Efficacy of oral zinc therapy in epidermodysplasia verruciformis with squamous cell carcinoma
A 24-year-old male presented in our out-patient department with complaints of multiple asymptomatic raised warty lesions on the face and extremities since 4 years of age and multiple asymptomatic light colored flat lesions on the trunk and axilla since 4 years of age. These lesions had appeared over a period of time and were progressively increasing in number, size and area of involvement.\nHe also had an asymptomatic non-healing ulcer in the right first web space for the last 1 year. Initially, it was small but over past 3 months it progressively increased in size. Mucocutaneous examination revealed multiple dark colored warty papules and plaques over the face, neck and extremities [Figures -]. Multiple hypopigmented macules like those of pityriasis versicolor were present predominantly in bilateral axilla, upper back and shoulders. An ulcer of size 6-7 cm was present in first web space of the right hand []. It was non-tender, firm in consistency and the surface showed hemorrhagic crusting with rolled out margins.\nHematological, renal, hepatic biochemical parameters and chest X-ray were normal. X-ray of the right hand showed soft-tissue shadows in first web space with no bony involvement. MRI of right hand showed ill-defined heterogeneous lesion in the first web space of right hand (2.4 × 2.8 × 3.3), involving the lumbricals and palmar interossei on the lateral aspect and closely averting flexor digitorum superficialis tendon.\nSkin biopsy from the warty lesion present on the extensor surface of right forearm revealed hyperkeratosis, irregular acanthosis, and an enlarged vacuolated cells suggestive of koilocytes. These histopathological features were consistent with EV []. Histopathological examination from the margin of ulcer present on the right first web space showed multiple dysplastic cells and was consistent with well differentiated squamous cell carcinoma. Rest of the metastatic work up was within normal limit.\nWith all above findings the diagnosis of EV with squamous cell carcinoma of right hand was made. The patient was started on oral zinc sulphate 550 mg/day (10 mg/kg) for twelve weeks and followed-up for the next 6 months. Serum zinc level prior to starting zinc therapy was 58.09 μg/100 mL [] and on completion of treatment it was 168 μg/100 mL (difference 168 - 58.09 = 109.91) []. The main outcome measured was complete clearance of verrucae at 12 weeks as observed on digital photographs taken by the physician delivering the treatment at baseline and 12 weeks. Complete clearance of verrucae was defined as the restoration of normal skin upon close inspection, as assessed by the physician [Figures -].\nThe squamous cell carcinoma of right hand was removed after surgical consultation. No side-effects were reported by patient during the therapy and in the follow-up period.