Non-malignant skin disease

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Non-malignant skin disease is relatively common. The pathology may or may not be specific. Some diseases require clinical information to diagnose.

An introduction to dermatopathology is in the dermatopathology article. Nevi (moles) and other melanocytic lesions are dealt with in the article melanocytic lesions.


Inflammatory conditions

Classification

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

Tabular comparison of inflammatory skin disease (adapted from Brister[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
-Lichen simplex chronicus (LSC)
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 SC tissue -Septal
-Nodular		 -?
-Erythema nodosum
Psoriasiform Epidermal thickening
and long rete ridges		 -Regular
-Irregular		 -Psoriasis
-?

Notes:

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

Psoriasis

General

  • Can be subclassified.

DDx:

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

Microscopic

Features:[2]

  • Epidermal thickened - as very long rete ridges (described as "test tube-morphology") - key feature.
    • Epidermis between rete ridges thin.

Seborrheic dermatitis

General

  • Very common.

Microscopic

Features:[3]

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

Lichen planus

General

  • An oral pathology.
  • May be seen where the sun don't shine - penis,[4] vulva and vagina.[5]

Etiology:

  • Autoimmune disease, T-cell–mediated.[6]

Clinical:[7]

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

Gross

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

Microscopic

Features:[8][9]

  • 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.[10]

DDx:

Notes:

  • Hyperkeratosis and hypergranulosis are not seen in erythema multiforme.
  • Colloid bodies = cytoid bodies = Civatte bodies = hyaline bodies = apoptotic bodies.[11]

Images:

Lichen sclerosus

Main article: Lichen sclerosus

Microscopic

Features:[12]

  • 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:[13]

  • 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).

Other

Squamous cell hyperplasia

General

  • Variant of spongiotic dermatitis.[16]

Etiology:[17]

  • Pruritus (itchness) -> mechanical trauma -> lichenification (thickened/leathery[18].

Microscopic

Features:[12]

  • Acanthosis (epithelial thickening).
  • Hyperkeratosis.

Other features:[19]

  • Spongiosis (epidermal intercellular edema -- cells appear to have a clear halo around 'em).
  • Parakeratosis = retention of nuclei in the stratum corneum.

Images:

Very common

Fibroepithelial polyp

  • AKA acrochordon, skin tag.

General

  • Benign.
  • Older people.
  • May be associated with pregnancy, diabetes, intestinal polyposis.[20]

Gross

  • Raised skin-coloured lesion.

Image:

Microscopic

Features:

  • On a stalk.
  • Benign epidermis.

Seborrheic keratosis

  • Abbreviated SK.

General

  • Benign.
  • Most common tumour in older people.[21]
  • "Large number" of SKs = paraneoplastic syndrome (Leser–Trélat sign).[22]

Epidemiology:

  • Old people.
  • Usu. in sun exposed area.[23]

Gross

  • "Stuck-on" appearance - raised lesion.

Image(s):

Microscopic

Features:[22]

  • Raised above skin surface.
  • Border sharply demarcated.
  • Hyperkeratosis - stratum corneum extra thick.
  • Horn cysts - intraepidermal collections of keratin.
  • Clusters of cells with brown granular material in the superficial dermis/dermoepidermal junction - pigmented melanocytes.

Images:

Verruca vulgaris

General

  • AKA common wart.
  • Etiology - HPV.

Notes:

Microscopic

Features:[24]

  • Hyperkeratosis (more keratin - thick stratum corneum).
  • Hypergranulosis (thicker stratum granulosum).
  • Acanthosis (thickening of the stratum spinosum).
  • Rete ridges lengthened (~7-10x normal).
  • Large blood vessels at the dermal-epidermal junction.

Memory device: there is more of everything - more s. corneum, s. granulosum, s. spinosum, longer rete ridges, more (larger) blood vessels.

Images:

Pilomatricoma

  • AKA pilomatrixoma.

General

  • Benign skin tumour.
  • Most common solid skin tumour of children.[25]

Clinical:

  • Hard nodule - calcification.
  • +/-Painful. (???)

Treatment:

  • Surgical excision.[25]

Microscopic

Features:[26]

  • Location: lower dermis/subcutaneous fat; thus, usu. surrounded by connective tissue.
  • Sharpy demarcated island of cells.
  • Calcification in 75% - with calcium staining (von Kossa).
  • Cells:[27]
    • Basaloid epithelial cells - have prominent nucleoli.
    • Anucleate squamous cells ("ghost cells").
  • Giant cell foreign body type granulomas (form in reaction to keratin).

Notes:

  • Keratin a prominent feature on cytology - lots of orange stuff.

Images:

DDx:

Dermatofibroma

  • Abbreviated DF.

General

  • AKA fibrous histiocytoma.
  • Reactive process -- it is not a neoplasm.
  • Usually associated with previous trauma.
    • In women... usually legs.

Microscopic

Features:[28]

  • Prominent fibrous bundles, especially at the edge of the lesion.
    • Surrounded by spindle cells (fibroblasts).
      • Usually thought of as fibroblasts surrounded by fibrous material ("collagen-trapping").
  • Lack of adnexal structures, i.e. no sweat glands, no hair.
  • +/-Epidermal changes - known as "dirty fingers":[29]
    • Acanthosis (thickened epithelial layer - specifically thickened stratum spinosum).
    • Basal keratinocyte hyperpigmentation.

Images:

DDx:

Subtypes

Like all common things... there are subtypes:[30]

  • Cellular.
  • Deep penetrating.
  • Lipidized - with foamy macrophages, hemorrhage and Touton-like giant cells.
  • Epithelioid cell histiocytoma.
  • Fibrotic.
  • Aneurysmal - large blood filled + features of lipidized.
  • Granular cell dermatofibroma.
  • Dermatofibroma with monster cells.

IHC

Features:[31][32]

  • Factor XIIIa +ve.
    • Usually negative in DFSP.
  • CD34 -ve.
    • Usually positive in DFSP.
  • D2-40 +ve.[33]
    • Usually negative in DFSP.

Ezcema

General

  • A nebulous thingy.
  • Very common.

DDx:

  • Contact allergy.
  • Drug reaction.
  • Food allergy.

Microscopic

Features:[34]

  • Spongiosis (epidermal edema); keratinocytes spacing increased - key feature.
  • +/-Interdermal vesicles.
  • +/-Eosinophils (may suggest Rx reaction).
  • Perivascular lymphocytes.

Less common

Molluscum contagiosum

  • Etiology: caused by molluscum contagiosum virus.

Microscopic

Features:

  • A suprabasilar epidermal lesion consisting of "molluscum bodies", i.e. molluscum bodies are found above the stratum basale.[35]
  • Molluscum bodies - key feature:
    • Large cells with abundant granular eosinophilic cytoplasm.
    • Small peripheral nucleus.

Image(s):

Note:

  • Molluscum bodies vaguely resemble signet ring cells -- but:
    • Cytoplasm eosinophilic and granular.
    • Nucleus usually smaller than in signet ring cell.
    • Molluscum bodies are only the epidermis - an uncommon place to find SRCs without finding them elsewhere.
  • The granular eosinophilic cytoplasm represents accumulated virons.

Syringoma

General

  • Benign sweat duct tumour.
  • Eccrine differentiation.
  • Usually close to lower eyelid.[36]

Microscopic

Features:[37]

  • Proliferation of benign ducts with lined by a bilayer (as in normal sweat ducts) with abnormal architecture:
    • Tadpole like appearing ducts.

Image:

Inverted follicular keratosis

Images:

Dermal cylindroma

General

Microscopic

Features:

  • Nests of cells that are surrounded by hyaline (i.e. glassy, eosinophilic, acellular) material.

Images:

Keratoacanthoma

  • Abbreviated KA.
  • Generally considered to be benign.
    • Rare reports of metastases suggesting it may be a form of squamous cell carcinoma.[39]

Clinical

  • May grow rapidly (weeks or months) then involute.
  • Main DDx is squamous cell carcinoma.
  • Exophytic lesion, well-circumscribed.

Microscopic

Features:[40]

  • Expansion of stratum spinosum - pushing tongue-like downward growth of epidermis into the dermis.
  • Keratin collection (keratin plug) at the center of lesion-superficial aspect.
  • Cells have glassy pink cytoplasm.
  • Minimal/no nuclear atypia.

Image:

Superficial dermal infiltrates

Discussed in detail by Alsaad and Ghazarian.[41]

Dermal perivascular lymphoeosinophilic infiltration (DPLI)

  • Microscopic appearance is just what it is called:
    • Lymphocytes and eosinophils around the vessels in the superficial dermis.

DDx:[41]

  • Insect bite - classically wedge-shaped.[42]
  • Drug reactions.
  • Urticarial reactions.
  • Prevesicular early stage of bullous pemphigoid.
  • HIV related dermatoses.

Notes:

  • May superficially resemble cutaneous lymphoma.[42]

Images:

Congenital dermal melanocytosis

  • AKA Mongolian spots.
  • Classically seen in asian children.

Gross:

  • Brown or blue-grey patch in the lumbosacral area.

Mastocytosis

General

  • Abundance of mast cells.
  • Predominantly in children - if skin only.

Microscopic

Features:[43]

  • Cells in the superficial/mid dermis that are:
    • Lymphocyte-like with more cytoplasm that is granular.
      • Cells may have spindled or stellate morphology.
      • Tend to be more abundant around vessels.
  • +/-Eosinophils (common).
  • +/-Edema - often prominent; gives cells a white halo.

Notes:

  • Lymphocyte vs. mast cell:
    • Lymphocytes = round; mast cells = ovoid.

Images:

Stains

Ichthyosis

General

  • Comes in different flavours.
  • Usu. inherited... thus a pediatric condition.

Clinical:

  • Fish scale-like appearance.

Microscopic

Features:[43]

  • Thick stratum corneum without basket-weave pattern.

Palmar fibromatosis

General

  • AKA Dupuytren's contracture.

Clinical:[44]

  • Usually older 60-70s.
  • Male > female.
  • Associated with:
    • Alcohol abuse.
  • May be familial.

Microscopic

Features:[45]

  • Bland spindle cells in dense collagen.
    • No nuclear atypia.
  • Giant cells.
  • +/-Mitotic figures.

Images:

Angiomyoma

General

  • Benign.
  • Female > male.[47]

Microscopic

Features:

  • Well-circumscribed lesion with fascicular architecture.
  • Spindle cells/epithelioid cell with moderate eosinophilic (pink) cytoplasm.
  • Thick-walled blood vessels. (???)

Images:

Angiokeratoma

General

Microscopic

Features:[48]

  • Ectatic superficial dermal vessels.
  • Overlying hyperkeratosis

Others: (???)

  • Irregular acanthosis.
  • Longer rete ridges.

Image:

DDx:

Panniculitis

DDx:

  • Erythema nodosum.
  • Erythema induratum.
  • Self-inflicted trauma.
  • Systemic lupus erythematosus.
  • Weird stuff.

Erythema nodosum

Features:[49]

  • Common.
  • Assoc. with IBD.

Microscopic

Features:[49]

  • Expanded (inter-adipocyte cluster) septa.
  • Neutrophils.
  • Fibrin.

Notes:

  • No vasculitis.

Erythema induratum

Features:[49]

  • Not common.
  • Etiology: unknown.

Microscopic

Features:[49]

  • Necrotizing granulomatous inflammation.
  • Necrotizing vasculitis of small/medium sized vessels (early).

DDx:

  • Infection.

Bullous disease

Main article: Bullous disease

Cysts

Main article: Dermal cysts

See also

References

  1. ↑ 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. ↑ Teichman, JM.; Sea, J.; Thompson, IM.; Elston, DM. (Jan 2010). "Noninfectious penile lesions.". Am Fam Physician 81 (2): 167-74. PMID 20082512.
  5. ↑ 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.
  6. ↑ URL: http://emedicine.medscape.com/article/1078327-overview. Accessed on: 11 September 2010.
  7. ↑ 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.
  8. ↑ URL: http://emedicine.medscape.com/article/1078327-overview. Accessed on: 11 September 2010.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ URL: http://www.careforumwales.org/cell-carcinoma/histopathologic-terminology.html. Accessed on: 28 August 2011.
  12. ↑ 12.0 12.1 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.
  13. ↑ 13.0 13.1 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.
  14. ↑ URL: http://medical-dictionary.thefreedictionary.com/spondylosis. Accessed on: 28 August 2011.
  15. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1011. ISBN 978-1416031215.
  16. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 296. ISBN 978-0470519035.
  17. ↑ URL: http://emedicine.medscape.com/article/1123423-overview. Accessed on: 20 August 2010.
  18. ↑ URL: http://www.medterms.com/script/main/art.asp?articlekey=10131. Accessed on: 20 August 2010.
  19. ↑ URL: http://emedicine.medscape.com/article/1123423-diagnosis. Accessed on: 20 August 2010.
  20. ↑ 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. 596. ISBN 978-1416054542.
  21. ↑ URL: http://emedicine.medscape.com/article/1059477-overview#a0199. Accessed on: 26 August 2011.
  22. ↑ 22.0 22.1 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. 595. ISBN 978-1416054542.
  23. ↑ URL: http://emedicine.medscape.com/article/1059477-overview. Accessed on: 26 August 2011.
  24. ↑ URL: http://missinglink.ucsf.edu/lm/DermatologyGlossary/verruca_vulgaris.html. Accessed on: 14 July 2010.
  25. ↑ 25.0 25.1 http://emedicine.medscape.com/article/1058965-overview
  26. ↑ http://emedicine.medscape.com/article/1058965-diagnosis
  27. ↑ http://www.bccancer.bc.ca/HPI/CE/cytotechnology/cytosleuthquiz/nongyne/ngcase02d.htm
  28. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 492. ISBN 978-0781765275.
  29. ↑ BD. 13 April 2011.
  30. ↑ Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 51. ISBN 978-0781779425.
  31. ↑ Abenoza P, Lillemoe T (October 1993). "CD34 and factor XIIIa in the differential diagnosis of dermatofibroma and dermatofibrosarcoma protuberans". Am J Dermatopathol 15 (5): 429–34. PMID 7694515.
  32. ↑ Goldblum JR, Tuthill RJ (April 1997). "CD34 and factor-XIIIa immunoreactivity in dermatofibrosarcoma protuberans and dermatofibroma". Am J Dermatopathol 19 (2): 147–53. PMID 9129699.
  33. ↑ Bandarchi B, Ma L, Marginean C, Hafezi S, Zubovits J, Rasty G (March 2010). "D2-40, a novel immunohistochemical marker in differentiating dermatofibroma from dermatofibrosarcoma protuberans". Mod. Pathol. 23 (3): 434–8. doi:10.1038/modpathol.2009.176. PMID 20062007.
  34. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1188. ISBN 978-1416031215.
  35. ↑ http://www.missionforvisionusa.org/anatomy/2006/08/what-is-molluscum-contagiosum.html
  36. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1177. ISBN 978-1416031215.
  37. ↑ URL: http://emedicine.medscape.com/article/1059871-diagnosis. Accessed on: 12 May 2010.
  38. ↑ URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC475744/. Accessed on: 11 May 2010.
  39. ↑ Mandrell JC, Santa Cruz D (August 2009). "Keratoacanthoma: hyperplasia, benign neoplasm, or a type of squamous cell carcinoma?". Semin Diagn Pathol 26 (3): 150–63. PMID 20043514.
  40. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 378. ISBN 978-1416002741.
  41. ↑ 41.0 41.1 Alsaad, KO.; Ghazarian, D. (Dec 2005). "My approach to superficial inflammatory dermatoses.". J Clin Pathol 58 (12): 1233-41. doi:10.1136/jcp.2005.027151. PMID 16311340.
  42. ↑ 42.0 42.1 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. 1269. ISBN 0-7216-0187-1.
  43. ↑ 43.0 43.1 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1185. ISBN 978-1416031215.
  44. ↑ URL: http://www.humpath.com/palmar-fibromatosis. Accessed on: 6 January 2011.
  45. ↑ URL: [1]. Accessed on: 6 January 2011.
  46. ↑ Wang L, Zhu H (2006). "Clonal analysis of palmar fibromatosis: a study whether palmar fibromatosis is a real tumor". J Transl Med 4: 21. doi:10.1186/1479-5876-4-21. PMC 1488873. PMID 16696857. http://www.biomedsearch.com/nih/Clonal-analysis-palmar-fibromatosis-study/16696857.html.
  47. ↑ Katenkamp D, Kosmehl H, Langbein L (1988). "[Angiomyoma. A pathologo-anatomic analysis of 229 cases]" (in German). Zentralbl Allg Pathol 134 (4-5): 423–33. PMID 3201831.
  48. ↑ 48.0 48.1 Karen, JK.; Hale, EK.; Ma, L. (2005). "Angiokeratoma corporis diffusum (Fabry disease).". Dermatol Online J 11 (4): 8. PMID 16403380.
  49. ↑ 49.0 49.1 49.2 49.3 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1199. ISBN 978-1416031215.
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