{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T13:57:53Z","timestamp":1780667873497,"version":"3.54.1"},"reference-count":38,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2020,9,28]],"date-time":"2020-09-28T00:00:00Z","timestamp":1601251200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background. Longstanding lymphedema can lead, especially when there is recurrence of erysipelas, to irreversible elephantiasis nostras verrucosa (ENV). This predisposes to new episodes of erysipelas, leading to further damage of the lymphatics and deterioration of the lymphedema as a whole. We report the results of 28 patients with primary lymphedema and surgical removal ENV of the forefoot and toes treated between 2006 and 2014. Method: Retrospective descriptive 5 year follow-up study of 28 patients with various diagnosis of primary lymphedema. Wound healing time, number of erysipelas, body mass index (BMI), recurrence of EVN and types of compression were documented during follow-up. Results: After preoperative multidisciplinary work up, operation of the toes with shaving and excision was performed within a conservative treatment program. During the follow up, the number of erysipelas attacks decreased dramatically (mean 17.6 vs. 0.6). Before treatment, no toecaps were used; and in follow up, it was a part of treatment. Recurrence of ENV was not observed. Compared to the literature with often BMI &gt; 35, the mean BMI in our group was 30.0 (overweight). In 12 patients, we concurrently performed circumferential suction-assisted lipectomy for end-stage lymphedema of the leg. Conclusion: Although lymphedema patients are treated with garments during the maintenance phase, compression of the toes is often too challenging. Surgical removal of the verrucosis of toes is an effective therapeutic modality as part of an integrated lymphedema treatment program to restore the shape of the toes and enable the wearing of toecaps. This technique can also be effective for ENV of origins other than primary lymphedema. Although ENV is a generally accepted term, it can have undesirable connotations. We suggest using a more inclusive name such as lymphostatic verrucosis, because long-lasting lymphatic impairment is involved in all ENV and the term verrucosis is above discussion.<\/jats:p>","DOI":"10.3390\/jcm9103139","type":"journal-article","created":{"date-parts":[[2020,9,28]],"date-time":"2020-09-28T10:39:58Z","timestamp":1601289598000},"page":"3139","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Shaving Technique and Compression Therapy for Elephantiasis Nostras Verrucosa (Lymphostatic Verrucosis) of Forefeet and Toes in End-Stage Primary Lymphedema: A 5 Year Follow-Up Study in 28 Patients and a Review of the Literature"],"prefix":"10.3390","volume":"9","author":[{"given":"Robert J.","family":"Damstra","sequence":"first","affiliation":[{"name":"Member European Reference Network ERN (VASCERN PPL), Department of Dermatology, Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, 9202 NN Drachten, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janine L.","family":"Dickinson-Blok","sequence":"additional","affiliation":[{"name":"Member European Reference Network ERN (VASCERN PPL), Department of Dermatology, Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, 9202 NN Drachten, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harry G.J.M.","family":"Voesten","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, Nij Smellinghe Hospital, 9202 NN Drachten, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,9,28]]},"reference":[{"key":"ref_1","first-page":"44","article-title":"Lymphedema in the morbidly obese patient: Unique challenges in a unique population","volume":"54","author":"Fife","year":"2008","journal-title":"Ostomy Wound Manag."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"202","DOI":"10.4103\/ijmy.ijmy_38_19","article-title":"Tuberculosis verrucosa cutis presenting with unilateral elephantiasis nostras verrucosa of the left lower limb: A rare entity","volume":"8","author":"Sinha","year":"2019","journal-title":"Int. J. Mycobacteriol."},{"key":"ref_3","first-page":"261","article-title":"A clinical symptom for the early and differential diagnosis of lymphedema","volume":"5","author":"Stemmer","year":"1976","journal-title":"VASA"},{"key":"ref_4","unstructured":"International Society of Lymphology (2016). The Diagnosis and Treatment of Peripheral Lymphedema: 2016 Consensus Document of the International Society of Lymphology. Lymphology, 49, 170\u2013184."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1001\/archderm.1955.01540290084026","article-title":"Elephantiasis nostras verrucosa; lymphostatic verrucosis","volume":"71","author":"Davis","year":"1955","journal-title":"AMA Arch. Derm."},{"key":"ref_6","first-page":"214","article-title":"Researches on elephantiasis nostras and elephantiasis tropica with special regard to their initial stage of recurring lymphangitis (lymphangitis recurrens elephantogenica). Supplementary note","volume":"72","author":"Castellani","year":"1969","journal-title":"J. Trop. Med. Hyg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1111\/cup.12441","article-title":"Histopathological and immunohistochemical features of nodular podoconiosis","volume":"42","author":"Wendemagegn","year":"2015","journal-title":"J. Cutan. Pathol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1104","DOI":"10.1016\/j.jaad.2010.04.047","article-title":"Elephantiasis nostras verrucosa: An institutional analysis of 21 cases","volume":"64","author":"Dean","year":"2011","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1111\/j.1529-8019.2009.01271.x","article-title":"Filariasis: Diagnosis and treatment","volume":"22","author":"Mendoza","year":"2009","journal-title":"Dermatol. Ther."},{"key":"ref_10","first-page":"210","article-title":"Podoconiosis, a neglected tropical disease","volume":"70","author":"Korevaar","year":"2012","journal-title":"Neth. J. Med."},{"key":"ref_11","first-page":"115","article-title":"Surgical treatment of elephantiasis of the feet in congenital lymphedema to facilitate the use of a compression mechanism","volume":"3","author":"Azoubel","year":"2010","journal-title":"Int. J. Gen. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1111\/j.1365-2133.1992.tb00465.x","article-title":"Elephantiasis nostras verrucosa: Beneficial effect of oral etretinate therapy","volume":"127","author":"Zouboulis","year":"1992","journal-title":"Br. J. Dermatol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1111\/iwj.13050","article-title":"Acitretin may improve symptoms and exudation in patients affected by elephantiasis nostras verrucosa: Report of a case","volume":"16","author":"Marasca","year":"2018","journal-title":"Int. Wound J."},{"key":"ref_14","first-page":"939","article-title":"Elephantiasis nostras verrucosa successfully treated by surgical debridement","volume":"30","author":"Iwao","year":"2004","journal-title":"Dermat. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1016\/j.jamcollsurg.2012.03.020","article-title":"Surgical Management of Inoperable Lymphedema: The Re-emergence of Abandoned Techniques","volume":"215","author":"Doscher","year":"2012","journal-title":"J. Am. Coll. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1016\/j.jcms.2012.11.009","article-title":"Surgical correction of rhinophyma: Comparison of two methods in a 15-year-long experience","volume":"41","author":"Lazzeri","year":"2013","journal-title":"J. Cranio Maxillofac. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1111\/j.1399-0004.2010.01394.x","article-title":"A new classification system for primary lymphatic dysplasias based on phenotype","volume":"77","author":"Connell","year":"2010","journal-title":"Clin. Genet."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1002\/bjs.10325","article-title":"Circumferential suction-assisted lipectomy in the treatment of primary and secondary end-stage lymphoedema of the leg","volume":"104","author":"Lamprou","year":"2016","journal-title":"Br. J. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1210","DOI":"10.1111\/j.1365-2133.2008.08503.x","article-title":"Erysipelas as a sign of subclinical primary lymphoedema: A prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg","volume":"158","author":"Damstra","year":"2008","journal-title":"Br. J. Dermatol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1350","DOI":"10.1111\/j.1365-2133.2007.08423.x","article-title":"Lymphatic abnormalities demonstrated by lymphoscintigraphy after lower limb cellulitis","volume":"158","author":"Soo","year":"2008","journal-title":"Br. J. Dermatol."},{"key":"ref_21","first-page":"756","article-title":"The Dutch lymphedema guidelines based on the International Classification of Functioning, Disability, and Health and the chronic care model","volume":"5","author":"Damstra","year":"2017","journal-title":"J. Vasc. Surg."},{"key":"ref_22","first-page":"454","article-title":"Diagnosis and treatment of primary lymphedema. Consensus document of the International Union of Phlebology (IUP)-2009","volume":"29","author":"Lee","year":"2010","journal-title":"Int. Angiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"141","DOI":"10.2165\/00128071-200809030-00001","article-title":"Elephantiasis nostras verrucosa: A review","volume":"9","author":"Sisto","year":"2008","journal-title":"Am. J. Clin. Dermatol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1111\/bjd.14556","article-title":"Pediatric primary lymphoedema: A cohort of 155 children and newborns","volume":"175","author":"Vidal","year":"2016","journal-title":"Br. J. Dermatol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1097\/00042728-200506000-00027","article-title":"Elephantiasis Nostras Verrucosa Treated with Surgical D\u00e9bridement","volume":"31","author":"Ferrandiz","year":"2005","journal-title":"Dermatol. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"326","DOI":"10.5021\/ad.2009.21.3.326","article-title":"A Case of Elephantiasis Nostras Verrucosa","volume":"21","author":"Yang","year":"2009","journal-title":"Ann. Dermatol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"bcr-2017-221492","DOI":"10.1136\/bcr-2017-221492","article-title":"Elephantiasis nostras verrucosa: A rare complication of lower limb lymphoedema","volume":"2017","author":"Keong","year":"2017","journal-title":"BMJ Case Rep."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1177\/1534734614536036","article-title":"Maggot Therapy for Elephantiasis Nostras Verrucosa Reveals New Applications and New Complications","volume":"13","author":"Borst","year":"2014","journal-title":"Int. J. Low. Extrem. Wounds"},{"key":"ref_29","first-page":"e551","article-title":"Elephantiasis nostras verrucose: Swelling with verrucose appearance of lower limbs","volume":"58","author":"Liaw","year":"2012","journal-title":"Can. Fam. Phys. Med. Fam. Can."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1111\/j.1365-4632.2012.05740.x","article-title":"Elephantiasis nostras verrucosa in a patient with obesity and chronic venous insufficiency","volume":"52","author":"Schiavo","year":"2013","journal-title":"Int. J. Dermatol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1002\/ccr3.795","article-title":"Gross-dependent lower limb lymphoedema","volume":"5","author":"Hennessy","year":"2017","journal-title":"Clin. Case Rep."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1183","DOI":"10.1007\/s00402-007-0498-1","article-title":"Elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis","volume":"128","author":"Turhan","year":"2007","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"764","DOI":"10.1046\/j.1365-4362.2000.00047-2.x","article-title":"Elephantiasis nostras verrucosa","volume":"39","author":"Vaccaro","year":"2000","journal-title":"Int. J. Dermatol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"673","DOI":"10.1503\/cmaj.080642","article-title":"What is your call? Cobblestone-like skin. Elephantiasis nostras verrucosa","volume":"179","author":"Guarneri","year":"2008","journal-title":"CMAJ"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"bcr-2017-221014","DOI":"10.1136\/bcr-2017-221014","article-title":"Elephantiasis nostras verrucosa secondary to recurrent erysipelas","volume":"2017","author":"Freitas","year":"2017","journal-title":"BMJ Case Rep."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"3347","DOI":"10.2169\/internalmedicine.2815-19","article-title":"Tolvaptan for the Treatment of Elephantiasis Nostras Verrucosa","volume":"58","author":"Eda","year":"2019","journal-title":"Intern. Med."},{"key":"ref_37","first-page":"E4","article-title":"Elephantiasis nostras verrucosa secondary to scleroderma","volume":"103","author":"Lee","year":"2019","journal-title":"Cutis"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"747","DOI":"10.1053\/j.jfas.2014.08.010","article-title":"Excision of Elephantiasis Nostras Verrucosa Lesions in a Patient with Hereditary Lymphedema: Case Report and Review of the Literature","volume":"54","author":"Pitcher","year":"2015","journal-title":"J. Foot Ankle Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/9\/10\/3139\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:14:36Z","timestamp":1760177676000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/9\/10\/3139"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,9,28]]},"references-count":38,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2020,10]]}},"alternative-id":["jcm9103139"],"URL":"https:\/\/doi.org\/10.3390\/jcm9103139","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,9,28]]}}}