dermatopathology- we’ve only just begun

DermatopathologyDermatopathology-- WeWe’’ve Only Just Begunve Only Just Begun

Paul K. Shitabata, M.D.Paul K. Shitabata, M.D.Dermatopathology Dermatopathology InstituteInstitute

PatternsPatterns

Epidermis

Dermis/Vessels/Hair Follicles

Fat/Vessels

AcantholysisAcantholysis

Loss of cohesion Loss of cohesion between epidermal or between epidermal or adnexaladnexal keratinacyteskeratinacytesGroverGrover’’s disease, s disease, PemphigusPemphigus, , DarierDarier’’ssdisease, Haileydisease, Hailey--HaileyHailey

AcanthosisAcanthosis

The increase in the The increase in the thickness of the stratum thickness of the stratum malpighiimalpighiiAcanthosisAcanthosis nigricansnigricans, , Pale cell Pale cell acanthomaacanthoma

ApoptosisApoptosis

Dropping off of colloid Dropping off of colloid bodies from the epidermis bodies from the epidermis into the dermisinto the dermisOccurs in disorders in which Occurs in disorders in which basal cell damage occurs, basal cell damage occurs, such as such as lichenoidlichenoid tissue tissue reactionsreactionsLichen Lichen planusplanus, LPLK, DLE, LPLK, DLE

BullaBulla

Cavity of at least 5 mm Cavity of at least 5 mm in diameter forming in diameter forming within or below the within or below the epidermisepidermisBullousBullous pemphigoidpemphigoid, , EBA, DHEBA, DH

CornoidCornoid

LamellaLamella

The The cornoidcornoid lamella is lamella is tilted toward the center tilted toward the center of such a lesionof such a lesionPeripherally migrating Peripherally migrating clone of abnormal clone of abnormal keratinocyteskeratinocytes forming forming the the cornoidcornoid lamella lamella PorokeratosisPorokeratosis

EpidermolyticEpidermolytic

HyperkeratosisHyperkeratosis

VacuolationVacuolation of the of the keratohyalinekeratohyaline granular granular layerlayerRule out Congenital Rule out Congenital IchthyosiformIchthyosiformerythrodermaerythrodermaAssociation with Association with dysplasticdysplastic nevinevi

LichenoidLichenoid

(Interface)(Interface)

Epidermal basal cell Epidermal basal cell damage manifested with damage manifested with cell death or cell death or liquefactiveliquefactivedegeneration (basal degeneration (basal vacuolar change)vacuolar change)Interface sometimes Interface sometimes applied only to applied only to poikilodermatouspoikilodermatousreactions with mild basal reactions with mild basal damage with vacuolar damage with vacuolar changechangeLichen Lichen planusplanus, Fixed drug , Fixed drug eruption, LPLKeruption, LPLK

ParakeratosisParakeratosis

Retention of nuclei in the Retention of nuclei in the stratum corneumstratum corneumNormal finding on Normal finding on mucous membranesmucous membranesSpongioticSpongiotic dermatitis dermatitis (Eczema)(Eczema)

PsoriasiformPsoriasiform

Epidermal hyperplasia Epidermal hyperplasia with regular elongation with regular elongation of of reterete ridgesridgesSeveral layers of scale Several layers of scale resulting from bouts of resulting from bouts of activityactivityPsoriasis, PRP, Lichen Psoriasis, PRP, Lichen striatusstriatus, MF, MF

SpongioticSpongiotic

IntraepidermalIntraepidermalintercellular edema with intercellular edema with widened intercellular widened intercellular spaces and elongation of spaces and elongation of intercellular bridgesintercellular bridgesSubclassifySubclassify by by inflammatory cell typeinflammatory cell typeEczemaEczema

UlcerUlcer

Obliteration of a Obliteration of a mucosal surfacemucosal surfaceUsually Usually fibrinopurulentfibrinopurulentbasebase

Epidermal Reaction PatternsEpidermal Reaction Patterns

Orthokeratosis

Spongiosis

AcanthosisParakeratosis

Hyperkeratosis

Modify by Inflammatory Cell

type

Spongiosis

Parakeratosis Acanthosis Hyperkeratosis

Orthokeratosis

Hyperkeratosis Acanthosis

Epidermal/DermalEpidermal/Dermal Reaction PatternsReaction Patterns

Superficial Superficial perivascularperivascularSuperficial and deep Superficial and deep perivascularperivascularNodular and diffuseNodular and diffuseIntraepidermalIntraepidermal vesicular and vesicular and pustularpustularSubepidermalSubepidermal vesicular vesicular

AbscessAbscess

Obliteration of tissue by Obliteration of tissue by suppurativesuppurative necrosisnecrosisMay have foreign body May have foreign body giant cellsgiant cellsConsider correlation with Consider correlation with culturesculturesConsider special stainsConsider special stains

CaseationCaseation

NecrosisNecrosis

Identical to coagulation Identical to coagulation necrosis and ischemic necrosis and ischemic necrosisnecrosisAffected tissue has lost its Affected tissue has lost its structural outline and appears structural outline and appears as pale as pale eosinophiliceosinophilic, , amorphous and finely amorphous and finely granulargranularTuberculosis, Tuberculosis, NecrobioticNecrobioticxanthogranulomaxanthogranuloma

FibrinoidFibrinoid

NecrosisNecrosis

Fibrin deposition in the Fibrin deposition in the wall of small vesselswall of small vesselsCommonly associated Commonly associated with with leukocytoclasticleukocytoclasticvasculitisvasculitis

Flame FiguresFlame Figures

Encrustation of Encrustation of eosinophiliceosinophilic granules granules around collagenaround collagenFrequent in conditions Frequent in conditions with dermal with dermal eosinophiliaeosinophiliaWellWell’’s syndrome, s syndrome, arthropod, drug reactionsarthropod, drug reactions

Granulation TissueGranulation Tissue

Newly formed dermis arising Newly formed dermis arising in healing wounds and in healing wounds and characterized by numerous characterized by numerous fibroblasts and new fibroblasts and new capillaries and an infiltrate capillaries and an infiltrate consisting of lymphoid cells, consisting of lymphoid cells, macrophages, and plasma macrophages, and plasma cellscellsDecubitusDecubitus ulcerulcer

GranulomaGranuloma

Chronic Chronic proliferativeproliferative lesion lesion consisting of mononuclear cells consisting of mononuclear cells and and epithelioidepithelioid cells or cells or multinucleated giant cells or bothmultinucleated giant cells or bothCells lie in groups and are often Cells lie in groups and are often surrounded by lymphoid cellssurrounded by lymphoid cells"Naked" "Naked" granulomasgranulomas have few to have few to none of these surrounding none of these surrounding lymphoid cellslymphoid cellsSarcoidosisSarcoidosis, foreign body, foreign body

GrenzGrenz

ZoneZone

A narrow area of A narrow area of uninvolved dermis uninvolved dermis between the epidermis between the epidermis and a dermal and a dermal inflammatory or inflammatory or neoplasticneoplastic infiltrate. infiltrate. ““GrenzGrenz”” is German for is German for ““borderborder””Some lymphomas, Some lymphomas, granulomagranuloma facialefaciale

NecrobiosisNecrobiosis

Altered collagen that Altered collagen that loses its normal loses its normal eosinophiliceosinophilic coloration coloration and and fibrillarfibrillar appearance, appearance, becoming slightly bluish becoming slightly bluish and "smudgedand "smudged““NecrobiosisNecrobiosis lipoidicalipoidica, , some infectionssome infections

Nuclear DustNuclear Dust

Fragmented nuclei Fragmented nuclei scattered in the dermis, scattered in the dermis, predominantly around predominantly around blood vesselsblood vesselsLeukocytoclasticLeukocytoclasticvasculitisvasculitis, , granulomagranulomafacialefaciale, Sweet, Sweet’’s syndromes syndrome

Epidermal ChangesSpongioticBallooning

Psoriasiform/Lichenoid

Epidermal Changes Interface

No Epidermal ChangesPerivascularIntestitial

Superficial/Deep

Lichenoid/Interface

Psoriasiform

Psoriasiform Lichenoid

Spongiotic

Superficial Superficial PerivascularPerivascular No Epidermal ChangesNo Epidermal Changes

TineaTinea versicolorversicolorDermatophytosisDermatophytosisErythrasmaErythrasmaPitted Pitted keratolysiskeratolysisVitiligoVitiligoSchamberg'sSchamberg's disease disease Viral Viral exanthemsexanthemsDrug eruption (one type)Drug eruption (one type)UrticariaUrticaria, late, lateErythemaErythema figuratumfiguratum, , superficial superficial

Superficial Superficial PerivascularPerivascular/Interstitial /Interstitial No Epidermal ChangesNo Epidermal Changes

Schamberg'sSchamberg's diseasediseasePUPPP PUPPP Dermatitis Dermatitis herpetiformisherpetiformisLinear Linear IgAIgA dermatosisdermatosisDermatitis Dermatitis herpetiformisherpetiformis--like like drug eruptionsdrug eruptionsAcute discoid lupus Acute discoid lupus erythematosuserythematosus/SLE/SLELeukocytoclasticLeukocytoclastic vasculitisvasculitisErythemaErythema marginatummarginatum

Superficial Superficial PerivascularPerivascular/Interstitial /Interstitial No Epidermal ChangesNo Epidermal Changes

BullousBullous pemphigoidpemphigoid/Herpes /Herpes gestationisgestationis, , urticarialurticarialPemphigusPemphigus vulgarisvulgaris, , urticarialurticarialArthropodArthropodPUPPP PUPPP UrticariaUrticariaPostinflammatoryPostinflammatory pigmentarypigmentaryalterationalterationMacular Macular amyloidosisamyloidosisUrticariaUrticaria pigmentosapigmentosaBrachioradialBrachioradial pruritispruritis

Superficial Superficial PerivascularPerivascular PsoriasiformPsoriasiform

PsoriasisPsoriasisAllergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitis dermatitis PityriasisPityriasis rubrarubra pilarispilarisSeborrheicSeborrheic dermatitis dermatitis

Superficial Superficial PerivascularPerivascular PsoriasiformPsoriasiform

DermatophytosisDermatophytosisCandidiasisCandidiasisLichen simplex Lichen simplex chronicuschronicusPrurigoPrurigo nodularisnodularisAcanthomaAcanthoma fissuratumfissuratumPressure papule from Pressure papule from prosthesisprosthesisSurfer's nodulesSurfer's nodulesChondrodermatitisChondrodermatitisnodularisnodularis helicishelicis

Superficial Superficial PerivascularPerivascular SpongioticSpongiotic

PsoriasiformPsoriasiform

Allergic contact Allergic contact dermatitisdermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reactionId reactionSeborrheicSeborrheic dermatitisdermatitisNonbullousNonbullous congenital congenital ichthyosiformichthyosiformerythrodermaerythrodermaLichen Lichen striatusstriatus

Superficial Superficial PerivascularPerivascular LichenoidLichenoid/Interface/Interface

Lichen Lichen planusplanusLichenoidLichenoid drugdrugPityriasisPityriasis lichenoideslichenoideschronicachronicaDLEDLEDermatomyositisDermatomyositisGVHGVHEMEM

Superficial Superficial PerivascularPerivascular Psoriasiform/LichenoidPsoriasiform/Lichenoid

Lichen Lichen striatusstriatusBullousBullous pemphigoidpemphigoidHerpes Herpes gestationisgestationis, , urticarialurticarialMycosis Mycosis fungoidesfungoides

Superficial/DeepSuperficial/Deep No Epidermal ChangesNo Epidermal Changes

Polymorphous light eruption, Polymorphous light eruption, earlyearlyErythemaErythema figuratumfiguratumErythemaErythema chronicumchronicum migransmigransPernioPernioErythemaErythema nodosumnodosumPMLE PMLE DLE, tumid DLE, tumid CLLCLLBB--cell lymphoma cell lymphoma

Superficial/DeepSuperficial/Deep No Epidermal ChangesNo Epidermal Changes

Arthropod insult Arthropod insult ErythemaErythema chronicumchronicum migransmigransScleroderma Scleroderma Leprosy, indeterminateLeprosy, indeterminate

Superficial/Deep Superficial/Deep PerivascularPerivascular

and Interstitialand Interstitial

SuppurativeSuppurative folliculitisfolliculitis, periphery, peripheryNeutrophilicNeutrophilic eccrineeccrine hidradenitishidradenitisFlea biteFlea biteCellulitisCellulitisErythropoieticErythropoietic protoporphyriaprotoporphyriaArthropodArthropodErythemaErythema chronicumchronicum migransmigransWell's syndrome Well's syndrome

Superficial/Deep Superficial/Deep PerivascularPerivascular

and Interstitialand Interstitial

GranulomaGranuloma annulareannulareNecrobiosisNecrobiosis lipoidicalipoidicaInterstitial Interstitial granulomatousgranulomatousdermatitis with arthritis dermatitis with arthritis Mycosis Mycosis fungoidesfungoides, , granulomatousgranulomatous

Superficial/Deep Superficial/Deep Epidermal Epidermal LichenoidLichenoid--InterfaceInterface

PLEVAPLEVAFixed drug eruptionFixed drug eruptionDermatophytosisDermatophytosisLyPLyPGVHGVHDLEDLEAcrodermatitisAcrodermatitis chronicachronicaatrophicansatrophicansMycosis Mycosis fungoidesfungoides, , plaque plaque

Nodular/Diffuse DermatitisNodular/Diffuse Dermatitis

Lymphocytes

Histiocytes(Granulomas)

EosinophilsPlasma cells

Neutrophils


HistiocytesHistiocytes((GranulomasGranulomas))

SarcoidalSarcoidalTuberculoidTuberculoidPalisadedPalisadedSuppurativeSuppurative


HistiocytesHistiocytes((GranulomasGranulomas))

TuberculoidTuberculoidSuppurativeSuppurative


Cell TypeCell Type DiagnosisDiagnosis

NeutrophilsNeutrophils SweetsSweets

EosinophilsEosinophils WellWell’’s, Hypersensitivitys, Hypersensitivity

Plasma cellsPlasma cells LymeLyme

diseasedisease

HistiocytesHistiocytes GranulomatousGranulomatous

diseasesdiseases

MixedMixed GranulomaGranuloma

facialefaciale

IntraepidermalIntraepidermal Vesicular Vesicular and and PustularPustular DermatitisDermatitis

Vesicular Pustular

Ballooning Spongiosis Acantholysis Cleaving Intracorneal Subcorneal

IntraepidermalIntraepidermal

Vesicular Vesicular DermatosisDermatosis

Spongiosis

Intraepidermal vesicle

Intraepidermal bullae


SpongiosisSpongiosis

Allergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reactionId reactionPhotoallergicPhotoallergic dermatitis, earlydermatitis, earlyDermatophytosisDermatophytosisMiliariaMiliaria rubrarubraGianottiGianotti--CrostiCrosti syndrome syndrome PityriasisPityriasis rosearoseaErythemaErythema annulareannulare centrifugumcentrifugumSeborrheicSeborrheic dermatitis dermatitis Lichen Lichen striatusstriatusPityriasisPityriasis alba alba Mycosis Mycosis fungoidesfungoides, , maculemacule/patch /patch


SpongiosisSpongiosis

PUPPPPUPPPAllergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reaction Id reaction BullousBullous pemphigoidpemphigoidHerpes Herpes gestationisgestationisPemphigusPemphigus vulgarisvulgaris, , urticarialurticarialIncontinentiaIncontinentia pigmentipigmentiToxic Toxic erythemaerythema of newborn of newborn Arthropod assault Arthropod assault


BallooningBallooning

HerpesHerpesOrfOrfParapoxParapox infectioninfectionMeaslesMeaslesHydroaHydroa aestivale/Hydroaaestivale/Hydroavacciniformevacciniforme


with with AcantholysisAcantholysis

PemphigusPemphigus vulgarisvulgarisPemphigusPemphigus vegetansvegetansPemphigusPemphiguserythematosuserythematosusPemphigusPemphigus foliaceusfoliaceusFogoFogo selvagemselvagemGroverGrover’’s diseases disease

IntraepidermalIntraepidermal SpongioticSpongiotic

Psoriasiform/LichenoidPsoriasiform/Lichenoid

Allergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reactionId reactionSeborrheicSeborrheic dermatitisdermatitisNonbullousNonbullous congenital congenital ichthyosiformichthyosiform erythrodermaerythrodermaLichen Lichen striatusstriatus

IntraepidermalIntraepidermal SpongioticSpongiotic

Psoriasiform/LichenoidPsoriasiform/Lichenoid

Lichen Lichen striatusstriatusBullousBullous pemphigoidpemphigoidHerpes Herpes gestationisgestationis, , urticarialurticarialMFMF

SubepidermalSubepidermal


Subepidermal

Minimal Mixed Lymphocytes

Neutrophils Neuts/Eos Mast Cells



BullousBullous pemphigoidpemphigoid/Herpes /Herpes gestationisgestationisCicatricialCicatricial pemphigoidpemphigoidDermatitis Dermatitis herpetiformisherpetiformis/Linear /Linear IgAIgA diseasedisease



EBAEBABullousBullous LELEBullousBullous mastocytosismastocytosisBullousBullous amyloidosisamyloidosisDrug reactionsDrug reactionsLPLP

Special CategoriesSpecial Categories

VasculitisVasculitisAlopeciaAlopeciaFolliculitis/PerifolliculitisFolliculitis/PerifolliculitisFibrosingFibrosing dermatitisdermatitisPanniculitisPanniculitis

VasculitisVasculitis

Mixed

Large Vessel

Small Vessel

VasculitisVasculitis

LeukocytoclasticLeukocytoclasticvasculitisvasculitisMicroscopic Microscopic arteritisarteritisPolyarteritisPolyarteritis nodosanodosaErythemaErythema induratuminduratum

Alopecia

Non-Inflammatory Inflammatory

Follicle density normal Follicle density decreased Lymphocytes Mixed

AlopeciaAlopecia NonNon--InflammatoryInflammatory

Follicle density normalFollicle density normalAndrogenic alopecia Androgenic alopecia TelogenTelogen effluviumeffluviumTrichotillomaniaTrichotillomania

Follicle density decreasedFollicle density decreasedTraction alopecia Traction alopecia

AlopeciaAlopecia InflammatoryInflammatory

Alopecia Alopecia areataareataLichen Lichen planopilarisplanopilarisDLEDLESclerodermaSclerodermaFolliculitisFolliculitis decalvansdecalvansTineaTinea capitiscapitisMajocchi'sMajocchi's granulomagranulomaBurns/RadiationBurns/RadiationSyphilis Syphilis ScarScar

LPPLPPSclerodermaSclerodermaDLEDLE

Spongiotic

PerifolliculitisSuppurative

Folliculitis

Granulomatous Fibrosing

Lymphocytes

Perifolliculitis

Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis

Infectious (Infectious (StaphStaph, Strep, , Strep, DermatophytosisDermatophytosisEndothrix/EctothrixEndothrix/Ectothrix))Acne Acne vulgarisvulgarisAcne Acne rosacearosaceaPerforating disordersPerforating disorders

Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis

InfundibulofolliculitisInfundibulofolliculitisAlopecia Alopecia mucinosamucinosaPerifolliculitisPerifolliculitis

ScurvyScurvyLichen Lichen planopilarisplanopilarisDLEDLERosaceaRosaceaKeratosisKeratosis pilarispilaris

FibrosingFibrosing

DermatitisDermatitis

Fibrosing Dermatitis

Fibrocytes Increased Fibrocytes Decreased

SclerosisRadiation

ScarScleroderma/Morphea

Antecedents to Fibrosis

UlcerGranulation tissue

Granulomas

Sclerosis

Fibrosis

Antecedent to Fibrosis

FibrosingFibrosing

DermatitisDermatitis

ScarScarChronic Chronic lymphedemalymphedemaKeloidKeloidDermatofibromaDermatofibromaAnetodermaAnetodermaAcrodermatitisAcrodermatitis chronicachronicaatrophicansatrophicansLSEA/LSEA/MorpheaMorpheaRadiation sclerosisRadiation sclerosis

PanniculitisPanniculitis

LobularWith or without Vasculitis

SeptalWith or without vasculitis

PanniculitisPanniculitis

ErythemaErythema nodosumnodosumErythemaErythema induratuminduratumLupus Lupus panniculitispanniculitisInfectiousInfectiousPancreatic fat necrosisPancreatic fat necrosisLympohmaLympohmaSubQSubQ fat necrosisfat necrosisPoststeroidPoststeroid panniculitispanniculitis

QuestionsQuestions

People talk fundamentals People talk fundamentals and superlatives and then and superlatives and then make some changes of make some changes of detail. detail.

Oliver Wendell Holmes Jr.Oliver Wendell Holmes Jr.

(1841 (1841 --

1935)1935)

dermatopathology- we’ve only just begun

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