Dermatology: Practical and Conceptual

230 Letter | Dermatol Pract Concept 2019;9(3):16

Dermatology Practical & Conceptual

Introduction

Verrucous epidermal nevus (VEN) is a benign, noninflam-

matory malformation usually present at birth or occurring

within the first years of life. It is composed of keratinocytes

that arise from pluripotential germ cells in the basal layer of

the embryonic ectoderm and results from mosaic postzygotic

mutations. VEN clinically appears as skin-colored to brown,

sharply demarcated, papillomatous papules coalescing into

plaques. The diagnosis is usually based on clinical presenta-

tion and, in selected cases, on histopathology examination

that reveals epidermal hyperplasia, papillomatosis with

elongation of rete ridges, and pigmented keratinocytes sur-

rounding the dermal papillae. Dermoscopy and reflectance

confocal microscopy (RCM) are valuable, noninvasive tech-

niques that support the diagnosis in clinical practice in several

fields of dermatology including cutaneous tumors as well as

inflammatory and infectious dermatoses [1]. Dermoscopy

has shown in 8 cases of VEN the characteristic presence of

large brown circles, consisting of hyperchromic brown edge

surrounding a hypochromic area.

The aim of this study was to evaluate and correlate der-

moscopy (Dermlite; 3Gen, San Juan Capistrano, CA, USA),

RCM (VivaScope3000; Caliber I.D., Rochester, NY, USA)

and histopathological findings in a series of 9 patients with a

clinical and/or histopathologically proven diagnosis of VEN.

In all cases VEN had been present since early infancy. All

participants provided informed consent.

Case Presentation

All examined lesions—3 located on the head, 4 on the

neck, and 2 on the trunk—clinically appeared as velvety

plaques with linear distribution and variable degree of pig-

mentation, ranging from light to dark brown (Figure 1A).

At dermoscopy, all lesions showed the presence of large

brown circles on a brownish background. No pigment net-

work, globules, comedo-like openings, or milia-like cysts

were observed (Figure 1B). RCM revealed, in all cases, a

normal epidermal honeycomb pattern (bright polygonal

cellular outlines and dark nuclei), papillomatosis, and the

constant presence of a well-defined, strongly bright rim of

Verrucous Epidermal Nevus: Dermoscopy,
Reflectance Confocal Microscopy, and

Histopathological Correlation
Anna Elisa Verzì1, Francesco Lacarrubba1, Enrica Quattrocchi1, Giuseppe Micali1

1 Dermatology Clinic, University of Catania, Italy

Key words: dermatoscope, dermoscopy, reflectance confocal microscopy, verrucous epidermal nevus, histopathology

Citation: Verzì AE, Lacarrubba F, Quattrocchi E, Micali G. Verrucous epidermal nevus: dermoscopy, reflectance confocal microscopy, and
histopathological correlation. Dermatol Pract Concept. 2019;9(3):230-231. DOI: https://doi.org/10.5826/dpc.0903a16

Accepted: December 3, 2019; Published: July 31, 2019

Copyright: ©2019 Verzì 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.

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Giuseppe Micali, MD, Dermatology Clinic, University of Catania, Via S. Sofia 78, 95123 Catania, Italy. Email:
cldermct@gmail.com

Letter | Dermatol Pract Concept 2019;9(3):16 231

pattern at RCM may also be observed in solar lentigo, len-

tigo simplex, and ink spot lentigo; in the first case, the bright

ring is due to hyperpigmentation of the basal keratinocytes,

and in the remaining 2 to hyperproliferation of melanocytes.

However, these disorders are clinically different from VEN

presenting with flat, nonpalpable, pigmented lesions.

In conclusion, our study suggests that the combined use

of dermoscopy and RCM may assist in the enhanced diag-

nosis of VEN, especially in those cases with unusual clinical

presentation.

References

1. Lacarrubba F, Ardigò M, Di Stefani A, Verzì AE, Micali G. Der-

matoscopy and reflectance confocal microscopy correlations in

nonmelanocytic disorders. Dermatol Clin. 2018;36(4):487-501.

2. Carbotti M, Coppola R, Graziano A, et al. Dermoscopy of ver-

rucous epidermal nevus: large brown circles as a novel feature for

diagnosis. Int J Dermatol. 2016;55(6):653-656.

monomorphous cells demarcating each dark dermal papilla

throughout the lesion (Figure 1C).

Conclusions

To the best of our knowledge, this is the first study describing

the RCM features of VEN. In our series, VEN showed pecu-

liar dermoscopic and RCM findings. In particular, the typical

presence at dermoscopy of large brown circles, as previously

reported [2], correlated with dermal papillae demarcated by

a rim of monomorphous and strongly bright cells seen at

RCM and corresponds to the histological arrangement of

pigmented keratinocytes surrounding the dermal papillae

(Figure 1D).

The dermoscopic brown circles have been observed, along

with other findings, in seborrheic keratosis and pigmented

squamous cell carcinoma, 2 disorders that, however, show

different age at onset and clinical features. A similar ringed

Figure 1. VEN of the

neck. (A) Clinical aspect. (B)

Dermoscopy showing large

brown circles (insert: a de-

tail) on a brownish back-

ground. (C) RCM showing a

well-defined, strongly bright

rim of monomorphous kerati-

nocytes demarcating each dark

dermal papilla. (D) Histopa-

thology showing arrangement

of pigmented keratinocytes

surrounding the dermal papil-

Verzì et al.]