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Is it inflammatory linear verrucous epidermal nevus or linear psoriasis?

A 28-year-old woman presented to us with a 24-year history of linear pruritic, papules and plaques on the left arm and left part of the body and a 13-year history of scaly plaques behind the left ear. There was no history of seasonal variation or family history of psoriasis. Cutaneous examination revealed the verrucous, erythematosquamous papules coalescent into band-like plaques in a linear pattern on the left thorax, abdomen and back further extending up to the lateral aspect of the superior limb, following Blaschko lines (Figure 1A). The multiple erythematous plaques localized behind the left ear were confluent covered by scales (Figure 1B). No psoriasis-form nail or disseminated psoriatic lesions were observed. Skin biopsies from the arm and behind the ear both showed psoriasiform features, including parakeratosis, hyperkeratosis, acanthosis with a regular elongation of the epidermal ridges and an inflammatory infiltrate of lymphocytes (Figure 1C and 1D). In addition, the biopsy from the arm revealed alternation of parakeratosis and orthokeratosis with the absence and presence of the granular layer respectively (Figure 1C). Immunohistochemically, the subsets of T-lymphocytes (CD2, CD4, CD8, CD25, CD45RO and CD45RA) and marker for epidermal growth (Ki-67) did not show difference between two lesions (Figure 1E–1H). Both 0.1% tacrolimus ointment and 0.2% tacalcitol ointment were applied topically twice daily for 4 months. All the lesions were not significantly changed, showing resistance to this therapy. Based on the clinical course and clinicopathologic correlation, the diagnosis of ILVEN was established.