Epidermal Verrucal Lesion with Velvety-Like Granular Surface at Female External Genitalia and Medial Aspect of the Thigh Compatible with Previous History of Longstanding Psoriasis : A Case Report

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INTRODUCTION
Psoriasis is a chronic inflammatory disease of the skin, nails, and joints.It is typically presented as red, plaques, most commonly on the elbows, knees, scalp, and lower back, but any skin surface can be involved.It is the commonest skin disease.It affects around 2% of the world's population, with increasing incidence in the last three decades.Psoriasis affects both males and females, with earlier onset in female and those with a family history.The age of onset shows a bimodal distribution with peaks at 30-39 years and 60-69 years in men, and 10 years earlier in women.The exact etiology is unknown but in general psoriasis is an immunologically mediated disease where the activation of T lymphocytes leads to the inflammation in the dermal component and secondary to the inflammatory events there is also that epidermal hyperproliferation (1,2) .
Psoriasis as a prototype of inflammatory dermatoses can be recognized by inflammation and epidermal changes.The histopathological hallmark is the regular elongation of the rete ridges.This is caused by the proliferation of keratinocytes, involving the epidermis partially or totally (5,6) .However, the pathogenesis is not as simple as described where psoriasis is defined as an immune mediated dermatosis of autoimmune nature.The pathogenesis is complex and still controversial but include autoimmune component and different cytokines had a role besides the role of keratinocytes and immune cells (7,8) .
Diagnosis of psoriasis is usually straightforward.However, at sometimes, it may be challenging.In these situations, the skin culture or biopsy for histopathological examination are required to confirm diagnosis (2,12,13) .

THE CASE
A 25 years' old female patient presented with epidermal verrucal lesion at the external genitalia and medial aspect of the thigh and pubic region.The mass was formed of abroad sheet of skin with a triangular shape measuring 12x11x6 cm (Figure 1).
The surface of the skin was rough with variable velvety like granular surface from one area to another.In addition, there was a diffuse salmon pink papules and plaques with overlying white scales on the trunk, groin, and upper and lower extremities.On the palms, we noticed punctate scaly papules with erythema.
The cut section of the vulval lesion showed marked thickening of the epidermis with upper dermal congested vessels.The lesion was compatible with the history of long-standing psoriasis.
A wide local excision with safety margin was performed (Figure 2).The defect was closed by sutures.The wound was healed without complications leaving a minimal scar with good aesthetic appearance (Figure 3).The excised specimen had been sent for histopathological examination.The results revealed a picture of psoriasiform dermatitis.Microscopically, there was epidermal hyperplasia with acanthosis and papillomatosis.
The elongation of rete ridges was more or less regular with evenly distributed manner.The upper dermis showed dilated congested capillaries with infiltration by mixed chronic inflammatory cells.The periphery of the lesion showed similar but milder pathological features with NO malignancy.

DISCUSSION
In this case report, we describe a patient who sustained velvety like swelling on the external genitalia, and medial aspect of the thigh.We explored plausible causes of the lesion, discussed our treatment plan, and reviewed published literature to confirm the originality this case.The decision was to excise the lesion with safety margin and send it for histopathological examination.The case was recovered without complications with satisfactory aesthetic results.The histopathology showed a psoriasiform manifestations.
Different conditions of inflammatory dermatosis share pathogenetic mechanism, mainly keratinocyte hyperactivity with severe inflammatory activity of the dermis leading to hyperproliferation of the epidermis.Other cells share in the inflammatory activity (e.g., neutrophils, dendritic cells, Tlymphocytes and macrophages) (14,15) .Thus, histopathology among others constitutes the pillars of proper diagnosis.In our patient, the presence other affected areas by psoriasis with a long history of disease elevated the suspicion of diagnosis.However, malignancy (verrucous carcinoma) could not be rule out from the clinical examination.Hence, the decision to excise surgically and send the excised tissue for histopathological examination.Likely, malignancy was not identified and the condition was a form of psoriatic dermatoses.The satisfactory aesthetic results with benign nature of the mass were reflected on the patient condition.
In addition to the clinical picture of the lesion, and although history was going with verrucous psoriasis (VP), we went to surgery due to atypical presentation.It is well-known that, VP is rare, could occur de novo, highly prevalent in men, appears in friction areas in obese, diabetic patients (16,17) .Also, the diagnosis was challenging due to similarity to other lesions including verruca vulgaris, epidermal nevi, fungal infection and squamous cell carcinoma (SCC).The overlapping histopathological features add to difficulty of diagnosis (18).Furthermore, the site of the lesion is uncommon and with no previous reported cases.
All previous features of our case are unique features confined to this case.

Figure ( 1 )
Figure(1): Epidermal verrucal lesion at the external genitalia and medial aspect of the thigh and pubic region, the surface of the skin is rough with variable velvety like granular surface.

Figure ( 2 )
Figure (2): Total excision of the mass was done at the medial aspect of the thigh, lateral border of labia majora, and mid suprapubic longitudinal incision .with suturing and drain insertion.

Figure ( 3 )
Figure (3):After complete healing and recovery with complete excision of the mass, and hidden incision at the medial aspect of the thigh, lateral border of labia majora with good aesthetic appearance.