CASE
A 64-year-old female presented to the outpatient clinic for the evaluation of flaking and itchy lesions on her bilateral hands and feet that were present for several months and caused difficulty with activities of daily living. Inconsistent use of betamethasone and narrowband ultraviolet (UV)-B on the affected areas were both reported, neither of which improved the patient's symptoms. The physical exam was remarkable for yellow plaques with moderate scaling on over 50% of the patient's bilateral palmoplantar surfaces (see Figures 1, 3). The differential diagnosis included palmoplantar keratoderma, tinea pedis, and psoriasis. A fungal culture was performed from the patient's right plantar foot, but ultimately came back negative for growth after one month. Upon follow up at the one-month mark, a shave biopsy was performed on the right plantar surface to rule out psoriasis vs palmoplantar keratoderma.
Upon completion of the starter pack, the patient returned to the clinic for re-evaluation, at which time she denied side effects of depression or headaches, but admitted to mild gastrointestinal (GI) upset that self-resolved. Upon exam, the patient's lesions were reduced in size by approximately 50% on all surfaces and were lessened to mild in severity (Figures 2, 4). To our knowledge, this is the first time that apremilast has ever been used in the treatment of VP and we found that this novel approach significantly improved the patient's quality of life.
Histopathology revealed hyperkeratosis with neutrophils within mounds of parakeratosis, digitated and psoriasiform epidermal hyperplasia, dilated blood vessels at the tips of dermal papillae, and a superficial perivascular mixed inflammatory cell infiltrate. The condition was diagnosed as verrucous psoriasis (VP); since there is currently no standard treatment protocol for VP, the options of topical steroids, calcineurin inhibitors, vitamin D analogues, intralesional kenalog, and apremilast were considered. Ultimately, the decision to start apremilast was made; the patient started the 5-day titration schedule and went on to complete the 28 day starter pack.
Upon completion of the starter pack, the patient returned to the clinic for re-evaluation, at which time she denied side effects of depression or headaches, but admitted to mild gastrointestinal (GI) upset that self-resolved. Upon exam, the patient's lesions were reduced in size by approximately 50% on all surfaces and were lessened to mild in severity (Figures 2, 4). To our knowledge, this is the first time that apremilast has ever been used in the treatment of VP and we found that this novel approach significantly improved the patient's quality of life.
