Difference between revisions of "Inflammatory skin disorders"

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'''Inflammatory skin disorders''', also '''inflammatory skin diseases''', are a significant part of [[dermatopathology]].  They lead to trepidation among pathologists that don't see lots of skin.
'''Inflammatory skin disorders''', also '''inflammatory skin diseases''', are a significant part of [[dermatopathology]].  They lead to trepidation among pathologists that don't see lots of skin.


=Classification=
*Bullous.
*Interface.
*Nodular & diffuse.
*Spongiotic.
*Vasculitis.
*Perivascular.
*Panniculitis.
*Psoriasiform.
'''Tabular comparison of inflammatory skin disease (adapted from ''Brinster''<ref name=pmid18418089>{{cite journal |author=Brinster NK |title=Dermatopathology for the surgical pathologist: a pattern based approach to the diagnosis of inflammatory skin disorders (part I) |journal=Adv Anat Pathol |volume=15 |issue=2 |pages=76–96 |year=2008 |month=March |pmid=18418089 |doi=10.1097/PAP.0b013e3181664e8d |url=}}</ref>):'''
{| class="wikitable"
| '''Pattern'''
| '''Key histologic feature'''
| '''Subclassifications'''
| '''Example'''
|-
| [[Bullous disease|Bullous]]
| "Empty space"
| -Subcorneal<br>-Suprabasillar<br>-Subepidermal
| -Pemphigus foliaceus<br>-[[Pemphigus vulgaris]]<br>-[[Dermatitis herpetiformis]]
|-
| Interface
| Inflammation at DE junction
| -Vacuolar (minimal)<br>-Lichenoid (band-like)
| -[[Erythema multiforme]], [[SLE]]<br>-[[Lichen planus]]
|-
| Nodular & diffuse
| Nodular & diffuse
| ?
|
|-
| Spongiotic
| Edema between keratinocytes
| -Acute<br>-Subacute<br>-Chronic
| -Poison Ivy<br>-Nummular dermatitis<br>-Atopic dermatitis
|-
| [[Vasculitis]]
| Inflammation of vessel wall
| ?
| ?
|-
| Perivascular
| Inflammation around vessels
| ?
| ?
|-
| [[Panniculitis]]
| Inflamm. of adipose tissue
| -Septal<br>-Nodular
| -[[Erythema nodosum]]<br>-[[Erythema induratum]]
|-
| Psoriasiform
| Epidermal thickening<br>and long rete ridges
| -Regular<br>-Irregular
| -Psoriasis<br>-[[Lichen simplex chronicus]]
|}
Notes:
*''DE junction'' = dermal-epidermal junction.
*The "empty space" in bullous disease ''in situ'' is filled with fluid.
=Non-specific patterns=
==Psoriasiform pattern==
===General===
*Can be subclassified.
DDx:
*Psoriasis vulgaris (most common).
*Psoriatic arthritis.
*Drug-induced.
*Others.
===Microscopic===
Features:<ref>{{Ref PBoD8|1191}}</ref><ref name=pmid18418089>{{cite journal |author=Brinster NK |title=Dermatopathology for the surgical pathologist: a pattern based approach to the diagnosis of inflammatory skin disorders (part I) |journal=Adv Anat Pathol |volume=15 |issue=2 |pages=76–96 |year=2008 |month=March |pmid=18418089 |doi=10.1097/PAP.0b013e3181664e8d |url=}}</ref>
*Regular epidermal thickening - as very long rete ridges (described as "test tube-morphology") - '''key feature'''.
**Epidermis between rete ridges thin ("thinning of suprapapillary plate").
*Parakeratosis.
*Thin/absent granular layer.
*Dilated blood vessels in superficial dermis.
*Neutrophil clusters (Munro microabscess).
=Specific diseases=
==Seborrheic dermatitis==
===General===
*Very common.
===Microscopic===
Features:<ref>{{Ref PBoD8|1191}}</ref>
*Spongiosis (epidermal edema).
*Acanthosis (epidermal thickening).
*"Follicular lipping" = parakeratosis with neutrophils.
*Perivascular neutrophils and lymphocytes.
==Systemic lupus erythematosus==
===General===
*Systemic disease with multi-organ manifestations.
===Microscopic===
Features:
*Lymphocytic interface dermatitis.<ref>JAH. 20 February 2009.</ref>
*Basal layer vacuolation.<ref name=pmid18384217>{{cite journal |author=Crowson AN, Magro CM, Mihm MC |title=Interface dermatitis |journal=Arch. Pathol. Lab. Med. |volume=132 |issue=4 |pages=652–66 |year=2008 |month=April |pmid=18384217 |doi= |url=http://www.archivesofpathology.org/doi/full/10.1043/1543-2165%282008%29132%5B652%3AID%5D2.0.CO%3B2}}</ref>
*Intradermal mucin.
==Dermatomyositis==
:''For the muscle manifestations see: [[Neuromuscular_pathology#Dermatomyositis]]''.
===General===
*Complement mediated disease - membrane attack complex.
*Usually middle age.
*Associated skin rash is common.
**May precede or follow muscle pathology.
*Associated with malignancy in approximately 10% of cases.<ref name=pmid20398365>{{cite journal |author=Chen YJ, Wu CY, Huang YL, Wang CB, Shen JL, Chang YT |title=Cancer risks of dermatomyositis and polymyositis: a nationwide cohort study in Taiwan |journal=Arthritis Res. Ther. |volume=12 |issue=2 |pages=R70 |year=2010 |pmid=20398365 |pmc=2888225 |doi=10.1186/ar2987 |url=}}</ref>
===Gross===
*Have lesions on the knuckles - ''Gottron's papules''.
===Microsopic===
Features:
*Lymphocytic interface dermatitis (inflammation at the dermal-epidermal junction).
*Loss of rete ridges.
==Lichen planus==
===General===
*An oral pathology.
*May be seen where the sun don't shine - [[penis]],<ref name=pmid20082512>{{Cite journal  | last1 = Teichman | first1 = JM. | last2 = Sea | first2 = J. | last3 = Thompson | first3 = IM. | last4 = Elston | first4 = DM. | title = Noninfectious penile lesions. | journal = Am Fam Physician | volume = 81 | issue = 2 | pages = 167-74 | month = Jan | year = 2010 | doi =  | PMID = 20082512 }}</ref> [[vulva]] and [[vagina]].<ref name=pmid20062629>{{Cite journal  | last1 = Gupta | first1 = R. | last2 = Bansal | first2 = B. | last3 = Singh | first3 = S. | last4 = Yadav | first4 = I. | last5 = Gupta | first5 = K. | last6 = Kudesia | first6 = M. | title = Lichen planus of uterine cervix - the first report of a novel site of occurrence: a case report. | journal = Cases J | volume = 2 | issue =  | pages = 9306 | month =  | year = 2009 | doi = 10.1186/1757-1626-2-9306 | PMID = 20062629 }}</ref>
Etiology:
*Autoimmune disease, T-cell–mediated.<ref>URL: [http://emedicine.medscape.com/article/1078327-overview http://emedicine.medscape.com/article/1078327-overview]. Accessed on: 11 September 2010.</ref>
Clinical:<ref name=Ref_PBoD8_1191>{{Ref PBoD8|1191}}</ref>
*6 Ps: pruritic (itchy), purple, polygonal, planar papules and plaques.
===Gross===
*Wickham striae = white lines/dots.
**Due to hypergranulosis.
===Microscopic===
Features:<ref>URL: [http://emedicine.medscape.com/article/1078327-overview http://emedicine.medscape.com/article/1078327-overview]. Accessed on: 11 September 2010.</ref><ref name=Ref_PBoD8_1192>{{Ref PBoD8|1192}}</ref>
*Loss of basal cells (stratum basale) -- '''key feature'''.
*Loss of rete ridges/formation of pointed rete ridges "sawtoothing".
*Interface dermatitis (lymphocytes at dermal-epidermal junction).
*Hypergranulosis; stratum granulosum thickened (grossly seen as "Wickham stria" = white lines).
*Hyperkeratosis; stratum corneum thickened.
*Necrotic basal cell in dermis = colloid bodies = Civatte bodies.<ref name=Ref_PCPBoD8_604>{{Ref PCPBoD8|604}}</ref>
DDx:
*[[Bullous disease]], subepithelial vesicular.
*[[Lichenoid keratosis]] - parakeratosis prominent.
Notes:
*Hyperkeratosis and hypergranulosis are not seen in [[erythema multiforme]].
*Colloid bodies = cytoid bodies = Civatte bodies = hyaline bodies = apoptotic bodies.<ref>URL: [http://www.careforumwales.org/cell-carcinoma/histopathologic-terminology.html http://www.careforumwales.org/cell-carcinoma/histopathologic-terminology.html]. Accessed on: 28 August 2011.</ref>
**DDx: systemic lupus erythematosus, lichen planus, and [[graft-versus-host disease]].
Images:
*[http://commons.wikimedia.org/wiki/File:Lichen_planus_intermed_mag.jpg Lichen planus - intermed. mag. (WC)]
*[http://commons.wikimedia.org/wiki/File:Lichen_planus_low_mag.jpg Lichen planus - low mag. (WC)].
==Lichen sclerosus==
{{Main|Lichen sclerosus}}
===Microscopic===
Features:<ref name=Ref_PBoD1065-6>{{Ref PBoD|1065-6}}</ref>
*Subepithelial fibrosis - '''key feature'''.
==Psoriasis==
===General===
*Chronic skin condition +/- systemic involvement:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
**[[Arthritis]].
**[[Myopathy]].
**Enteropathy, e.g. [[inflammatory bowel disease]].
**Syondylitic joint disease (spondylos = vertebrae<ref>URL: [http://medical-dictionary.thefreedictionary.com/spondylosis http://medical-dictionary.thefreedictionary.com/spondylosis]. Accessed on: 28 August 2011.</ref>).
Clinical:
*''Auspitz sign'' = pin-point bleeding on removal of scale.
*''Koebner phenomenon'' = lesions form at site of trauma.
===Microscopic===
Features:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
*Acanthosis + long rete ridges - '''key feature'''.
*Parakeratosis.
*Dilated vessels in superficial dermis (give rise to ''Auspitz sign'').
*Spongiform pustules = PMNs in stratum spinosum.
*PMNs in parakeratotic stratum corneum (Munro microabscess).
=DDx for groups=
==Spongiotic dermatitides==
==Spongiotic dermatitides==
DDx:<ref name=pmid18418089>{{cite journal |author=Brinster NK |title=Dermatopathology for the surgical pathologist: a pattern based approach to the diagnosis of inflammatory skin disorders (part I) |journal=Adv Anat Pathol |volume=15 |issue=2 |pages=76–96 |year=2008 |month=March |pmid=18418089 |doi=10.1097/PAP.0b013e3181664e8d |url=}}</ref>
DDx:<ref name=pmid18418089>{{cite journal |author=Brinster NK |title=Dermatopathology for the surgical pathologist: a pattern based approach to the diagnosis of inflammatory skin disorders (part I) |journal=Adv Anat Pathol |volume=15 |issue=2 |pages=76–96 |year=2008 |month=March |pmid=18418089 |doi=10.1097/PAP.0b013e3181664e8d |url=}}</ref>

Revision as of 18:00, 19 September 2011

Inflammatory skin disorders, also inflammatory skin diseases, are a significant part of dermatopathology. They lead to trepidation among pathologists that don't see lots of skin.

Classification

  • Bullous.
  • Interface.
  • Nodular & diffuse.
  • Spongiotic.
  • Vasculitis.
  • Perivascular.
  • Panniculitis.
  • Psoriasiform.

Tabular comparison of inflammatory skin disease (adapted from Brinster[1]):

Pattern Key histologic feature Subclassifications Example
Bullous "Empty space" -Subcorneal
-Suprabasillar
-Subepidermal 		-Pemphigus foliaceus
-Pemphigus vulgaris
-Dermatitis herpetiformis
Interface Inflammation at DE junction -Vacuolar (minimal)
-Lichenoid (band-like) 		-Erythema multiforme, SLE
-Lichen planus
Nodular & diffuse Nodular & diffuse ?
Spongiotic Edema between keratinocytes -Acute
-Subacute
-Chronic 		-Poison Ivy
-Nummular dermatitis
-Atopic dermatitis
Vasculitis Inflammation of vessel wall ? ?
Perivascular Inflammation around vessels ? ?
Panniculitis Inflamm. of adipose tissue -Septal
-Nodular 		-Erythema nodosum
-Erythema induratum
Psoriasiform Epidermal thickening
and long rete ridges 		-Regular
-Irregular 		-Psoriasis
-Lichen simplex chronicus

Notes:

  • DE junction = dermal-epidermal junction.
  • The "empty space" in bullous disease in situ is filled with fluid.

Non-specific patterns

Psoriasiform pattern

General

  • Can be subclassified.

DDx:

  • Psoriasis vulgaris (most common).
  • Psoriatic arthritis.
  • Drug-induced.
  • Others.

Microscopic

Features:[2][1]

  • Regular epidermal thickening - as very long rete ridges (described as "test tube-morphology") - key feature.
    • Epidermis between rete ridges thin ("thinning of suprapapillary plate").
  • Parakeratosis.
  • Thin/absent granular layer.
  • Dilated blood vessels in superficial dermis.
  • Neutrophil clusters (Munro microabscess).

Specific diseases

Seborrheic dermatitis

General

  • Very common.

Microscopic

Features:[3]

  • Spongiosis (epidermal edema).
  • Acanthosis (epidermal thickening).
  • "Follicular lipping" = parakeratosis with neutrophils.
  • Perivascular neutrophils and lymphocytes.

Systemic lupus erythematosus

General

  • Systemic disease with multi-organ manifestations.

Microscopic

Features:

  • Lymphocytic interface dermatitis.[4]
  • Basal layer vacuolation.[5]
  • Intradermal mucin.

Dermatomyositis

For the muscle manifestations see: Neuromuscular_pathology#Dermatomyositis.

General

  • Complement mediated disease - membrane attack complex.
  • Usually middle age.
  • Associated skin rash is common.
    • May precede or follow muscle pathology.
  • Associated with malignancy in approximately 10% of cases.[6]

Gross

  • Have lesions on the knuckles - Gottron's papules.

Microsopic

Features:

  • Lymphocytic interface dermatitis (inflammation at the dermal-epidermal junction).
  • Loss of rete ridges.

Lichen planus

General

Etiology:

  • Autoimmune disease, T-cell–mediated.[9]

Clinical:[10]

  • 6 Ps: pruritic (itchy), purple, polygonal, planar papules and plaques.

Gross

  • Wickham striae = white lines/dots.
    • Due to hypergranulosis.

Microscopic

Features:[11][12]

  • Loss of basal cells (stratum basale) -- key feature.
  • Loss of rete ridges/formation of pointed rete ridges "sawtoothing".
  • Interface dermatitis (lymphocytes at dermal-epidermal junction).
  • Hypergranulosis; stratum granulosum thickened (grossly seen as "Wickham stria" = white lines).
  • Hyperkeratosis; stratum corneum thickened.
  • Necrotic basal cell in dermis = colloid bodies = Civatte bodies.[13]

DDx:

Notes:

  • Hyperkeratosis and hypergranulosis are not seen in erythema multiforme.
  • Colloid bodies = cytoid bodies = Civatte bodies = hyaline bodies = apoptotic bodies.[14]

Images:

Lichen sclerosus

Main article: Lichen sclerosus

Microscopic

Features:[15]

  • Subepithelial fibrosis - key feature.

Psoriasis

General

Clinical:

  • Auspitz sign = pin-point bleeding on removal of scale.
  • Koebner phenomenon = lesions form at site of trauma.

Microscopic

Features:[16]

  • Acanthosis + long rete ridges - key feature.
  • Parakeratosis.
  • Dilated vessels in superficial dermis (give rise to Auspitz sign).
  • Spongiform pustules = PMNs in stratum spinosum.
  • PMNs in parakeratotic stratum corneum (Munro microabscess).

DDx for groups

Spongiotic dermatitides

DDx:[1]

  • Atopic dermatitis.
  • Contact dermatitis.
  • Stasis dermatitis.
  • Seborrheic dermatitis.
  • Nummular dermatitis.
  • Spongiotic drug eruption.

Psoriasiform dermatitides

Regular psoriasiform dermatitis

DDx:[1]

  • Psoriasis vulgaris.
  • Dermatophyte infection.
  • Pityriasis rubra pilaris.

Irregular psoriasiform dermatitis

Interface dermatitides

Vacuolar interface dermatitides

DDx:[1]

Others:[1]

Lichenoid interface dermatitides

DDx:[1]

Bullous disease

Subcorneal bullous disorders

DDx with acantholysis:[1]

DDx without acantholysis:DDx:[1]

Suprabasilar bullous disorders

DDx:[1]

Subepidermal bullous disorders

DDx:[1]

Others:

Perivascular inflammation

Lymphocytes

Lymphocytes (tightly cuffed):[1]

  • Infections.
  • Medications.
  • Malignancy.
  • Vitiligo (with absent melanocytes).
  • Scleroderma/morphea.

Lymphocytes & plasma cells +/-eosinophils:

  • Erythema chronicum migrans (Lyme disease).

Lymphocytes (not tightly cuffed):

  • Viral exanthems.
  • Drug eruptions.

Lymphocytes & eosinophils:

  • Drug reaction.
  • Insect bite.
  • Dermatophyte infection.

Neutrophils

DDx:[1]

  • Cellulitis.
  • Neutrophilic eccrine hidradenitis (idiopathic palmar-plantar hidradenitis)

With eosinophils:

  • Urticaria.

Eosinophils

DDx:[1]

  • Hypersensitivity reaction/drug reaction.
  • Insect bite.
  • Bullous pemphigoid, urticarial.

Mast cells

Vasculitis

Main article: Vasculitides


See also

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Brinster NK (March 2008). "Dermatopathology for the surgical pathologist: a pattern based approach to the diagnosis of inflammatory skin disorders (part I)". Adv Anat Pathol 15 (2): 76–96. doi:10.1097/PAP.0b013e3181664e8d. PMID 18418089.
  2. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1191. ISBN 978-1416031215.
  3. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1191. ISBN 978-1416031215.
  4. ↑ JAH. 20 February 2009.
  5. ↑ Crowson AN, Magro CM, Mihm MC (April 2008). "Interface dermatitis". Arch. Pathol. Lab. Med. 132 (4): 652–66. PMID 18384217. http://www.archivesofpathology.org/doi/full/10.1043/1543-2165%282008%29132%5B652%3AID%5D2.0.CO%3B2.
  6. ↑ Chen YJ, Wu CY, Huang YL, Wang CB, Shen JL, Chang YT (2010). "Cancer risks of dermatomyositis and polymyositis: a nationwide cohort study in Taiwan". Arthritis Res. Ther. 12 (2): R70. doi:10.1186/ar2987. PMC 2888225. PMID 20398365. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888225/.
  7. ↑ Teichman, JM.; Sea, J.; Thompson, IM.; Elston, DM. (Jan 2010). "Noninfectious penile lesions.". Am Fam Physician 81 (2): 167-74. PMID 20082512.
  8. ↑ Gupta, R.; Bansal, B.; Singh, S.; Yadav, I.; Gupta, K.; Kudesia, M. (2009). "Lichen planus of uterine cervix - the first report of a novel site of occurrence: a case report.". Cases J 2: 9306. doi:10.1186/1757-1626-2-9306. PMID 20062629.
  9. ↑ URL: http://emedicine.medscape.com/article/1078327-overview. Accessed on: 11 September 2010.
  10. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1191. ISBN 978-1416031215.
  11. ↑ URL: http://emedicine.medscape.com/article/1078327-overview. Accessed on: 11 September 2010.
  12. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1192. ISBN 978-1416031215.
  13. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 604. ISBN 978-1416054542.
  14. ↑ URL: http://www.careforumwales.org/cell-carcinoma/histopathologic-terminology.html. Accessed on: 28 August 2011.
  15. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1065-6. ISBN 0-7216-0187-1.
  16. ↑ 16.0 16.1 Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 603. ISBN 978-1416054542.
  17. ↑ URL: http://medical-dictionary.thefreedictionary.com/spondylosis. Accessed on: 28 August 2011.
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