Severe Hyperkeratosis Associated With Chronic Lower-Extremity Lymphedema Complicated by Cellulitis: A Case Report

Elephantiasis nostras verrucosa (ENV) is a rare, end-stage complication of chronic nonfilarial lymphedema, marked by progressive dermal fibrosis, hyperkeratosis, and verrucous skin changes, which increase susceptibility to recurrent infections and chronic wounds. We present a 77-year-old man with longstanding bilateral lower-extremity lymphedema, severe hyperkeratosis, malodorous drainage, and polymicrobial wound infection. Examination revealed extensive verrucous lesions with worsening edema and drainage from chronic venous stasis wounds, along with hyperkeratotic changes consistent with ENV. Management included intravenous cefepime and a multidisciplinary approach using the TIME framework, with involvement of infectious disease, wound care, and vascular surgery. He was discharged with a structured wound care plan, ongoing antimicrobials, and coordinated outpatient follow-up. This case underscores the dermatologic and infectious complications of advanced lymphedema and the microbiologic complexity of chronic wounds. Effective management requires early recognition, culture-guided therapy, edema control, structured wound management, and optimization of comorbidities to improve healing, reduce recurrence, and minimize healthcare burden.