A Case of Psoriasis Verrucosa Successfully Treated With Adalimumab
November 2012 | Volume 11 | Issue 11 | Case Reports | 74 | Copyright © November 2012
We herein report a case of psoriasis verrucosa that was successfully treated with adalimumab. A 55-year-old Japanese male
had a five-year history of psoriasis vulgaris treated with topical agents. His past history included atypical psychosis treated with
lithium carbonate and obesity. Despite treatment, verrucous scales developed on erythematous plaque. After treatment with
adalimumab, these improved remarkably, and the patient's Psoriasis Area and Severity Index score decreased from 16.2 to 3.7. J Drugs Dermatol.
Psoriasis verrucosa is a peculiar clinical form of psoriasis
characterized by very thick and hard scales adherent to
erythematous lesions, producing a wartlike appearance.1 The case of a Japanese patient with psoriasis verrucosa that
was successfully treated with adalimumab is herein described.
A 55-year-old Japanese male had a five-year history of psoriasis
vulgaris treated with topical corticosteroids and a topical
vitamin D3 ointment. He also had atypical psychosis treated
with lithium carbonate and mild obesity (body mass index 28
kg/m2). He had scaly erythema on the trunk and extremities,
but verrucous scales on erythematous plaque developed
three years ago (Figure 1). The biopsy specimen of verrucous
lesions showed marked hyperkeratosis and parakeratosis
with infiltrating neutrophils, severe papillomatosis with thinning
of the granular layer, elongation and thickening of the
rete ridges, and diffuse infiltration of lymphocytes into the
upper dermis (Figure 2).
Immunohistochemical staining for the human papilloma virus
protein was negative (polyclonal rabbit antibovine papillomavirus
type 1 antibody; Dako, Glostrup, Denmark). Clinical and
histopathological findings led to the diagnosis of psoriasis
verrucosa. His mental condition prevented adequate treatment
of the verrucous lesions. He had been receiving oral
cyclosporine (3 mg/kg daily) for a year, although it showed
little efficacy (Psoriasis Area and Severity Index [PASI] score
16.2). Adalimumab (40 mg every other week) was given for the skin eruption, and it showed remarkable efficacy in five
months (PASI score 3.7; Figure 3).
Psoriasis verrucosa is a rare, atypical clinical form of psoriasis,
featuring a wartlike appearance or a wartlike cracked surface.
Psoriasis verrucosa commonly develops on the legs, palms,
backs of the hands, soles, and ankles. Psoriasis verrucosa is
associated with obesity, diabetes mellitus, and peripheral circulatory
failure.1 One possible explanation for why the reported
case subject developed psoriasis verrucosa is that lithium
carbonate inhibits adenylate cyclase and decreases cyclic adenosine
monophosphate in keratinocytes. It inhibits the G2
block in cell cycle division and promotes keratinocyte turnover.
Another hypothesis is that lithium carbonate and insufficient
treatment may have promoted the development of psoriasis
verrucosa. Oral etretinate is reported to be very effective for
psoriasis verrucosa.1-3 Adalimumab impacts dermal-based immunocytes,
and the epidermal compartment also responds by
restoration of normal differentiation.4 Increases in the mRNA
levels of interleukin (IL)-1b, IL-8, IL-17c, and IL-20 in psoriatic skin
have already been shown to be significantly reduced after adalimumab
treatment.5 It has been pointed out that adalimumab
reduces p38 mitogen-activated protein kinase (MAPK) phosphorylation,
with a subsequent decrease in the expressions
of p38 MAPK-regulated genes in patients with psoriasis.5 The
present case of psoriasis verrucosa is the first to be successfully
treated with adalimumab. Further studies are required to
elucidate both the cause and the ideal treatment of this disease.