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 skin conditions are dealt with in inflammatory skin disorders.

Other

Squamous cell hyperplasia

  • AKA lichen simplex chronicus,[1] abbreviated LSC.

General

  • May be considered a variant of spongiotic dermatitis.[2]; more specifically, some think it is an atopic dermatitis (which fits in the large spongiotic dermatitis category).[3]

Etiology:[4]

  • Pruritus (itchness) -> mechanical trauma -> lichenification (thickened/leathery[5].

Note:

  • Similar to prurigo nodularis (PN).
    • PN is nodular/has dome-shaped lesions.[3]

Microscopic

Features:[6]

  • Acanthosis (epithelial thickening).
  • Hyperkeratosis.

Other features:[7]

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

Images:

Very common

Dermatomycosis

General

Note:

  • Dermatophytosis is a type of dermatomycosis.

Microscopic

Features:

  • Microorganisms - key feature.
    • Often hyphae (candida) - like twigs of a tree... branching.
  • Perivascular inflammation.
  • Exocytosis - blood cell infiltrate the epidermis.

Images:

Stains

Cicatrix

General

  • Previous surgery, biopsy, trauma.

Microscopic

Features:

  • Loss of adnexal structures.
  • Dense collagen - fibers run parallel to the dermal-epidermal (DE) junction.
  • Loss of dermal papilla.

Image:

Fibroepithelial polyp

  • AKA acrochordon, skin tag.

General

  • Benign.
  • Older people.
  • May be associated with pregnancy, diabetes, intestinal polyposis.[8]

Gross

  • Raised skin-coloured lesion.

Image:

Microscopic

Features:

  • On a stalk / epithelium on three sides.
  • Benign epidermis.

Image:

Actinic keratosis

  • AKA solar keratosis. (???)

General

Clinical: yellow-brown scaly, patches, sandpaper sensation.

Risk factors:[10]

  • Sun exposure.
  • Immune suppression (e.g. organ transplant recipients).

Microscopic

Features:[11]

  • Epidermal nuclear atypia:
    • Variation is size, shape and staining.
      • Nuclear enlargement - key feature.
        • Should involve the basal layer.
  • Abnormal epidermal architecture:
    • Pallisading. (???)
  • +/-Parakeratosis.
  • +/-Irregular acanthosis.

Image:

Seborrheic keratosis

  • Abbreviated SK.

General

  • Benign.
  • Most common tumour in older people.[12]
  • "Large number" of SKs = paraneoplastic syndrome (Leser–Trélat sign).[13]

Epidemiology:

  • Old people.
  • Usu. in sun exposed area.[14]

Gross

  • "Stuck-on" appearance - raised lesion.

Image(s):

Microscopic

Features:[13]

  • 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:

Pilomatricoma

  • AKA calcifying epithelioma of Malherbe[15], AKA pilomatrixoma.

General

  • Benign skin tumour.
  • Most common solid skin tumour of children.[16]
  • CTNNB1 gene mutation important in pathogenesis.[17]

Clinical:

  • Hard nodule - calcification.
  • +/-Painful.

Treatment:

  • Surgical excision.[16]

Microscopic

Features:[18]

  • Lower dermis/subcutaneous adipose lesion; thus, usu. surrounded by connective tissue.
    • Sharpy demarcated island of cells.
    • Calcification in 75% - with calcium staining (von Kossa).
  • Cells:[19]
    • 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:[20]

  • 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":[21]
    • Acanthosis (thickened epithelial layer - specifically thickened stratum spinosum).
    • Basal keratinocyte hyperpigmentation.

Images:

DDx:

Subtypes

Like all common things... there are subtypes:[22]

  • 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:[23][24]

  • Factor XIIIa +ve.
    • Usually negative in DFSP.
  • CD34 -ve.
    • Usually positive in DFSP.
  • D2-40 +ve.[25]
    • Usually negative in DFSP.

Ezcema

General

  • A nebulous thingy.
  • Very common.

DDx:

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

Microscopic

Features:[26]

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

Very common - viral

Verruca vulgaris

General

  • AKA common wart.
  • Etiology - HPV.

Notes:

Microscopic

Features:[27]

  • 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:

Verruca plana

General

  • Common.
  • Usu. hands and face.[28]

Microscopic

Features:[28]

  • Orthokeratosis with basketweave pattern.
  • Hypergranulosis.
  • Viral keratohyaline.
  • Koilocytes.
  • Acanthosis - yet flat surface and base.

Notes:

  • It differs from verruca vulgaris... (1) orthokeratosis, (2) flat surface and base.

Less common

Cutaneous calcinosis

  • AKA calcinosis cutis.

General

  • Benign in itself; underlying cause may not be benign.

Subtypes:[29]

  1. Dystrophic - due to death of cells; may be related to a tumour.
  2. Metastatic - due to chronic renal failure; hyperkalemia; paraneoplastic phenomenon.
  3. Iatrogenic - post surgical.
  4. Idiopathic.

Microscopic

Features:

  • Dermal calcification:
    • Acellular purple blobs on H&E.
      • +/-Artefactual tearing of surrounding tissue due to processing (cutting).
      • +/-Small artefactual lines ~1-2 micrometers due to processing (cutting).
    • Usu. well-circumscribed.

Images:

Dilated pore of Winer

General

  • Benign.
  • Looks like zit.

Microscopic

Features:[30]

  • Dilated hair follicle with keratin.
  • Acanthosis.
  • Budding of epidermis (into dermis).

Lichenoid keratosis

  • AKA lichen planus-like keratosis.

General

  • Caucasians - middle age or older.

Clinical DDx:[31]

  • BCC, SCC, melanocytic neoplasm.

Microscopic

Features:[32]

  • Hyperkeratosis.
  • Parakeratosis.
  • Band of inflammatory cells at DE junction (lichenoid inflammation).
  • Dead keratinocytes (Civatte bodies).
  • Dermal melanophages.

DDx:

Images:

Granuloma annulare

General

  • Benign and self-limited condition.
  • Etiology unknown - may be assoc. with trauma.[33]

Microscopic

Features:[34]

  • Dermal palisading granuloma around:
    • Necrotic collagen - key feature.
      • Nuclei "missing" - have undergone karyolysis.
    • Mucin.
      • Loose/pale, paucicellular, eosinophilic.
  • Chronic inflammatory cells.

Notes:

  1. There may be multiple small foci with intervening normal dermis.[33]
  2. Granuloma annulare can be subclassified into subcutaneous and interstitial.
  3. Histomorphologically similar to Rheumatoid nodule.

DDx:

Images:

Necrobiosis lipoidica

General

Associated with:

Microscopic

Features:[33]

  • Dermal palisading granuloma around:
    • Necrotic collagen - key feature.
      • Nuclei "missing" - have undergone karyolysis.
  • Little mucin, no normal dermis between foci.

DDx:

Keloid

General

  • Sites of previous trauma/surgery, esp. in dark skinned individuals.[20]

Microscopic

Features:[20]

  • Thick collagen bundles - surrounded by paler staining fibroblasts - key feature.
  • Lesion replaces adnexal structures, e.g. hair, sweat glands.

DDx:

  • Hypertrophic scar.

Images:

Angiofibroma

See also: nasopharyngeal angiofibroma.

General

Clinical:

  • Firm, dome-shaped, flesh coloured.

Microscopic

Features:[20]

  • Dome-shaped.
  • Fibrotic dermis.
    • Enlarged fibroblasts.
  • Dilated small vessels.

Image:

Molluscum contagiosum

General

  • 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.[36]
  • Molluscum bodies - key feature:
    • Large cells with abundant granular eosinophilic cytoplasm.
    • Small peripheral nucleus.

Image(s):

Notes:

  • Molluscum bodies very 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.

Superficial dermal infiltrates

Discussed in detail by Alsaad and Ghazarian.[37]

Dermal perivascular lymphoeosinophilic infiltration (DPLI)

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

DDx:[37]

  • Insect bite - classically wedge-shaped.[38]
  • Drug reactions.
  • Urticarial reactions.
  • Prevesicular early stage of bullous pemphigoid.
  • HIV related dermatoses.

Notes:

  • May superficially resemble cutaneous lymphoma.[38]

Images:

Congenital dermal melanocytosis

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

Gross:

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

Mastocytosis

General

Classification:[39]

  1. Cutaneous (only) - usually children.
    • Urticaria pigmentosa.
    • Others.
  2. Systemic - usually adults.
    • Indolent subvariant.
    • Aggressive subvariant.
    • Leukemic subvariant.

Microscopic

Features:[40]

  • 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

IHC

  • CD117 +ve.
  • Tryptase +ve.[41]

Ichthyosis

General

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

Gross

  • Fish scale-like appearance.

Image:

Microscopic

Features:[40]

  • Thick stratum corneum without basket-weave pattern.

Palmar fibromatosis

General

  • AKA Dupuytren's contracture.

Clinical:[42]

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

Microscopic

Features:[43]

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

Images:

Angiomyoma

General

  • Benign.
  • Female > male.[45]

Microscopic

Features:

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

Images:

Angiokeratoma

General

Notes:

Microscopic

Features:[46]

  • Ectatic superficial dermal vessels.
  • Overlying hyperkeratosis

Others: (???)

  • Irregular acanthosis.
  • Longer rete ridges.

Images:

DDx:

Inverted follicular keratosis

General

  • Benign skin lesion.
  • Central face - middle age.[47]
  • Uncommon.

Clinical DDx:[47][48]

Microscopic

Features:[47]

  • Keratinocyte of cytologically benign proliferation.
  • "Squamous eddies" (whorls of keratin).
  • Coarse keratohyaline granules.

DDx:

Images:

Panniculitis

Main article: Panniculitis

This is dealt with in the panniculitis article.

DDx for panniculitis:

Rare

Porokeratosis

General

  • Genetic.
  • Several subtypes.

Notes:

  • Not the same as punctate porokeratotic keratoderma.[49]

Microscopic

Features:

  • Cornoid lamella (pathognomonic) - key feature:
    • Compact keratosis over a hair follicle.
  • +/-Rete ridge loss.

Nevus sebaceous

  • AKA nevus sebaceous of Jadassohn.

General

  • Congenital.
  • Face or scalp.

Microscopic

Features:

  • Abundant sebaceous glands.

Bullous disease

Main article: Bullous disease

Cysts

Main article: Dermal cysts

See also

References

  1. ↑ 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.
  2. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 296. ISBN 978-0470519035.
  3. ↑ 3.0 3.1 Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 26. ISBN 978-0443066542.
  4. ↑ URL: http://emedicine.medscape.com/article/1123423-overview. Accessed on: 20 August 2010.
  5. ↑ URL: http://www.medterms.com/script/main/art.asp?articlekey=10131. Accessed on: 20 August 2010.
  6. ↑ 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.
  7. ↑ URL: http://emedicine.medscape.com/article/1123423-diagnosis. Accessed on: 20 August 2010.
  8. ↑ 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.
  9. ↑ URL: http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=1196583692. Accessed on: 1 September 2011.
  10. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1180. ISBN 978-1416031215.
  11. ↑ URL: http://emedicine.medscape.com/article/1099775-workup#a0723. Accessed on: 1 September 2011.
  12. ↑ URL: http://emedicine.medscape.com/article/1059477-overview#a0199. Accessed on: 26 August 2011.
  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. 595. ISBN 978-1416054542.
  14. ↑ URL: http://emedicine.medscape.com/article/1059477-overview. Accessed on: 26 August 2011.
  15. ↑ Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 387. ISBN 978-0443066542.
  16. ↑ 16.0 16.1 URL: http://emedicine.medscape.com/article/1058965-overview. Accessed on: 10 September 2011. Cite error: Invalid <ref> tag; name "emed1058965" defined multiple times with different content
  17. ↑ 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. 597. ISBN 978-1416054542.
  18. ↑ URL: http://emedicine.medscape.com/article/1058965-diagnosis. Accessed on: 10 September 2011.
  19. ↑ http://www.bccancer.bc.ca/HPI/CE/cytotechnology/cytosleuthquiz/nongyne/ngcase02d.htm
  20. ↑ 20.0 20.1 20.2 20.3 20.4 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.
  21. ↑ BD. 13 April 2011.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ URL: http://missinglink.ucsf.edu/lm/DermatologyGlossary/verruca_vulgaris.html. Accessed on: 14 July 2010.
  28. ↑ 28.0 28.1 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 480. ISBN 978-0781765275.
  29. ↑ URL: http://emedicine.medscape.com/article/1103137-overview. Accessed on: 21 September 2011.
  30. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 486. ISBN 978-0781765275.
  31. ↑ Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 346. ISBN 978-0443066542.
  32. ↑ Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 347. ISBN 978-0443066542.
  33. ↑ 33.0 33.1 33.2 33.3 33.4 Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 51. ISBN 978-0443066542.
  34. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 478. ISBN 978-0781765275.
  35. ↑ URL: http://www.drdittmar.lu/Services.aspx. Accessed on: 1 September 2011.
  36. ↑ http://www.missionforvisionusa.org/anatomy/2006/08/what-is-molluscum-contagiosum.html
  37. ↑ 37.0 37.1 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.
  38. ↑ 38.0 38.1 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.
  39. ↑ Arock, M.; Valent, P. (Aug 2010). "Pathogenesis, classification and treatment of mastocytosis: state of the art in 2010 and future perspectives.". Expert Rev Hematol 3 (4): 497-516. doi:10.1586/ehm.10.42. PMID 21083038.
  40. ↑ 40.0 40.1 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.
  41. ↑ Rudzki, Z.; Sotlar, K.; Kudela, A.; Starzak-Gwóźdź, J.; Horny, HP. (2011). "Systemic mastocytosis (SM) and associated malignant bone marrow histiocytosis - a hitherto undescribed form of SM-AHNMD.". Pol J Pathol 62 (2): 101-4. PMID 21866466.
  42. ↑ URL: http://www.humpath.com/palmar-fibromatosis. Accessed on: 6 January 2011.
  43. ↑ URL: [1]. Accessed on: 6 January 2011.
  44. ↑ 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.
  45. ↑ 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.
  46. ↑ 46.0 46.1 Karen, JK.; Hale, EK.; Ma, L. (2005). "Angiokeratoma corporis diffusum (Fabry disease).". Dermatol Online J 11 (4): 8. PMID 16403380.
  47. ↑ 47.0 47.1 47.2 Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 387. ISBN 978-0443066542.
  48. ↑ URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC475744/. Accessed on: 11 May 2010.
  49. ↑ Alikhan, A.; Burns, T.; Zargari, O. (2010). "Punctate porokeratotic keratoderma.". Dermatol Online J 16 (1): 13. PMID 20137755.
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