Spongiotic and Psoriasiform

Dermatitis

Melissa Piliang, MD

Cleveland Clinic

Dermatology and Anatomic Pathology

Disclosure

• No conflicts of interest

Spongiosis

Spongiotic Reaction Pattern

• Eczematous tissue reaction

• Intraepidermal intercellular edema = spongiosis

• Widened intercellular spaces between

keratinocytes -> stretches desmosomes

• Desmosome failure = vesicle

Spongiotic Reaction Pattern• Allergic contact derm.

• Irritant contact derm.

• Dyshidrotic derm.

• Nummular derm.

• Atopic dermatitis

• Seborrheic dermatitis

• Mycosis fungoides

• Arthropod assault

• Dermatophytosis

• Gianotti-Crosti Syn.

• Miliaria

• Light reactions

• Pityriasis rosea

• Erythema annular centrifugum (EAC)

• Meyerson’s nevus

Spongiotic Dermatoses• Acute

– More edema - vesicles

– Orthokeratosis

• Subacute– Less prominent spongiosis

– Epidermal hyperplasia

– Parakeratosis (wet-scale crust)

• Chronic– Minimal spongiosis

– Massive epidermal hyperplasia

– Hyperkeratosis and parakeratosis

Spongiotic Dermatitis

• Acute – Spongiosis -> intraepidermal vesicle– Papillary dermal edema

– Perivascular lymphohistiocytic infiltrate – Exocytosis of lymphocytes

– Normal stratum corneum– Absence of epidermal hyperplasia

– Prototype: Allergic contact dermatitis

• Contact with an allergen after sensitization

• Type IV delayed cell-mediated immunologic reaction

• Appears 24 to 72 hours after exposure to allergen

Irritant Contact

Dermatitis• Direct toxic effect of an irritant substance, e.g.

detergents, solvents.

• More common than allergic contact dermatitis

• Occurs at the site of contact with the irritant

• Granuloma gluteale infantum: diaper-related

irritant dermatitis, candida albicans

Irritant contact dermatitis:

- Spongiosis

- Necrotic keratinocytes

- Perivascular infiltrate

- +/- Neutrophils

- Ballooning of keratinocytes

in the upper epidermis

Spongiotic Dermatitis

• Subacute:

– Less spongiosis

– Parakeratosis

– Epidermal hyperplasia

– Prototype: Atopic dermatitis

Subacute Spongiotic Dermatitis

• Atopic Dermatitis:

– Parakeratosis

– Epidermal

hyperplasia

– Mild spongiosis

– Focal lymphocytic

exocytosis

Spongiotic Dermatoses

• Chronic: – Minimal spongiosis

– Orthokeratosis with areas of parakeratosis

– Hypergranulosis

– Moderate to marked epidermal hyperplasia

– Perivascular lymphohistiocytic infiltrate

– Papillary dermal fibrosis (may be prominent)

– Prototype: Lichen simplex chronicus

Lichen Simplex

Chronicus/Prurigo Nodule

• Chronic rubbing or scratching

• Pruritic thick plaques

• Accentuation of skin markings

• Papules, nodules and excoriation

Lichen Simplex Chronicus

• Hyperkeratosis

• Vertical streaking of

collagen bundles

• Irregular psoriasiform

epidermal hyperplasia

• Follicular hyperplasia

• Mild spongiosis

Prurigo Nodularis

• Irregular hyperplasia

• Follicular hyperplasia

• Inward bending rete

• Scale crust

• ‘Hairy palm sign’

Spongiosis with Intraepidermal

Eosinophils• DDx:

– Incontinentia pigmenti, vesicular stage

– Bullous pemphigoid, urticarial phase

– Herpes gestationis

– Pemphigus vulgaris, urticarial phase

– Arthropod assault

– Drug eruption (necrotic keratinocytes, interface dermatitis)

– Erythema toxicum neonatorum

Eosinophilic Spongiosis

• Spongiosis

• Eosinophils

• DIF: Linear IgG and C3

• Bullous Pemphigoid

Eosinophilic Spongiosis

• Incontinentia Pigmenti

• Dyskeratosis

Psoriasiform Reaction Pattern

• Epidermal hyperplasia• Elongation of rete ridges• Examples:

– Psoriasis– Pityriasis rubra pilaris (PRP)– Lichen simplex chronicus– Subacute and chronic spongiotic dermatitides– Dermatophytoses– Pityriasis rosea (‘herald patch’)– Acrodermatitis enteropathica– Syphilis– Inflammatory linear verrucous epidermal nevus

Psoriasis VulgarisClinical Features

• 2% of the population, all racial groups

• Hyperproliferation of the epidermal

keratinocytes

• Overexpression of keratins 6 and 16

Psoriasis Vulgaris• Psoriasiform

epidermal hyperplasia

• Regular elongation of

rete

• Club-shaped

thickening of rete

• Parakeratosis

• Hypogranulosis

Psoriasis Vulgaris• Neutrophilic

exocytosis -> abscess– Munro microabscess -

in the parakeratotic layers

– Spongiform pustule of Kogoj - within the spinous layer

• Perivascular and interstitial lymphocytic infiltrate

Guttate psoriasis: -Focal parakeratosis

-Neutrophils

-Less epidermal hyperplasia,

less regular

-Spongiosis

Differential dx = pityriasis rosea.

Pustular psoriasis: subcorneal pustules

Medications: Iodides, Salicylates,

Progesterone

Follow w/drawal of systemic steroids

Pustular psoriasis:

-Psoriasiform epidermal hyperplasia

-Parakeratosis

-Larger subcorneal pustules

Clues that it may NOT be

psoriasis…..• Eosinophils

– Allergic contact

– Atopic dermatitis

– Medication

• Spongiosis– Dermatophyte infection

– Atopic dermatitis

• Neutrophils in stratum corneum– Syphilis

– Dermatophyte infections

• Impetiginization

– Atopic dermatitis

• Hypergranulosis

– Lichen simplex chronicus

– Pityriasis rubra pilaris

• Solitary lesion

– Clear cell acanthoma

HIV-associated Psoriasiform

Dermatitis

Plasma Cells

HIV-associated Psoriasiform

Dermatitis• Varied clinical presentation

– Seborrheic dermatitis

– Classic psoriasis

• May have predominantly acral involvement

with pustules and severe nail dystrophy

HIV PD vs Psoriasis Vulgaris

• Classic psoriasis

features:

– Psoriasiform epidermal

hyperplasia

– Confluent

parakeratosis

– Subcorneal pustules

• Clues:

– Suprapapillary plates

are not thinned

– Plasma cells present

– Neutrophil or

lymphocyte

karyorrhexis

– Apoptotic

keratinocytes

Seborrheic Dermatitis

• Irregular psoriasiform hyperplasia

• Scale crusts

• Shoulder parakeratosis at hair follicle

• Neutrophils in stratum corneum/epidermis

near follicular ostia

• Parakeratosis overlying a subcorneal neutrophilic pustule

• Psoriasiform hyperplasia

• “indistinguishable from pustular psoriasis” - McKee

Reiter’s SyndromeHistopathologic features

• Features more suggestive of Reiter’s:– A thicker stratum corneum

– Larger spongiform pustules

– Eczematous changes

– A thicker suprapapillary plate

– Neutrophils in the dermis

– The absence of clubbing of the rete ridges

Pityriasis Rubra Pilaris Clinical Features

• Small follicular papules and central keratin plug

• Perifollicular erythema →→ confluent

• “Islands of sparing”

• Waxy orange PPK

Pityriasis Rubra Pilaris (PRP)

Histopathologic Features

• Parakeratosis -> Checkerboard pattern•• Irregular epidermal hyperplasia with broad

• Prominent follicular plugging

• Perifollicular parakeratosis

• Thick suprapapillary plates

• Focal or confluent hypergranulosis

Pityriasis Rubra Pilaris• Checkerboard parakeratosis

– Accentuated at follicle

• Follicular plug

• Focal or confluent hypergranulosis

• Sparse superficial perivascular lymphocytes

Pityriasis rosea

Mounds of parakeratosis

Mild epidermal

hyperplasia

Mild spongiosis

Extravasated RBC’s

Perivascular infiltrate

ILVEN

• Psoriasiform epidermal

hyperplasia

• Alternating hyperkeratosis and

parakeratosis

• Neutrophils in stratum corneum

• Mild spongiosis

Parakeratosis, epidermal hyperplasia, mild spongiosis,

lymphocytic exocytosis, and superficial lymphocytic infiltrate

ILVEN:

Dermatophyte Infections

• Annular scaly plaques

• Psoriasiform epidermal hyperplasia and neutrophils think fungus

• ALWAYS remember to search stratum corneum for fungal elements!!!– GMS, PAS

Parakeratosis – site of fungus, may have neutrophils in the stratum corneum

Irregular psoriasiform hyperplasia

Variable spongiosis

Superficial perivascular lymphocytic infiltrate – often with eosinophils

Tinea:

Clear Cell Acanthoma

• Solitary papule

• Lower legs

• Phosphorylase mutation

Clear Cell Acanthoma • Glycogen rich keratinocytes

• Abrupt transition

• Psoriasiform hyperplasia

• Parakeratosis

• Neutrophils in stratum corneum

Granular Parakeratosis

• Acquired abnormality of keratinization

• Scaly red to hyperpigmented pruritic plaques

• Due to failure to degrade keratohyaline granules

• Clears spontaneously

Granular Parakeratosis• Compact hyperkeratosis with parakeratosis

• Granules within the stratum corneum

• Preserved granular layer

Clinical

Syphilis

• ‘Neuts in horn’ – neutrophils in the stratum

corneum

• Plasma cells

• Ice pick elongation of rete pegs

• Lichenoid infiltrate with plasma cells

• Order special stains liberally

Erythrokeratoderma Variabilis

Erythrokeratoderma Variabilis

• 2 distinct morphologic features:– Hyperkeratotic fixed plaques

– Transient erythema

• AD (rare AR and sporadic)

• 2/3 mutations encoding transmembrane proteins form gap junctions

• GJB3- connexin 31

• GJB4- connexin 30.3

CDS l May 14, 2009

Thank You

pilianm@ccf.org