Issue link: https://viewer.e-digitaledition.com/i/96304
+++++++++++++++++++ + +++ +DIAGNOSTICSU +++ +++++++++++++++++++ CASE OF THE MONTH With Crutchfield Dermatology A 60-YEAR-OLD MAN WITH CHRONIC AND RECURRENT BOUTS OF LYMPHEDEMA OF THE LOWER EXTREMITIES HAD NOT BEEN SEEN BY A PHYSICIAN FOR SEVERAL YEARS. HE PRESENTED WITH DOZENS OF INDIVIDUAL AND COALESCING DARK PINK/VIOLET NODULES ON HIS LOWER EXTREMITIES. THE LESIONS WERE VERY PRURITIC AND MILDLY PAINFUL. WHAT IS YOUR DIAGNOSIS? Diagnosis: Elephantiasis Nostras Verrucosa Chronic lymphedema, lymphangitis and obstruction of the major lymphatic channels of the skin can result in permanent hypertrophic nodular fibrosis. This end-stage presentation has been called elephantiasis nostras verrucosa (different from the elephantiasis tropica seen from lymphatic blockage from filarial worms). At this point, it is extremely difficult to treat. Treatment Care of a primary care physician is recommended for the management of the underlying causes of the lymphedema. For symptomatic relief and to control additional development and progression, knee-high, compression stockings that are custom fit with the pressure of 30 mmHg or greater can be beneficial. They should be worn as much as possible throughout the day, and the patient should apply triamcinolone 0.1% cream once daily. Although not perfect, many patients report a significant and satisfactory improvement of both the symptoms and the condition with this treatment protocol. Abstract Elephantiasis nostras verrucosa is a rare, chronic, deforming disorder characterized by hyperkeratosis and papillomatosis of the epidermis with underlying woody fibrosis of the dermis and subcutaneous tissue. Chronic lymphedema — either congenital or secondary to infection, surgery, radiation, neoplastic obstruction, obesity, portal hypertension or chronic congestive heart failure — plays a pivotal role in the pathogenesis. Without appropriate intervention, the progressive cutaneous changes will culminate in massive and grotesque enlargement of the affected body region. For more information, contact Charles E. Crutchfield III, M.D., at Crutchfield Dermatology or visit www.CrutchfieldDermatology.com. I