Key Clinical Message
In patients with psoriasis, reactivation of latent HPV may be unrelated to recent immunomodulators. This requires further research of possible mechanisms and public awareness.
A 35-year-old man presented with multiple incidental white and erythematous, cauliflower-like, filiform, painless warts in the perianal and bilateral inguinal regions (Figure 1). Several of the warts had hyperpigmented tips. He noticed the warts approximately 3 months previously, and they recently increased in number. The patient had a history of plaque psoriasis and inverse psoriasis since the age of 16 years and had scaly, erythematous plaques with sharp margins over his scalp, face, neck, trunk, gluteal cleft, upper limbs, and lower limbs (Figure 2). His palms and the soles of his feet did not have any warts. The Koebner phenomenon and Auspitz sign were present. He had received topical corticosteroids, topical calcipotriene, tar, systemic methotrexate, and ultraviolet (UV) irradiation, all of which were ineffective and were discontinued 3 years prior to the present complaint. He denied any history of unprotected sexual exposure or anal sexual contact. The patient had not received an HPV vaccine. He had no oral ulcers, arthralgia, nor dysuria. Upon physical examination, there was no fever, warts over the penis, or scrotum, as well as no urethral discharge or palpable lymphadenopathy. There were no intra-anal lesions. Syphilis screening tests (Venereal Disease Research Laboratory and Treponema pallidum particle agglutination tests) and an anti-human immunodeficiency virus screening test (enzyme-linked immunosorbent assay) were non-reactive. We performed tumor excision and electrocauterization for the perianal lesions. Histopathological findings were compatible with condyloma acuminata (Figure 3). Clinical follow-up showed no tumor recurrence, but the typical Koebner phenomenon was observed in the excisional sites 2 weeks postoperatively.