Received date: March 21, 2014; Accepted date: July 17, 2014; Published date: July 25, 2014
Citation: Kawtar I, Mariame M, Siham L, Fatimazahra M, Hassania A, et al. (2014) Verrucous Psoriasis and Verrucous Lichen Associated With an Autoimmune Hepatitis. J Clin Diagn Res 2:107. doi:10.4172/2376-0311.1000107
Copyright: © 2014 Kawtar I, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Verrucous psoriasis is a rare form of Psoriasis which has a clinical characteristic and histological appearance. Only few cases have been reported in the literature. We report a rare case of verrucous psoriasis associated with verrucous lichen appeared in a patient with an autoimmune hepatitis.
Psoriasis is a common inflammatory skin disease with a wide range of presentation and a relapsing course. In its typical presentation, it is a scaly erythematous plaque with thick silvery white scale. Verrucous psoriasis is a rare form of psoriasis with a clinical characteristic and histological presentation, it presents as a warty erythematous plaque, with a narrow differential diagnosis with warts .
Lichen planus is a cell-mediated immune response of unknown origin. In addition to the cutaneous eruption, it can involve the mucous membranes, nails and scalp. It has various clinical presentations, in which verrucous lichen presents as a hypertrophic plaque mainly in the lower extremities .
We report a case of these 2 entities that appeared in a patient suffering from an autoimmune hepatitis.
The examination revealed scaly erythematous plaques in the face, trunk and extremities, warty erythematous plaques in the feet, verrucous plaques in the right thigh, fingers and in perianal area, and many pigmented plaques in the legs Figures 1 and 2.
A Skin biopsy of the erythematous scaly lesion showed psoriasis as an epidermal hyperplasia with parakeratosis. In addition, the biopsies of the verrucous lesions made on the thigh, hand and perianal area pointed out a verrucous psoriasis with an epidermal hyperplasia with parakeratosis and prominent papillomatosis Figure 3, while the biopsy of the warty lesion of the leg revealed verrucous lichen as an orthokeratosic hyperkeratosis, papillomatosis with a lymphocytic infiltrate band Figure 4.
Hematological tests reveal an elevated sedimentation rate, liver enzymes, and gamma immunoglobulin. Anti nuclear antibody were positive at 1/320, but the anti SLA antibody, anti LC1, anti endoplasmic reticulum, anti smooth muscle and the hepatitis serology were all negative.
Our patient was prescribed topical corticosteroids, keratolytics and systemic corticosteroids prednisone at 1 mg/kg/day, without another immunosuppressive treatment due to financial problems. She died few months later.
Verrucous psoriasis is a rare form of Psoriasis; just 20 cases have been reported in the literature. The researches demonstrated that Men were affected more than women with a sex ratio of 1.6 and the medium age of 53 years old [4-7].
Verrucous psoriasis has a characteristic scaly erythematous plaque with a verrucous surface. In this respect, histology indicated acanthosic epidermis with parakeratosic hyperkeratosis, an atrophy of the Malpighi mucous body, and Munro’s micro abscess associated with an important papillomatosis [1,6,7].
The lesions are localised mainly in the elbows, hands, knees and feet, which are frictions area. This is closely associated with the theory of repeated trauma in the genesis of verrucous lesions. Other etiologies have been reported as predisposing factors for verrucous psoriasis like problems at the lymphatic’s circulation, or microangiopathy in diabetes and obesity. Other authors consider it as a progressive form of vulgaris psoriasis [5-7].
This entity doesn’t respond well to local therapy (dermocorticosteroid, vitamine D, puvatherapy), some authors reported the efficacy of etretinate, adalimumab and methotrexate. But it’s not a codified therapy because it’s a rare form [4-8].
Our patient didn’t have predisposing factors for verrucous psoriasis, as a result, we consider it a progressive form of vulgaris psoriasis. On the other hand our patient had atypical localizations, in the right thigh and the perianal area which are not a friction sites.
Verrucous lichen is a variant of lichen planus, it presents as a verrucous plaques mainly in the lower extremities with chronic course leaving a residual hyperpigmentation. At the histology we find an acanthosis, papillomatosis, hypergranulosis and an orthokeratosic hyperkeratosis The choice of a therapeutic agent depends indeed on the extend of lesions, using topical or systemic steroids, puvatherapy, acitretine and cyclosporine with a good outcome [3,4].
Our patient had two dermatologic affections that have a trouble of the keratinisation in common, verrucous psoriasis and hypertrophic lichen; their association has never been reported in the literature. Additionally, our patient had an autoimmune hepatitis; this diagnosis was made on the simplified criteria of the score 2008 of the International Autoimmune Hepatitis Group.
This combination can be explained by the genetic and immunologic predisposition belonging to a mosaic of autoimmunity defining a spectrum of 3 immune diseases .
Our case is the first to be reported in the literature, it shows the association of 2 autoimmune diseases with an inflammatory disease: autoimmune hepatitis, verrucous psoriasis, vulgaris psoriasis and verrucous lichen.
We reported a unique case where many autoimmune diseases are present, and which need a multidisciplinary approach.
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