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Elephantiasis nostras verrucosa

Last reviewed: July 2023

Authors: Dr Anne-Marie Aubin and Dr Thomas Barrett, Department of Dermatology, John Hunter Hospital, Australia (2023)

Reviewing dermatologist: Dr Ian Coulson

Edited by the DermNet content department


What is elephantiasis nostras verrucosa?

Elephantiasis nostras verrucosa (ENV) is a rare and severe form of chronic lymphoedema. It leads to cutaneous changes including scarring, non-pitting oedema, hyperkeratosis, cobblestone-like papules, and indurated plaques on gravity-dependent body parts. 

ENV predominantly affects the lower legs in a symmetrical fashion. Other sites that may be affected include the proximal thighs, abdomen, amputation stumps, and scrotum.

It is also known as lymphostatic verrucosis, elephantiasis crurum papillaris et verrucosa, ‘mossy leg’, lymphangitis recurrens elephantogenica, and lymphostatic papillomatosis cutis. ‘Nostras’ is a term used to describe the non-filiarial form of elephantiasis. 

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Who gets elephantiasis nostra verrucosa?

Elephantiasis nostras verrucosa is rare and can occur in males and females of all races. 

It is associated with obesity and recurrent soft tissue infections. Other risk factors include malignancy, congestive heart failure, chronic venous insufficiency, previous trauma, hypothyroidism, and radiation. 

What causes elephantiasis nostra verrucosa?

Elephantiasis nostras verrucosa is caused by chronic lymphostasis, which results in protein accumulation within the interstitial fluid, inducing fibroblast proliferation. This is thought to cause progressive fibrosis of the lymphatic drainage system, leading to obstruction. As the condition progresses, ulcers may develop, leading to recurrent secondary infection.

Conditions which cause impaired lymphatic drainage and can lead to ENV include:

What are the clinical features of elephantiasis nostras verrucosa? 

  • Non-pitting oedema (positive Kaposi-Stemmer sign)
  • Grossly enlarged and disfigured appendages
  • Hyperkeratosis of the epidermis
  • Papillomatous lesions and verrucous growths (‘cobblestone’ appearance)
  • ‘Woody’ or ‘mossy’ textured skin
  • Overlying ulcerations and crusts.

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How do clinical features vary in differing types of skin?

Striking white bright plaques and depigmentation have been reported in Fitzpatrick skin type VI. This is speculated to result from impaired melanogenesis due to chronic inflammation associated with lymphoedema.

What are the complications of elephantiasis nostra verrucosa?

How is elephantiasis nostra verrucosa diagnosed?

Diagnosis is often made clinically, excluding other causes of lymphoedema on history and examination. 

Patients often reveal a long history of oedema prior to the onset of fibrosis, hyperkeratosis, papules, and verrucous lesions. Recent travel, time course, and onset may differentiate from other causes such as filariasis

Kaposi-Stemmer sign (an inability to pinch the skin overlying the base of the second toe) is indicative of lymphoedema.


  • Bloods: full blood count, Giemsa-stained blood smear, and/or specific antigen testing may help rule out filariasis.
  • Biopsy may prove useful in excluding secondary malignancy but is often not necessary for diagnosis. Histology of ENV commonly shows acanthosis, papillomatosis, loss of adnexal structures, and progressive fibrosis.
  • Imaging studies such as CT, MRI, lymphoscintigraphy, and lymphangiography may prove useful in determining the degree and cause of lymphoedema. 

What is the differential diagnosis for elephantiasis nostras verrucosa?

What is the treatment for elephantiasis nostras verrucosa?

Elephantiasis nostras verrucosa is difficult to treat with no known cure. The underlying cause should be treated to prevent further complications. Treatment of ENV can be conservative, medical, or surgical, depending on the severity and deformity.

Conservative treatment

Medical treatment


Surgical treatment

Surgical treatment may be indicated when fibrosis or nodules occur. Techniques of shaving, excision, and electrocauterisation can be used, however, the risk of scarring, infection, and non-healing ulcers should be considered. 

Several case reports have found that ablative carbon dioxide laser is well tolerated and provides cosmetic and symptomatic benefits to ENV patients.

How do you prevent elephantiasis nostras verrucosa?

Prevention of ENV relies on early management of lymphoedema through proper local hygiene, regular moisturiser, compression, lymphatic massage, weight loss, and exercise.

What is the outcome for elephantiasis nostras verrucosa?

Elephantiasis nostras verrucosa can result in progressive deformity of the limbs and reduced quality of life when the condition becomes debilitating.

Patients with ENV are at increased risk of malignancies such as squamous cell carcinoma, and angiosarcomas (Stewart-Treves syndrome), and should therefore be followed up to monitor for further complications.

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  • Chawla S, Gan A, Ramakrishnan R, et al. Elephantiasis nostras verrucosa in skin of color. Int J Dermatol. 2022;61(2):e46-e47. doi: 10.1111/ijd.15907. Journal
  • Damstra RJ, Dickinson-Blok JL, Voesten HG. 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. J Clin Med. 2020;9(10):3139. doi: 10.3390/jcm9103139. Journal
  • Dean SM, Zirwas MJ, Horst AV. Elephantiasis nostras verrucosa: an institutional analysis of 21 cases. J Am Acad Dermatol. 2011;64(6):1104–1110. doi: 10.1016/j.jaad.2010.04.047. Journal
  • Fredman R, Tenenhaus M. Elephantiasis nostras verrucosa. Eplasty. 2012;12:ic14. Article
  • Gomez-Meade C, Combs A, Obed J, Skopit S. Elephantiasis Nostras Verrucosa: A case report. J Am Acad Dermatol. 2010;62(3). Journal
  • Kar Keong N, Siing Ngi AT, Muniandy P, Voon Fei W. Elephantiasis nostras verrucosa: a rare complication of lower limb lymphoedema. BMJ Case Rep. 2017;2017:bcr2017221492. doi: 10.1136/bcr-2017-221492. Journal
  • Liaw FY, Huang CF, Wu YC, Wu BY. Elephantiasis nostras verrucosa: swelling with verrucose appearance of lower limbs. Can Fam Physician. 2012;58(10):e551–e553. Journal
  • Moussa Y, Moussa M, Abou Chakra M. Penoscrotal Elephantiasis nostras verrucosa: A case report and literature review. Int J Surg Case Rep. 2019;65:127–130. doi: 10.1016/j.ijscr.2019.10.070. Journal
  • Sancho ADQ, Cura LRD, Alonso SA, López MAG. Treatment of Elephantiasis Nostras Verrucosa with CO2 Laser. Indian Dermatol Online J. 2019;10(6):704-706. doi: 10.4103/idoj.IDOJ_484_18. Journal
  • Sisto K, Khachemoune A. Elephantiasis nostras verrucosa: a review. Am J Clin Dermatol. 2008;9(3):141-146. doi: 10.2165/00128071-200809030-00001. Journal

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