# Unusual Presentation of Epidermodysplasia Verruciformis (EV) in Non-Sun Exposed Area: A Case Report

## TL;DR

A rare case of skin cancer in a sun-protected area was found in a woman with a genetic skin condition called EV, challenging the usual understanding of where such cancers occur.

## Contribution

This is the second global case of SCC in a non-sun-exposed area among EV patients, challenging the sun-exposure paradigm.

## Key findings

- A 28-year-old woman with EV developed SCC on her scalp, a non-sun-exposed area.
- The patient had multiple lesions resembling trichoblastic and verrucous carcinoma.
- This case highlights the need for close monitoring and UV protection in EV patients.

## Abstract

Introduction and Importance: Epidermodysplasia verruciformis (EV), a rare hereditary skin disorder linked to HPV immunity, increases the risk of squamous cell carcinoma (SCC), typically in sun-exposed areas. This case highlights an extraordinary instance of SCC in a Sun-shielded region, marking the second documented case globally.

Methods: The medical records and histopathological slides of the case were retrospectively reviewed. This work has been reported based on the CARE criteria.

Case Presentation: A 28-year-old Palestinian woman, who adheres to a sun-protective Hijab due to her Muslim faith and has limited sun exposure working in a clothing store, with painful scalp lesions presented at the dermatology clinic. She and her siblings were diagnosed with EV. Three years ago, a painful, enlarging lesion on her scalp led to a diagnosis of trichoblastic carcinoma, followed by the development of six similar lesions. A year later, she returned with multiple painful, pus-producing lesions exhibiting features of trichoblastic and verrucous carcinoma, posing a challenging clinical scenario.

Clinical Discussion: EV is a rare genetic skin disorder linked to EVER1/TCM6 or EVER2/TCM8 gene mutations, causing widespread warts due to specific HPV types. It heightens the risk of nonmelanoma skin cancer (NMSC), mainly SCC, often associated with beta-HPVs 5 and 8. Notably, atypical cases challenge the sun-exposure SCC concept. The reatment involves UV protection, retinoids, and close monitoring, critical to prevent lesion recurrence and aggressive malignancy interventions upon therapy discontinuation.

Conclusion: In this unique case, a patient with EV developed SCC in an uncommonly sun-protected skin area, highlighting the extreme rarity of such an event within the context of this condition's complications.