- Research Article
- 10.1111/ijd.70366
Navigating the Diagnosis of Epidermodysplasia Verruciformis in the Genomic Era.
- Jun 01, 2026
- International journal of dermatology
- Sajjad Biglari + 1 more +1
Epidermodysplasia verruciformis (EV) was described as a congenital skin disease and later as a Mendelian disorder in 1922 and 1946, respectively [1]. For decades, EV was considered a monogenic entity and was also interchangeably referred to as Treeman syndrome (TMS). However, recent advancements in next-generation sequencing (NGS) have revealed that the pathogenesis of EV is distinct from TMS [2]. In fact, a recent study showed that TMS, in some cases, is caused by biallelic loss-of-function CD28 mutations and that TMS warts are driven by α-human papillomavirus (HPV) [2]. Furthermore, at least 21 genes have been implicated in EV pathogenesis. Persistent disseminated flat-like warts in EV patients are derived, for the most part, from weakly virulent, E5- and E8-deficient β-HPVs, which exclusively reside within keratinocytes. However, these β-HPVs, lacking the E5 and E8 genes that are expressed in other genera of more pathogenic HPVs, typically cause only asymptomatic infections in the general population [1]. It is noteworthy that, in addition to β-HPVs, non-β-HPVs (including α- and γ-HPVs) are occasionally associated with the EV phenotype [3]. Mechanistic insights gained from studies of single-gene disorders with EV manifestations suggest dual contributions of keratinocyte-intrinsic immunity and adaptive T-cell immunity to β-HPV clearance. Ultrarare and private mutations in genes governing either keratinocyte-intrinsic immunity or adaptive T-cell immunity, at the priming or effector level, confer predisposition to severe β-HPV infections (Figure 1). These observations led Shen et al., in this issue of the International Journal of Dermatology, and other research groups to categorize EV into classic (TMC6, TMC8, and CIB1), nonclassic (e.g., DOCK8, STK4), and acquired forms [4, 5]. A total of 439 EV patients, comprising 137 classic (typical) EV patients, 46 nonclassic (atypical) EV patients, and 256 acquired EV (AEV) patients, were reviewed. The most commonly reported genes were TMC6, CIB1, TMC8, STK4, and DOCK8. A total of 31 distinct HPVs, belonging to the α-, γ-, and β-HPV genera, were associated with the EV phenotype, with β-HPV-5, -8, and -20 identified as the most common types. Collectively, these genomics-driven advances in EV understanding herald a paradigm shift in the diagnosis, prognosis, and monitoring of EV in the era of precision dermatology. While single-gene EV is a pediatric clinical condition (with an age of onset before 12 years in 89% of cases), most AEV patients are adults, and the disease is prevalent among HIV and transplant populations [5]. The phenocopy in AEV patients underscores the effective suppression of the same surveillance pathways for HPV clearance that are disrupted in hereditary forms [4, 5]. A review of oncologic data in EV patients offers clinically actionable insight into the age of onset and extent of cancer risk. The majority (56%) of monogenic EV patients develop malignancy, occurring decades earlier than in the general population. Moreover, the distinction between isolated and syndromic EV has implications for cancer management: cutaneous malignancies predominate in isolated EV, while extracutaneous malignancies are more common in syndromic forms. These results support genotype-informed cancer surveillance strategies in EV patients. Furthermore, they indicate that EV should be integrated into broader hereditary cancer predisposition frameworks [5]. In sum, EV offers a unique human knockout model for the study of host–virus co-evolution, tissue-specific immunity, and early carcinogenesis. Furthermore, recent genomic advances shift the paradigm of EV from a mere dermatologic curiosity to a prototype for precision dermatology. The authors employed large language models to refine manuscript grammar and phrasing, then reviewed, edited, and accepted full responsibility for the final content. The LEO Foundation (grant LF-OC-22-000965) and the US NIH (grant R01AI143810) supported the authors' studies. The authors declare no conflicts of interest. Clinical and Molecular Perspectives on Epidermodysplasia Verruciformis, https://doi.org/10.1111/ijd.70295. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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