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CORRESPONDENCE Table of Contents  
Ahead of print publication
Verrucous inverse psoriasis: A novel variant of psoriasis


 Department of Dermatology, Far Eastern Memorial Hospital, New Taipei, Taiwan

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Date of Submission03-Aug-2022
Date of Decision16-Oct-2022
Date of Acceptance02-Nov-2022
Date of Web Publication15-Dec-2022
 


How to cite this URL:
Su HA, Tsai YC. Verrucous inverse psoriasis: A novel variant of psoriasis. Dermatol Sin [Epub ahead of print] [cited 2023 Feb 5]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=363837




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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 psoriasis.

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Two 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 psoriasis.

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The 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 Top

1.
Khalil FK, Keehn CA, Saeed S, Morgan MB. Verrucous psoriasis: A distinctive clinicopathologic variant of psoriasis. Am J Dermatopathol 2005;27:204-7.  Back to cited text no. 1
    
2.
Bommer S. Psoriasis verucosa. Hautarzt 1952;3:246-9.  Back to cited text no. 2
    
3.
Sezer E, Lehman JS, Yalçın Ö, Tüfek İ, Keskin S, Durmaz EÖ, et al. Oyster-shaped hyperkeratotic plaques on the penis. Dermatol Pract Concept 2015;5:37-8.  Back to cited text no. 3
    
4.
Scavo S, Gurrera A, Mazzaglia C, Magro G, Pulvirenti D, Gozzo E, et al. Verrucous psoriasis in a patient with chronic C hepatitis treated with interferon. Clin Drug Investig 2004;24:427-9.  Back to cited text no. 4
    
5.
Micali G, Verzì AE, Giuffrida G, Panebianco E, Musumeci ML, Lacarrubba F. Inverse psoriasis: From diagnosis to current treatment options. Clin Cosmet Investig Dermatol 2019;12:953-9.  Back to cited text no. 5
    
6.
Cook LC, Hanna C, Foulke GT, Seiverling EV. Dermoscopy in the diagnosis of inflammatory dermatoses: Systematic review findings reported for psoriasis, lupus, and lichen planus. J Clin Aesthet Dermatol 2018;11:41-2.  Back to cited text no. 6
    
7.
Al Rudaisat M, Cheng H. Dermoscopy features of cutaneous warts. Int J Gen Med 2021;14:9903-12.  Back to cited text no. 7
    
8.
Kim BY, Son Y, Cho HR, Lee D, Eo SK, Kim K. Miconazole suppresses 27-Hydroxycholesterol-induced inflammation by regulating activation of monocytic cells to a proinflammatory phenotype. Front Pharmacol 2021;12:691019.  Back to cited text no. 8
    

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Correspondence Address:
Ya-Chu Tsai,
No. 21, Section 2, Nanya South Road, Banciao, New Taipei 220
Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1027-8117.363837



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