Limited role of calicipotriol in inflammatory linear verrucous epidermal naevus

Taru Garg, Binod K Khaitan, Apra Sood

 Department of Dermatology & Venereology, AIIMS New Delhi 110029, India

Correspondence Address:
Taru Garg
Department of Dermatology & Venereology, AIIMS New Delhi 110029
India

To the Editor,

A 2-year-old boy presented with a moderately itchy linear plaque on the trunk extending from the lower back to the lower leg on the posterior aspect. The lesion was first noticed at birth on the leg and it gradually extended proximally and distally as a lin-ear band. There was no family history of similar dis-ease or psoriasis. Examination showed erythematous, verrucous papules with mild scaling coalescing to from plaques in a linear arrangement extending from the right side of the lower back along the right buttock,thigh and leg upto the right ankle. The boy was otherwise in good health and systemic exami-nation revealed no abnormality. Histopathology from the lesion showed hyperkeratosis with foci of parkeratosis and irregular acanthosis. In the upper dermis there were large and small aggregates of lym-phocytes and histiocytes. The clinical and histologi-cal features were consistent with the diagnosis of psoriasiform type of inflammatory linear verrucous epidermal naevus (ILVEN).

He was treated with topical betamethasone valerate 0.12% twice daily for 5 months. There was an initial improvement in the form of reduction of erythema and symptomatic relief in itching but subsequently the lesion stopped responding and there was further progression of the induration and scal-ing. Thereafter a combination of topical 0.05% be-tamethasone dipropionate with 3% salicylic acid oint-ment was tried for 4 weeks with no improvement.

He was then treated with application of 0.05% calcipotriol ointment twice a day. After 4 weeks there was about 50% flattening of the lesion and signifi-cant reduction in the erythema. After 16 weeks of treatment there was complete flattening of the le-sions, with remaining hypopigmentation and mini-mal erythema. Application of calcipotriol was stopped thereafter, a repeat biopsy was taken which showed reduction in hyperkeratosis, foci of parakeratosis, acanthosis and perivascular dermal inflammation.

After 3 weeks papules started reappearing on the same sites. As there was progression of the lesions, application of calcipotriol was restarted and continued for 4 months with significant flattening of the lesions. Then the treatment was discontinued. After another two months the lesions recurred. Calcipotriol application was restarted but the fre-quency of application was reduced to once every al-ternate day. There was partial regression of the lesion.

There is no definite medical treatment for ILVEN. Calcipotriol is one of the modalities suggested for the treatment of ILVEN. A few cases have been reported in the literature with some beneficial effect of calcipotriol in ILVEN.[1],[2],[3] In these reports,lesions showed significant improvement in 4 weeks. But fol-low-up period was rather short varying from 4-12 weeks. In our case,we followed the patient for more than 2 years. Our patient also had significant re-sponse after 4 weeks and complete flattening of the lesions after 16 weeks. But on stopping the treatment,there was recurrence of the lesions and to maintain the beneficial effect regular and long-term use of topical calcipotriol was required. However,because of the high cost of the drug,this may not be possible and there are known side ef-fects of systemic absorption of calcipotriol if used for a prolonged period.

Other treatment modalities described for the treatment of ILVEN are topical corticosteroids, topi-cal retinoids, dithranol, cryotherapy, flash lamp pumped pulsed tunable dye laser.[4] Recurrence of the lesions remains a major problem with all these thera-peutic modalities except in situations where physical destruction with cryotherapy or laser is deep enough to leave behind significant scars. With calcipotriol too, not only is the cost a limiting factor, but regular or intermittent treatment with calcipotriol brings the pa-tient under temporary remission only.

1.	Micali G, Nasca MR,Musumeci ML. Effect of topical calcipotriol on inflammatory linear verrucous epidermal naevus. Pediatr Dermatol 1995; 12: 386-387. [Google Scholar]
2.	Gatti S, Carrozzo AM, Orlandi A et al. Treatment of inflammatory linear verrucous epidermal naevus with calcipotriol. Br J Dermatol 1995; 132: 837-832. [Google Scholar]
3.	Mitsuhashi Y, Katagiri Y, Kondo S.Treatment of inflammatory linear verrucous epidermal naevus with topical vitamin D3. Br J Dermatol 1997; 136: 134-135. [Google Scholar]
4.	Rulo HFC, Van de Kerkhof PCM. Treatment of inflammatory linear verrucous epidermal naevus. Dermatologica 1991; 182: 112 - 114. [Google Scholar]