dermatopathology- we’ve only just begun
TRANSCRIPT
DermatopathologyDermatopathology-- WeWe’’ve Only Just Begunve Only Just Begun
Paul K. Shitabata, M.D.Paul K. Shitabata, M.D.Dermatopathology Dermatopathology InstituteInstitute
PatternsPatterns
Epidermis
Dermis/Vessels/Hair Follicles
Fat/Vessels
AcantholysisAcantholysis
Loss of cohesion Loss of cohesion between epidermal or between epidermal or adnexaladnexal keratinacyteskeratinacytesGroverGrover’’s disease, s disease, PemphigusPemphigus, , DarierDarier’’ssdisease, Haileydisease, Hailey--HaileyHailey
AcanthosisAcanthosis
The increase in the The increase in the thickness of the stratum thickness of the stratum malpighiimalpighiiAcanthosisAcanthosis nigricansnigricans, , Pale cell Pale cell acanthomaacanthoma
ApoptosisApoptosis
Dropping off of colloid Dropping off of colloid bodies from the epidermis bodies from the epidermis into the dermisinto the dermisOccurs in disorders in which Occurs in disorders in which basal cell damage occurs, basal cell damage occurs, such as such as lichenoidlichenoid tissue tissue reactionsreactionsLichen Lichen planusplanus, LPLK, DLE, LPLK, DLE
BullaBulla
Cavity of at least 5 mm Cavity of at least 5 mm in diameter forming in diameter forming within or below the within or below the epidermisepidermisBullousBullous pemphigoidpemphigoid, , EBA, DHEBA, DH
CornoidCornoid
LamellaLamella
The The cornoidcornoid lamella is lamella is tilted toward the center tilted toward the center of such a lesionof such a lesionPeripherally migrating Peripherally migrating clone of abnormal clone of abnormal keratinocyteskeratinocytes forming forming the the cornoidcornoid lamella lamella PorokeratosisPorokeratosis
EpidermolyticEpidermolytic
HyperkeratosisHyperkeratosis
VacuolationVacuolation of the of the keratohyalinekeratohyaline granular granular layerlayerRule out Congenital Rule out Congenital IchthyosiformIchthyosiformerythrodermaerythrodermaAssociation with Association with dysplasticdysplastic nevinevi
LichenoidLichenoid
(Interface)(Interface)
Epidermal basal cell Epidermal basal cell damage manifested with damage manifested with cell death or cell death or liquefactiveliquefactivedegeneration (basal degeneration (basal vacuolar change)vacuolar change)Interface sometimes Interface sometimes applied only to applied only to poikilodermatouspoikilodermatousreactions with mild basal reactions with mild basal damage with vacuolar damage with vacuolar changechangeLichen Lichen planusplanus, Fixed drug , Fixed drug eruption, LPLKeruption, LPLK
ParakeratosisParakeratosis
Retention of nuclei in the Retention of nuclei in the stratum corneumstratum corneumNormal finding on Normal finding on mucous membranesmucous membranesSpongioticSpongiotic dermatitis dermatitis (Eczema)(Eczema)
PsoriasiformPsoriasiform
Epidermal hyperplasia Epidermal hyperplasia with regular elongation with regular elongation of of reterete ridgesridgesSeveral layers of scale Several layers of scale resulting from bouts of resulting from bouts of activityactivityPsoriasis, PRP, Lichen Psoriasis, PRP, Lichen striatusstriatus, MF, MF
SpongioticSpongiotic
IntraepidermalIntraepidermalintercellular edema with intercellular edema with widened intercellular widened intercellular spaces and elongation of spaces and elongation of intercellular bridgesintercellular bridgesSubclassifySubclassify by by inflammatory cell typeinflammatory cell typeEczemaEczema
UlcerUlcer
Obliteration of a Obliteration of a mucosal surfacemucosal surfaceUsually Usually fibrinopurulentfibrinopurulentbasebase
Epidermal Reaction PatternsEpidermal Reaction Patterns
Orthokeratosis
Spongiosis
AcanthosisParakeratosis
Hyperkeratosis
Modify by Inflammatory Cell
type
Spongiosis
Parakeratosis Acanthosis Hyperkeratosis
Orthokeratosis
Hyperkeratosis Acanthosis
Epidermal/DermalEpidermal/Dermal Reaction PatternsReaction Patterns
Superficial Superficial perivascularperivascularSuperficial and deep Superficial and deep perivascularperivascularNodular and diffuseNodular and diffuseIntraepidermalIntraepidermal vesicular and vesicular and pustularpustularSubepidermalSubepidermal vesicular vesicular
AbscessAbscess
Obliteration of tissue by Obliteration of tissue by suppurativesuppurative necrosisnecrosisMay have foreign body May have foreign body giant cellsgiant cellsConsider correlation with Consider correlation with culturesculturesConsider special stainsConsider special stains
CaseationCaseation
NecrosisNecrosis
Identical to coagulation Identical to coagulation necrosis and ischemic necrosis and ischemic necrosisnecrosisAffected tissue has lost its Affected tissue has lost its structural outline and appears structural outline and appears as pale as pale eosinophiliceosinophilic, , amorphous and finely amorphous and finely granulargranularTuberculosis, Tuberculosis, NecrobioticNecrobioticxanthogranulomaxanthogranuloma
FibrinoidFibrinoid
NecrosisNecrosis
Fibrin deposition in the Fibrin deposition in the wall of small vesselswall of small vesselsCommonly associated Commonly associated with with leukocytoclasticleukocytoclasticvasculitisvasculitis
Flame FiguresFlame Figures
Encrustation of Encrustation of eosinophiliceosinophilic granules granules around collagenaround collagenFrequent in conditions Frequent in conditions with dermal with dermal eosinophiliaeosinophiliaWellWell’’s syndrome, s syndrome, arthropod, drug reactionsarthropod, drug reactions
Granulation TissueGranulation Tissue
Newly formed dermis arising Newly formed dermis arising in healing wounds and in healing wounds and characterized by numerous characterized by numerous fibroblasts and new fibroblasts and new capillaries and an infiltrate capillaries and an infiltrate consisting of lymphoid cells, consisting of lymphoid cells, macrophages, and plasma macrophages, and plasma cellscellsDecubitusDecubitus ulcerulcer
GranulomaGranuloma
Chronic Chronic proliferativeproliferative lesion lesion consisting of mononuclear cells consisting of mononuclear cells and and epithelioidepithelioid cells or cells or multinucleated giant cells or bothmultinucleated giant cells or bothCells lie in groups and are often Cells lie in groups and are often surrounded by lymphoid cellssurrounded by lymphoid cells"Naked" "Naked" granulomasgranulomas have few to have few to none of these surrounding none of these surrounding lymphoid cellslymphoid cellsSarcoidosisSarcoidosis, foreign body, foreign body
GrenzGrenz
ZoneZone
A narrow area of A narrow area of uninvolved dermis uninvolved dermis between the epidermis between the epidermis and a dermal and a dermal inflammatory or inflammatory or neoplasticneoplastic infiltrate. infiltrate. ““GrenzGrenz”” is German for is German for ““borderborder””Some lymphomas, Some lymphomas, granulomagranuloma facialefaciale
NecrobiosisNecrobiosis
Altered collagen that Altered collagen that loses its normal loses its normal eosinophiliceosinophilic coloration coloration and and fibrillarfibrillar appearance, appearance, becoming slightly bluish becoming slightly bluish and "smudgedand "smudged““NecrobiosisNecrobiosis lipoidicalipoidica, , some infectionssome infections
Nuclear DustNuclear Dust
Fragmented nuclei Fragmented nuclei scattered in the dermis, scattered in the dermis, predominantly around predominantly around blood vesselsblood vesselsLeukocytoclasticLeukocytoclasticvasculitisvasculitis, , granulomagranulomafacialefaciale, Sweet, Sweet’’s syndromes syndrome
Epidermal ChangesSpongioticBallooning
Psoriasiform/Lichenoid
Epidermal Changes Interface
No Epidermal ChangesPerivascularIntestitial
Superficial/Deep
Lichenoid/Interface
Psoriasiform
Psoriasiform Lichenoid
Spongiotic
Superficial Superficial PerivascularPerivascular No Epidermal ChangesNo Epidermal Changes
TineaTinea versicolorversicolorDermatophytosisDermatophytosisErythrasmaErythrasmaPitted Pitted keratolysiskeratolysisVitiligoVitiligoSchamberg'sSchamberg's disease disease Viral Viral exanthemsexanthemsDrug eruption (one type)Drug eruption (one type)UrticariaUrticaria, late, lateErythemaErythema figuratumfiguratum, , superficial superficial
Superficial Superficial PerivascularPerivascular/Interstitial /Interstitial No Epidermal ChangesNo Epidermal Changes
Schamberg'sSchamberg's diseasediseasePUPPP PUPPP Dermatitis Dermatitis herpetiformisherpetiformisLinear Linear IgAIgA dermatosisdermatosisDermatitis Dermatitis herpetiformisherpetiformis--like like drug eruptionsdrug eruptionsAcute discoid lupus Acute discoid lupus erythematosuserythematosus/SLE/SLELeukocytoclasticLeukocytoclastic vasculitisvasculitisErythemaErythema marginatummarginatum
Superficial Superficial PerivascularPerivascular/Interstitial /Interstitial No Epidermal ChangesNo Epidermal Changes
BullousBullous pemphigoidpemphigoid/Herpes /Herpes gestationisgestationis, , urticarialurticarialPemphigusPemphigus vulgarisvulgaris, , urticarialurticarialArthropodArthropodPUPPP PUPPP UrticariaUrticariaPostinflammatoryPostinflammatory pigmentarypigmentaryalterationalterationMacular Macular amyloidosisamyloidosisUrticariaUrticaria pigmentosapigmentosaBrachioradialBrachioradial pruritispruritis
Superficial Superficial PerivascularPerivascular PsoriasiformPsoriasiform
PsoriasisPsoriasisAllergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitis dermatitis PityriasisPityriasis rubrarubra pilarispilarisSeborrheicSeborrheic dermatitis dermatitis
Superficial Superficial PerivascularPerivascular PsoriasiformPsoriasiform
DermatophytosisDermatophytosisCandidiasisCandidiasisLichen simplex Lichen simplex chronicuschronicusPrurigoPrurigo nodularisnodularisAcanthomaAcanthoma fissuratumfissuratumPressure papule from Pressure papule from prosthesisprosthesisSurfer's nodulesSurfer's nodulesChondrodermatitisChondrodermatitisnodularisnodularis helicishelicis
Superficial Superficial PerivascularPerivascular SpongioticSpongiotic
PsoriasiformPsoriasiform
Allergic contact Allergic contact dermatitisdermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reactionId reactionSeborrheicSeborrheic dermatitisdermatitisNonbullousNonbullous congenital congenital ichthyosiformichthyosiformerythrodermaerythrodermaLichen Lichen striatusstriatus
Superficial Superficial PerivascularPerivascular LichenoidLichenoid/Interface/Interface
Lichen Lichen planusplanusLichenoidLichenoid drugdrugPityriasisPityriasis lichenoideslichenoideschronicachronicaDLEDLEDermatomyositisDermatomyositisGVHGVHEMEM
Superficial Superficial PerivascularPerivascular Psoriasiform/LichenoidPsoriasiform/Lichenoid
Lichen Lichen striatusstriatusBullousBullous pemphigoidpemphigoidHerpes Herpes gestationisgestationis, , urticarialurticarialMycosis Mycosis fungoidesfungoides
Superficial/DeepSuperficial/Deep No Epidermal ChangesNo Epidermal Changes
Polymorphous light eruption, Polymorphous light eruption, earlyearlyErythemaErythema figuratumfiguratumErythemaErythema chronicumchronicum migransmigransPernioPernioErythemaErythema nodosumnodosumPMLE PMLE DLE, tumid DLE, tumid CLLCLLBB--cell lymphoma cell lymphoma
Superficial/DeepSuperficial/Deep No Epidermal ChangesNo Epidermal Changes
Arthropod insult Arthropod insult ErythemaErythema chronicumchronicum migransmigransScleroderma Scleroderma Leprosy, indeterminateLeprosy, indeterminate
Superficial/Deep Superficial/Deep PerivascularPerivascular
and Interstitialand Interstitial
SuppurativeSuppurative folliculitisfolliculitis, periphery, peripheryNeutrophilicNeutrophilic eccrineeccrine hidradenitishidradenitisFlea biteFlea biteCellulitisCellulitisErythropoieticErythropoietic protoporphyriaprotoporphyriaArthropodArthropodErythemaErythema chronicumchronicum migransmigransWell's syndrome Well's syndrome
Superficial/Deep Superficial/Deep PerivascularPerivascular
and Interstitialand Interstitial
GranulomaGranuloma annulareannulareNecrobiosisNecrobiosis lipoidicalipoidicaInterstitial Interstitial granulomatousgranulomatousdermatitis with arthritis dermatitis with arthritis Mycosis Mycosis fungoidesfungoides, , granulomatousgranulomatous
Superficial/Deep Superficial/Deep Epidermal Epidermal LichenoidLichenoid--InterfaceInterface
PLEVAPLEVAFixed drug eruptionFixed drug eruptionDermatophytosisDermatophytosisLyPLyPGVHGVHDLEDLEAcrodermatitisAcrodermatitis chronicachronicaatrophicansatrophicansMycosis Mycosis fungoidesfungoides, , plaque plaque
Nodular/Diffuse DermatitisNodular/Diffuse Dermatitis
Lymphocytes
Histiocytes(Granulomas)
EosinophilsPlasma cells
Neutrophils
Nodular/Diffuse DermatitisNodular/Diffuse Dermatitis
HistiocytesHistiocytes((GranulomasGranulomas))
SarcoidalSarcoidalTuberculoidTuberculoidPalisadedPalisadedSuppurativeSuppurative
Nodular/Diffuse DermatitisNodular/Diffuse Dermatitis
HistiocytesHistiocytes((GranulomasGranulomas))
TuberculoidTuberculoidSuppurativeSuppurative
Nodular/Diffuse DermatitisNodular/Diffuse Dermatitis
Cell TypeCell Type DiagnosisDiagnosis
NeutrophilsNeutrophils SweetsSweets
EosinophilsEosinophils WellWell’’s, Hypersensitivitys, Hypersensitivity
Plasma cellsPlasma cells LymeLyme
diseasedisease
HistiocytesHistiocytes GranulomatousGranulomatous
diseasesdiseases
MixedMixed GranulomaGranuloma
facialefaciale
IntraepidermalIntraepidermal Vesicular Vesicular and and PustularPustular DermatitisDermatitis
Vesicular Pustular
Ballooning Spongiosis Acantholysis Cleaving Intracorneal Subcorneal
IntraepidermalIntraepidermal
Vesicular Vesicular DermatosisDermatosis
Spongiosis
Intraepidermal vesicle
Intraepidermal bullae
IntraepidermalIntraepidermal
SpongiosisSpongiosis
Allergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reactionId reactionPhotoallergicPhotoallergic dermatitis, earlydermatitis, earlyDermatophytosisDermatophytosisMiliariaMiliaria rubrarubraGianottiGianotti--CrostiCrosti syndrome syndrome PityriasisPityriasis rosearoseaErythemaErythema annulareannulare centrifugumcentrifugumSeborrheicSeborrheic dermatitis dermatitis Lichen Lichen striatusstriatusPityriasisPityriasis alba alba Mycosis Mycosis fungoidesfungoides, , maculemacule/patch /patch
IntraepidermalIntraepidermal
SpongiosisSpongiosis
PUPPPPUPPPAllergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reaction Id reaction BullousBullous pemphigoidpemphigoidHerpes Herpes gestationisgestationisPemphigusPemphigus vulgarisvulgaris, , urticarialurticarialIncontinentiaIncontinentia pigmentipigmentiToxic Toxic erythemaerythema of newborn of newborn Arthropod assault Arthropod assault
IntraepidermalIntraepidermal
BallooningBallooning
HerpesHerpesOrfOrfParapoxParapox infectioninfectionMeaslesMeaslesHydroaHydroa aestivale/Hydroaaestivale/Hydroavacciniformevacciniforme
IntraepidermalIntraepidermal
with with AcantholysisAcantholysis
PemphigusPemphigus vulgarisvulgarisPemphigusPemphigus vegetansvegetansPemphigusPemphiguserythematosuserythematosusPemphigusPemphigus foliaceusfoliaceusFogoFogo selvagemselvagemGroverGrover’’s diseases disease
IntraepidermalIntraepidermal SpongioticSpongiotic
Psoriasiform/LichenoidPsoriasiform/Lichenoid
Allergic contact dermatitisAllergic contact dermatitisNummular dermatitisNummular dermatitisDyshidroticDyshidrotic dermatitisdermatitisId reactionId reactionSeborrheicSeborrheic dermatitisdermatitisNonbullousNonbullous congenital congenital ichthyosiformichthyosiform erythrodermaerythrodermaLichen Lichen striatusstriatus
IntraepidermalIntraepidermal SpongioticSpongiotic
Psoriasiform/LichenoidPsoriasiform/Lichenoid
Lichen Lichen striatusstriatusBullousBullous pemphigoidpemphigoidHerpes Herpes gestationisgestationis, , urticarialurticarialMFMF
SubepidermalSubepidermal
Vesicular Vesicular DermatosisDermatosis
Subepidermal
Minimal Mixed Lymphocytes
Neutrophils Neuts/Eos Mast Cells
SubepidermalSubepidermal
Vesicular Vesicular DermatosisDermatosis
BullousBullous pemphigoidpemphigoid/Herpes /Herpes gestationisgestationisCicatricialCicatricial pemphigoidpemphigoidDermatitis Dermatitis herpetiformisherpetiformis/Linear /Linear IgAIgA diseasedisease
SubepidermalSubepidermal
Vesicular Vesicular DermatosisDermatosis
EBAEBABullousBullous LELEBullousBullous mastocytosismastocytosisBullousBullous amyloidosisamyloidosisDrug reactionsDrug reactionsLPLP
Special CategoriesSpecial Categories
VasculitisVasculitisAlopeciaAlopeciaFolliculitis/PerifolliculitisFolliculitis/PerifolliculitisFibrosingFibrosing dermatitisdermatitisPanniculitisPanniculitis
VasculitisVasculitis
Mixed
Large Vessel
Small Vessel
VasculitisVasculitis
LeukocytoclasticLeukocytoclasticvasculitisvasculitisMicroscopic Microscopic arteritisarteritisPolyarteritisPolyarteritis nodosanodosaErythemaErythema induratuminduratum
Alopecia
Non-Inflammatory Inflammatory
Follicle density normal Follicle density decreased Lymphocytes Mixed
AlopeciaAlopecia NonNon--InflammatoryInflammatory
Follicle density normalFollicle density normalAndrogenic alopecia Androgenic alopecia TelogenTelogen effluviumeffluviumTrichotillomaniaTrichotillomania
Follicle density decreasedFollicle density decreasedTraction alopecia Traction alopecia
AlopeciaAlopecia InflammatoryInflammatory
Alopecia Alopecia areataareataLichen Lichen planopilarisplanopilarisDLEDLESclerodermaSclerodermaFolliculitisFolliculitis decalvansdecalvansTineaTinea capitiscapitisMajocchi'sMajocchi's granulomagranulomaBurns/RadiationBurns/RadiationSyphilis Syphilis ScarScar
LPPLPPSclerodermaSclerodermaDLEDLE
Spongiotic
PerifolliculitisSuppurative
Folliculitis
Granulomatous Fibrosing
Lymphocytes
Perifolliculitis
Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis
Infectious (Infectious (StaphStaph, Strep, , Strep, DermatophytosisDermatophytosisEndothrix/EctothrixEndothrix/Ectothrix))Acne Acne vulgarisvulgarisAcne Acne rosacearosaceaPerforating disordersPerforating disorders
Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis
InfundibulofolliculitisInfundibulofolliculitisAlopecia Alopecia mucinosamucinosaPerifolliculitisPerifolliculitis
ScurvyScurvyLichen Lichen planopilarisplanopilarisDLEDLERosaceaRosaceaKeratosisKeratosis pilarispilaris
FibrosingFibrosing
DermatitisDermatitis
Fibrosing Dermatitis
Fibrocytes Increased Fibrocytes Decreased
SclerosisRadiation
ScarScleroderma/Morphea
Antecedents to Fibrosis
UlcerGranulation tissue
Granulomas
Sclerosis
Fibrosis
Antecedent to Fibrosis
FibrosingFibrosing
DermatitisDermatitis
ScarScarChronic Chronic lymphedemalymphedemaKeloidKeloidDermatofibromaDermatofibromaAnetodermaAnetodermaAcrodermatitisAcrodermatitis chronicachronicaatrophicansatrophicansLSEA/LSEA/MorpheaMorpheaRadiation sclerosisRadiation sclerosis
PanniculitisPanniculitis
LobularWith or without Vasculitis
SeptalWith or without vasculitis
PanniculitisPanniculitis
ErythemaErythema nodosumnodosumErythemaErythema induratuminduratumLupus Lupus panniculitispanniculitisInfectiousInfectiousPancreatic fat necrosisPancreatic fat necrosisLympohmaLympohmaSubQSubQ fat necrosisfat necrosisPoststeroidPoststeroid panniculitispanniculitis
QuestionsQuestions
People talk fundamentals People talk fundamentals and superlatives and then and superlatives and then make some changes of make some changes of detail. detail.
Oliver Wendell Holmes Jr.Oliver Wendell Holmes Jr.
(1841 (1841 --
1935)1935)