Tolvaptan for the Treatment of Elephantiasis Nostras Verrucosa

Elephantiasis Nostras Verrucosa: A Treated Case With Dietary Intervention and Acitretin

Elephantiasis nostras verrucosa (ENV) is a rare and extreme complication of chronic non-filarial lymphedema. It can lead to severe disfiguration of body parts, especially the lower extremities, and is characterized by non-pitting edema and papulonodules with a verrucose or cobblestone-like appearance. Obesity is a risk factor of ENV. Various treatments have been reported for ENV. A 52-year-old woman presented to our outpatient dermatology clinic with non-pitting edema, cobblestone-like papulonodules, and erythematous plaques on both legs for 2 years. Her medical history included morbid obesity with a body mass index of 44.8 kg/m2, hypertension, and type II diabetes mellitus. Biopsy specimens obtained from skin lesions showed multiple dilated lymph nodes throughout the papillary and reticular dermis. Doppler ultrasonography and lymphoscintigraphy revealed lymph stasis and lymphedema, respectively. Based on clinical, histopathological, and imaging findings, the final diagnosis was ENV. She was initially treated with conservative approaches such as compression stockings and dietary intervention for a month. She went on a low-calorie diet (1350 kcal/day) consisting protein 50.7 g/day, fat 32.5 g/day, and carbohydrate 202.7 g/day, for a month. Owing to the hyperkeratotic lesions, she was given oral acitretin 0.3 mg/kg/day. The dosage was increased to 0.6 mg/kg/day after one month. The lesions were slightly flattened after 2 months of therapy. Acitretin was ceased. Early identification is crucial for preventing morbidity in patients with ENV. Management of ENV is challenging for physicians because of the lack of definitive treatment and poor prognosis. In the management of ENV, it is crucial to treat underlying causes, such as obesity. Acitretin induces loosening and thinning of the hyperkeratotic stratum corneum. Thus, it can result in improvement of cutaneous ENV lesions.

Shaving Technique and Compression Therapy for Elephantiasis Nostras Verrucosa (Lymphostatic Verrucosis) of Forefeet and Toes in End-Stage Primary Lymphedema: A 5 Year Follow-Up Study in 28 Patients and a Review of the Literature

Background. Longstanding lymphedema can lead, especially when there is recurrence of erysipelas, to irreversible elephantiasis nostras verrucosa (ENV). This predisposes to new episodes of erysipelas, leading to further damage of the lymphatics and deterioration of the lymphedema as a whole. We report the results of 28 patients with primary lymphedema and surgical removal ENV of the forefoot and toes treated between 2006 and 2014. Method: Retrospective descriptive 5 year follow-up study of 28 patients with various diagnosis of primary lymphedema. Wound healing time, number of erysipelas, body mass index (BMI), recurrence of EVN and types of compression were documented during follow-up. Results: After preoperative multidisciplinary work up, operation of the toes with shaving and excision was performed within a conservative treatment program. During the follow up, the number of erysipelas attacks decreased dramatically (mean 17.6 vs. 0.6). Before treatment, no toecaps were used; and in follow up, it was a part of treatment. Recurrence of ENV was not observed. Compared to the literature with often BMI > 35, the mean BMI in our group was 30.0 (overweight). In 12 patients, we concurrently performed circumferential suction-assisted lipectomy for end-stage lymphedema of the leg. Conclusion: Although lymphedema patients are treated with garments during the maintenance phase, compression of the toes is often too challenging. Surgical removal of the verrucosis of toes is an effective therapeutic modality as part of an integrated lymphedema treatment program to restore the shape of the toes and enable the wearing of toecaps. This technique can also be effective for ENV of origins other than primary lymphedema. Although ENV is a generally accepted term, it can have undesirable connotations. We suggest using a more inclusive name such as lymphostatic verrucosis, because long-lasting lymphatic impairment is involved in all ENV and the term verrucosis is above discussion.

Elephantiasis nostras verrucosa in the setting of lymphoedema tarda and neurofibromatosis type 1

Elephantiasis nostras verrucosa (ENV) comprises an uncommon skin disease characterised by dermal fibrosis with hyperkeratotic, verrucous and papillomatous lesions that usually occur after chronic lymphoedema. We describe the case of a 56-year-old-man with neurofibromatosis type 1, no known surgical history, no chronic medication and no travel history, presenting with worsening non-pitting oedema and impressive foul-smelling mossy plaques and cobblestone-like nodules in both legs and feet, especially on the right, compatible with the diagnosis of ENV.