INTRODUCTION
Psoriasis is a multisystem, chronic inflammatory disease identified by a variety of presentations and clinical features that manifest primarily on the skin, as well as in the joints and appendages. In its most common presentation, the skin is affected by scaling erythematous plaques. Several subtypes of psoriasis exist, including plaque psoriasis, psoriatic arthritis, and guttate psoriasis, among others. Verrucous psoriasis (VP) is a particularly rare variant of the disease, with less than 40 cases reported along with an atypical presentation and, as a result, it can prove to be difficult both in diagnosis and treatment.1
VP is characterized clinically by verrucous erythematous plaques that most commonly present along the trunk and extremities.2 VP occurs more frequently in males, with a ratio of 1.6 and a mean age of 53 years old at presentation.3 Although the etiology remains unclear, associations with lymphatic obstruction, microangiopathy, diabetes, and obesity have been proposed.3 Other theories suspect that it is associated with repeated trauma to the skin in individuals with a pre-existing diagnosis of psoriasis.3-4
VP is often resistant to therapy and its response may be multifactorial, with variable response to treatments. Treatment options are limited and based on anecdotal case reports which include topical and systemic agents.4 Our case is unique because this involves presentation of VP in an adolescent male involving over 50% of the body surface area responding in a robust fashion to biologic therapy with ixekizumab.
VP is characterized clinically by verrucous erythematous plaques that most commonly present along the trunk and extremities.2 VP occurs more frequently in males, with a ratio of 1.6 and a mean age of 53 years old at presentation.3 Although the etiology remains unclear, associations with lymphatic obstruction, microangiopathy, diabetes, and obesity have been proposed.3 Other theories suspect that it is associated with repeated trauma to the skin in individuals with a pre-existing diagnosis of psoriasis.3-4
VP is often resistant to therapy and its response may be multifactorial, with variable response to treatments. Treatment options are limited and based on anecdotal case reports which include topical and systemic agents.4 Our case is unique because this involves presentation of VP in an adolescent male involving over 50% of the body surface area responding in a robust fashion to biologic therapy with ixekizumab.
CASE REPORT
A 14-year-old African American male with comorbid obesity presented to the dermatology clinic with a 6-year history of skin lesions and associated alopecia causing a debilitating psychosocial impairment. He was previously diagnosed with ichthyosis vulgaris and treated with systemic and biologic therapy with adalimumab and acitretin, respectively, which provided minimal relief and he was lost to follow-up thereafter. Five years later, and without treatment during this time, he presented with coalescent linear verruciform plaques extending across >50% of his body surface area (BSA) with a predominance on extensor surfaces (Figures 1,2).
