Verruciform xanthoma is an uncommon lesion with a predilection for the oral mucosa of middle-aged persons or on the scrotum of middle‒aged-to-elderly Japanese men. The most common site for verruciform xanthoma is the oral mucosa. Extraoral verruciform xanthoma is extremely uncommon; it has been reported on the anogenital skin such as the vulva, scrotum, penis, and extremities. [1, 2] Lesions on the perineum or on the skin often have some predisposing factor, such as lymphedema  or an epidermal nevus. [4, 5] Verruciform xanthoma can also occur in association with CHILD (congenital hemidysplasia with ichthyosiform erythroderma and limb defects) syndrome.
Most commonly, the lesion has a verruciform appearance, but it may appear polypoid, papillomatous, or sessile. Rarely, verruciform xanthomas have been found to occur in cysts. The primary distinguishing feature of verruciform xanthoma is the presence of large numbers of lipid-laden foamy histiocytes in, and essentially limited to, the connective-tissue papillae in the lesion.
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The pathophysiology of verruciform xanthoma remains unknown.
Verruciform xanthoma is uncommon, with a frequency of 0.025-0.095%. [6, 7, 8] To date, at least 300 cases have been reported in the oral cavity, [8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18] seven on the lip, [19, 20, 21] 24 on the penis, [1, 2, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43] 20 on the vulva, [29, 44, 45, 46, 47, 48, 49, 50, 51, 52] one in the anal region,  three on the nose or nasal vestibule, [54, 55] two on the ear,  four on the distal extremities (including three on the feet),  and individual cases elsewhere on the skin. At least 23 cases have been reported on the scrotum, almost all of them in Japanese men. [58, 59, 60] Three cases of esophageal verruciform xanthoma have been reported. [29, 61, 62, 63] A single case of multiple verruciform xanthoma lesions has been reported in internal organs; the lesions were in the upper aerodigestive tract of a child with a systemic lipid storage disease. 
Most cases of verruciform xanthoma are reported in whites, but blacks are also affected.  Most scrotal cases of verruciform xanthoma occur in middle‒aged-to-elderly Japanese men. This may be caused by chronic pressure associated with the Japanese tradition of sitting on the floor. 
Most oral cases of verruciform xanthoma occur in middle-aged persons (mean age, 40-60 y), and most scrotal cases occur in middle‒aged-to-elderly Japanese men (mean age, 65 y). However, the age at occurrence varies widely; verruciform xanthoma can occur in persons aged 2.5-89 years. 
Verruciform xanthoma is exceedingly rare in children aged 10 years or younger, except in epidermal nevi or in the context of CHILD syndrome.
The prognosis for verruciform xanthoma is excellent after local surgical excision, and verruciform xanthoma typically does not require medical, chemical, or radiological treatment after surgery.  Recurrence is rare.
Patients should be reassured after adequate excision and accurate diagnosis that verruciform xanthoma is cured.