10.5826/dpc.1401a32
text/xml
2160-9381
3573
en
Dimitri  Luz Felipe da Silva
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
adalimumab
Unilateral Verrucous Psoriasis Successfully Treated With Adalimumab 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2024-01-31
2023-05-30
2024-01-31
2024-02-21
e2024032
Dermatol Pract Concept
Dimitri  Luz Felipe da Silva
2024/01/31
10.5826/dpc.1401a32
e2024032
University of Santo Amaro, São Paulo, Brazil
2160-9381
adalimumab
en
e2024032
Shivers L, Montanez-Wiscovich ME. Verrucous psoriasis treated with methotrexate and acitretin combination therapy. Cutis. 2019;104(6):E10-E12. PMID: 31939936.
Unilateral Verrucous Psoriasis Successfully Treated With Adalimumab 
https://dpcj.org/index.php/dpc/article/download/3573/2553
             Unilateral Verrucous Psoriasis Successfully
                     Treated With Adalimumab
         Artur Antônio Duarte1, Ana Gabriella Bandeira Freire Andrade1, Caroline Costa
             de Mendonça1, Mônica Ramos de Freitas1, Dimitri Luz Felipe da Silva1


1 University of Santo Amaro, São Paulo, Brazil



Key words: psoriasis, adalimumab
Citation: Antônio Duarte A, Andrade AGBF, Costa de Mendonça C, Ramos de Freitas M, Luz Felipe da Silva D. Unilateral Verrucous
Psoriasis Successfully Treated With Adalimumab. Dermatol Pract Concept. 2024;14(1):e2024032. DOI: https://doi.org/10.5826/
dpc.1401a32
Accepted: June 23, 2023; Published: January 2024
Copyright: ©2024 Antônio Duarte et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Ana Gabriella Bandeira Freire Andrade, University of Santo Amaro, São Paulo, Brazil.
E-mail: anagabriellabandeira@gmail.com




Introduction                                                             erythematous plaques with thick, verrucous-like crusts, well
                                                                         adherent in the lower left quadrant of the abdomen, left
Verrucous psoriasis (VP) is a rare variant of psoriasis that             breast (medial upper quadrant) and left axilla. The lesions
typically arises in patients with established psoriasis but can          followed Blaschko lines and did not extend beyond the mid-
occur de novo [1]. There is a higher prevalence in men [2]. The          line (Figure 1).
disease usually appears in areas of friction, and is associated               A skin biopsy showed regular psoriasiform acanthosis
with obesity, diabetes mellitus, and peripheral circulatory              of the epidermis, widening of the bases of the interpapillary
failure [3]. We report a case of unilateral verrucous psoriasis          ridges, thinning of the suprapapillary portion, laminar hy-
with a good response to treatment with adalimumab.                       perparakeratosis containing Munro microabscesses, Kogoj
                                                                         spongiform pustule in the epidermis and dilatation, capillary

Case Presentation                                                        tortuosity in the papillary dermis (Figure 2).
                                                                              Clinical and histopathological findings led to the di-
A 31-year-old female patient reported pruritic scaly erythem-            agnosis of unilateral verrucous psoriasis. Treatment with
atous lesions over the body for 5 years. Previous betameth-              clobetasol, methotrexate oral and UVB-NB phototherapy
asone with salicylic acid cream without improvement of the               was started with partial response. Adalimumab (40 mg ev-
lesions was used. She had a personal history of obesity grade            ery two weeks) was then opted out and showed efficacy of
II and was asthmatic using formoterol fumarate dihydrate                 90% (psoriasis area severity index [PASI] 90) after 12 weeks
plus budesonide. Dermatological examination found scaly                  (Figure 3).




Research Letter | Dermatol Pract Concept. 2024;14(1):e2024032                                                                            1
                     Figure 1. (A) Verrucous psoriasis on the left side of the abdomen. (B) Verrucous psoriasis of the
                     breast and left armpit.



                                                                           Conclusions
                                                                           VP is characterized by symmetric hypertrophic verrucous
                                                                           plaques that may have an erythematous base and involve the
                                                                           legs, arms, trunk, and dorsal aspect of the hands; malodor is
                                                                           frequent [4].
                                                                              It has been hypothesized that marked hyperkeratosis
                                                                           is induced by repeat trauma to the extremities in patients
                                                                           with established psoriasis or by anoxia from conditions that
                                                                           predispose to poor circulation, such as diabetes mellitus and
                                                                           pulmonary disease [3].
                                                                              The diagnosis of VP can be challenging because of its
                                                                           similarity to other entities, including verruca vulgaris; epi-

Figure 2. (H&X10) Regular acanthosis with a psoriasiform pattern,
                                                                           dermal nevus; contact dermatitis, eczema, fungal infection
thinning of the suprapapillary portion, Kogoj spongiform pustule in the    and squamous cell carcinoma [4,5]. Histopathologically,
epidermis and capillary dilation and tortuosity in the papillary dermis.   overlapping features of verruca vulgaris and psoriasis have
                                                                           been described [2,4].
                                                                              Regarding treatment, this condition is sometimes refrac-
                                                                           tory. Use of topical therapies such as corticosteroids and ker-
                                                                           atolytics has minimal response in monotherapy. The greatest
                                                                           successes reported so far have been with systemic therapy
                                                                           such as methotrexate and acitretin, used alone or in combi-
                                                                           nation [4]. As for immuno-biologicals, the few reported cases
                                                                           showed only a partial response.
                                                                              However, the unilateral variant of VP is even more un-
                                                                           common, with only one case reported in the literature so far.
                                                                           In this case, only topical treatment was chosen, as the patient
                                                                           refused systemic therapy.
                                                                              We report the first case of unilateral verrucous psoriasis
                                                                           that, after refractoriness to treatment with topical cortico-
Figure 3. Significant improvement of verrucous lesions after 2 months      steroids, phototherapy and oral methotrexate, showed an
of use of adalimumab with few residual nodular lesions.                    excellent response to the immuno-biological Adalimumab,



2                                                                              Research Letter | Dermatol Pract Concept. 2024;14(1):e2024032
reaching PASI 90 after 12 weeks of treatment. Therefore, we        2. Rejeb SB, Dhaoui A, Ghachem DB, Souissi A, Bellil K. Psoriasis
aim to contribute to the recognition of this entity and pro-          with verrucous appearance: a case report. Our Dermatology On-
                                                                      line. 2017;8(1):63–65. DOI: 10.7241/ourd.20171.17
mote more assertive therapeutic alternatives.
                                                                   3. Khalil FK, Keehn CA, Saeed S, Morgan MB. Verrucous Psori-
                                                                      asis: A Distinctive Clinicopathologic Variant of Psoriasis. Am
References                                                            J Dermatopathol. 2005;27(3):204-207. DOI: 10.1097/01.dad
                                                                      .0000157450.39033.31. PMID: 15900122.
1. Sanyal RD, Vyas NS, Sapadin AN, Phelps RG. Unilateral           4. Shivers L, Montanez-Wiscovich ME. Verrucous psoriasis treated
   ­Verrucous Psoriasis. Cutis. 2021;107(2):97-98. DOI: 10.12788      with methotrexate and acitretin combination therapy. Cutis.
    /cutis.0174. PMID: 33891840.                                      2019;104(6):E10-E12. PMID: 31939936.




Research Letter | Dermatol Pract Concept. 2024;14(1):e2024032                                                                     3
