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Spongiotic and Psoriasiform
Dermatitis
Melissa Piliang, MD
Cleveland Clinic
Dermatology and Anatomic Pathology
Disclosure
• No conflicts of interest
Spongiosis
Spongiotic Reaction Pattern
• Eczematous tissue reaction
• Intraepidermal intercellular edema = spongiosis
• Widened intercellular spaces between
keratinocytes -> stretches desmosomes
• Desmosome failure = vesicle
Spongiotic Reaction Pattern• Allergic contact derm.
• Irritant contact derm.
• Dyshidrotic derm.
• Nummular derm.
• Atopic dermatitis
• Seborrheic dermatitis
• Mycosis fungoides
• Arthropod assault
• Dermatophytosis
• Gianotti-Crosti Syn.
• Miliaria
• Light reactions
• Pityriasis rosea
• Erythema annular centrifugum (EAC)
• Meyerson’s nevus
Spongiotic Dermatoses• Acute
– More edema - vesicles
– Orthokeratosis
• Subacute– Less prominent spongiosis
– Epidermal hyperplasia
– Parakeratosis (wet-scale crust)
• Chronic– Minimal spongiosis
– Massive epidermal hyperplasia
– Hyperkeratosis and parakeratosis
Spongiotic Dermatitis
• Acute – Spongiosis -> intraepidermal vesicle– Papillary dermal edema
– Perivascular lymphohistiocytic infiltrate – Exocytosis of lymphocytes
– Normal stratum corneum– Absence of epidermal hyperplasia
– Prototype: Allergic contact dermatitis
• Contact with an allergen after sensitization
• Type IV delayed cell-mediated immunologic reaction
• Appears 24 to 72 hours after exposure to allergen
Irritant Contact
Dermatitis• Direct toxic effect of an irritant substance, e.g.
detergents, solvents.
• More common than allergic contact dermatitis
• Occurs at the site of contact with the irritant
• Granuloma gluteale infantum: diaper-related
irritant dermatitis, candida albicans
Irritant contact dermatitis:
- Spongiosis
- Necrotic keratinocytes
- Perivascular infiltrate
- +/- Neutrophils
- Ballooning of keratinocytes
in the upper epidermis
Spongiotic Dermatitis
• Subacute:
– Less spongiosis
– Parakeratosis
– Epidermal hyperplasia
– Prototype: Atopic dermatitis
Subacute Spongiotic Dermatitis
• Atopic Dermatitis:
– Parakeratosis
– Epidermal
hyperplasia
– Mild spongiosis
– Focal lymphocytic
exocytosis
Spongiotic Dermatoses
• Chronic: – Minimal spongiosis
– Orthokeratosis with areas of parakeratosis
– Hypergranulosis
– Moderate to marked epidermal hyperplasia
– Perivascular lymphohistiocytic infiltrate
– Papillary dermal fibrosis (may be prominent)
– Prototype: Lichen simplex chronicus
Lichen Simplex
Chronicus/Prurigo Nodule
• Chronic rubbing or scratching
• Pruritic thick plaques
• Accentuation of skin markings
• Papules, nodules and excoriation
Lichen Simplex Chronicus
• Hyperkeratosis
• Vertical streaking of
collagen bundles
• Irregular psoriasiform
epidermal hyperplasia
• Follicular hyperplasia
• Mild spongiosis
Prurigo Nodularis
• Irregular hyperplasia
• Follicular hyperplasia
• Inward bending rete
• Scale crust
• ‘Hairy palm sign’
Spongiosis with Intraepidermal
Eosinophils• DDx:
– Incontinentia pigmenti, vesicular stage
– Bullous pemphigoid, urticarial phase
– Herpes gestationis
– Pemphigus vulgaris, urticarial phase
– Arthropod assault
– Drug eruption (necrotic keratinocytes, interface dermatitis)
– Erythema toxicum neonatorum
Eosinophilic Spongiosis
• Spongiosis
• Eosinophils
• DIF: Linear IgG and C3
• Bullous Pemphigoid
Eosinophilic Spongiosis
• Incontinentia Pigmenti
• Dyskeratosis
Psoriasiform Reaction Pattern
• Epidermal hyperplasia• Elongation of rete ridges• Examples:
– Psoriasis– Pityriasis rubra pilaris (PRP)– Lichen simplex chronicus– Subacute and chronic spongiotic dermatitides– Dermatophytoses– Pityriasis rosea (‘herald patch’)– Acrodermatitis enteropathica– Syphilis– Inflammatory linear verrucous epidermal nevus
Psoriasis VulgarisClinical Features
• 2% of the population, all racial groups
• Hyperproliferation of the epidermal
keratinocytes
• Overexpression of keratins 6 and 16
Psoriasis Vulgaris• Psoriasiform
epidermal hyperplasia
• Regular elongation of
rete
• Club-shaped
thickening of rete
• Parakeratosis
• Hypogranulosis
Psoriasis Vulgaris• Neutrophilic
exocytosis -> abscess– Munro microabscess -
in the parakeratotic layers
– Spongiform pustule of Kogoj - within the spinous layer
• Perivascular and interstitial lymphocytic infiltrate
Guttate psoriasis: -Focal parakeratosis
-Neutrophils
-Less epidermal hyperplasia,
less regular
-Spongiosis
Differential dx = pityriasis rosea.
Pustular psoriasis: subcorneal pustules
Medications: Iodides, Salicylates,
Progesterone
Follow w/drawal of systemic steroids
Pustular psoriasis:
-Psoriasiform epidermal hyperplasia
-Parakeratosis
-Larger subcorneal pustules
Clues that it may NOT be
psoriasis…..• Eosinophils
– Allergic contact
– Atopic dermatitis
– Medication
• Spongiosis– Dermatophyte infection
– Atopic dermatitis
• Neutrophils in stratum corneum– Syphilis
– Dermatophyte infections
• Impetiginization
– Atopic dermatitis
• Hypergranulosis
– Lichen simplex chronicus
– Pityriasis rubra pilaris
• Solitary lesion
– Clear cell acanthoma
HIV-associated Psoriasiform
Dermatitis
Plasma Cells
HIV-associated Psoriasiform
Dermatitis• Varied clinical presentation
– Seborrheic dermatitis
– Classic psoriasis
• May have predominantly acral involvement
with pustules and severe nail dystrophy
HIV PD vs Psoriasis Vulgaris
• Classic psoriasis
features:
– Psoriasiform epidermal
hyperplasia
– Confluent
parakeratosis
– Subcorneal pustules
• Clues:
– Suprapapillary plates
are not thinned
– Plasma cells present
– Neutrophil or
lymphocyte
karyorrhexis
– Apoptotic
keratinocytes
Seborrheic Dermatitis
• Irregular psoriasiform hyperplasia
• Scale crusts
• Shoulder parakeratosis at hair follicle
• Neutrophils in stratum corneum/epidermis
near follicular ostia
• Parakeratosis overlying a subcorneal neutrophilic pustule
• Psoriasiform hyperplasia
• “indistinguishable from pustular psoriasis” - McKee
Reiter’s SyndromeHistopathologic features
• Features more suggestive of Reiter’s:– A thicker stratum corneum
– Larger spongiform pustules
– Eczematous changes
– A thicker suprapapillary plate
– Neutrophils in the dermis
– The absence of clubbing of the rete ridges
Pityriasis Rubra Pilaris Clinical Features
• Small follicular papules and central keratin plug
• Perifollicular erythema →→ confluent
• “Islands of sparing”
• Waxy orange PPK
Pityriasis Rubra Pilaris (PRP)
Histopathologic Features
• Parakeratosis -> Checkerboard pattern•• Irregular epidermal hyperplasia with broad
• Prominent follicular plugging
• Perifollicular parakeratosis
• Thick suprapapillary plates
• Focal or confluent hypergranulosis
Pityriasis Rubra Pilaris• Checkerboard parakeratosis
– Accentuated at follicle
• Follicular plug
• Focal or confluent hypergranulosis
• Sparse superficial perivascular lymphocytes
Pityriasis rosea
Mounds of parakeratosis
Mild epidermal
hyperplasia
Mild spongiosis
Extravasated RBC’s
Perivascular infiltrate
ILVEN
• Psoriasiform epidermal
hyperplasia
• Alternating hyperkeratosis and
parakeratosis
• Neutrophils in stratum corneum
• Mild spongiosis
Parakeratosis, epidermal hyperplasia, mild spongiosis,
lymphocytic exocytosis, and superficial lymphocytic infiltrate
ILVEN:
Dermatophyte Infections
• Annular scaly plaques
• Psoriasiform epidermal hyperplasia and neutrophils think fungus
• ALWAYS remember to search stratum corneum for fungal elements!!!– GMS, PAS
Parakeratosis – site of fungus, may have neutrophils in the stratum corneum
Irregular psoriasiform hyperplasia
Variable spongiosis
Superficial perivascular lymphocytic infiltrate – often with eosinophils
Tinea:
Clear Cell Acanthoma
• Solitary papule
• Lower legs
• Phosphorylase mutation
Clear Cell Acanthoma • Glycogen rich keratinocytes
• Abrupt transition
• Psoriasiform hyperplasia
• Parakeratosis
• Neutrophils in stratum corneum
Granular Parakeratosis
• Acquired abnormality of keratinization
• Scaly red to hyperpigmented pruritic plaques
• Due to failure to degrade keratohyaline granules
• Clears spontaneously
Granular Parakeratosis• Compact hyperkeratosis with parakeratosis
• Granules within the stratum corneum
• Preserved granular layer
Clinical
Syphilis
• ‘Neuts in horn’ – neutrophils in the stratum
corneum
• Plasma cells
• Ice pick elongation of rete pegs
• Lichenoid infiltrate with plasma cells
• Order special stains liberally
Erythrokeratoderma Variabilis
Erythrokeratoderma Variabilis
• 2 distinct morphologic features:– Hyperkeratotic fixed plaques
– Transient erythema
• AD (rare AR and sporadic)
• 2/3 mutations encoding transmembrane proteins form gap junctions
• GJB3- connexin 31
• GJB4- connexin 30.3
CDS l May 14, 2009
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