Verrucous carcinoma masquerading as a chronic leg ulcer: a case report from a resource-limited setting

Abstract

Introduction and importance: Verrucous carcinoma (VC) is a rare, well-differentiated, low-grade variant of squamous cell carcinoma characterized by locally aggressive behavior with minimal metastatic potential. Cutaneous verrucous carcinoma (CVC) of the lower leg is exceedingly uncommon and frequently mimics benign conditions such as chronic ulcers, infections, or warts, leading to significant diagnostic delays. This poses substantial management challenges, particularly in resource-limited settings where access to advanced imaging, specialized testing, and reliable long-term follow-up is restricted. Presentation of the case: A 45-year-old man presented with a 2-year history of a non-healing, progressively enlarging, fungating mass on the anterolateral aspect of his left leg, measuring 10 × 6 cm, with foul-smelling discharge and surrounding hyperpigmentation. He had no conventional risk factors (e.g., chronic osteomyelitis, venous stasis, trauma, immunosuppression, or smoking) and had received multiple empiric antibiotic courses without improvement. Physical examination revealed no palpable inguinal lymph nodes. Plain radiography suggested cortical bone involvement of the fibula. Histopathology following wide local excision confirmed verrucous squamous cell carcinoma with clear margins. The patient attended one early postoperative visit, which showed satisfactory healing, but was subsequently lost to follow-up because of geographic isolation and financial barriers. Clinical discussion: This case illustrates an atypical presentation of CVC in a relatively young patient without identifiable predisposing factors, with a 2-year diagnostic delay consistent with the existing literature, in which such lesions are commonly misdiagnosed as infections or benign hyperplasia. Superinfection and pseudoepitheliomatous hyperplasia often obscure superficial biopsies, underscoring the need for deep and repeated sampling. Imaging was restricted to plain X-ray due to resource constraints, precluding definitive evaluation of bone invasion. Wide local excision with clear margins remains the gold-standard treatment, while radiotherapy is contraindicated due to the risk of anaplastic transformation. Loss to follow-up highlights systemic challenges in low-resource environments, including poverty, distance, and inadequate referral networks. Conclusion: Heightened clinical suspicion for VC is essential when evaluating chronic non-healing lower extremity ulcers unresponsive to conventional therapy, even in younger patients or resource-limited settings. Early deep biopsy and complete surgical excision with clear margins are critical to prevent extensive local invasion. Consistent long-term follow-up is vital for early detection of recurrence, despite significant logistical and economic barriers in low-resource contexts.