Untitled Observation | Dermatol Pract Concept 2015;5(4):9 37 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com The patient A 26-year-old man presented with a one-week history of lesions on the glans penis. The patient also stated that he had recurrent episodes of genital warts, which had been electrocauterized on previous occasions. He denied trauma, medication and history of another skin disorder. Physical examination revealed remarkably thick and hard, hyperkera- totic, oyster-shaped scales adherent to multiple erythematous lesions on the glans penis. Hyperpigmented, clustered ver- rucous papules, which coalesced to form plaques, were also detected on the shaft of his penis (Figure 1). A shave biopsy from a hyperkeratotic lesion on the glans penis was performed; photomicrographs are presented in Figure 2A, B. What is your diagnosis? Answer and explanation Psoriasis verrucosa of the glans penis, in association with condyloma acuminatum On histopathological examination, marked hyperkera- tosis, parakeratosis and neutrophilic clusters in the stratum corneum were noted. Papillomatosis and acanthosis of the epidermis with neutrophilic collections in the upper stratum Malpighii along with vascular dilatation and perivascular lymphocytic infiltration of the dermis were also detected. Oyster-shaped hyperkeratotic plaques on the penis Engin Sezer1, Julia S. Lehman2, Özben Yalçın3, İlter Tüfek4, Selçuk Keskin4, Emel Öztürk Durmaz1, Sedef Sahin1 1 Department of Dermatology, Acıbadem University School of Medicine, Istanbul, Turkey 2 Department of Dermatology, Mayo Clinic, Rochester, MN, USA 3 Department of Pathology, Sisli Etfal Training Hospital, Istanbul, Turkey 4 Department of Urology, Acıbadem University School of Medicine, Istanbul, Turkey Key words: Psoriasis verrucosa, condyloma acuminatum, penis Citation: Sezer E, Lehman JS, Yalçın Ö, Tüfek I, Kekson S, Durmaz EO, Sahin S. Oyster-shaped hyperkeratotic plaques on the penis. Dermatol Pract Concept 2015;5(4):9. doi: 10.5826/dpc.0504a09 Received: June 3, 2015; Accepted: July 29, 2015; Published: October 31, 2015 Copyright: ©2015 Sezer 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. All authors have contributed significantly to this publication. Corresponding author: Engin Sezer, MD, Acıbadem University School of Medicine, Department of Dermatology, Buyukdere Caddesi No: 40, Istanbul, 34457, Turkey. Tel. + 902123044626; Fax. +902123044440. Email: eseze@yahoo.com Figure 1. Thick, hyperkeratotic plaques on an erythematous base on the glans in association with warty, hyperpigmented papules on the shaft, of the penis. [Copyright: ©2015 Sezer et al.] mailto:eseze@yahoo.com 38 Observation | Dermatol Pract Concept 2015;5(4):9 with Munro’s microabscesses, Kogoj’s spongiform pustules in the stratum Malpighii, and dilated blood vessels in the upper dermis with lymphocytic inflammation [2,3]. Although condy- loma acuminatum lesions, characterized by hyperpigmented, verrucous papules, were identified elsewhere on the penis in our patient, the lesion on the glans lacked koilocytosis, clumped kerato- hyalin granules, and negative immu- nohistochemistry for HPV, as well as neutrophilic microabscesses in the stra- tum corneum and epidermis, therefore arguing against a diagnosis of genital wart in this instance. Associated features of PV such as obesity, cardiac dysfunction, lymphatic congestion and psychosis were absent in our case [1-4]. Some authors have sug- gested that local lymphatic disturbances and phlebitis may cause increased venous and lymphatic pressure, leading Treponemal tests, namely VDRL and TPHA as well as immunohistochemical staining for the human papillomavirus (HPV), were negative. Psoriasis verrucosa (PV) is a rare form of psoriasis, with only a few cases reported in the literature. Lesions are characterized by hard and thick hyper- keratotic plaques on the top of an ery- thematous base (as in our case). The lesions are located mainly on the trunk and extremities and, until now, penile involvement has not been reported. There is a male predominance (5:1), including our patient, and a history of long-term psoriasis (5-25 years) in all patients, excluding our case, who had rapid onset without previous pso- riatic lesions [1-5]. Histopathological examination revealed combined fea- tures of psoriasis and verrucae, namely, marked papillomatosis with acanthosis, massive hyperkeratosis/parakeratosis Figure 2. (A) Marked papillomatosis, hyperkeratosis and congested blood vessels are ob- served at low magnification (hematoxylin and eosin stain; original magnification, X100). (B) Neutrophilic collections in the epidermis and stratum corneum (hematoxylin and eosin stain; original magnification, X400). [Copyright: ©2015 Sezer et al.] to leakage of plasma and proteins from blood, resulting in collagen fibrosis and epidermal hyperplasia [3]. We hypoth- esize that previous electrocauterization procedures for condyloma acuminatum may have resulted in lymphatic distur- bances and activate PV via Koebneriza- tion. The treatment approaches for PV include oral retinoids, adalimumab, topical calcipotriol, corticosteroids and 5% crude coal tar [1-5]. We achieved marked regression of the lesions with a combination regimen of topical 5% salicylic acid and corticosteroid oint- ment including betamethasone valer- ate. Finally we suggest that a diagnosis of PV should be kept in mind in cases with oyster-like, hard, hyperkeratotic plaques on an erythematous base and histopathological findings including marked papillomatosis and neutrophilic microabscesses in the epidermis and stratum corneum. References 1. Wakamatsu K, Naniwa K, Hagiya K, Ichi- miya M, Muto M. Psoriasis verrucosa. J Dermatol. 2010;37(12):1060-2. 2. Okuyama R, Tagami H. Psoriasis verru- cosa in an obese Japanese man: a prompt clinical response observed with oral etretinate. J Eur Acad Dermatol Venereol. 2006;20(10):1359-61. 3. Nakamura S, Mihara M, Hagari Y, Shi- mao S. Psoriasis verrucosa showing pe- culiar histologic features. J Dermatol. 1994;21(2):102-5. 4. Maejima H, Katayama C, Watarai A, Nishiyama H, Katsuoka K. A case of psoriasis verrucosa successfully treated with adalimumab. J Drugs Dermatol. 2012;11:74-5. 5. Erkek E, Bozdogan O. Annular verrucous psoriasis with exaggerated papillomatosis. Am J Dermatopathol. 2001;23(2):133-5.