Verrucous Lichen Planus

Sir, Lichen planus (LP), first described by Erasmus Wilson in 1869, is a chronic inflammatory and immune-mediated disease characterized by purple, polygonal, pruritic, papular eruption affecting the skin, mucosa, hair, and the nails.[1] Morphologically, it can be of the following types: annular, linear, hypertrophic, atrophic, vesiculobullous, ulcerative, follicular, actinic, and LP pigmentosus.[2] Verrucous LP is one of the relatively rare clinical variants. It occurs as extremely pruritic, thick, elevated, purplish hypertrophic lesions seen mainly over the extremities, shin, with a chronic course. Here, we present the report of a middle-aged male who came with a very unusual presentation of verrucous LP over the hands and fingers. A 42-year-old man presented to the outpatient department with multiple asymptomatic raised, warty lesions over both hands for the last 1 year. There was no history of trauma. The lesions initially started as small papules and gradually increased to attain the present size. He had received treatment previously in the form of certain topical ointments without any relief. There was no systemic complaint like fever, respiratory distress, or joint pain. On examination, he was found to have multiple well-defined whitish verrucous plaques of varying sizes seen bilaterally over the hands and fingers [Figures 1 and 2]. Some of the nails were dystrophic with subungual hyperkeratosis and dyspigmentation. He also had an incompletely and partially amputated distal phalanx in his right hand, which was an accidental finding. Scalp and mucosa were normal. There was no evidence of koebnerization, and Wickham’s striae were not apparently visible. Based on these findings, a provisional clinical diagnosis of tuberculosis verrucosa cutis, verruca vulgaris, and hypertrophic lupus erythematosus was made.Figure 1: Raised, warty plaques over both palmsFigure 2: Raised, warty plaques over dorsum of both handsSystemic examination did not reveal any abnormality. Routine hematological and biochemical investigations were normal. A histopathologic examination revealed basket weave type of hyperkeratosis with papillomatosis, wedge-shaped hypergranulosis, acanthosis, sawtoothing of rete ridges, and focal basal cell degeneration. The subepithelium showed pigment incontinence and dense band of lymphohistiocytic infiltration in the papillary dermis hugging the epidermis [Figures 3 and 4].Figure 3: Hyperkeratosis, wedge-shaped hypergranulosis, acanthosis, sawtoothing of rete ridges, focal basal cell degeneration (H and E, 40×)Figure 4: Papillomatosis and dense band of lymphohistocytic infiltration in papillary dermis (H and E, 10×)Antinuclear antibody, double-stranded deoxyribonucleic acid (DNA) antibody, chest X-ray, and Mantoux were negative. Based on the above findings, a definite diagnosis of verrucous LP was made. We started systemic isotretinoin (40 mg daily) to the patient, and he responded well within 6 weeks [Figures 5 and 6].Figure 5: Post-treatment image showing excellent improvement to systemic retinoidsFigure 6: Post-treatment image showing excellent improvement to systemic retinoidsVerrucous LP is one of the rarest variants of LP, and there is only one case report mentioning the entity to the best of our knowledge.[3] There are few distinct differences from classical hypertrophic LP which is extremely pruritic and mostly occurs over the shin and ankles.[4] In our patient, the lesions were completely asymptomatic, and the morphology and site of them were very unusual. Histopathologically, instead of pseudoepitheliomatous hyperplasia and focal infiltrates below the rete ridges, there were papillomatosis and band-shaped infiltrate at the dermo-epidermal junction, which differentiate it from hypertrophic LP. The resistance to treatment is a striking feature in verrucous LP, and retinoids are less commonly used in treatment of LP. But our patient responded excellently to systemic retinoids within 6 weeks of therapy. We report the case for the peculiar clinical and histopathologic presentation of a relatively rare condition. 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 initials 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.