Elephantasis Nostras Verrucosa and Psoriasis

Abstract

A 60-year-old man came to our observation because of hyperkeratotic plaques on the lower limbs, of 8 weeks duration.On physical examination, his legs showed indurated, cobblestone-like, grayish lesions, pink verrucous projections, and nonpitting edema ( Figure 1). Kaposi-Stemmer sign was evident. Few psoriatic plaques were present on the trunk and the upper limbs.The patient was affected by morbid obesity (body mass index 41 kg/m 2 ). His medical history was relevant for heart failure, venous insufficiency, lymphedema, autoimmune hypothyroidism, and psoriasis.At the time of the first visit, he was receiving furosemide 25 mg/d, enalapril 20 mg/d, thyroxine 100 µg/d, citalopram 20 mg/d, acetyl salicylic acid 100 mg/d, omeprazole 20 mg/d, acitretin 10 mg/d, emollients, and calcipotriol/betamethasone dipropionate ointment.The patient referred a worsening of the peripheral edema and effort dyspnea in the past week. A chest X-ray was taken and revealed pulmonary congestion due to congestive heart failure. He was hospitalized and blood tests were all within normal limits, except for an elevated reactive C protein (45 mg/L). An arteriovenous color Doppler ultrasonography (model MyLab40, Esaote, Genova, Italy) using a 7.5 to 12 MHz linear array transducer confirmed mild to moderate venous insufficiency. Filarial elephantiasis was excluded on the basis of the anamnesis and a diagnosis of elephantiasis nostras verrucosa (ENV) was made. Intravenous furosemide treatment was started, followed after 72 hours by the oral administration of the drug, in association with the increase of oral acitretin to 50 mg/d (0.4 mg/kg/d). Daily cleaning of the legs with chlorhexidine 2% aqueous solution was done to prevent over-infections. The patient initially used compressive bandages and after 2 weeks began to carry graduated support stockings (compression index 23-32 mm Hg). At follow-up visit, 2 months later, the patient had lost 15 kg and the lesions had resolved almost completely (Figure 2).Elephantiasis nostras verrucosa is a rare condition considered an exaggerated form of secondary lymphedema that usually involves lower extremities, deformed by progressive fibrosis of the skin. 1 The term "nostras" refers to elephantiasis involving individuals resident in areas where filariasis is not endemic. 2 ENV is clinically characterized by hard, thick, warty, or papillomatous projections and cobblestone-like lesions, with nonpitting edema. 1,2 ENV mainly affects the lower limbs, even though it has been reported in external genitals, abdomen, buttocks, upper limbs, and face. 3,4 The diagnosis of ENV is based on clinical history and physical examination. Skin biopsy, computed tomography, magnetic resonance imaging, lymphangiography, and 486156I JLXXX10.1177/1534734613486156The International Journal of Lower Extremity WoundsSavoia et al research-article2013

Kompressionstherapie bei entzündlichen Dermatosen der Beine

“…Bei einem Patienten wurde ein Lymphödem Stadium III als Trigger einer Psoriasis vulgaris beschrieben. Auch hier zeigte sich unter einer alleinigen Kompressionstherapie des Lymphödems eine deutliche Besserung der Psoriasis-Plaques [25]. In einer prospektiven randomisierten klinischen Studie wurde erstmalig der Einfluss der Kompressionstherapie der Unterschenkel bei insgesamt 30 Patienten mit Psoriasis über vier Wochen in einem Halbseitenversuch untersucht.…”

Compression therapy in dermatology

“…Here, too, the psoriasis plaques healed under compression therapy without further treatment measures. 16 Psoriatic plaques on the lower legs are often more resistant to treatment compared to other affected areas of the body.…”

Kompressionstherapie in der Dermatologie

“…Bei einem anderen Patienten war ein Lymphödem Stadium III ein Auslösefaktor einer Psoriasis vulgaris. Auch hier heilten die Psoriasis‐Plaques unter Kompressionstherapie ohne weitere Behandlungsmaßnahmen ab 16 Psoriasis‐Plaques an den Unterschenkeln sind im Vergleich zu anderen betroffenen Körperregionen häufig besonders therapierefraktär.…”