Sagis Dermatopathology Case Review: Verruciform Xanthoma

Case Overview

Presented by Jennifer Vickers, MD
Educational dermpath case series for dermatology residents

Patient: 27-year-old man
Lesion Location: Scrotum

A biopsy of a verrucous lesion on the scrotum was performed.

Take a moment to review the histologic images below, do you know how Dr. Vickers came to this diagnosis?

(Low-power histologic view of verrucous lesion)

Key Histologic Findings

On examination, several defining features stand out:

• Papillomatosis
• Wedge-shaped parakeratosis with intracorneal neutrophils
• Foam cells (xanthoma cells) within the dermal papillae

(Medium power showing papillomatosis)

(High power showing foamy macrophages in dermal papillae)

(High power showing parakeratosis and neutrophils)

Differential Diagnosis: Three Common Mimickers

When evaluating a verrucous lesion like this, several differentials come to mind. Let’s walk through the three most likely contenders and highlight what sets them apart.

1️⃣ Condyloma Acuminatum

Etiology: Human papillomavirus (HPV), most commonly types 6 and 11
Histology:

• Papillomatous epidermal hyperplasia
• Koilocytosis (perinuclear clearing in keratinocytes)
• May have fibrovascular cores
• Lacks foam cells

Key Distinction:
Although condyloma and verruciform xanthoma both exhibit papillomatosis, koilocytes are the hallmark of condyloma. Verruciform xanthoma, in contrast, lacks HPV-associated changes.

2️⃣ Verruca Vulgaris

Etiology: HPV (types 2 and 4 most common)
Histology:

• Prominent papillomatosis and hyperkeratosis
• Elongated rete ridges curving inward
• Koilocytosis may be present in the upper epidermis
• No foamy macrophages

Key Distinction:
While verruca vulgaris and verruciform xanthoma share a verrucous architecture, verruca vulgaris displays viral cytopathic effect and lacks the xanthomatous infiltrate that defines verruciform xanthoma.

3️⃣ Verrucous Carcinoma

Etiology: Low-grade variant of squamous cell carcinoma
Histology:

• Exophytic and endophytic growth pattern
• Minimal cytologic atypia
• Pushing, bulbous borders
• May show keratin pearls and inflammation

Key Distinction:
Unlike verruciform xanthoma, verrucous carcinoma shows invasive downward growth and a more aggressive epithelial proliferation. No foamy macrophages are seen.

The Final Diagnosis:
Verruciform Xanthoma

The presence of foamy macrophages (lipid-laden histiocytes) within dermal papillae is diagnostic. This lesion is not associated with HPV, setting it apart from other verrucous lesions in the anogenital region.

Key Takeaways for Dermatology Residents:

• Always evaluate verrucous lesions at high power — subtle findings make the diagnosis.
• Verruciform xanthoma can appear in oral, genital, or cutaneous sites.
• While benign, correct identification prevents unnecessary concern for HPV or malignancy.

📚 Quick Summary

💬 Final Thought

Verruciform xanthoma is a classic dermatopathology “look-alike” that rewards careful microscopic examination. Remember: the foam cells tell the story.

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