoscopy of verrucae.

The third case was a 30-year-old male patient who reported with a new growth just adjacent to an original warty lesion on his left cheek. The original lesion had been present since his infancy and had been asymptomatic. A few weeks ago, he had noticed a new growth just medial to the original one [Figure 3]. The dermoscopy of the entire lesion was quite similar to our previous cases, wherein the medial new lesion depicted features of verruca while the lateral part was consistent with VEN [Figure 3]a.
Figure 3: (a) Verrucous papules on the cheek with verrucae medially and verrucous epidermal nevus laterally; (b) Dermoscopy of third case with hemorrhagic dots inferiorly and medially (verrucae) and cerebriform pattern laterally verrucous epidermal nevus

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The fourth case was a 27-year-old male patient who also complained of an increase in the size of his preexisting scalp lesion (which was present since his childhood). His lesion had increased as a filiform projection for the last few weeks [Figure 4]. Similarly, the dermoscopy yielded similar results, with the basal part showing features of VEN and the distal filiform part being consistent with verrucae [Figure 4]a.
Figure 4: A patient with a verrucous scalp lesion – verrucous epidermal nevus proximally and verruca distally. (b) Dermoscopy of the third case with cerebriform pattern superiorly (basal aspect) and hemorrhagic dots inferiorly (distal aspect)

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In addition, we performed histopathology in the second and fourth cases (not done in the other two cases due to cosmetic concerns). The portions of the lesions consistent with verruca dermoscopically showed hyperkeratosis, papillomatosis and the presence of koilocytes. This validated the diagnosis of verrucae. The portion consistent with VEN dermoscopically showed hyperkeratosis, parakeratosis, prominent granular layer, papillomatosis with a chronic inflammatory infiltrate in the dermis, and the absence of koilocytes, thus confirming the diagnosis [Figure 2]a and [Figure 2]b. The general physical examination was normal in all the patients with no other associated anomaly.

Hence, dermoscopy is a novel tool in the armamentarium of a dermatologist. It has simplified the clinical diagnosis of multiple cutaneous lesions which otherwise can even confuse the most skilled clinician. One such group of disorders are the keratinous lesions which can have an infective (e.g. verruca vulgaris) or a noninfective (e.g. VEN) etiology.

VEN is a common noninflammatory cutaneous hamartoma composed predominantly of epidermal keratinocytes, with each lesion being derived from a single mutant keratinocyte.[5] It is seen at birth or later in life with an average incidence of 1 per 1000 births.[6] The lesions are flat, soft, velvety, and papillomatous at birth (or in the initial months of their appearance) but become more keratotic and verruciform with increasing age.[7] Distinct from VEN, verruca vulgaris is a hyperkeratotic papilloma due to HPV infection, frequently occurring over hands of children and young adults, but may be located on any cutaneous or mucosal surface.[8] At times, verruca vulgaris resembles VEN and can cause diagnostic difficulty in some cases. In such cases, differentiation is aided by dermoscopy.

On dermoscopy, VEN exhibits brown circles of varying dimensions (each comprising a hyperchromic brown edge surrounding a hypochromic area) which can be localized or seen in the entire lesion. In addition, cerebriform appearance, milia-like cysts, fissures, brown globules, or cobblestone-like appearance can be seen.[9] The classical dermoscopic features of verruca vulgaris are large dotted vessels corresponding to multiple densely located papillae, with a red dot in the middle or a loop on white background, i.e. whitish halo, which gives an appearance reminiscent of frogspawn.[10]

Thus, dermoscopy is an emerging technique in dermatology which should be employed more frequently in rare and difficult to assess cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Ho VC. Benign epithelial tumors. In: Freedberg IM, Eizen AZ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine. 5th ed. New York: McGraw-Hill; 1999. p. 873-90.  Back to cited text no. 1
    
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Attia A, Elbasiouny MS. Treatment of verrucous epidermal nevus using long pulsed Nd: YAG laser. Egypt Dermatol Online J 2010;6:2.  Back to cited text no. 2
    
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Sterling JC, Handfield-Jones S, Hudson PM; British Association of Dermatologists. Guidelines for the management of cutaneous warts. Br J Dermatol 2001;144:4-11.  Back to cited text no. 3
    
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Gorlin RJ, Lohen MM, Stephen LL. Syndrome of the Head and Neck. 3rd ed. New York: Oxford University Press; 1990. p. 362-6.  Back to cited text no. 4
    
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Inakanti Y, Kumar S, Nagaraja A, Peddireddy S, Abhiram R, Meghana GB, et al. A case of zosteriform verrucous epidermal nevus at an unusual location. J Pak Assoc Dermatol 2014;24:173-1758.  Back to cited text no. 5
    
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Pierson D, Bandel C, Ehrig T, Cockerell CJ. Benign epidermal tumors and proliferations. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. Philadelphia: Mosby; 2003. p. 1697-720.  Back to cited text no. 7
    
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Lipke MM. An armamentarium of wart treatments. Clin Med Res 2006;4:273-93.  Back to cited text no. 8
    
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Carbotti M, Coppola R, Graziano A, Verona Rinati M, Paolilli FL, Zanframundo S, et al. Dermoscopy of verrucous epidermal nevus: Large brown circles as a novel feature for diagnosis. Int J Dermatol 2016;55:653-6.  Back to cited text no. 9
    
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Teoli M, Di Stefani A, Botti E, Mio G, Chimenti S. Dermoscopy for treatment monitoring of viral warts. Dermatology 2006;212:318.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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