Extensive presentation of verruca plana in a healthy individual.

A 27-year-old healthy man presented with non-itchy hyperpigmented skin lesions involving the trunk of duration 3 years. Examination revealed numerous coalescing, rough, slightly elevated brownish papules involving large areas of back, chest, and abdomen. There were no other cutaneous or systemic findings. Cutaneous biopsy was suggestive of verruca plana, which confirmed our clinical diagnosis. Here, we report this case of verruca plana due to its rare extensive involvement and unusual site in a non-immunocompromised individual.

Introduction

Warts are benign skin tumors that commonly involve the skin and other epithelial tissues, caused by human papilloma virus infection.[1] HPV type 3 and, less often, types 10, 27, and 41 most often causes flat warts [verruca plana]. They generally occur in multiples and are grouped on the face, neck, dorsa of the hands, wrists, or the knees.[2] In rare instances, there is extensive involvement with lesions on the extremities and trunk as well.[3] This is the first reported case of verruca plana, with its extensive and exclusive involvement of the trunk, and absolute sparing of the sun-exposed areas in a healthy individual.

Case Report

A 27-year-old man presented with non-itchy hyperpigmented papular skin lesions involving the trunk since 3 years. There was no family history of similar lesions.

On examination, numerous hyperpigmented, rough, slightly elevated papules, with size in the range of 2-4 mm diameter were noted. Most of the papules coalescing to form plaque-like lesions involved the back, chest and abdomen, with absolute sparing of the other areas of the body [Figure 1a and b]. No other cutaneous or systemic findings were noted.

Figure 1

a) Numerous hyperpigmented, rough, slightly elevated papules coalescing to form plaque-like lesions over the chest and abdomen, b) Similar lesions over the back.

Histopathologically, epidermis showed hyperkeratosis, focal mild irregular acanthosis with koilocytic changes in most of the keratinocytes. Papillomatosis and elongation of rete ridges were absent. Cellular or nuclear enlargement, dysplastic changes, or keratohyaline pigmentation were absent [Figure 2].

Figure 2

Histopathology of warty lesions showing epidermal hyperkeratosis, focal mild irregular acanthosis with koilocytic changes in most of the keratinocytes. Papillomatosis and elongation of rete ridges are absent. Cellular or nuclear enlargement, dysplastic changes or keratohyaline pigment are absent [H and E, stain × 20]

Investigations were carried out to determine the immune status of the patient. Routine investigations on blood, urine, and stool did not reveal any abnormality. The result of enzyme-linked immunosorbent assay (ELISA) for HIV was negative. HPV typing was not done as the facility was not available. Immunologic screening revealed a normal level of IgG, IgM, and IgA.

Discussion

Warts are benign proliferation of the skin resulting from infection with human papilloma virus (HPV). On skin, HPV infection may manifest as common warts, flat warts, and filiform warts. Depending on the site, palmar and plantar warts, anogenital warts, oral warts and conjunctival warts may also occur.[4] HPV type 3 and, less often, types 10, 27, and 41 often cause flat warts.[2] Plane warts are smooth, skin colored or pigmented, 1-5mm papules usually seen on the face, dorsa of hands and shins.[4] Interestingly, in our case, there has been involvement of only the trunk with absolute sparing of other areas.

Histopathologically, verrucae planae shows hyperkeratosis and acanthosis but, unlike verruca vulgaris, these have no papillomatosis, but only slight elongation of the rete ridges, and no areas of parakeratosis also. In the upper stratum malpighii, including the granular layer, there is diffuse vacuolization of the cells. Some of the vacuolated cells lie at the centers of the cells, and some of them appear deeply basophilic. The dermis appears normal.[5] All these features were consistent with findings of our case.

The extensive involvement of verrucae planae in our case led us to rule out conditions like Darier's disease and epidermodysplasia verruciformis, as the typical dirty-appearing, greasy papules sparing the face and neck were absent. Further, family history in the former was absent, and there was lack of associated tinea versicolor-like lesions in the latter.

We report this case because we found that in the absence of HIV infection or any other immunocompromised condition, such extensive presentation of verruca plana was possible.