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Verrucous DLE: A rare presentation misdiagnosed as plantar warts

Verrucous DLE (discoid lupus erythematosus) is a rare variant of cutaneous lupus erythematosus which can easily be misdiagnosed as verruca. The morphologic presentation of this rare disease should be kept in mind and should not be missed because of its rarity. A 45 year female with multiple verrucous lesions who was being treated as case of cutaneous warts was diagnosed as verrucous DLE and responded remarkably with hydroxychloroquine.


Introduction
Cutaneous lupus erythematosus can present as classical discoid lesion (DLE) or papulosquamous or annular lesions as seen in subacute cutaneous lupus erythematosus. [1] Verrucous or hypertrohic DLE is a rare variant that can be misdiagnosed with conditions like verruca or squamous cell carcinoma. We herein describe a rare presentation of verrucous DLE in a 45 year female who was being treated as cutaneous warts till date.

Case Report
A 45 year female presented with multiple skin lesions over face, ear, lips and soles for last 3 years. On clinical examination the lesions on face and ears were well defined, atrophic, scaly plaques with hyperpigmented border while the lesions on soles were large, well defined hyperpigmented, hypertrophic verrucous plaques of size ranging from 3×2 cm approximately. The patient did not have any history of photosentivity, oral lesions or joint symptoms. She had multiple visits at some private institution where she was being treated as a case of cutaneous warts for a long time but no improvement was seen during the course of treatment. The patient's complete hemogram, urine routine examination, liver, and renal function tests were normal. Viral markers were negative. ANA profile was also negative. Our patient did not qualify for the diagnosis of SLE. Histopathogical examination showed irregular epidermal hyperplasia with hyperkeratosis, acanthosis, vacoular basal cell degeneration and peri-appendegeal and lymphohistiocytic infiltrate at dermoepidermal interface. Based on history, clinical examination http://jmscr.igmpublication.org/home/ ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v9i5.13 and histopathology we kept the diagnosis of verrucous DLE and started patient on hydroxychloroquine 200 mg twice a day along with intralesional triamcinolone 40mg/ml repeated every 3 weeks. Follow up at 6 and 10 weeks was done with remarkable improvement in the lesions.

Discussion
Verrucous DLE was first described by Behçet in 1940 as lupus erythematosus hypertrophicus et profundus. [2] Clinically it is characterized by hypertrophic verrucous plaques with minimal scaling on forearms, face, upper trunk, palms and soles. Other morphological presentations of the disease include violaceous papules, blackish hyperkeratotic ulcers, [3] depigmented atrophic plaques, [4] and keratoacanthoma like papulonodular verrucous lesions. [5] The lesions may simulate hypertrophic lichen planus, verrucae, keratoacanthoma or squamous cell carcinoma. [6] In contrast, classical lesions of DLE present with plaques with atrophy, follicular plugging, and adherent scales. The Chronic nature, treatment refractory lesions and potential to develop malignancy are causes of concern in verrucous DLE. Squamous cell carcinoma may develop on long standing persistent hypertrophic lupus erythematosus lesions. Regular follow up has to be done in such patients.
Various treatment modalities for verrucous DLE include hydroxychloroquine, intralesional triamcinolone, [6] isotretinoin, thalidomide, [7,8] and acitretin. [9] We report this case to highlight the diagnostic dilemma posed by this rare disease. It was misdiagnosed as cutaneous warts and was being treated for warts till date. The clinical presentations of the rare variants of cutaneous lupus should be taken into consideration while approaching the diagnosis.

Conclusion
The rare variants cutaneous lupus erythematosus like verrucous DLE should be taken into account while approaching the verrucous lesions along with its close differentials like warts that may cause dignostic dilemma.