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A Retrospective Clinicopathological Study of Cases of Perforating Dermatoses in a Tertiary Care Centre

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A Retrospective Clinicopathological Study of Cases of Perforating Dermatoses in a Tertiary Care Centre International Journal of Research in Dermatology Kandasamy S et al. Int J Res Dermatol. 2019 Nov;5(4):722-727 http://www.ijord.com DOI: http://dx.doi.org/10.18203/issn.2455-4529.IntJResDermatol20194563 Original Research Article A retrospective clinicopathological study of cases of perforating dermatoses in a tertiary care centre Saradha Kandasamy1, Prathiba Subramanian2*, Geetharani Gopalan3, 3 Ashwini Krishnamoorthy 1 Department of Dermatology, Venerealogy and Leprosy, Stanley Medical College, Chennai, Tamil Nadu, India 2Consultant Dermatologist, Namakkal, Tamil Nadu, India 3 Department of Dermatology, Venerealogy and Leprosy, Madurai Medical College, Madurai, Tamil Nadu, India Received: 25 July 2019 Revised: 15 September 2019 Accepted: 17 September 2019 *Correspondence: Dr. Prathiba Subramanian, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Perforating deramtoses is a group of diseases characterized by extrusion of dermal materials such as inflammatory cells or extracellular substances through the epidermis. They can be classified as primary and secondary perforating dermatoses. This study was done to assess the prevalence and associated systemic diseases of perforating dermatoses in our setting. Methods: This is a retrospective study done by reviewing the hospital records of patients who attended the skin OPD, Government Rajaji Hospital, Madurai Medical College, Madurai during the period June 2008 to June 2010. All patients diagnosed clinically as perforating dermatoses and supported by histopathological examination were included. Results: Kyrle’s disease (54%) was the commonest type, followed by reactive perforating collagenosis (43%) and perforating calcific elastosis (3%). About 53% of the patients presented as hyperkeratotic papules and 43% as hyperkeratotic, plugged, umbilicated papules and plaques. Erythematous papules arranged in annular and serpiginous pattern in the periphery of the central atrophic plaques were noted in 1 patient (3%). Lower extremities (73%) were the most commonly involved site. (67%) patients had at least one systemic disease and commonest association was diabetes mellitus (53%), chronic renal failure (36%), hypothyroidism (3%). Conclusions: Perforating dermatoses is a uncommon dermatological condition characterized by Trans Epidermal Elimination of dermal substances. Since it has a strong association with systemic diseases screening for systemic diseases is required for all cases. Keywords: Transepidermal elimination, Primary, Secondary, Extremities, Systemic associations 1 INTRODUCTION mucin or altered connective tissue components. Primary perforating dermatoses - Kyrle’s disease (hyperkeratosis Perforating dermatoses is a heterogenous group of follicularis et parafollicularis in cutem penetrans), disorders characterized by trans epithelial elimination reactive perforating collagenosis (RPC), elastosis (TEE) in which material from the dermis is extruded perforans serpiginosa (EPS), perforating folliculitis (PF). through the epidermis to the exterior with little or no Associated with systemic diseases -renal disease and /or disruption of the surrounding structures. The extruded diabetes mellitus, malignancy, hepatic, endocrinological disorders, AIDS, tuberculosis, pulmonary aspergillosis, material may include inflammatory cells, red cells, 2-9 microorganisms and extracellular substances, such as neurodermatitis, atopic dermatitis and scabies. The International Journal of Research in Dermatology | October-December 2019 | Vol 5 | Issue 4 Page 722 Kandasamy S et al. Int J Res Dermatol. 2019 Nov;5(4):722-727 clinical and histopathological findings may resemble any associated systemic diseases were reviewed. of these four primary perforating dermatoses (Kyrle’s, Histopathological correlation of the clinically diagnosed RPC, EPS, PF).10 As a secondary component in primary cases was reviewed. Comorbidities and associated dermatoses such as granuloma annulare, pseudoxanthoma systemic diseases of those cases was also obtained from elasticum, chondrodermatitis nodularis helices, lichen the records. nitidus, lichen planus, keratoacanthomas and necrobiosis lipoidica. RESULTS Aims and objectives Thirty patients were diagnosed as perforating dermatoses with clinical and histopathological features during the To delineate the clinical and histopathological study period from June 2008 to June 2010. features of various types of perforating dermatoses. To find out the potential relationship existing Type of perforating dermatoses between the perforating dermatoses and systemic disease. Among the 30 patients of perforating dermatoses, Kyrle’s disease was the commonest type as shown in Table 1. METHODS Table 1: Types of perforating dermatoses. Study design: This was a retrospective study. No. of Types of perforating dermatoses % Study place and period patients Kyrle’s disease 16 54 The study was carried out by reviewing the records from Reactive perforating collagenosis 13 43 June 2008 to June 2010 of patients with perforating Perforating calcific elastosis 1 3 dermatoses in the department of Dermatology, Government Rajaji Hospital, Madurai Medical College, Total 30 100 Madurai. Sex distribution Study group 20 patients were males and 10 patients were females as Patients who were clinically diagnosed as perforating shown in Table 2. dermatoses and supported by histopathological confirmation were included in this study. Table 2: Sex distribution. Procedure Types of perforating dermatoses Male Female Kyrle’s disease 11 5 This study was done by reviewing the records of patients Reactive perforating collagenosis 9 4 who were clinically diagnosed as perforating dermatoses. Perforating calcific elastosis - 1 Brief clinical history regarding the duration of disease, Total 20 10 symptoms at time of presentation and history regarding A B C Figure 1: Clinical picture of perforating dermatoses. (A) Kyrle’s disease: hyperkeratotic papules over thigh and back; (B) reactive perforating collagenosis: umbilicated papules and plaques over forearm and legs; (C) perforating calcific elastosis: plaque over periumbilical region. International Journal of Research in Dermatology | October-December 2019 | Vol 5 | Issue 4 Page 723 Kandasamy S et al. Int J Res Dermatol. 2019 Nov;5(4):722-727 Morphology of lesions Histopathology In 16 (53%) of the patients, the lesions were Histopathological evaluations revealed three types of hyperkeratotic papules as in Figure 1 (A) and in 13 (43%) lesions: hyperkeratotic, plugged, umbilicated papules and plaques as in Figure 1 (B) were apparent. Erythematous papules Histopathological features of 16 (54%) cases showed arranged in annular and serpiginous pattern in the epidermal invagination filled with keratotic plug periphery of the central atrophic plaques as in Figure 1 admixed with cellular debris and neutrophils as (C) were noted in 1 patient (3%). shown in Figure 2 (A and B). In biopsy specimens of these 16 patients, Masson trichrome and elastic van Most commonly involved site Gieson stains were negative in the epidermis and in the crater as shown in Figure 2. Hence, the overall Lower extremities (73%) were the most commonly histological appearance in these 16 cases was involved site as shown in Table 3. consistent with Kyrle’s disease as shown in Table 5. Table 3: Sites of involvement. Region No. of patients Percentage (%) Head 5 23 Trunk 17 57 Upper extremities 19 63 Lower extremities 22 73 Symptoms A B The presenting symptoms of the patients were itching in 63% and pain in 7%. 30% of patients were asymptomatic as shown in Table 4. Figure 2: Histopathology of Kyrle’s disease. (A) Structure of epidermis showing a cup shaped Table 4: Symptoms. invagination; (B) epidermal invagination filled with keratotic plug and cellular debris. Symptoms No. of patients Percentage (%) Itching 19 63 Pain 2 7 Asymptomatic 9 30 Table 5: Biopsy findings KD RPC PCE Biopsy findings A B Parakeratosis 12 8 - Hyperkeratosis 16 10 1 Keratotic plugging 15 9 1 Acanthosis 16 11 1 Dyskeratotic cells 5 - - Transepidermal channel Keratin 16 9 1 Cellular debris 13 7 1 Altered collagen fibers - 13 - C D Altered elastic fibers - - 1 Papillary dermis Lymphocytes 10 4 1 Figure 3: Histopathology of reactive perforating collagenosis. (A) Cup shaped invagination of Neutrophils 12 6 1 epidermis filled with plug containing keratin and Altered collagen fibers - 13 - cellular debris; (B) transepidermal elimination of Altered elastic fibers - - - collagen fibres; (C) Masson trichrome stain for Reticular dermis collagen showing transepidermal elimination of Altered elastic fibers - - 1 collagen stained blue; (D) Verhoeff van Gieson stain KD: Kyrle’s disease; RPC: Reactive perforating collagenosis; showing elimination of collagen stained red. PCE: Perforating calcific elastosis. International Journal of Research in Dermatology | October-December 2019 | Vol 5 | Issue 4 Page 724 Kandasamy S et al. Int J Res Dermatol. 2019 Nov;5(4):722-727 Histopathological features of 13 (43%) cases showed followed by chronic renal failure, hypothyroidism and cup shaped invagination of the epidermis filled with hypertension as shown in Table 6. a plug consisting of keratin, cellular debris and neutrophils as in Figure 3 (A).
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