10.5826/dpc.1204a200
text/xml
2160-9381
2330
en
Claudio Guarneri
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Cobblestone-like skin
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Image Letter
2022-10-31
2022-01-21
2022-10-31
2022-12-05
e2022200
Dermatol Pract Concept
Claudio Guarneri
2022/10/31
10.5826/dpc.1204a200
e2022200
Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Dermatology, University of Messina, Messina, Italy C/O A.O.U.P. “Gaetano Martino”, via Consolare Valeria, 1 – 98125 Messina (Italy)
2160-9381
en
e2022200
Kar Keong N, Siing Ngi AT, Muniandy P, Voon Fei W. Elephantiasis nostras verrucosa: a rare complication of lower limb lymphoedema. BMJ case reports. 2017;2017. doi:10.1136/bcr-2017-221492
Cobblestone-like skin
https://dpcj.org/index.php/dpc/article/download/2330/1815
                                         Cobblestone-like Skin
                             Laura Macca1, Luca Di Bartolomeo1, Claudio Guarneri2


1 Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, Messina, Italy.
2 Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Dermatology, University of Messina,
  Messina, Italy.



Citation: Macca L, Di Bartolomeo L, Guarneri C. Cobblestone-like skin. Dermatol Pract Concept. 2022;12(4):e2022200.
DOI: https://doi.org/10.5826/dpc.1204a200
Accepted: March 2, 2022; Published: October 2022
Copyright: ©2022 Macca 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: Claudio Guarneri, MD, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of
Dermatology, University of Messina, Messina, Italy C/O A.O.U.P. “Gaetano Martino”, via Consolare Valeria, 1 – 98125 Messina (Italy);
Phone number: +390902212894. Fax number: +390902927691. E-mail: cguarneri@unime.it




Case presentation                                                        Teaching point
A 55-year-old Caucasian man who was positive for obesity,                ENV is an uncommon dermatological disorder character-
hypertension and congestive heart failure presented for a                ized by hyperkeratotic, verrucous, and papillomatous pro-
sixteen-months history of recurrent lower limbs swelling with            jections [1]. Keong described it as “a non-filariasis chronic
progressive thickening of the skin. Clinical examination re-             lymphedema, causing disfigurement of the extremities, and
vealed lymphedema with deformed fibrotic enlargement of                  it will lead to recurrent infections and disabilities” [2]. The
the extremities. Brownish pigmentation, with generalized li-             diagnosis is based on anamnesis and peculiar skin modifi-
chenification (Figure 1A) and cobblestone-like papules and               cations [1]. Differential diagnosis includes venous stasis
nodules on the lower two thirds of both legs were also nota-             dermatitis, pretibial myxedema and filariasis [1]. Several
ble (Figure 1B). Swabs from some ulcerated lesions of the left           therapeutic options have been described in literature such
pretibial area were obtained, but cultures did not show any              as skin care, weight reduction, compressive medications and
pathogens growth. Histological examination of a nodular le-              physiotherapy [2]. Oral retinoids, surgery, and antimicrobi-
sion showed hyperkeratosis, parakeratosis, and acanthosis of             als for super infections have also been used [1]. The unique
the epidermis, as well as edema and dilated lymphatic spaces             target of the therapy is represented by restoring function and
in the papillary and reticular dermis. No neoplastic changes             reducing physical disability. As chronic lymphedema could
were found. Diagnosis of elephantiasis nostras verrucosa                 be the antechamber of lymphangiosarcoma, long-term fol-
(ENV) was made upon clinical and histopathological findings.             low-up is highly recommended [2].




Image Letter | Dermatol Pract Concept. 2022;12(4):e2022200                                                                            1
             Figure 1. (A) Lymphedema of the lower extremities, with brownish pigmentation and generalized thick-
             ening of the pretibial skin. (B) Close view of cobblestone-like papules and nodules on the lower two-thirds
             of left leg.




References                                                           2. Kar Keong N, Siing Ngi AT, Muniandy P, Voon Fei W. Ele-
                                                                        phantiasis nostras verrucosa: a rare complication of lower limb
1. Guarneri C, Vaccaro M. Cobblestone-like skin. CMAJ.                  lymphoedema. BMJ Case Rep. 2017;2017:bcr2017221492.
   2008;179(7):673-674. DOI:10.1503/cmaj.080642. PMID:                  DOI:10.1136/bcr-2017-221492. PMID: 28847994. PMCID:
   18809899. PMCID: PMC2535733.                                         PMC5624055.




2                                                                           Image Letter | Dermatol Pract Concept. 2022;12(4):e2022200
