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Psoriasis verrucosa complicated by generalized pustular psoriasis

Dear Editor, Psoriasis verrucosa is a rare subtype of psoriasis characterized by papillomatous, remarkably hyperkeratotic plaques. Most cases have a history of pre-existing psoriasis vulgaris, suggesting a concomitant condition rather than an independent subtype of psoriasis. Here, we report a case of psoriasis verrucosa that developed during a course of generalized pustular psoriasis (GPP) following psoriasis vulgaris. A 72-year-old man presented with a 4-year history of hyperkeratotic plaques on the lower legs. He had been diagnosed with psoriasis vulgaris at 54 years old and had been administrated 10 mg/day of etretinate. Furthermore, he had repeatedly developed generalized pustulosis that showed a typical spongiform pustule of Kogoj in the skin biopsy (Fig. 1a), which established the diagnosis of GPP. He had also been treated for chronic venous insufficiency and type 2 diabetes mellitus. His height and weight were 168 cm and 58 kg, respectively. Physical examination revealed large erythematous and papillomatous plaques with thick, adherent scales on the lower legs (Fig. 1b–d). Skin lesions and edema were observed predominantly on the left leg. Histopathology showed marked hyperkeratosis, parakeratosis with aggregated neutrophils (Munro’s microabscesses), thinning of the granular layer, psoriasiform acanthosis with severe papillomatosis, dilated dermal vessels and perivascular lymphocytic infiltration (Fig. 1e,f). Immunohistochemistry and polymerase chain reaction testing for human