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Invisible Dermatoses

To our knowledge, Martin Brownstein and tle else besides a cornoid lamella. Multiple Asher Rabinowitz first used the term "invisi- sections must be searched to find this struc• ble dermatoses."* Generations of dermatolo• ture (p. 176). gists, however, have struggled with biopsy 3. -Often the only clue to ich• specimens from diseased that appear to be thyosis vulgaris is the absence of a granular normal under the microscope. Since normal layer that is associated with compact hy• skin is rarely ever biopsied in clinical practice, perkeratosis. In the absence of hyperkera• one must assume that some is present. tosis, this is an easy diagnosis to miss. Technical problems must be eliminated, such 4. Pigment changes- looks almost as sampling errors where normal skin on an normal, except that are miss• edge of the biopsy specimen has been sectioned ing (as is ). Conditions that have in• and the diseased tissue has been left in paraf- creased melanin, but normal numbers of fin. It is wise to check again to see if the cli• melanocytes (e.g., and cafe au lait nician might have submitted normal skin (e.g., spots) may be mistaken for normal black pruritus, resolved urticaria, patient insisting skin. that normal spot is painful, and normal skin obtained for IF but submitted for H&E stain• ing). At this point, one needs a strategy for studying skin that appears histologically nor• Dermal mal, but must contain disease. We consider the following conditions: 1. Incontinence of pigment-Melanin in the papillary may be the only clue to a der• matitis that involved the epidermal-dermal Epidermal Diseases junction (e.g., or erythematosus ). 2. Amorphous deposits in the papillae-Ma• 1. and fungal disease• cular amyloidosis can have very subtle deposits Check the stratum corneum for hyphae and of amyloid in the dermal papillae; other forms do a PAS stain. of cutaneous amyloidosis may have deposition 2. Porokeratosis-Porokeratosis may have lit- around blood vessels. Special stains for amy• loid will help. *Brownstein MH, Rabinowitz AD: The invisible 3. Mast cell infiltrates (p. 161)-Mastocyto• dermatoses. J Am Acad Dermatol 8:579-588, mas are easy to identy, but both urticaria pig• 1983. mentosa and macularis eruptiva

209 210 Invisible Dermatoses perstans may have only slightly increased long axis traverses the border between diseased numbers of mast cells. Eosinophils, increased and normal skin or by studying punch biopsy pigment, and increased vessels are adjunctive specimens from diseased and contralateral clues. normal skin (the latter would then, by defini• 4. Dermal melanocytes-Sometimes, the de• tion, be an invisible dermatosis if misfiled or position of dermal spindle-shaped melanocytes transposed). in a blue can be quite subtle. In the more Macular , or anetoderma, is defined diffuse dermal melanocytic conditions (e.g., by the absence of elastin with normal collagen; Mongolian spot in the neonates), it often is im• in atrophoderma, however, the dermis is sim• possible to find the melanocytes. ply reduced in thickness, but contains normal 5. Argyria-A patient may be almost • elastin and collagen. Both present as depres• black clinically with cutaneous silver deposits sions; thus, a careful biopsy procedure, com• and still have only subtle grains of silver about parison with normal skin, and use of special dermal sweat ducts histologically. Always ex• stains all are required for an accurate diagno• amine the basement membrane zone around sis. In focal dermal hypoplasia, the dermis also sweat ducts in otherwise normal skin. is thinned, but to such an extent that the di• 6. Urticaria-Urticarial lesions often may agnosis is obvious. nevus (or show only minimal edema with a sparse peri• the shagreen patch in ) has vascular lymphocyte infiltrate. Sometimes, a an excess of elastin, collagen, or both. Once resolving urticarial lesion will be normal or a again, only comparison within normal skin and true invisible dermatosis. use of special stains will allow a diagnosis. 7. Connective tissue-Connective tissue ab• There are many other examples of invisible normalities can be very subtle; here, it often is dermatoses; hopefully, however, these few dis• necessary to compare normal and abnormal ease entities will give the beginner a means of structures either by studying an ellipse whose approaching the problem. Further Readings

Walter H. C. Burgdorf

As mentioned in the introduction, this book (As mentioned on p. 57, Dr. Ackerman's was produced without references to help main• book gives a sense of order to the befuddling tain its simple format. I hope that every reader world of inflammatory skin disorders. I will have access to at least one additional der• highly commend both his approach and his matopathology textbook and will consult it book.) often; both for further information and for ref• Ackerman AB, Niven J, Grant-Kels JM: Dif• erences. This annotated reading list is selec• ferential Diagnosis in Dermatopathology. tive-not inclusive. Hopefully it provides an Lea & Febiger, Philadelphia, 1982, 195 pp. adequate introduction to the literature of (The format of this effort is unique. Dr. Ack• derma topa thology. erman and his coworkers contrast 45 pairs of difficult histologic diagnoses, such as Pa• STANDARD TEXTBOOKS get's disease versus Bowen's disease, with Lever WF, Schaumberg-Lever G: Histopath• color pictures and lists of diagnostic ology of the Skin. JB Lippincott, Philadel• criteria.) phia, 1983, 848 pp. (Dr. Lever's book is the classic text with the Enzinger FM, Weiss SW: Tumors. best references. I cannot imagine studying a The CV Mosby Co, St. Louis, 1983, 840 pp. microscopic slide or writing about skin pa• (Dr. Enzinger and Dr. Weiss have produced a masterpiece; readable, but unquestion• thology without a copy at my side.) ably authoritative. Dermal proliferations, Pinkus H, Mehregan AH: A Guide to whether neural, muscular, vascular, or fibro• Dermatohistopathology. Appleton-Century• blastic, are reviewed in depth; but, in a prac• Crofts, New York, 1981,591 pp. tical fashion.) (If you canfind an older edition of this text, buy it. Dr. Pinkus was among the first to em• McGovern VJ: : Histological Diag• phasize correlation of skin anatomy and dis• nosis and Prognosis. Raven Press, New ease, an embryologic approach to appenda• York, 1983, 197 pp. geal tumors, and pattern diagnosis. In later Roses DF, Harris MN, Ackerman AB: Diag• editions, his text has become more diffuse nosis and Management of Cutaneous Ma• and encyclopedic.) lignant Melanoma. WB Saunders, Philadel• phia, 1983, 304 pp. OTHER BOOKS (Malignant melanoma is, at once, the most Ackerman AB: Histologic Diagnosis of In• important single topic in and a flammatory Skin Diseases. Lea & Febiger, most difficult subject to adequately cover in Philadelphia, 1978, 863 pp. an introductory textbook. These two new

211 212 Further Readings

books have been most helpful to me in trying ology papers appear in the following journals: to keep abreast of this crucial area.) American Journal of Surgical Pathology Archives of Dermatology PERODICALS British Journal of Dermatology No textbook can be up to date; something is Cancer always new in the literature. Two journals are Histopathology devoted specifically to dermatopathology: Journal of the American Academy of American Journal of Dermatopathology Dermatology Journal of Cutaneous Pathology Once again, other valuable dermatopathology These two journals, however, have not cap• articles appear outside of this short list; how• tured the market as far as quality skin pathol• ever, if you read the above journals, you will ogy articles. Many outstanding dermatopath- rarely be too far behind in studying skin. Glossary

This glossary is highly restricted; it only in• Buckshot scatter: Random distribution of cludes those dermatopathologic terms that are melanocytes through in malignant used in the histologic descriptions in this man• melanoma. ual. Many important expressions have been omitted simply because of the limited size of Cartwheel pattern: Spindle-shaped tumors the text. Furthermore, no attempt has been may be arranged so that the elongated cells ra• made to define normal structures or diseases; diate from a central point like a cartwheel. these subjects are listed in the index. Caseation necrosis: Total necrosis, initially described in tuberculosis; histologically, one : Accumulation of neutrophils. sees no remnants of cell structures, just ne• : Loss of adhesion between epi• crotic material. dermal cells. Civatte body: Degenerated keratinocyte, Acanthosis: Thickening of epidermis because which appears homogeneous and eosinophilic; of increased number of keratinocytes (see common in lichen planus. Hypertrophy). Collarette: A little collar; refers to a periph• Atrophy: Condition of being flattened or eral process, such as scale about a lesion or an thinned; most often refers to a thinned layer, epidermal reaction about a tumor, or such as such as epidermis or dermis. the epidermis encompassing the metastatic Atypia: Cytologic abnormality of cells, with malignant melanoma (p. 138). abnormal irregularly shaped nuclei and mi• Colloid body: See Civatte body. toses; suggesting a malignant change. Cornoid lamella: Parakeratotic column in porokeratosis. Ballooning degeneration: Epidermal change Corps ronds: Dyskeratotic acantholytic cell, in viral , where marked intracellular with a central basophilic nucleus, clear halo, edema destroys the intercellular connections. and peripheral keratin shell. Basaloid: Resembling cells of the basal Cuffing: Accumulation of cells (usually lym• layer. phocytes) about a vessel. Basket-weave : When the nor• Cytolysis: Destruction of cells, as in viral de• mal horny layer pattern of retained cell walls struction of epidermis. and "lost" cytoplasm is exaggerated, the wall remnants resemble basket-weaving. Basophilic: Bluish color resembling basal Desmoplasia: Proliferation of dermal fibrous cells' color (on hematoxylin and eosin stain). elements, as in desmoplastic malignant Basophilic degeneration: Actinic degenera• melanoma. tion of collagen; the damaged collagen stains Dirty feet: Accumulation of melanin at base bluish, rather than the normal reddish tint. of rete ridges in actinic . 213 214 Glossary

Dyskeratosis: Abnormal, usually premature, Horn pseudocyst: Epidermal invagination in keratinization of epidermal cells, which lead to . individual cell keratinization rather than or• Hydropic degeneration: Damage to the cells derly formation of stratum corneum; can be of the basal layer, which produces tiny spaces either acantholytic (as in Darier's disease) or or vacuoles in the cells. neoplastic (as in Bowen's disease). : Thickening of the stratum Dysplasia: Tissue change with disordered granulosum (granular layer). growth that includes both cytologic abnormal• Hyperkeratosis: Thickening of the stratum ities (atypia) and pattern abnormalities. corneum. Hypertrophy: Literally, excessive growth• in contrast to acanthosis; hypertrophy suggests Edema: Tissue swelling from leakage of fluid an epidermal thickening by an increase in cell out of vessels. size, not cell number. Entrapment of collagen: Change at periph• Hypoplasia: Thinning because of a decrease ery of (Fig. 174); probably in cell number. does not involve any "trapping," but small fragments of normal collagen appear to be en• Incontinence of pigment: Dropping of mela• circled by abnormal collagen. nin into the dermis because of inflammation at Eosinophilic: Reddish color, as the granules the epidermal-dermal junction. of an eosinophil (in hematoxylin and eosin Indian filing: Distribution of infiltrating stain). tumor cells between strands of collagen. Epidermotropism: Migration of cells into the In situ: Confined to the epidermis. epidermis without associated or other signs of inflammation. Kamino body: Eosinophilic globules in epi• Epidermolysis: Separation of epidermis from dermis of Spitz nevi. dermis at epidermal-dermal junction; now Kogoj's pustule: See spongiform pustule of somewhat archaic, since the junction has be• Kogoj. come so complex. Epidermolytic hyperkeratosis: Peculiar Lentiginous: Resembling a lentigo with elon• granular degeneration of epidermis, which is gated rete ridges. seen in a variety of congenital and acquired Leukocytoclasia: Destruction of neutrophils conditions. to leave nuclear fragments and dust; seen in Exocytosis: Migration of cells into the epi• . dermis with associated spongiosis. Lichenoid: Resembling lichen planus with a band-like infiltrate at the epidermal-dermal junction. Fibrinoid degeneration: Collagen or vessel wall acquires a bright eosinophilic homoge• Metachromasia: Phenomenon in which ma• neous appearance. terial stains with a color different from that of Fibrosis: Proliferation of dermal fibrous the dye used, as with mast cell granules that elements. stain purple with the blue Giemsa stain. Freundenthal's lacuna: Subepidermal space Microabscess: Tiny abscess (see Munro and (or lacuna) in . Pautrier). Monomorphism: Uniformity of cell types, as Grain: Dyskeratotic-acantholytic cell with in an infiltrate composed solely of small condensed keratin. lymphocytes. Grenz zone: Zone of normal dermis between Mucin: General term for amorphous glyco• dermal infiltrate and epidermis. proteins. Dermal mucins are basophilic and Ground-glass cytoplasm: Eosinophilic amor• represent variations in ground substance. Epi• phous change in cytoplasm of epidermal cells dermal mucins are secretory products (e.g., in (as in keratoacanthoma). the ductal tumors of Paget's disease). Glossary 215

Munro microabscess: Accumulation of neu• Pseudoepitheliomatous hyperplasia: Down• trophils in parakeratotic stratum corneum of ward reactive epidermal proliferation that . mimics in any chronic inflammation and at the edge of chronic ulcers. Necrobiosis: Degenerative change in colla• Psoriasiform: Resembling psoriasis with gen (literally in a condition of life and death), elongation of rete ridges. which is best seen in granuloma annula:e. Necrolysis: Separation of tissue caused by Reticular degeneration: Epidermal change in cell death. viral blisters in which only cell walls are left in Necrosis: Cell or tissue death. multilocular blisters. Also may be seen in very Nuclear dust: See leukocytoclasia. severe spongiosis.

Pagetoid: Resembling Paget's disease, with Saw-toothing: Notching of the lower epider• clear cells distributed throughout the epider• mis in lichen planus. mis; also seen in Bowen's disease and malig• Sclerosis: Proliferation of dermal fibrous nant melanoma. elements. : Lesion that resembles a nipple in Solar elastosis: See basophilic degeneration. the sense of having many tiny undulations; his• Spongiform pustule of Kogoj: Large neutro• tologically, show . philic pustule in pustular psoriasis; larger and Papillomatosis: Elongation of dermal papil• lower in the epidermis than Munro lae, with associated hyperkeratosis. microa bscess. : Retention of nuclei in the Spongiosis: Intercellular edema in epider• stratum corneum. mis; hallmark of acute inflammation. Pautrier microabscess: Atypical cerebriform Squirting papilla: Neutrophils in flattened lymphocytes clustered in the epidermis with• epidermal plate and overlying stratum cor• out spongiosis in . neum in psoriasis. Perivasculitis: Accumulation of cells (usu• Storiform pattern: Spindle-shaped tumors ally lymphocytes) about vessels without vessel may be arranged so that the elongated cells in• wall damage. tertwine to resemble weaving. Pleomorphism: Variation in the appearance of cells of the same type. Vacuolar degeneration: See hydropic de• Polymorphism: Variation in types of cells. generation. Porokeratosis: Literally means keratiniza• . Vasculitis: Inflammation damaging a blood tion about pores, but has come to mean disor• vessel; in the skin, usually associated with ders of keratinization with cornoid lamellae. leukocytoclasia. Index

All the major concepts in the text are included in the index. Every disease reference is included, including all those places where a given disease process is mentioned in a differential diagnosis. The major page reference where a disease is illustrated is signified by italic type. No glossary terms are indexed. Individual special stains are not indexed; they are cross-referenced on page 27.

Acanthosis nigricans, 39, 146 , 44, 54-55 Dermatomyositis, 95 Acral lentinginous malignant Carcinoma, basal cell, 40, 157, ,54-55 melanoma, 13 7 181-184 Dermatoses Acrokeratosis verruciformis, 39 nodular, 181-182 classification, 57 Acrospiroma, eccrine, 159 morpheaform, 181-184 invisible, 209-210 Actinic degeneration, 16-17 pigmented, 182 lichenoid, 66-68 keratosis, 39, 93,141,172-175 superficial, 181-183 psoriasiform, 57-65 Actinomycosis, 46 Carcinoma, squamous cell Dermatosis, transient Adenoma sebaceum, 151 in situ, 177-178 acantholytic, 83, 143, AIDS, 198-199 invasive, 186-188 144 Anchoring fibrils, 11-12 Cherry angioma, 192-193 Dermis, embryology, 3-4 Angiokeratoma, 195 Clark's levels, 130 pathology, 16-17 Angioma, 192-193 Clear cell hidradenoma, 159 structure, 11-14 Angiosarcoma, 200 Clear cells, epidermal, 177 Desmosome, 6 Apocrine Collagen, 11-13 Dyskeratoma, warty, 143 gland, 8-9 Comma tails, 154 , 16, 142-145 hidrocystoma, 160 Compound nevus, 118-120 Dysplasia, 16 bite, 56, 79-80 Condyloma acuminatum, 42-43, Dysplastic nevus, 126-127 Atrophy, 23-24 149 Congenital nevus, 122 Eccrine Bacterid, pustular, 60 Cornoid lamella, 176 gland, 9-10 Balanitis xerotica obliterans, 97 Corps rond, 143 tumors, 157-160 Basal cell carcinoma, see , 23 acrospiroma, 159 carcinoma , 172-173 clear cell hidradenoma, Basal lamina, 11-12 Cylindroma, 156 159 Basal layer, 5-6 Cyst, 21-22,152-153 dermal duct tumor, 157 Basement membrane zone, 11- epidermoid, 152-153 hidradenoma, clear cell, 12, 15-16 pilar, 152-153 159 Biopsy specimen Cytology, 17-20 hidrocystoma, 160 fixation, 25-26 poroma, 157 obtaining, 25 Darier's disease, 83, 142-143 spiradenoma, 158 processing, 26 Decapitation secretion, 9 Elastin, 13 , 21-22 Dermal duct tumor, 157 Electron microscopy, 28 Blue nevus, 128 Dermatofibroma, 106-107, 128 Embryology, 3-4 Bowenoid papulosis, 42 Dermatofibrosarcoma Eosinophil, 18 Bowen's disease, 149,172,177-178 protuberans, 108-109 Epidermal-dermal junction, 11- Breslow's depths, 130 12, 15-16 Bulla, 21-22 acute, 68-70 Epidermal nevus, 140-141 Bullous diseases, 81-91 chronic, 70-71 Epidermis, embryology, 3-4 immunofluoresence, 26-27 herpetiformis, 89-90 pathology, 15-16 mechanisms, 81 interface, 15-16, 62-63 structure, 5-11 table, 82 lichenoid, 66-68 , 152-153 , 76, 87-88 seborrheic, 57 Epidermolysis bullosa, 91 217 218 Index

Epidermolytic hyperkeratosis, Hive, 22 sclerosus et atrophicus, 91, 140, 174 Horn pseudocyst, 147 97-98 Erosion, 23-24 Horny layer, 6 simplex chronicus, 72 elevatum diutinum, Hypertrophy, 24. Lichenification, 24 105 Lichenoid , 76-77,91 Immunofiuoresence, 26-27 actinic keratosis, 67, 93, 172 , 75 Immunohistochemistry, 27-28 dermatitis, 66-67 Erythroplasia, 177 Immunoperoxidase,27-28, III keratosis, 67 Excoriation, 23-24 , 44-45, 59, 78 Lupus band test, 93-94 Indian filing, 201-202 Lupus erythematosus, 79, 92- Fibrils, anchoring, 11-12 Interface dermatitis, 15-16,62- 95, 102 Fibroblast, 20 63 discoid, 92-94 Fibroepithelioma, Pinkus, 149, Intradermal nevus, II 8-1 21 hypertrophic, 72 185 Invisible dermatoses, 209-210 subacute, 95 , 108 Irritated seborrheic keratosis, systemic, 95 Fixation, 25-26 149-150 Lupus vulgaris, 47-48 Fissure, 23-24 Lymphangioma, 196 Flat , 40-41 Junctional nevus, 118-119 Lymphocyte, 18 Fordyce spot, 8 Juvenile xanthogranuloma, I lO- Lymphocytic infiltrate, 79-80 Foreign body 1lI,123 Lymphocytic perivasculitis, 61, giant cell, 19-20 70-71, 73, 76, 87 granuloma, 100, 103-104 Kamino body, 123 Lymphoid hyperplasia, 79-80 Freudenthal's lacunae, 172, 175 Kaposi's , 198-199 Lymphoma, malignant, 203-204 Fungal diseases, 54-55 Keratin, 6 differential diagnosis, 79 Keratoacanthoma, 189-191 epithelioid, 50 , 42-43 Keratohyalin, 6 mycosis fungoides, 205-206 Giant cell, 18-20 Keratosis T-cell, 205-206 foreign body, 19-20 actinic, 39, 141, 172-175 Lymphomatoid papulosis, 61 Langhans, 19-20, 47-48 hypertrophic actinic, 189 nevus, 121 lichenoid actinic, 67, 93, Macule, 22 Touton, 19-20, II 0-1 II 172 Malherbe tumor, 155 viral, 34-35 lichenoid, 67 Mast cell Gland seborrheic, 39, 40, 42, 141, infiltrate, 161-163 apocrine, 8-9 147-150,157,185 structure, 20 eccrine, 9-10 irritated seborrheic, 149- Mastocytoma, 110, 123, 161- sebaceous, 8 150 163, 197 Glomus tumor, 161,197, stucco, 39 , 10, 115-116 Grain, 143 Kogoj pustule, 59 Melanoma, malignant Granular layer, 6 acral lentiginous, 137 Granuloma, annulare, 40, 98-99 Lamina lucida, 11-12 depths, 130 faciale, 105 Laminin, 11-12 general aspects, 129-131 foreign body, 100, 103-104 Langerhans cell, 10-11,207 histologic criteria, 131 pyogenic, 194-195 Langhans giant cell, 19-20,47- , 117, 132-133 tuberculoid,47-48 48 metastatic, 138-139 Ground substance, 13 , 163-165 nodular, 135-136 Lentigo superficial spreading, 134- Hailey-Hailey disease, 83, 143, actinic, 117 135, 177 144-145 maligna, 117 survival, 130 Hair simple, 116 Merkel cell, 11, 13 destruction, 66-67, 92-94 Lentigo maligna melanoma, Mesenchyme, 3 structure, 7-8 132-133 Metastatic tumors Halo nevus, 122 , 49-51 malignant melanoma, 138- , 192-193 lepromatous, 49-50, 112 139 Hemangiopericytoma, 197 tuberculoid, 49-51, 100 other, 201-202 Herpes virus, 34-35 LEOPARD syndrome, 116 Microfibrils, 11-12 Hidradenoma, clear cell, 159 Leukemia, 203-204 , 36-37 Hidmcystoma, 160 Leukocyte, 18 Monocyte, 18 apocrine, 160 Leukocytoclastic vasculitis, 61, , 95-96, 97 eccrine, 160 73, 76 Munro microabscess, 57, 59 Histiocyte, 18 Lichen, nitidus, 67 Muscles, 14 , 49, 106-107, 112 planus, 66-67, 91,93 Mycosis fungoides, 62-63, 205- Histiocytosis X, 206-207 hypertrophic, 72 206 Index 219

Necrobiosis, 99 lichenoides et varioliformis Stratum, basale, 5-6 acuta, 52, 61, 64, 73 corneum, 6 diabeticorum, 99 rosea, 61, 64-65 granulosum, 6 Necrolysis, toxic epidermal, 76- Plane wart, 40-41 lucidum,6 78 Plaque, 21 spinosum,6 Nerves, 13 Plasma cell, 18 Strawberry hemangioma, 192- Neural nevus, 168 Polarization, 104 193 Neurilemmoma, 169 Polyarteritis nodosa, 74 Stucco keratosis, 39 , 166-168 Polymorphonuclear leukocyte, Subcorneal pustulosis, 44, 59 Neutrophil, 18 18 Sulfur granule, 46 Nevus, epidermal, 140-141 Porokeratosis, 140, 176 Superficial spreading malignant inflammatory, 140 Poroma, eccrine, 157 melanoma, 134-135, 177 Jadassohn, 140-141, 151 , 91 Sweet syndrome, 105 sebaceous, 140-141, 151 Port wine stain, 192-193 , 52-53 Nevus, meianocytic, 118-128, Prickle cell layer , 6 Syringoma, 40, 154 168 Pseudocyst, horn, 147 blue, 128 Psoriasis, 52, 57-58, 64 T-cell lymphoma, 205-206 compound,118-120 pustular, 44, 59 Telangiectasia macularis congenital, 122 Pustular bacterid, 60 eruptiva et perstans, 161 dysplastic, 126-127 Pustule, 21-22 Tonofibril, 6 halo, 122 Pustulosis Tonofilament, 6 intradermal, 118-121 palmar-plantar, 60 Touton giant cell, 20, 111 junctional,118-119 sub corneal, 44, 59 Toxic epidermal necrolysis, 76- neural,168 Pyogenic granuloma, 194-195 78 recurrent, 125 Transient acantholytic spindle and epithelioid, 123- Recurrent nevus, 125 dermatosis, 83, 143, 144 124 Rheumatoid nodule, 99 Tuberculosis, 47-48 Spitz, 110, 123-124 , 102 Tzanck smear, 34-35 Nodular malignant melanoma, 135-136 Sarcoidosis, 40, 50, 100-101 , 23-24 Nodule, 21-22 Sarcoma, Kaposi's, 198-199 Urticaria, 22 , 56 Urticaria pigmentosa, 161 Paget's disease, 177, 179-180 Scalded skin, staphylococcal, 44, Painful tumors, 163 78,86 Varicella-zoster virus, 34-35 Palmar-plantar pustulosis, 60 Scale, 23 Vasculitis, leukocytoclastic, 61, Panniculitis, 75 Scar, 23-24 73,76 Papilloma, 39 Scleredema, 95 Verruca, 38-43, 141 Papilloma viruses, 38-43 , 95-96 vulgaris, 38-39 , 21-22 Scleromyxedema, 95 Vesicle, 21-22 Papulosis, Bowenoid, 42 Sclerosis, 24 Vessels, 13-14 lymphomatoid,61 Sebaceous gland, 8 Viral diseases, 33-43 , 57, 61-63 hyperplasia, 151 herpes, 34-35 guttate, 62 nevu~ 140-141, 151 molluscum contagiosum, 36- interface, 62-63 Seborrheic dermatis, 57 37 Patch,22 Seborrheic keratosis, 39, 40, 42, verruca, 38-43 Pautrier microabscess, 205-206 141,147-150,157 , 38-43 Pemphigoid antigen, 11-12 irritated, 149-150 Von Recklinghausen's disease, Pemphigoid, bullous, 76, 87-88 Senile sebaceous hyperplasia, 151 166 , 44,82-86, 143, 144 Sezary cell, 205-206 foliaceus, 86, 144 Shadow cell, 155 Wart, 38-43 vegetans, 85 , 170-171 common, 38-39 vulgaris, 82-84 Special stains, 25-26 flat, 40-41 Perivasculitis, lymphocytic, 61, Spindle and epithelioid nevus, genital, 42-43 70-71, 73, 76, 87 123-124 plane, 40-41 Peutz-J eghers syndrome, 116 Spiradenoma, eccrine, 158 Warty dyskeratoma, 143 Phagocyte, 18 Spitz nevus, 123-124 Pilar cyst, -152-153 Stains, special, 26-27 Xanthelasma, 112-113 Pilomatricoma, 155 Staphylococcal scalded skin Xanthogranuloma, juvenile, Pinkus tumor, 149,185 syndrome, 44, 78, 86 110-111, 123 Pityriasis Stewart-Treves syndrome, , 49, 106, 112-113 lichenoides chronica, 62, 64 200 verruciform, 112