Full-thickness surgical excision for the treatment of inflammatory linear verrucous epidermal nevus

A case of inflammatory linear verrucous epidermal nevus successfully treated with Brodalumab

Inflammatory linear verrucous epidermal nevus (ILVEN) is a rare type of epidermal nevus, commonly arising in childhood. We present a case of a 13-year-old female with Blaschkoid psoriasiform plaques extending from her left foot to the scalp, sparing the right side of the body. While treatment options historically show variable success, we trialed an IL-17a receptor inhibitor as studies have shown increased levels of IL-17 receptor expression in ILVEN keratinocytes. At both 3 and 6 months after treatment initiation there was found to be significant improvement. We propose brodalumab as an effective treatment option for widespread ILVEN.

Epidermal Nevi: What Is New

This article reviews the clinical findings of epidermal nevi and their associated syndromes and provides an update on their pathogenic genetic changes as well as targeted therapies detailed to date.

Off-Label Therapeutic Potential of Crisaborole

Crisaborole, a topical phosphodiesterase-4 inhibitor, was recently approved in 2016 for the treatment of mild to moderate atopic dermatitis in adults and children greater than 2 years of age. Since that time, several case reports and a small randomized controlled trial have been published regarding the off-label use of crisaborole for the treatment of other inflammatory dermatologic disorders. This paper reviews the current, albeit limited, evidence for off-label use of crisaborole for psoriasis, seborrheic dermatitis, vitiligo, and inflammatory linear verrucous epidermal nevus. Additional potential therapeutic uses for crisaborole are also postulated, based on its mechanism of action. Future studies are required to elucidate the full therapeutic potential of crisaborole; however, it is a welcome addition to the current nonsteroid topical treatments for inflammatory dermatologic disease.

Massive Vulvar Linear Verrucous Epidermal Nevus Presenting at Menarche

BACKGROUND

Epidermal nevi are benign hamartomatous growths of the skin that present at birth and develop in early childhood often linearly along the "lines of Blaschko." Verrucous linear epidermal nevi are the most common epidermal nevi and often are located on the trunk or extremities. There is minimal evidence regarding vulvar involvement and subsequent management of the associated cosmetic deformity in this anatomic location.

CASE

An 11-year-old menarchal girl who underwent full-thickness dermal excision of a 9.6 × 4.5 × 3.2 cm left benign vulvar epidermal nevus (noninflammatory type) with primary reconstruction and closure using a mons rotational skin flap.

SUMMARY AND CONCLUSION

Surgical excision of large vulvar nevi can be achieved with desirable cosmetic outcomes with use of rotational skin flaps and primary closure.

Successful Treatment of Inflammatory Linear Verrucous Epidermal Nevus with Tacrolimus and Fluocinonide

Background:

Inflammatory linear verrucous epidermal nevus (ILVEN) is a relatively rare disorder that is characterized by an early age at onset; severely pruritic linear papules and plaques; histologic features resembling spongiotic dermatitis, psoriasis, or lichenified dermatitis; and poor response to treatment.

Objective:

To report the successful treatment of ILVEN with potent topical steroid and tacrolimus ointments.

Methods:

An 11-year-old girl presented with a 1-year history of markedly pruritic, progressive linear eruption that extended from the right foot to the right buttock. She had failed treatment with pimecrolimus, calcipotriol, mometasone furoate, triamcinolone, tazarotene, and alpha-hydroxy acid. Histologic examination revealed the findings of spongiotic dermatitis.

Results:

The lesions resolved with fluocinonide ointment and tacrolimus 0.1% ointment.

Conclusion:

The combination of two therapeutic agents with different mechanisms of action likely resulted in the successful treatment of this usually resistant condition.

Linear verrucous epidermal nevi-effects of carbon dioxide laser therapy

Linear epidermal nevus is a congenital malformation characterized by linear, often one-sided arrangement. The lesions are localized along the Blaschko's lines, are present at birth, or appear in early childhood. They can be single or multiple, and have various colors-from skin color to dark brown. These lesions persist through the whole life making a significant cosmetic defect. Here, we present three clinical cases of epidermal nevus treated with CO2 laser. In a female patient, verrucous, dark brown skin eruptions were observed at the back of earlobe and down the neck. In the cases of the male patients, the lesions were located in the area of the neck and left blade. The removal of nevi was performed in stages, by cutting and evaporation using a CO2 laser. A very good therapeutic effect was obtained. CO2 laser treatment is the method of choice for the removal of extensive epidermal nevi. It is characterized by high efficacy and safety.

Genital/Perigenital Inflammatory Linear Verrucous Epidermal Nevus: A Case Series

Background:

Inflammatory linear verrucous epidermal nevus (ILVEN) is a distinct variety of keratinocytic epidermal naevus. In contrast to non-inflammatory epidermal naevi, ILVEN are far less common, usually erythematous and intractably pruritic. ILVEN usually appears at birth or early childhood and has a linear distribution following the Blaschko lines. Genital/perigenital involvement is relatively rare.

Objectives:

To describe the clinical features of 9 children with ILVEN localized to the genital and perigenital areas.

Method:

A retrospective study of 9 children with ILVEN presenting to a tertiary care Dermatology Clinic between 2007 and 2014 was undertaken. The clinical and histopathological features were reviewed.

Results:

Nine children (6 females, 3 males) were included in the study based on their characteristic clinicopathological features. The lesions were associated with severe itching in all cases. The mean age at presentation was 4 years (range 1-11 years). Onset of lesions was before 6 months of age in 8 patients. Left sided involvement was twice as common as the right sided one. Male patients had penoscrotal and groin involvement while all the female children had vulvar lesions. None of the children had any extracutaneous abnormalities. The children were treated with topical agents with variable relief or symptoms.

Conclusions:

The possibility of ILVEN should be considered in every linear genital lesion in children. We have presented the largest series of perigenital ILVEN reported in English literature.

Perianal verrucous epidermal nevus masquerading as warts

Verrucous epidermal naevus (VEN) is a rare form of epidermal naevus. We present a case of VEN occurring over the perianal region of a 7-year-old boy. The lesion was initially thought to be an area of chronic dermatitis; however it was refractory to treatment. Histopathology confirmed the diagnosis of VEN. VEN in the inguinogenital region may be misdiagnosed as flexural psoriasis, genital warts or sexual abuse. This is what precisely happened to our patient for a duration of more than 1 year.

Vulvar and perianal condyloma superimposed inflammatory linear verrucous epidermal nevus: a case report and review of the literature

Inflammatory linear verrucous epidermal nevus (ILVEN) is a benign cutaneous hamartoma characterized by intensely erythematous, pruritic, and inflammatory papules that occur as linear bands along the lines of Blaschko. There is a considerable clinical and histological resemblance between ILVEN and linear psoriasis, lichen striatus, linear lichen planus, and invasion of epidermal nevus by psoriasis. The pathogenesis of ILVEN is unknown. It is regarded as a genetic dyskeratotic disease reflecting genetic mosaicism. Here, a case of vulvar and perianal condyloma superimposed ILVEN is presented.

Giant inflammatory linear verrucous epidermal nevus: successfully treated with full thickness excision and skin grafting

Inflammatory linear verrucous epidermal nevus (ILVEN) is a pruritic, erythematous scaly epidermal nevus which follows a Blaschko's lines. Lichen striatus, linear Darier disease, linear porokeratosis, linear lichen planus, linear psoriasis, and the verrucous stage of incontinentia pigmenti may all have similar clinical presentations as the linear verrucous epidermal nevus. ILVEN can be distinguished from true nevoid psoriasis by pruritus and lack of response to antipsoriatic treatments. Various therapeutic modalities have been described, but no one therapy has been successful consistently. Though giant ILVEN is a relative contraindication to surgical excision, here we report a case showing effectiveness of full thickness excision and skin grafting for this condition.

Epidermolytic hyperkeratosis in inflammatory linear verrucous epidermal nevus

Epidermolytic hyperkeratosis presents with perinuclear vacuolization of the keratinocytes in spinous and granular layers, keratinocytes with ill-defined limits, which leads to a reticulate appearance of the epidermis, an increased number of variously shaped and sized basophilic keratohyalin granules and the same sized eosinophilic trichohyalin granules, at any level of epidermis, mainly in the stratum granulosum, and compact hyperkeratosis. This minor reactive pathologic reaction pattern of skin is found in large variety of diseases. This paper is the first case report of such pattern in inflammatory linear verrucous epidermal nevus. Our case is of a 23-year-old man with pruritic verrucous lesions of trunk and extremities initiated since 13 years ago. Physical examination revealed white linear hyperkeratotic lesions, some of them on erythematous background and also classic epidermal nevus. No skeletal, ophthalmic, and nervous system involvement was detected. Microscopic study of pruritic verrucous lesions showed psoriasiform acanthosis, mild papillomatous, hyperkeratosis, and epidermolytic hyperkeratotic changes in hair follicles and acrosyrinx accompanied with moderate perivascular inflammation.

Epidermal nevi

Nevi or nests of cells may be made up of a variety of cell types. The cell types that live in the epidermis include epidermal cells or keratinocytes, sebaceous glands, hair follicles, apocrine and eccrine glands, and smooth muscle cells. This article discusses epidermal or keratinocyte nevi, nevus sebaceous, nevus comedonicus, smooth muscle hamartomas, and inflammatory linear verrucous epidermal nevi. Syndromes associated with epidermal nevi are also reviewed.

[CO2 laser therapy of verrucous epidermal nevus]

INTRODUCTION

Verrucous epidermal nevus are benign epidermal hyperplasias. Their treatments are disappointing because of recurrences and anaesthetic scars. The aim of this study was to evaluate the efficacy of continuous carbon dioxide laser in the treatment of verrucous epidermal nevus.

MATERIAL AND METHODS

It was a retrospective study concerning all patients treated for epidermal verrucous nevus by carbon dioxide laser from 1991 to 2003. Several criteria were evaluated by the patients, a dermatologist and a staff (external observers). Aesthetic result, recurrences, pain due to treatment and global result were evaluated by the patients when they came back.

RESULTS

Twenty-one patients (12 F and 9 M), medium age 20.4, were evaluated with a 40.4 months follow-up (7 to 165 months). The epidermal verrucous nevus was situated on the neck or on the head for 62% of them (n = 13). Among these 21 patients, 86% (n = 19) estimated their skin as "cured" or "nearly normal" or "much improved". The rate was the same for the dermatologist. As for the staff, thanks to photos, only 53% of results were satisfying. The recurrences were never complete, but moderate in 38% of patients. Five patients, medium age 12,5, had hypertrophic scars. Among them, three were only partially hypertrophic.

DISCUSSION

A literature review has been made. Our satisfaction rates (nearly 90%) were slightly higher than other studies rates using carbon dioxide laser (74%) or other types of lasers (87%). The medium follow-up was longer than the one of other laser CO2 studies (26.7 months) or other lasers studies' (15.8 months). This study shows that continuous wave carbon dioxide laser is an easy and effective treatment of verrucous epidermal nevus. Aesthetic results are satisfying but moderate recurrences often occur. To prevent hypertrophic scars, we suggest to exclude teenagers.

Er:YAG Laser Treatment of Verrucous Epidermal Nevi

BACKGROUND

The term verrucous epidermal nevi refers to benign hyperplasia of the epidermis. Numerous treatment modalities have been tried, but no ideal treatment is yet available. We would like to present our experience with Er:YAG laser ablation in the treatment of verrucous epidermal nevi.

OBJECTIVE

The purpose of this study is to assess the long-term results of Er:YAG laser treatment of verrucous epidermal nevi.

METHODS

Twenty patients with verrucous epidermal nevi were treated with Er:YAG laser. Twelve patients were treated with the variable-pulsed Er:YAG laser, a 5-mm handpiece at the setting of 7.0 to 7.5 J/cm2, at a 500-micros pulse duration. The dual-mode Er:YAG laser, with a 2-mm handpiece at the setting of 6.3 J/cm2, at a 350-micros pulse duration (25 microns ablation), was used in eight patients. The laser was fired at 5 Hz until all epidermal nevi were removed. The results of treatment were evaluated for the changes of skin lesions, texture, and color by physicians over a 24-month period.

RESULTS

After a single laser treatment, successful elimination of the verrucous epidermal nevi was observed in 15 patients. Five patients (25%) showed a relapse within 1 year after the treatment. Postoperative healing time was 7 to 10 days. Erythema occurred in all patients after the laser treatment and subsided in 2 months. Postinflammatory hyperpigmentation occurred in two patients (10%). One patient (5%) experienced transient hypopigmentation. Mild to moderate postoperative acne flare-up occurred in one patient (5%) with facial lesions. No other adverse effects, including scarring, were observed.

CONCLUSION

The Er:YAG laser ablation is an effective, safe, and nonscarring method for the treatment of verrucous epidermal nevi.