epidermodysplasia verruciformis ( ev ) is most commonly inherited in an autosomal recessive manner , although sporadic , sex - linked , and autosomal dominant inheritance has been described . the disease is characterized by chronic infection with human papilloma virus hpv types 3 , 5 , 8 , 9 , 10 , 12 , 14 , 17 , 20 , 21 , 23 , 25 , 28 , 38 , 47 , 49 . widespread skin eruptions of flat to papillomatous , wartlike lesions and reddish brown pigmented plaques on the trunk , extremities and the face are typical . malignant skin tumor especially squamous cell carcinoma develops in 30 - 70% patients , most commonly on sun exposed areas starting between the ages of 20 and 40 years . a 24-year - old male presented in our out - patient department with complaints of multiple asymptomatic raised warty lesions on the face and extremities since 4 years of age and multiple asymptomatic light colored flat lesions on the trunk and axilla since 4 years of age . these lesions had appeared over a period of time and were progressively increasing in number , size and area of involvement . he also had an asymptomatic non - healing ulcer in the right first web space for the last 1 year . initially , it was small but over past 3 months it progressively increased in size . mucocutaneous examination revealed multiple dark colored warty papules and plaques over the face , neck and extremities [ figures 1 - 3 ] . multiple hypopigmented macules like those of pityriasis versicolor were present predominantly in bilateral axilla , upper back and shoulders . an ulcer of size 6 - 7 cm was present in first web space of the right hand [ figure 2 ] . it was non - tender , firm in consistency and the surface showed hemorrhagic crusting with rolled out margins . response of oral zn therapy on the face response of oral zn therapy on the upper extremities response of oral zn therapy on the lower extremities hematological , renal , hepatic biochemical parameters and chest x - ray were normal . x - ray of the right hand showed soft - tissue shadows in first web space with no bony involvement . mri of right hand showed ill - defined heterogeneous lesion in the first web space of right hand ( 2.4  2.8  3.3 ) , involving the lumbricals and palmar interossei on the lateral aspect and closely averting flexor digitorum superficialis tendon . skin biopsy from the warty lesion present on the extensor surface of right forearm revealed hyperkeratosis , irregular acanthosis , and an enlarged vacuolated cells suggestive of koilocytes . histopathological examination from the margin of ulcer present on the right first web space showed multiple dysplastic cells and was consistent with well differentiated squamous cell carcinoma . histopathological examination shows hyperkeratosis , irregular acanthosis and koilocytes ( black arrows ) ( h and e , 400 ) with all above findings the diagnosis of ev with squamous cell carcinoma of right hand was made . the patient was started on oral zinc sulphate 550 mg / day ( 10 mg / kg ) for twelve weeks and followed - up for the next 6 months . serum zinc level prior to starting zinc therapy was 58.09 g/100 ml [ table 1 ] and on completion of treatment it was 168 g/100 ml ( difference 168 - 58.09 = 109.91 ) [ table 1 ] . the main outcome measured was complete clearance of verrucae at 12 weeks as observed on digital photographs taken by the physician delivering the treatment at baseline and 12 weeks . complete clearance of verrucae was defined as the restoration of normal skin upon close inspection , as assessed by the physician [ figures 1 - 3 ] . serological and clinical response after oral zinc therapy the squamous cell carcinoma of right hand was removed after surgical consultation . no side - effects were reported by patient during the therapy and in the follow - up period . the pathophysiology of ev is linked to defective cell - mediated immunity , with elucidation of mutations in ever1 ( epidermodysplasia verruciformis enhancing region ) and ever2 genes . although , the role of ever1 and ever2 genes in the pathogenesis of ev remains unclear , one hypothesis is that they are involved in the control of hpv infection within keratinocytes , or they play a role in the immune response to the infection itself . intracellular zinc homeostasis regulated by a complex of ever proteins and zinc transporter proteins may play a role in inhibiting ev - hpv ( epidermodysplasia verruciformis - human papilloma virus ) expression , especially ever2 was found to inhibit free zinc influx to nucleoli . however , an estimated 25% of patients with ev lack mutations in ever1 and ever2 , with the genetic defect in these patients not yet elucidated . because hpv infection is non - lytic , antigen presentation occurs very slowly . hpv infection does not induce inflammatory cytokines therefore , therapeutic options aimed at modulating the immune system and facilitating the production of cytokines have been proposed . morbidity and mortality associated with ev may be avoided by early recognition of the disease , sun avoidance , monitoring by a dermatologist , and treatment of premalignant and malignant lesions . medical management for ev includes topical imiquimod and 5-fluorouracil , systemic retinoids , interferon - alpha , cimetidine , zinc , and combination therapy [ table 2 ] . comparison in between various therapeutic modalities in epidermodysplasia verruciformis oral zinc had been used by many authors either alone as well as in combination therapy with satisfactory to good results [ tables 2 and 3 ] . prescribing zinc is due to its immunomodulatory effects . more importantly , this element modulates dna and rna related enzymes and is also involved in many immunologic processes . proposed that toll - like receptors mediated regulation of zinc homeostasis which influences dendritic cell function . zinc may be administered as acetate , gluconate or sulphate , but the latter seems to be better tolerated . zinc therapy in warts and epidermodysplasia verruciformis in this patient , with oral zinc sulphate we got the fairly satisfactory results as warty lesions on the extremities were flattened more as compared to facial lesions in the range of 20 - 40% . area wise clearance rate was 20% on face , 30% proximal upper extremities , 35% distal upper extremities , 35% proximal lower extremities and 40% distal lower extremities . there was no improvement in the pityriasis versicolor like hypopigmented lesions on the axilla and upper back . so far studies conducted on zinc in multiple or recalcitrant warts and ev showed response rate from 50% to 70% without any recurrence after 6 months of follow up [ table 3 ] . in present case , response rate was from 20% to 40% without any recurrence after 6 months . we concluded that zinc therapy had a role in treatment of ev but in previous studies the response rate was much higher ( 50 - 70% ) as compared to our observation ( 20 - 40% ) . the higher response rates of 50 - 70% were obtained in cases of recalcitrant common warts where the hpv types and pathophysiology involved are different from that in epidermodysplasia verruciformis edv . this may be a reason of lower response rate with zinc therapy in our case but still more clinical trials are required to evaluate the actual response rate with zinc therapy in ev .
epidermodysplasia verruciformis ( ev ) is a rare , inherited disorder that predisposes patients to widespread human papillomavirus ( hpv ) infection and cutaneous squamous cell carcinomas . 
 there is still no definitive therapeutic modality for ev . 
 a 24 year old male patient with ev was treated with oral zinc sulphate , one of the cheapest and safe immuno - modulator available as therapeutic agent with satisfactory result .