Difference between revisions of "Inflammatory skin disorders"

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Inflammatory skin disorders (view source)

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| -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]]
| [http://commons.wikimedia.org/wiki/File:Pemphigus_vulgaris_-_low_mag.jpg (WC)]
| [[Image:Pemphigus_vulgaris_-_low_mag.jpg|thumb|150px|center|[[pemphigus vulgaris|PV]] (WC)]]
|-
|-
| [[Interface_dermatitides|Interface]]
| [[Interface_dermatitides|Interface]]
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| -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 and diffuse dermatitides|Nodular & diffuse]]  
| [[Nodular and diffuse dermatitides|Nodular & diffuse]]  
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| -neutrophic<br>-lymphocytic<br>-plasmic<br>-eosinophilic<br>-histocytic
| -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]]  
| -follicular occlusion triad, ruptured cyst/follicle<br>-[[CTCL]], reactive<br>-[[plasma cell neoplasm]], [[syphilis]]<br>-eosinophilic cellulitis, [[Kimura disease]]<br>-[[granuloma annulare]], [[sarcoidosis]], [[TB]]  
| [http://commons.wikimedia.org/wiki/File:Cutaneous_T-cell_lymphoma_-_very_high_mag.jpg (WC)]
| [[Image:Cutaneous_T-cell_lymphoma_-_very_high_mag.jpg|thumb|center|110px|[[CTCL]] (WC)]]
|-
|-
| [[Spongiotic_dermatitides|Spongiotic]]
| [[Spongiotic_dermatitides|Spongiotic]]
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| -small vessel <br> -medium vessel <br> -large vessel
| -small vessel <br> -medium vessel <br> -large vessel
| -[[leukocytoclastic vasculitis]]<br>-[[PAN]]<br>-[[giant cell arteritis]]
| -[[leukocytoclastic vasculitis]]<br>-[[PAN]]<br>-[[giant cell arteritis]]
| [http://commons.wikimedia.org/wiki/File:Churg-Strauss_syndrome_-_high_mag.jpg (WC)]
| [[Image:Churg-Strauss_syndrome_-_high_mag.jpg |thumb|150px|[[Eosinophilic granulomatosis with polyangiitis|EGPA]] (WC)]]
|-
|-
| [[Dermatitides_with_perivascular_inflammation|Perivascular]]
| [[Dermatitides_with_perivascular_inflammation|Perivascular]]
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| -neutrophilic<br>-lymphocytic<br>-mastocytic<br>-eosinophilic
| -neutrophilic<br>-lymphocytic<br>-mastocytic<br>-eosinophilic
| -[[cellulitis]]<br>-viral exanthem, Rx reaction<br>-[[mastocytosis]]<br>-insect bite, Rx reaction  
| -[[cellulitis]]<br>-viral exanthem, Rx reaction<br>-[[mastocytosis]]<br>-insect bite, Rx reaction  
| [http://commons.wikimedia.org/wiki/File:Dermal_perivascular_lymphoeosinophilic_infiltrate_-_high_mag.jpg (WC)]
| [[Image:Dermal_perivascular_lymphoeosinophilic_infiltrate_-_high_mag.jpg |thumb|center|110px|DPLI (WC)]]
|-
|-
| [[Panniculitis]]
| [[Panniculitis]]
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| -regular<br>-irregular
| -regular<br>-irregular
| -[[psoriasis]]<br>-[[lichen simplex chronicus]]
| -[[psoriasis]]<br>-[[lichen simplex chronicus]]
| [http://commons.wikimedia.org/wiki/File:Lichen_simplex_chronicus_-_very_low_mag.jpg (WC)]
| [[Image:Lichen_simplex_chronicus_-_very_low_mag.jpg|thumb|150px|center|[[Lichen simplex chronicus|LSC]] (WC)]]
|}
|}
Notes:  
Notes:  
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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.
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Features - classic:
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.
*Thin epidermis.
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*[[Discoid lupus erythematosus]].
*[[Discoid lupus erythematosus]].
*Drug reaction (drug-induced lupus erythematosus).
*Drug reaction (drug-induced lupus erythematosus).
*[[Solar elastosis]] - may be confused with ''mucin''; vacuolar interface dermatitis ''not'' present


Images:
====Images====
*[[WC]]:
<gallery>
**[http://commons.wikimedia.org/wiki/File:Vacuolar_interface_dermatitis_-_intermed_mag.jpg Vacuolar interface dermatitis with dermal mucin - intermed. mag. (WC)].
Image:Vacuolar_interface_dermatitis_-_low_mag.jpg | Vacuolar interface dermatitis with dermal mucin - low mag. (WC)
**[http://commons.wikimedia.org/wiki/File:Vacuolar_interface_dermatitis_-_high_mag.jpg Vacuolar interface dermatitis with dermal mucin - high 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==
==Discoid lupus erythematosus==
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==Lichen planus==
==Lichen planus==
:''Should '''not''' be confused with [[lichen planus-like keratosis]]''.
:''Should '''not''' be confused with [[lichen planus-like keratosis]]''.
*Abbreviated ''LP''.
===General===
===General===
*An [[oral pathology]] - classically.
*An [[oral pathology]] - classically.
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*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]] (lichen planus-like keratosis) - parakeratosis prominent, no oral mucosal involvement.  
*[[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]].


Notes:
====Images====
*Hyperkeratosis and hypergranulosis are not seen in [[erythema multiforme]].
<gallery>
*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>
Image:Lichen_planus_intermed_mag.jpg | Lichen planus - intermed. mag. (WC/Nephron)
**DDx: [[systemic lupus erythematosus]], [[lichen planus]], and [[graft-versus-host disease]].
Image:Lichen_planus_low_mag.jpg | Lichen planus - low mag. (WC/Nephron)
</gallery>


Images:
===Stains===
*[http://commons.wikimedia.org/wiki/File:Lichen_planus_intermed_mag.jpg Lichen planus - intermed. mag. (WC)]
*PAS-D or PAS-F to exclude a fungal infection.
*[http://commons.wikimedia.org/wiki/File:Lichen_planus_low_mag.jpg Lichen planus - low mag. (WC)].


===Sign out===
===Sign out===
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- LICHEN PLANUS.
- LICHEN PLANUS.
</pre>
</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.
Fungal organisms are not identified with a PAS-D stain.


==Lichen sclerosus==  
==Lichen sclerosus==  
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*Other considerations:
*Other considerations:
**Drug-induced psoriasis.<ref>{{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>
**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====
====Clinical====
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Common locations:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>  
Common locations:<ref name=Ref_PCPBoD8_603>{{Ref PCPBoD8|603}}</ref>  
*Knees, elbows, scalp, glands penis.
*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 (psoriasiform hyperplasia).
*"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.
*Thinning of the suprapapillary plate.
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Note:
Note:
*[[Dermatophytosis]] = ring worm; dermatophystosis != [[dermatomycosis]].
*[[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===
===Stains===
*[[PASD stain]] -ve for [[fungi|fungal]] organisms.
*[[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==
==Lichen striatus==
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*[[Spongiotic dermatitides]].
*[[Spongiotic dermatitides]].


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Spongiotic_dermatitis_-_high_mag.jpg Mild spongiotic dermatitis - high mag. (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Spongiotic_dermatitis_-_very_high_mag.jpg Mild spongiotic dermatitis - very high mag. (WC)].
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==
==Sweet syndrome==
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DDx ''rips'':
DDx ''rips'':
*Rheumatoid neutrophilic dermatitis.
*Rheumatoid neutrophilic dermatitis.
*Bowel-associated dermatosis-arthritis syndrome.
*[[Bowel-associated dermatosis-arthritis syndrome]] (BADAS).
*[[Pyoderma gangrenosum]].
*[[Pyoderma gangrenosum]].
*Sweet syndrome.  
*Sweet syndrome.  
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==Pyoderma gangrenosum==
==Pyoderma gangrenosum==
===General===
{{Main|Pyoderma gangrenosum}}
*May be seen in [[IBD]] (UC and CD) - approximately 30% of cases.<ref name=pmid16858047/>
 
Clinical
*''[[Pathergy]]'' = minor trauma (to the skin) results in a non-healing lesion.<ref name=pmid22202507>{{Cite journal  | last1 = Wong | first1 = WW. | last2 = Machado | first2 = GR. | last3 = Hill | first3 = ME. | title = Pyoderma gangrenosum: the great pretender and a challenging diagnosis. | journal = J Cutan Med Surg | volume = 15 | issue = 6 | pages = 322-8 | month =  | year =  | doi =  | PMID = 22202507 }}</ref>
 
===Gross===
*Skin ulceration - classically on the legs.<ref name=pmid16858047>{{Cite journal  | last1 = Brooklyn | first1 = T. | last2 = Dunnill | first2 = G. | last3 = Probert | first3 = C. | title = Diagnosis and treatment of pyoderma gangrenosum. | journal = BMJ | volume = 333 | issue = 7560 | pages = 181-4 | month = Jul | year = 2006 | doi = 10.1136/bmj.333.7560.181 | PMID = 16858047 | PMC = 1513476 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513476/?tool=pubmed }}</ref>
 
===Microscopic===
Features:<ref name=pmid16858047/>
*Early: lymphocytes cells only in the dermis - often perivascular & vascular.
**+/-Fibrinoid necrosis of vessels at edge of lesion.
*Late: abscess formation ([[neutrophil]]s).
 
DDx:
*[[Vasculitis]].
*[[Sweet syndrome]].
 
Image:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513476/figure/fig5/ Pyoderma gangrenosum (nih.gov)].


==Necrobiotic xanthogranuloma==
==Necrobiotic xanthogranuloma==
*Abbreviated ''NXG''.
*Abbreviated ''NXG''.
===General===
{{Main|Necrobiotic xanthogranuloma}}
*Usually elderly.<ref name=Ref_Derm629>{{Ref Derm|629}}</ref>
 
===Gross===
Features:
*Periorbital - classic location.<ref name=pmid17544963>{{Cite journal  | last1 = Fernández-Herrera | first1 = J. | last2 = Pedraz | first2 = J. | title = Necrobiotic xanthogranuloma. | journal = Semin Cutan Med Surg | volume = 26 | issue = 2 | pages = 108-13 | month = Jun | year = 2007 | doi = 10.1016/j.sder.2007.02.008 | PMID = 17544963 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_Derm629>{{Ref Derm|629}}</ref>
*"Necrobiotic granuloma":
**Palisading granuloma with a core collagen-like material.
*+/-Cholesterol clefts - common.
*+/-[[Touton giant cell]]s.
*+/-Atypical foreign body-type giant cells +/- asteroid bodies.
 
DDx:
*[[Granuloma annulare]].
*[[Necrobiosis lipoidica]] - has plasma cells.
*Granuloma-forming infections - positive stains for microorganisms.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Asteroid_bodies_high_mag_cropped.jpg Asteroid body (WC)].


=DDx for pattern=
=DDx for pattern=
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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]].
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*Psoriasis vulgaris.
*Psoriasis vulgaris.
*Dermatophyte infection.
*Dermatophyte infection.
*Pityriasis rubra pilaris.
*[[Pityriasis rubra pilaris]].


===Irregular psoriasiform dermatitis===
===Irregular psoriasiform dermatitis===
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*'''L'''upus erythematosus.
*'''L'''upus erythematosus.
*'''L'''ymphocytic infiltrate of Jessner / tumid lupus erythematosus.
*'''L'''ymphocytic infiltrate of Jessner / tumid lupus erythematosus.
*Polymorphous '''l'''ight eruption.
*[[polymorphous light eruption|Polymorphous '''l'''ight eruption]].
*'''L'''yme disease.
*'''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 659: Line 668:


=====Tuberculoid=====
=====Tuberculoid=====
*Tuberculosis.
*[[Tuberculosis]].
*Tertiary [[syphilis]] - usu. abundant plasma cells.
*Tertiary [[syphilis]] - usu. abundant plasma cells.
*Cutaneous leishmaniasis.
*Cutaneous leishmaniasis.
Michael
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