Introduction
Verrucous lesions are defined as “pertaining to or marked by wart like growth pattern”. However, not all verrucous lesions are associated with Human Papilloma Virus. Few lesions look similar to warts clinically but with different conditions, pathology, prognosis and treatment. Verrucous lesions may be caused by inflammatory, neoplastic, autoimmune, apocrine and eccrine gland disorders. Histopathology plays a very important role in such cases to diagnose the condition.1
Case 1
A 70- year- old man presented with itchy hyperpigmented plaque over left knee since 10 yrs years with verrucous growth over lesion for 2 years, Figure 1(a). Biopsy from verrucous lesion showed marked proliferation of the stratified squamous epithelium with a focus of micro invasive islands of the tumour into the subepithelium, Figure 1(b).
It was diagnosed as Squamous cell Carcinoma overlying Lichen simplex chronicus. The lesion was treated with wide local excision.
Case 2
A 65 year -old male patient presented with hyperpigmented verrucous plaque over lateral aspect of right thigh for 2 years,Figure 2(a).
Histopathology showed keratinocytes with marked proliferation of malignant cells arising from epidermis, with separate islands of malignant cells showing plemorphism and atypia, diagnosed as well differentiated squamous cell carcinoma, Figure 2(2b). The lesion was surgically excised.
Figure 1
a: Verrucous lesion over hyperpigmented plaque on left knee; b: Marked proliferation of the stratified squamous epithelium with a foci of micro invasive islands of the tumour into the subepithelium, H and E x 100]
Figure 2
a: Hyperpigmented verrucous plaque over lateral aspect of right thigh; b: Keratinocytes with marked proliferation of malignant cells arising from epidermis, with separate islands of malignant cells showing plemorphism and atypia, H and E x 100]
Figure 3
a: Multiple erythematous verrucous nodules over thigh; b: Papillary projection arising from epidermis, showing double layered epithelium with decapritions of secretion, H and E x 100]
Case 3
A 22-year-old man, presented with multiple erythematous nodules over left thigh, which initially started as papules during childhood, with increase in size and verrucous surface over the lesions associated with erosions and mild serous discharge since 3 years, Figure 3(a).
Histopathology showed papillary projection arising from epidermis. These projections are showing double layered epithelium with decapritions of secretion, consistent with Syringocystadenoma papilliferum, Figure 3(b). The lesions were excised.
Case 4
A 9-year-old girl presented with solitary skin coloured plaque measuring 1*1 cm with verrucous surface, over left side of forehead since 1 year, Figure 4(a). Biopsy showed stratified squamous epithelium with subepithelial eccrine and apocrine glands, with chordromyxonal areas, suggestive of Chondroid syringoma. Figure 4(b), and the lesion was excised.
Case 5
A 25-yearold lady presented with multiple verrucous papules over the nose, associated with mild itching on exposure to sunlight since 2 years, Figure 5(a). Histopathology showed hyperplasia of sebaceous glands, Figure 5(b). It was initially treated with oral isotretinoin 20mg for 1 month with topical tretinoin 0.05 % with no improvement. Then the lesions were removed by radiofrequency abalation.
Discussion
Cutaneous warts, also known as verruca vulgaris are caused by infection of keratinocytes with Human papilloma virus, visible as well defined hyperkeratotic protrusions. There are many conditions which may present with verrucous surface and thus can create confusion while diagnosing clinically.1
Squamous cell carcinoma (SCC)
Malignant cutaneous neoplasms contribute only around 1–2% of all malignancies in blacks and Indians, compared to 20- 30% in Caucasians. Cutaneous SCC is the most common skin malignancy in dark skin and tends to arise in non-healing ulcers, chronic scars, inflammatory, infectious, and genodermatoses in 20–40% of cases. 2
A study done in north India found Chronic inflammatory dermatoses and genodermatoses as a predisposing factor in 12.2% cases of cutaneous SCC. 3
In our first case, squamous cell carcinoma was developed on longstanding Lichen Simplex Chronicus.
Syringocystadenoma papilliferum (SCAP)
Syringocystadenoma papilliferum is a benign adnexal tumor which commonly occurs during childhood or adolescence. The lesoons usually present on scalp and forehead as papules or smooth plaques with nodular or verrucous transformation seen at puberty. 4
Rare clinical patterns include linear and segmental variants. 5
Our 3rd case is a very rare case of SCAP, where it was present on unusual site (thigh), with a linear distribution.
Chondroid syringoma
Chondroid syringoma, also known as a cutaneous mixed tumor is one of the rare skin appendageal neoplasm with the presence of sweat gland elements set in a cartilaginous stroma. 6
The benign type has a predilection for the head and neck region of the middle-aged men whereas, the malignant type is more commonly encountered at the extremities of the females and is characterized by rapid growth, local invasion, and distant metastasis due to the paucity of specific diagnostic clinical and radiological features, the pathological evaluation is imperative for a definite diagnosis of chondroid syringoma especially for those occurring at atypical sites. 7
Sebaceous hyperplasia
Sebaceous hyperplasia is a common, benign condition wherein single or multiple asymptomatic discrete yellowish papules present commonly over face, rarely over chest and genitalia. Surface of the lesions is usually smooth to slightly verrucous.
Therapeutic options include oral isotretinoin, electrocautery, chemical cautery, cryotherapy surgical exicision and photodynamic therapy (with combined use of 5-aminolevulinic acid and visible light).8
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