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Elephantiasis Nostras Verrucosa: A Dermatological Manifestation of Obesity
Belden S., B.A., Frankel E., M.D.
Kent Hospital, Warwick, RI
Introduction: It is well known that there are many concerning medical conditions
associated with obesity. Often underappreciated at the bedside are its dermatological
manifestations. Considering the rise in the number of obese patients today, it is logical
to speculate that primary care providers will start seeing a larger spectrum of such
dermatoses in the future, particularly if these patients do not receive regular preventative
health screenings aimed at controlling their BMI. One such cutaneous manifestation of
obesity is elephantiasis nostras verrucosa (ENV). Here we examine the presentation of
an obese woman with bilateral lower extremity hyperkeratosis, lichenification and
verrucous eruptions with a cobblestone-like appearance.
Case: An 85-year-old obese (BMI 32.5) Caucasian woman was found to have lower
extremity skin deformities upon presentation to the emergency department for acute
mental status change. She did not receive regular medical care and was unable to
recall when the leg changes began. Examination of the lower extremities revealed
malodorous, significantly enlarged, non-pitting, hyperpigmented, verrucous,
cobblestone-like lesions extending from the anterior surface of the distal dorsum of the
foot to the tibial plateau, bilaterally. The right leg was more edematous than the left and
contained multiple, depressed, excoriated ridges embedded within the hyperkeratosis.
Foot examination revealed bilateral dorsal hyperkeratosis with discoloration and
hyponychium of the toenail plates. There was a positive Kaposi-Stemmer sign bilaterally.
Remaining dermatologic full-body exam revealed multiple abdominal striae and several
axillary acrochordrons. Lower extremity venous duplex Doppler ultrasound revealed
normal duplex waveforms, compressibility and augmentation during calf compression
with normal color flow. Relevant laboratory findings included a urinary analysis, which
revealed a concurrent urinary tract infection demonstrated by a urine culture of 4+ E.
cloacae. The patient was treated for her urinary tract infection and discharged to a
skilled nursing facility. She refused any type of intervention for her lower extremity
deformities.
Discussion: Elephantiasis nostras verrucosa (ENV) is one of four subtypes of
elephantiasis characterized by dermal fibrosis and epidermal changes consisting of
verrucous, hyperkeratotic and papillomatous lesions. Its unique pathophysiology has
been linked to chronic lymphedema, which in itself has multiple etiologies; one of which
is obesity. Based on the clinical presentation and ultrasoundography, we were able to
conclude that obesity was the driving factor behind the pathogenesis of ENV in our
patient. Her poor hygiene served as a catalyst.
It is important for practitioners to familiarize themselves with not only the
common dermatoses of obesity, such as striae, acanthosis nigricans or acrochordons,
but also those whose incidence may be on the rise. A thorough dermatological
evaluation of obese patients should be encouraged at all routine physical examinations
to protect and prevent physiological alterations from occurring in the skin.