Difference between revisions of "Inflammatory skin disorders"

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Inflammatory skin disorders (view source)

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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.  Non-inflammatory skin disease is covered in ''[[dermatologic neoplasms]]'' and ''[[non-malignant skin disease]]''.


=Classification=
=Classification=
Line 11: Line 11:
*Psoriasiform.
*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>):'''
'''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><ref name=pmid18948765>{{Cite journal  | last1 = Brinster | first1 = NK. | title = Dermatopathology for the surgical pathologist: a pattern-based approach to the diagnosis of inflammatory skin disorders (part II). | journal = Adv Anat Pathol | volume = 15 | issue = 6 | pages = 350-69 | month = Nov | year = 2008 | doi = 10.1097/PAP.0b013e31818b1ac6 | PMID = 18948765 }}</ref>):'''
{| class="wikitable"
{| class="wikitable"
| '''Pattern'''
| '''Pattern'''
Line 17: Line 17:
| '''Subclassifications'''
| '''Subclassifications'''
| '''Example'''
| '''Example'''
| '''Image'''
|-
|-
| [[Bullous disease|Bullous]]
| [[Bullous disease|Bullous]]
| "Empty space"
| large "empty spaces"
| -Subcorneal<br>-Suprabasillar<br>-Subepidermal
| -subcorneal<br>-suprabasillar<br>-subepidermal
| -Pemphigus foliaceus<br>-[[Pemphigus vulgaris]]<br>-[[Dermatitis herpetiformis]]
| -[[pemphigus foliaceus]]<br>-[[pemphigus vulgaris]]<br>-[[dermatitis herpetiformis]]
| [[Image:Pemphigus_vulgaris_-_low_mag.jpg|thumb|150px|center|[[pemphigus vulgaris|PV]] (WC)]]
|-
|-
| Interface
| [[Interface_dermatitides|Interface]]
| Inflammation at DE junction
| inflammation at DE junction
| -Vacuolar (minimal)<br>-Lichenoid (band-like)  
| -vacuolar (minimal)<br>-lichenoid (band-like)  
| -[[Erythema multiforme]], [[SLE]]<br>-[[Lichen planus]]  
| -[[erythema multiforme]], [[SLE]]<br>-[[lichen planus]]
| [[Image:Vacuolar interface dermatitis - high mag.jpg|thumb|center|150px|[[vacuolar interface dermatitis|VID]] (WC)]]
|-
|-
| Nodular & diffuse  
| [[Nodular and diffuse dermatitides|Nodular & diffuse]]
| Nodular & diffuse
| intradermal inflammatory infiltrate - nodular and/or diffuse
| ?
| -neutrophic<br>-lymphocytic<br>-plasmic<br>-eosinophilic<br>-histocytic
|
| -follicular occlusion triad, ruptured cyst/follicle<br>-[[CTCL]], reactive<br>-[[plasma cell neoplasm]], [[syphilis]]<br>-eosinophilic cellulitis, [[Kimura disease]]<br>-[[granuloma annulare]], [[sarcoidosis]], [[TB]]
| [[Image:Cutaneous_T-cell_lymphoma_-_very_high_mag.jpg|thumb|center|110px|[[CTCL]] (WC)]]
|-
|-
| Spongiotic
| [[Spongiotic_dermatitides|Spongiotic]]
| Edema between keratinocytes
| small empty spaces between keratinocytes - can see squamous bridges (best seen at high power); +/- quasi-microvacuolar appearance
| -Acute<br>-Subacute<br>-Chronic
| -acute<br>-subacute<br>-chronic
| -Poison Ivy<br>-Nummular dermatitis<br>-Atopic dermatitis
| -poison ivy<br>-nummular dermatitis<br>-[[atopic dermatitis]]
| [http://commons.wikimedia.org/wiki/File:Spongiotic_dermatitis_%282%29_Dyshidrotic_.JPG severe (WC)], [http://commons.wikimedia.org/wiki/File:Spongiotic_dermatitis_-_very_high_mag.jpg mild (WC)]
|-
|-
| [[Vasculitis]]
| [[Vasculitis]]
| Inflammation of vessel wall
| inflammation of vessel wall/vessel was destruction
| ?
| -small vessel <br> -medium vessel <br> -large vessel
| ?
| -[[leukocytoclastic vasculitis]]<br>-[[PAN]]<br>-[[giant cell arteritis]]
| [[Image:Churg-Strauss_syndrome_-_high_mag.jpg |thumb|150px|[[Eosinophilic granulomatosis with polyangiitis|EGPA]] (WC)]]
|-
|-
| Perivascular
| [[Dermatitides_with_perivascular_inflammation|Perivascular]]
| Inflammation around vessels
| inflammation around vessels
| ?
| -neutrophilic<br>-lymphocytic<br>-mastocytic<br>-eosinophilic
| ?
| -[[cellulitis]]<br>-viral exanthem, Rx reaction<br>-[[mastocytosis]]<br>-insect bite, Rx reaction
| [[Image:Dermal_perivascular_lymphoeosinophilic_infiltrate_-_high_mag.jpg |thumb|center|110px|DPLI (WC)]]
|-
|-
| [[Panniculitis]]
| [[Panniculitis]]
| Inflamm. of adipose tissue
| inflammation of adipose tissue
| -Septal<br>-Nodular
| -septal<br>-lobular
| -[[Erythema nodosum]]<br>-[[Erythema induratum]]
| -[[erythema nodosum]], [[scleroderma panniculitis]]<br>-[[erythema induratum]], infection
|
|-
|-
| Psoriasiform
| [[Psoriasiform dermatitides|Psoriasiform]]
| Epidermal thickening<br>and long rete ridges  
| epidermal thickening<br>and long rete ridges  
| -Regular<br>-Irregular
| -regular<br>-irregular
| -Psoriasis<br>-[[Lichen simplex chronicus]]
| -[[psoriasis]]<br>-[[lichen simplex chronicus]]
| [[Image:Lichen_simplex_chronicus_-_very_low_mag.jpg|thumb|150px|center|[[Lichen simplex chronicus|LSC]] (WC)]]
|}
|}
Notes:  
Notes:  
Line 71: Line 80:
*Psoriatic arthritis.
*Psoriatic arthritis.
*Drug-induced.
*Drug-induced.
*[[Dermatomycosis]] (fungal infection).
*Others.
*Others.


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===Microscopic===
===Microscopic===
Features:<ref>{{Ref PBoD8|1191}}</ref>
Features:<ref>{{Ref PBoD8|1191}}</ref>
*Spongiosis (epidermal edema).
*[[Spongiosis]] (epidermal edema).
*Acanthosis (epidermal thickening).
*Acanthosis (epidermal thickening).
*"Follicular lipping" = parakeratosis with neutrophils.
*"Follicular lipping" = parakeratosis with neutrophils.
*Perivascular neutrophils and lymphocytes.
*Perivascular neutrophils and lymphocytes.


==Systemic lupus erythematosus==
==Lupus erythematosus==
{{Main|Systemic lupus erythematosus}}
===General===
===General===
*Systemic disease with multi-organ manifestations.  
*A group of skin diseases - includes:
**The systemic disease, [[systemic lupus erythematosus]], that typically has multi-organ involvement.


===Microscopic===
===Microscopic===
Features:
Features - classic:
*Lymphocytic interface dermatitis.<ref>JAH. 20 February 2009.</ref>
*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>
*Basal layer vacuolization.<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.
*Intradermal mucin.
*Thin epidermis.
*Compact stratum corneum.
DDx:
*[[Discoid lupus erythematosus]].
*Drug reaction (drug-induced lupus erythematosus).
*[[Solar elastosis]] - may be confused with ''mucin''; vacuolar interface dermatitis ''not'' present
====Images====
<gallery>
Image:Vacuolar_interface_dermatitis_-_low_mag.jpg | Vacuolar interface dermatitis with dermal mucin - low mag. (WC)
Image:Vacuolar_interface_dermatitis_-_intermed_mag.jpg | Vacuolar interface dermatitis with dermal mucin - intermed. mag. (WC)
Image:Vacuolar_interface_dermatitis_-_high_mag.jpg | Vacuolar interface dermatitis with dermal mucin - high mag. (WC)
Image:Vacuolar_interface_dermatitis_-_very_high_mag.jpg | Vacuolar interface dermatitis with dermal mucin - very high mag. (WC)
</gallery>
==Discoid lupus erythematosus==
===General===
*Typically self-limited and isolated.
**It is '''not''' associated with ''[[systemic lupus erythematosus]]''.
===Microscopic===
Features:<ref>URL: [http://www.dermpedia.org/baby-dermpedia-for-beginners/discoid-lupus-erythematosus http://www.dermpedia.org/baby-dermpedia-for-beginners/discoid-lupus-erythematosus]. Accessed on: 7 March 2012.</ref>
*Lymphocytic interface dermatitis with basal layer vacuolation and keratinocyte apoptosis.
*Deep dermal lymphocytes.
*Basket weave stratum corneum.
*Dermal mucin.
*Thick dermal-epidermal basement membrane.
DDx:
*[[Lupus erythematosus]].
Image:
*[http://www.dermpedia.org/baby-dermpedia-for-beginners/discoid-lupus-erythematosus DLE (dermpedia.org)].


==Dermatomyositis==
==Dermatomyositis==
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**May precede or follow muscle pathology.
**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>
*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>
Clinical:
*Jo-1 +ve.


===Gross===
===Gross===
Line 119: Line 166:
===Microsopic===
===Microsopic===
Features:
Features:
*Lymphocytic interface dermatitis (inflammation at the dermal-epidermal junction).
*Vacuolar interface dermatitis (lymphocytic inflammation at the dermal-epidermal junction).
*Loss of rete ridges.
*+/-Loss of rete ridges.
 
DDx:
*Lupus.


==Lichen planus==
==Lichen planus==
:''Should '''not''' be confused with [[lichen planus-like keratosis]]''.
*Abbreviated ''LP''.
===General===
===General===
*An oral pathology.
*An [[oral pathology]] - classically.
*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>
*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>


Line 133: Line 185:
*6 Ps: pruritic (itchy), purple, polygonal, planar papules and plaques.
*6 Ps: pruritic (itchy), purple, polygonal, planar papules and plaques.


Note:
*Clinically, lichen planus and [[lichen sclerosus]] are similar. The main difference is lichen planus involves mucous membranes.<ref name=pmid20868406>{{Cite journal  | last1 = McPherson | first1 = T. | last2 = Cooper | first2 = S. | title = Vulval lichen sclerosus and lichen planus. | journal = Dermatol Ther | volume = 23 | issue = 5 | pages = 523-32 | month =  | year =  | doi = 10.1111/j.1529-8019.2010.01355.x | PMID = 20868406 }}</ref>
===Gross===
===Gross===
*Wickham striae = white lines/dots.
*Wickham striae = white lines/dots.
Line 145: Line 199:
*Hyperkeratosis; stratum corneum thickened.
*Hyperkeratosis; stratum corneum thickened.
*Necrotic basal cell in dermis = colloid bodies = Civatte bodies.<ref name=Ref_PCPBoD8_604>{{Ref PCPBoD8|604}}</ref>
*Necrotic basal cell in dermis = colloid bodies = Civatte bodies.<ref name=Ref_PCPBoD8_604>{{Ref PCPBoD8|604}}</ref>
**Pink bodies approximately the size of a keratinocyte.
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]].


DDx:
DDx:
*[[Bullous disease]], subepithelial vesicular.
*[[Bullous disease]], subepithelial vesicular.
*[[Lichenoid keratosis]] - parakeratosis prominent.  
*[[Lichenoid keratosis]] (lichen planus-like keratosis) - parakeratosis prominent, no oral mucosal involvement.
*Fungal infection.<ref name=Ref_Derm36>{{Ref Derm|36}}</ref>
*Lichenoid drug reaction - unusual body site affected, separated clinically.
*Lichenoid [[actinic keratosis]] - basal atypia, [[solar elastosis]].
 
====Images====
<gallery>
Image:Lichen_planus_intermed_mag.jpg | Lichen planus - intermed. mag. (WC/Nephron)
Image:Lichen_planus_low_mag.jpg | Lichen planus - low mag. (WC/Nephron)
</gallery>
 
===Stains===
*PAS-D or PAS-F to exclude a fungal infection.


Notes:
===Sign out===
*Hyperkeratosis and hypergranulosis are not seen in [[erythema multiforme]].
<pre>
*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>
FORESKIN, CIRCUMCISION:
**DDx: systemic lupus erythematosus, lichen planus, and [[graft-versus-host disease]].
- LICHEN PLANUS.
</pre>
 
<pre>
VULVA, LEFT POSTERIOR FOURCHETTE, BIOPSY:
- COMPATIBLE WITH LICHEN PLANUS.
</pre>
 
====Micro====
The sections show skin with a lymphoplasmacytic interface dermatitis, basal cell loss, hypergranulosis, hyperkeratosis, loss of the rete ridges and Civatte bodies.
 
The epidermis matures to the surface. No significant nuclear atypia is identified.


Images:
Fungal organisms are not identified with a PAS-D stain.
*[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==  
==Lichen sclerosus==  
Line 169: Line 250:
===General===
===General===
*Chronic skin condition +/- systemic involvement:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
*Chronic skin condition +/- systemic involvement:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
**[[Arthritis]].
**[[Arthritis]], i.e. psoriatic arthritis.
**[[Myopathy]].
**[[Myopathy]].
**Enteropathy, e.g. [[inflammatory bowel disease]].
**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>).
**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:
*Other considerations:
**Drug-induced psoriasis.<ref name=pmid21489366>{{Cite journal  | last1 = Milavec-Puretić | first1 = V. | last2 = Mance | first2 = M. | last3 = Ceović | first3 = R. | last4 = Lipozenčić | first4 = J. | title = Drug induced psoriasis. | journal = Acta Dermatovenerol Croat | volume = 19 | issue = 1 | pages = 39-42 | month = Mar | year = 2011 | doi =  | PMID = 21489366 }}</ref>
 
====Clinical====
*''Auspitz sign'' = pin-point bleeding on removal of scale.
*''Auspitz sign'' = pin-point bleeding on removal of scale.
*''Koebner phenomenon'' = lesions form at site of trauma.
*''Koebner phenomenon'' = lesions form at site of trauma.
Common locations:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
*Knees, elbows, scalp, glans [[penis]].


===Microscopic===
===Microscopic===
Features:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
Features:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>
*Acanthosis + long rete ridges - '''key feature'''.
*"Regular" acanthosis + long rete ridges (psoriasiform hyperplasia).
**"Regular" ([[Psoriasiform dermatitides|psoriasiform change]]) = rete ridges are of similar length and thickness.
*Parakeratosis.
*Parakeratosis.
*Dilated vessels in superficial dermis (give rise to ''Auspitz sign'').
*Dilated vessels in superficial dermis (give rise to ''Auspitz sign'').
*Spongiform pustules = PMNs in stratum spinosum.
*Spongiform pustules = [[PMN]]s in stratum spinosum.
*PMNs in parakeratotic stratum corneum (Munro microabscess).
*PMNs in parakeratotic stratum corneum (Munro microabscess).
*Thinning of the suprapapillary plate.
**The epidermis between rete ridges is thinner than in the normal adjacent skin - '''key feature'''.
DDx:
*[[Dermatomycosis]] ([[Fungi|fungal infection]]).
*Drug reaction.
Note:
*[[Dermatophytosis]] = ring worm; dermatophystosis != [[dermatomycosis]].
====Images====
www:
*[http://missinglink.ucsf.edu/lm/dermatologyglossary/img/Dermatology%20Glossary/Glossary%20Histo%20Images/Psoriasis_low_power.jpg Psoriasis - low mag. (ucsf.edu)].<ref>URL: [http://missinglink.ucsf.edu/lm/dermatologyglossary/psoriasis.html http://missinglink.ucsf.edu/lm/dermatologyglossary/psoriasis.html]. Accessed on: 4 September 2013.</ref>
===Stains===
*[[PASD stain]] -ve for [[fungi|fungal]] organisms.
===Sign out===
<pre>
SKIN LESION, LEFT ARM, PUNCH BIOPSY:
- SKIN WITH ACANTHOSIS, HYPERKERATOSIS, FOCAL PARAKERATOSIS, PROMINENT
  DILATED VESSELS IN THE SUPERFICIAL DERMIS, SUPERFICIAL SPONGIFORM PUSTULES.
- MILD NONSPECIFIC PERIVASCULAR INFLAMMATION.
- NEGATIVE FOR FUNGAL ORGANISMS WITH PAS STAINING.
COMMENT:
The findings are compatible with psoriasis. 
</pre>
====Micro====
The sections show skin with regular psoriasiform change, hyperkeratosis, focal parakeratosis, prominent dilated vessels in the superficial dermis, superficial clusters of intraepidermal neutrophils (spongiform pustules) and thinning of the suprapapillary plate is present. A few perivascular inflammatory cells are present.
There is no epidermal necrosis. Eosinophils are not apparent. The lymphocytes do not have significant atypia.
==Lichen striatus==
===General===
Features:<ref name=pmid15283785>{{Cite journal  | last1 = Taniguchi Abagge | first1 = K. | last2 = Parolin Marinoni | first2 = L. | last3 = Giraldi | first3 = S. | last4 = Carvalho | first4 = VO. | last5 = de Oliveira Santini | first5 = C. | last6 = Favre | first6 = H. | title = Lichen striatus: description of 89 cases in children. | journal = Pediatr Dermatol | volume = 21 | issue = 4 | pages = 440-3 | month =  | year =  | doi = 10.1111/j.0736-8046.2004.21403.x | PMID = 15283785 }}</ref>
*Benign, self-limited.
Clinical:
*Linear rash usu. on lower extremity.
*Associated with atopy, [[lichen sclerosus]].<ref name=pmid15283785/>
*Children.
Clinical image:
*[http://perridermatology.com/blog/2011/3/7/lichen-planus-lichen-striatus.html LS (perridermatology.com)].
===Microscopic===
Features:
*"Ball and glove" pattern:
**Rete ridges (glove) surround nexts of lymphocytes (ball).
*Hyperkeratosis.
*Parakeratosis.
DDx:
*[[Lichen planus]].
Images:
*[http://www.dermpathdiagnostics.com/dxref.asp?catid=25&id=57 Lichen striatus (dermpathdiagnostics.com)].
*[http://www.drmihm.com/cases/case.cfm?CaseID=42 Lichen striatus (drmihm.com)].
==Lichen aureus==
===General===
*Rare.
Clinical:<ref name=pmid17511956/>
*Plaques + minimal scale - erythematous/golden.
===Microscopic===
Features:<ref name=pmid17511956>{{Cite journal  | last1 = Hazan | first1 = C. | last2 = Fangman | first2 = B. | last3 = Cohen | first3 = D. | title = Lichen aureus. | journal = Dermatol Online J | volume = 13 | issue = 1 | pages = 23 | month =  | year = 2007 | doi =  | PMID = 17511956 | URL = http://dermatology.cdlib.org/131/cases/NYUcases/051606_9.html }}</ref>
*Lymphocyte-predominant perivascular pattern.
**May have features suggestive of vacuolar interface pattern.
*Fibrosis of superficial papillary dermis.
Images:
*[http://dermatology.cdlib.org/131/cases/NYUcases/051606_9.html Lichen aureus (cdlib.org)].
==Granuloma faciale==
===General===
*Considered a [[vasculitis]].<ref name=dermatlas_gf>URL: [http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1289066309 http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1289066309]. Accessed on: 23 September 2011.</ref>
===Microscopic===
Features:<ref name=Ref_Derm198-9>{{Ref Derm|198-9}}</ref>
*Neutrophilic vasculitis - often subtle:
**Neutrophils within blood vessel walls.
**Vessels destruction ([[fibrinoid necrosis]] or nuclear dust).
*Mixed inflammatory superficial dermal infiltrate.
**Eosinophils, neutrophils, plasma cells, histiocytes.
*Lesion separated from the (normal) epidermis (Grenz zone).<ref name=dermatlas_gf>URL: [http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1289066309 http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1289066309]. Accessed on: 23 September 2011.</ref>
DDx of chronic fibrosing [[leukocytoclastic vasculitis]]:<ref name=Ref_Derm198-9>{{Ref Derm|198-9}}</ref>
*Granuloma faciale.
*Erythema elevatum diutinum - lacks Grenz zone.
*Inflammatory pseudotumour.
Image:
*[http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1289066309 Granuloma faciale (dermatlas.med.jhmi.edu)].
==Atopic dermatitis==
*[[AKA]] ''atopic eczema'', [[AKA]] ''infantile eczema''.
===General===
*Very common - especially in children.<ref name=ad_nih>URL: [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001856/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001856/]. Accessed on: 28 December 2011.</ref>
**Most children outgrow the condition.
===Microscopic===
Features:
*Spongiotic dermatitis.
DDx:
*[[Spongiotic dermatitides]].
====Images====
<gallery>
Image:Spongiotic_dermatitis_-_high_mag.jpg | Mild spongiotic dermatitis - high mag. (WC)
Image:Spongiotic_dermatitis_-_very_high_mag.jpg | Mild spongiotic dermatitis - very high mag. (WC)
</gallery>
==Sweet syndrome==
===General===
*Uncommon.
===Microscopic===
Features:
*Nodular and diffuse pattern - neutrophils predominant - without pus.
DDx ''rips'':
*Rheumatoid neutrophilic dermatitis.
*[[Bowel-associated dermatosis-arthritis syndrome]] (BADAS).
*[[Pyoderma gangrenosum]].
*Sweet syndrome.
Image:
*[http://dermatology.cdlib.org/94/NYU/Apr2002/041602-7b.jpg Sweet syndrome (cdlib.org)].<ref>URL: [http://dermatology.cdlib.org/94/NYU/Apr2002/7.html http://dermatology.cdlib.org/94/NYU/Apr2002/7.html]. Accessed on: 4 January 2012.</ref>
==Granuloma inguinale==
:'''Not''' to be confused with ''[[granuloma annulare]]''.
*Previously known as ''donovanosis''.
===General===
*Infection caused by ''Klebsiella granulomatis'' - [[Gram stain|Gram]]-negative, rod-shaped bacteria.
**Used to be known as ''Calymmatobacterium granulomatis''.<ref name=pmid12473810>{{cite journal |author=O'Farrell N |title=Donovanosis |journal=Sex Transm Infect |volume=78 |issue=6 |pages=452–7 |year=2002 |month=December |pmid=12473810 |pmc=1758360 |doi= |url=http://sti.bmj.com/cgi/pmidlookup?view=long&pmid=12473810}}</ref>
Location:
*[[Penis]].
*[[Vulva]].
Clinical:<ref name=pmid21738983>{{Cite journal  | last1 = Bezerra | first1 = SM. | last2 = Jardim | first2 = MM. | last3 = Silva | first3 = VB. | title = Granuloma inguinale (Donovanosis). | journal = An Bras Dermatol | volume = 86 | issue = 3 | pages = 585-6 | month = Jun | year = 2011 | doi =  | PMID = 21738983 |URL = http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962011000300028&lng=en&nrm=iso&tlng=en }}</ref>
*Sexually transmitted.
*Nodule or papule developing into a painless ulcer in the inguinal region.
*No lymphadenopathy (unlike [[syphilis]]).
===Microscopic===
Features:
*Donovan bodies - '''key feature''':
**Rod-shaped bodies within histiocytes.
DDx:
*[[Syphilis]].
Image:
*[http://microblog.me.uk/213 Granuloma inguinale - crappy image (microblog.me.uk)].
===Stains===
*[[Giemsa stain]] - highlights organisms.
==Pyoderma gangrenosum==
{{Main|Pyoderma gangrenosum}}
==Necrobiotic xanthogranuloma==
*Abbreviated ''NXG''.
{{Main|Necrobiotic xanthogranuloma}}


=DDx for pattern=
=DDx for pattern=
==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>
*Atopic dermatitis.
*[[Atopic dermatitis]].
*Contact dermatitis.
*[[Contact dermatitis]].
*Stasis dermatitis.
*Stasis dermatitis.
*[[Seborrheic dermatitis]].
*[[Seborrheic dermatitis]].
Line 201: Line 459:
*Psoriasis vulgaris.
*Psoriasis vulgaris.
*Dermatophyte infection.
*Dermatophyte infection.
*Pityriasis rubra pilaris.
*[[Pityriasis rubra pilaris]].


===Irregular psoriasiform dermatitis===
===Irregular psoriasiform dermatitis===
Line 218: Line 476:
*[[Systemic lupus erythematosus]].
*[[Systemic lupus erythematosus]].
*Morbillifrom viral exanthem.
*Morbillifrom viral exanthem.
Additional:<ref name=pmid16311340>{{Cite journal  | last1 = Alsaad | first1 = KO. | last2 = Ghazarian | first2 = D. | title = My approach to superficial inflammatory dermatoses. | journal = J Clin Pathol | volume = 58 | issue = 12 | pages = 1233-41 | month = Dec | year = 2005 | doi = 10.1136/jcp.2005.027151 | PMID = 16311340 | PMC = 1770784}}</ref>
*Phototoxic dermatitis.
*Acute radiation dermatitis.
*Erythema multiforme-like drug eruption.
*Lichen sclerosis et atrophicus.
*[[Erythema dyschromicum perstans]] (ashy dermatosis).
Super lame mnemonic ''Danny G & SLE'':
*'''D'''ermatomyositis, '''G'''VHD, '''S'''LE, '''L'''ichen sclerosus, '''E'''rythema multiforme.


===Lichenoid interface dermatitides===
===Lichenoid interface dermatitides===
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*Lichenoid drug eruption.
*Lichenoid drug eruption.
*Fixed drug eruption.
*Fixed drug eruption.
Additional:<ref name=pmid16311340>{{Cite journal  | last1 = Alsaad | first1 = KO. | last2 = Ghazarian | first2 = D. | title = My approach to superficial inflammatory dermatoses. | journal = J Clin Pathol | volume = 58 | issue = 12 | pages = 1233-41 | month = Dec | year = 2005 | doi = 10.1136/jcp.2005.027151 | PMID = 16311340 | PMC = 1770784}}</ref>
*[[Lichen planus-like keratosis]].
*Lichenoid [[actinic keratosis]].
*Lichen nitidus.
*Pigmented purpuric dermatosis.
*Lichen [[amyloidosis]].
*Pityriasis lichenoides chronica.
*[[HIV]] dermatitis.
*[[Syphilis]].
*[[Urticaria pigmentosa]].
*Chronic [[graft versus host disease]].


==Bullous disease==
==Bullous disease==
{{Main|Bullous disease}}
===Subcorneal bullous disorders===
===Subcorneal bullous disorders===
DDx '''with''' acantholysis:<ref name=pmid18418089/>
DDx '''with''' acantholysis:<ref name=pmid18418089/>
*[[Pemphigus foliaceous]].
*[[Pemphigus foliaceus]].
*[[Bullous impetigo]].
*[[Bullous impetigo]].
*[[Staphylococcual scaled skin syndrome]].
*[[Staphylococcal scalded skin syndrome]].


DDx '''without''' acantholysis:DDx:<ref name=pmid18418089/>
DDx '''without''' acantholysis:DDx:<ref name=pmid18418089/>
*Subcorneal pustular demratosis (Sneddon-Wilkinson disease)
*Subcorneal pustular dermatosis (Sneddon-Wilkinson disease).
*Pustular psoriasis.
*Pustular psoriasis.
*Pustular drug eruption ([[acute generalized exanthematous pustulosis]]).
*Pustular drug eruption ([[acute generalized exanthematous pustulosis]]).
Line 245: Line 526:
*[[Darier disease]].
*[[Darier disease]].
*[[Grover disease]] (transient acantholytic dermatosis).
*[[Grover disease]] (transient acantholytic dermatosis).
Memory device - ''PhD'' + ''Grover'' = '''P'''emphigus vulgaris, '''H'''ailey-Hailey, '''D'''arier, '''G'''rover.


===Subepidermal bullous disorders===
===Subepidermal bullous disorders===
Line 252: Line 535:
*[[Porphyria cutanea tarda]].
*[[Porphyria cutanea tarda]].
*Epidermolysis bullosa acquista.
*Epidermolysis bullosa acquista.
*[[Dermatitis herpetiformsis]].
*[[Dermatitis herpetiformis]].
*Linear IgA disease.
*Linear IgA disease.


Line 260: Line 543:
*Bullous [[systemic lupus erythematosus]].
*Bullous [[systemic lupus erythematosus]].


==Perivascular inflammation==
Mnemonic ''DELPHI'':
*'''D'''ermatitis herpetiformis.
*'''E'''pidermolysis bullosa acquisita.
*Bullous '''l'''upus erythematosis.
*'''P'''emphigoid, bullous.
*'''H'''erpes gestationis - rare autoimmune bullous dermatosis of pregnancy, not related to HSV.<ref>URL: [http://emedicine.medscape.com/article/1063499-overview http://emedicine.medscape.com/article/1063499-overview]. Accessed on: 23 September 2011.</ref>
*Linear '''I'''gA disease.
 
==Dermatitides with perivascular inflammation==
===Lymphocytes===
===Lymphocytes===
Lymphocytes (tightly cuffed):<ref name=pmid18418089/>
Lymphocytes (tightly cuffed):<ref name=pmid18418089/>
Line 267: Line 558:
*Malignancy.
*Malignancy.
*Vitiligo (with absent melanocytes).
*Vitiligo (with absent melanocytes).
*Scleroderma/morphea.
*[[Scleroderma]]/morphea.


Lymphocytes & plasma cells +/-eosinophils:
Lymphocytes & plasma cells +/-eosinophils:
Line 280: Line 571:
*Insect bite.
*Insect bite.
*Dermatophyte infection.
*Dermatophyte infection.
A simple memory device - 6 Ls:<ref name=dermpathmd>URL: [http://www.dermpathmd.com/mnemonics/mnemonics_dermatopathology.htm http://www.dermpathmd.com/mnemonics/mnemonics_dermatopathology.htm]. Accessed on: 23 September 2011.</ref>
*'''L'''ymphoma.
*Pseudo'''l'''ymphoma (cutaneous lymphoid hyperplasia, lymphocytoma cutis).
*'''L'''upus erythematosus.
*'''L'''ymphocytic infiltrate of Jessner / tumid lupus erythematosus.
*[[polymorphous light eruption|Polymorphous '''l'''ight eruption]].
*'''L'''yme disease.


===Neutrophils===
===Neutrophils===
DDx:<ref name=pmid18418089/>
DDx:<ref name=pmid18418089/>
*Cellulitis.
*[[Cellulitis]].
*Neutrophilic eccrine hidradenitis (idiopathic palmar-plantar hidradenitis)
*Neutrophilic eccrine hidradenitis (idiopathic palmar-plantar hidradenitis)


Line 291: Line 590:
===Eosinophils===
===Eosinophils===
DDx:<ref name=pmid18418089/>
DDx:<ref name=pmid18418089/>
*Hypersensitivity reaction/drug reaction.
*[[Hypersensitivity]] reaction/drug reaction.
*Insect bite.
*Insect bite.
*Bullous pemphigoid, urticarial.
*Bullous pemphigoid, urticarial.
Line 300: Line 599:
==Vasculitis==
==Vasculitis==
{{Main|Vasculitides}}
{{Main|Vasculitides}}
General DDx:
*Infection.
*Autoimmune.
*Malignancy.
*Toxic (medications).
Small vessel:
*[[Small vessel leukocytoclastic vasculitis]] (LCV).
Medium vessel:
*[[Polyarteritis nodosa]].
*[[Wegener's granulomatosis]].
Medium vessels often with small vessel involvement:
*[[Churg-Strauss syndrome]].
*[[Microscopic polyangiitis]].
*Mixed cryoglobulinemia.
*[[Connective tissue diseases]].
Large vessel:
*[[Giant cell arteritis]].
==Nodular and diffuse dermatitides==
===Neutrophils===
====With pus (suppurative)====
Neutrophils only:
*Follicular occlusion triad.
*Ruptured cyst/follicle.
Neutrophils and eosinophils:
*Halogenoderma.
*Blastomycosis-like pyoderma (pyoderma vegetans) - due to bacterial infection, usu. ''S. aureus''.
====Without pus====
With vasculitis:
*Neutrophils only: see ''[[vasculitides]]''.
*Mixed infiltrate: [[granuloma faciale]], erythema elevatinum diutinum.
Without vasculitis:
*[[Sweet syndrome]].
*[[Pyoderma gangrenosum]].
*[[Rheumatoid arthritis|Rheumatoid neutrophilic dermatitis]].
*Bowel-associated dermatosis-arthritis syndrome.
===Lymphocytes===
*Reactive lymphoid hyperplasia - may be due to drugs.
*[[Lymphoma|Lymphoid malignancy]].
===Plasma cells===
*Inflammation.
*[[Plasma cell neoplasm]]s.
*Infections:
**[[Syphilis]] - lichenoid/psoriasiform pattern.
**[[Chancroid]].
**[[Granuloma inguinale]].
**[[Lymphogranuloma venereum]].
===Eosinophils===
*Eosinophilic cellulitis (Wells syndrome).
**Insect bites.
*Hypereosinophilic syndrome (HES).
*[[Angiolymphoid hyperplasia with eosinophilia]] (ALHE).
*[[Kimura disease]].
===Histiocytes===
====Granulomatous====
=====Sarcoidal=====
*[[Sarcoidosis]] - have few lymphoid cells around them; thus called "naked granulomas".<ref name=pmid18948765>{{Cite journal  | last1 = Brinster | first1 = NK. | title = Dermatopathology for the surgical pathologist: a pattern-based approach to the diagnosis of inflammatory skin disorders (part II). | journal = Adv Anat Pathol | volume = 15 | issue = 6 | pages = 350-69 | month = Nov | year = 2008 | doi = 10.1097/PAP.0b013e31818b1ac6 | PMID = 18948765 }}</ref>
=====Tuberculoid=====
*[[Tuberculosis]].
*Tertiary [[syphilis]] - usu. abundant plasma cells.
*Cutaneous leishmaniasis.
=====Foreign body-type granulomas=====
=====Palisaded granumolas=====
Blue granuloma:
*[[Granuloma annulare]].
*[[Wegener granulomatosis]].
*Rheumatoid vasculitis.
Red granuloma:
*[[Rheumatoid nodule]].
*[[Necrobiosis lipoidica]].
*[[Necrobiotic xanthogranuloma]].
*[[Churg-Strauss syndrome]].


=See also=
=See also=
Line 307: Line 692:
=References=
=References=
{{Reflist|2}}
{{Reflist|2}}
=External links=
*[http://www.dermpathmd.com/mnemonics/mnemonics_dermatopathology.htm Dermatopathology mnemonics (dermpathmd.com)].


[[Category:Dermatopathology]]
[[Category:Dermatopathology]]
Michael
48,466

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