A Rare Case of Unilateral Psoriasis with Verruca Vulgaris:

Challenges in Diagnosis and Treatment

Marsha Bianti

, Shannaz Nadia Yusharyahya

,Sondang P. Sirait

Eyleny Meisyah Fitri

, Endi Novianto

Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia/

Dr. Cipto Mangunkusumo National Central General Hospital, Indonesia

Keywords: HPV, Unilateral Psoriasis, Verruca Vulgaris

Abstract: Unilateral psoriasis is a rare clinical variant of plaque psoriasis with unclear pathogenesis. We report a 51-

year old woman with a 5-year history of itchy, red, scaly patches on the unilateral right breast, arm, and leg.

There were also some vegetating masses on top of the red patches on her lower right leg. Physical

examination revealed multiple erythematous plaques with coarse-white scales overlying it, distributed along

Blaschko lines on her right side of the body and multiple verrucous nodules on erythematous plaques on her

lateral aspect of lower right leg. Histopathology examination showed epidermal psoriasiform hyperplasia

and collections of neutrophils. Numerous koilocytes were also seen. Qualitative Human Papillomavirus

(HPV) genotyping test was done on lesion on the leg and the result was positive. The diagnosis of unilateral

psoriasis with verruca vulgaris was made based onclinico-histopathological findings. To date, there is no

guideline available for unilateral psoriasis. She was treated with topical steroid and 5% LCD in vaseline

album for psoriasis and 30% salicylic acid in vaseline album for verruca vulgaris and reported

improvement. In this case, HPV infection occurs simultaneously. Theoretically, psoriasis lesions are

resistant to infection. On the other hand, various microorganisms, including viruses, are known to be

associated with exacerbations of psoriasis and HPV infection is considered an opportunistic

infection.Unilateral psoriasis with verruca vulgaris is a very rare case. Recognition of this unusual clinical

picture of psoriasis variant with overlapping verruca vulgaris is necessary to avoid delayed diagnosis and

perform prompt treatment.

1 INTRODUCTION

Psoriasis is a chronic, immune-mediated disorder

with a various predisposition combined with

environmental triggers, for example trauma,

infections, medications, and psychological

stress.(Yan de Kerkhof et al., 2018)The lesion is

characterized by sharply demarcated erythematous

plaque with coarse-micaceous scale. The plaque may

be localized or widespread in distribution with

predilection in scalp, elbows, knees, hands, feet,

trunk, and nails. Yan de Kerkhof et al.,

2018;Gudjonsson et al., 2012)

The occurrence of psoriasis in a linear or

unilateral orsegmental along the lines of Blaschko is

very rare.(Nasimi et al., 2016;Ghoneim et al. 2017).

Considerable diagnostic confusion exists, since these

lesions can clinically resemble very closely to other

linear dermatoses such as inflammatory linear

verrucous epidermal nevus (ILVEN). The

pathogenesis of unilateral psoriasis remains unclear,

however genetic mosaicism is proposed to be the

underlying mechanism. (Ghoneim et al. 2017).

To date, there is no treatment guideline

specifically for unilateral psoriasis, so treatment was

based on the algorithm for psoriasis vulgaris.

However, the prognosis is not very good due to

various inconsistent treatment results and

recalcitrant cases. (Ghoneim et al. 2017).

Psoriasis can be provoked or exacerbated by a

variety of different environmental factors, including

viral infections, such as papillomaviruses and

retroviruses. (Fry L et al., 2007). Nevertheless, the

incidence of overlapping psoriasis and verruca

vulgaris cases are extremely rare. During 2016-

2018, there was only one case of unilateral psoriasis

and verruca vulgaris in Department of Dermatology

and Venereology, Faculty of Medicine Universitas

286

Bianti, M., Yusharyahya, S., Sirait, S., Fitri, E. and Novianto, E.

A Rare Case of Unilateral Psoriasis with Verruca Vulgaris: Challenges in Diagnosis and Treatment.

DOI: 10.5220/0009986902860289

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 286-289

ISBN: 978-989-758-469-5

Indonesia/Dr. Cipto Mangun kusumo National

Central General Hospital. (Data Kunjungan Pasien

Poliklinik Kulit dan Kelamin RSUPN Cipto Mangun

Kusumo Divisi Alergi - Imunologi, 2016-2018). We

report a rare case of unilateral psoriasis with verruca

vulgaris. The aim of this case report is recognition of

this uncommon psoriasis variant with overlapping

HPV infection to avoid delayed diagnosis and

perform prompt treatment.

2 CASE

A 51-year-old woman with no past medical history

presented with itchy, red, scaly patches on the

unilateral right breast, arm, and leg. She came to our

clinic on July 19

2018 with chief complaints of red,

scaly patches on her right side of the body, started

on her right lower leg, accompanied by itch, which

she felt very bothersome, since 5 years ago.

She had not seek medical treatment for this

condition and self-treated with application of cajuput

oil, engine lubricant oil, and several over-the-

counter ointments for itch. She also soaked her leg

with hot water and scratch the lesions to alleviate the

itch. Sometimes she used tools, such as comb, back

of the knife, or stones to scratch. These provide

transient symptomatic relief but the skin lesions

persist.

One year ago, the lesion spread to the right arm

and right lower back. Still, she had not seek medical

treatment and continue the application of previous

oils. Two weeks prior to admission, the lesions

spread to right breast. Patient also complained of a

vegetating mass in her lower right leg. The

vegetating mass was located on the previous

patches. She forgot the time of the onset, but she

noticed enlargement of the mass. There were no itch

or pain reported.

Patient denied any joint pain. No history of

atopic and allergy were recorded on patient, as well

as on her family. There were no history of similar

complaints in family. History of contact with plants

or farming-related were denied. History of contact

with irritants, other than mentioned above, were

denied.

Physical examination revealed multiple,

erythematous plaque, lenticular-plaques in size,

circumscribed, discrete-confluent, with coarse-white

scale overlying it on the right breast, lower right

back, right arm, right leg-foot. The lesions are

unilaterally distributed. There were

onychodystrophy and onychodiscoloration on 1

digits of right foot. On her lateral aspect of lower

right leg, we found multiple verrucous nodules on

the top of the erythematous scaly plaques. The Body

Surface Area (BSA) was 8% and the Psoriasis Area

Severity Index (PASI) score was 6.6. The itch was

evaluated with Visual Analog Scale (VAS) and

showed mild itch with score 3-4.

Biopsies from two locations were performed.

The first was from erythematous plaque on patient’s

right breast. Histopathological examination revealed

regular acanthosis, column of parakeratosis,

orthokeratosis, and collections of

neutrophilsbeneaththe stratum corneum (Munro

microabcesses). In the dermis, infiltration of

lymphocytes was seen. These findings were

according to psoriasis. The second location is from

her right lower leg. The lesion was verrucous nodule

with granulation tissue. In the epidermis, seen

parakeratosis, crust, acanthosis with elongated rete

ridges, some rete ridges were seen arborizing.

Spongiform pustules and numerous koilocytes were

seen. In the dermis, seen some chronic inflammatory

cells. Qualitative HPV genotyping test was done on

lesion on the leg and the result was positive,

indicating the presence of HPV infection

concomitantly with psoriasis.

The diagnosis of unilateral psoriasis with verruca

vulgaris was made based on clinic-histopathological

findings. She was treated with 0.25%

desoximethasone ointment and 5% LCD in vaseline

album for psoriasis and 30% salicylic acid in

vaseline album for verruca vulgaris. She has not

come for follow up yet but reported mild

improvement in her skin lesions.

A Rare Case of Unilateral Psoriasis with Verruca Vulgaris: Challenges in Diagnosis and Treatment

287

Figure 1.Clinical manifestation in patient

Figure 2.Histopathology findings from erythematous plaque on right breast. (Pointed by yellow arrow) A. regular

acanthosis B. column of parakeratosis C. collections of neutrophils (Munro microabscesses)

Figure 3. Histopathology findings from verrucous nodules on right lower leg. (Pointed by yellow arrow) A. acanthosis with

arborizing elongated rete ridges B. acanthosis with arborizing elongated rete ridges C. collections of neutrophils (Pointed by

yellow arrow) andkoilocytes (pointed by red arrow)

3 DISCUSSION

Unilateralpsoriasis is a rare form of psoriasis

which characterized by typical psoriasis lesion but

only unilaterallydistributed. Case reports of this

variant of psoriasis are still scarce and the

pathogenesis remains unclear although genetic

mosaicismwas suggested to be the cause. (Ghoneim

et al. 2017).Occurrence of psoriasis in a linear or

unilateral distribution raised diagnostic confusion,

since these lesions can clinically resemble other

linear dermatoses.

The main differential diagnosis is ILVEN which

shows similar distribution. (Altmant et al., 1971)

described the diagnostic criteria of ILVEN: early

onset, predominance in women, prevalence in the

lower extremity, pruritus, and recalcitrance to

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

288

treatment. Histopathology examination in addition to

the clinical characteristics to some degree could help

to distinguish between these two entities. In some

cases, if they share the same histology findings, a

definite diagnosis can be made only with meticulous

history taking, detailed clinical examination and

follow-up to observe treatment result (Gudjonsson et

al., 2012;Saraswat A. et al., 2004). Late onset of

erythematous and scaly plaques with quite rapid

progression and involvement of nails, and a response

to antipsoriatic treatment indicate psoriasis in this

case.

Patient was initially suspected with

chromoblastomycosis because of the lesions on her

lower right leg (verrucous nodules on erythematous

plaques) mimicked subcutaneous mycoses infection.

There were no history of contact with plants or

penetrating injury, such as a thorn prick, and the

histopathology findings showed no muriform bodies.

Therefore, chromoblastomycosis could be excluded

from our differential diagnosis.

Histopathology examination was performed to

confirm the diagnosis. Two specimens were taken,

the first was from patient’s right breast and the

findings were according to psoriasis. The second

specimen was taken from patient’s right leg and

interestingly, numerous koilocytes were seen. This

finding was according to psoriasis with verruca

vulgaris. To establish the diagnosis even further,

qualitative HPV genotyping was done and the result

was positive, indicating HPV infection

concomitant with psoriasis lesions. Theoretically,

psoriasis lesions are resistant to infection due to high

production of antimicrobial peptides and interferon

gamma. On the other hand, various microorganisms,

including viruses, are known to be associated with

exacerbations of psoriasis. HPV infection of

keratinocytes is favored by epidermal proliferation,

it could be argued that infection is secondary to the

hyperproliferative process in psoriasis and represents

a type of opportunistic infection.(Fry L et al., 2007).

In addition, patient’s habit to manipulate lesions by

scratching due to the itch may cause trauma that

became port d’entrée of HPV infection.

To date, there are no specific guideline for

unilateral psoriasis. Treatment options were based

on the algorithm for psoriasis vulgaris and some of

the cases showed unresponsiveness. The patient was

treated in accordance with treatment algorithm from

Indonesian PsoriasisStudy Group. Patient was

classified as moderate psoriasis and received topical

treatment with 0.25% desoximethasone ointment

and 5% LCD in vaseline album. We didn’t perform

phototherapy because it may further worsen the

verruca vulgaris. Segmental manifestations of

psoriasis respond less favorably to systemic

therapies. The chronicity and resistance to

antipsoriatic agents were suggested to be in part due

to the loss of heterozygosity in cells where the

lesions occur.

As for the verruca vulgaris, 30%

salicylic acid in vaseline album was prescribed. She

has not come for follow up yet but reported mild

improvement in her skin lesions, particularly lesions

on her right leg.

4 CONCLUSION

Unilateral psoriasis with verruca vulgaris is a very

rare case. We report a 51-year old woman with a 5-

year history of itchy, red, scaly patches on the

unilateral right breast, arm, and leg. Over the

following year there were also some vegetating

masses on top of the red patches on her lower right

leg. The diagnosis of unilateral psoriasis with

verruca vulgaris was made based on clinico-

histopathological findings. The patient was treated in

accordance with treatment algorithm for psoriasis

vulgaris from Indonesian Psoriasis Study Group. She

was treated with topical steroid and 5% LCD in

vaseline album for psoriasis and 30% salicylic acid

in vaseline album for verruca vulgaris and reported

improvement.

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