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Symposium Appearances in : The diagnostic Dermatopathology and the deceptive

Bhushan Madke, Bhavana Doshi, Uday Khopkar1, Atul Dongre1

Department of Dermatology, ABSTRACT Topiwala National Medical College and B.Y.L. Nair Dermatopathology involves study of the microscopic morphology of skin sections. It mirrors Hospital, 1Seth GS Medical College and KEM Hospital, pathophysiologic changes occurring at the microscopic level in the skin and its appendages. Mumbai, India Sometimes, we come across certain morphologic features that bear a close resemblance to our physical world. These close resemblances are referred to as “appearances” in parlance Address for correspondence: to dermatopathology. Sometimes, these “appearances” are unique to a certain skin disorder Dr. Uday Khopkar and thus help us to clinch to a definitive diagnosis (e.g., “tadpole” appearance in ). OPD 117, 2nd Floor, OPD However, frequently, these appearances are encountered in many other skin conditions Building, Seth GS Medical and can be therefore be misleading. In this paper, we attempt to enlist such “appearances” College and K.E.M Hospital, Parel, Mumbai - 400 012, commonly found in the dermatopathologic literature and also enumerate their differential India. diagnoses. E-mail: [email protected] Key words: Appearances, dermatopathology, skin disorders, tumors

INTRODUCTION html file of Lever’s of Skin 9th edition. All relevant searches were noted and a literature Dermatopathologic descriptions of various cutaneous review was performed for each of the “appearance.” tumors and disorders are frequently referred to by No attempt has been made by the authors to make this their characteristic appearances. While labeling the paper comprehensive to include every uncommon appearance of a condition like “dilapidated brick “appearance.” However, we have tried our best to wall” or “jigsaw puzzle” may not always help in the compile all the possible “appearances” seen on understanding of , it makes recall easier. histopathology on the basis of the available literature It is from this point of view that we set upon to enlist and with relevance to Indian dermatology. For ease of the various labeled appearances in dermatopathology. referencing, they have been placed in an alphabetical order. At places, we have tried to demonstrate the A thorough literature search was performed in Medline similarity between histopathological features and the with the keywords “dermatopathologic appearances,” physical world around us. “histopathological appearances,” Portable document format (pdf) version of Rook’s Textbook of Dermatology ANTLER LIKE/STAG HORN APPEARANCE 8th edition and Fitzpatrick Dermatology in General Literally, antler means deciduous horn of a member Medicine 7th edition was screened with the search word of the deer family. Dowling Degos (DDD) “appearance.” A similar search was carried out in the is an autosomal‑dominant disorder characterized

Access this article online by spotted and reticulate pigmentation of the flexures. Histopathology of the lesional skin shows Quick Response Code: Website: www.ijdvl.com delicate digitate downgrowth of the layer with melanocytic at the tip giving the DOI: [1] 10.4103/0378-6323.110769 resemblance to antler‑like pattern [Figure 1]. However, a similar appearance may be seen in Haber’s syndrome, PMID: Galli Galli disease (acanthoeytic variant of Dowling ***** Dego disease) and pigmented actinic keratosis.[2]

How to cite this article: Madke B, Doshi B, Khopkar U, Dongre A. Appearances in dermatopathology: The diagnostic and the deceptive. Indian J Dermatol Venereol Leprol 2013;79:338-48. Received: June, 2012. Accepted: September, 2012. Source of Support: Nil. Conflict of Interest: None declared.

338 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 Madke, et al. Appearances in dermatopathology

BOX SHAPED/SQUARED OFF APPEARANCE resolving folliculitis and Sweet’s syndrome. The busy dermis appearance can also be seen in the early Biopsy from the indurative stage of morphea (localized stage of Kaposi's , desmoplastic melanoma, scleroderma) is squared off at the edges, giving the cutis, interstitial granulomatous drug appearance of box‑shaped (or boxed dermis appearance) reaction, mastocytosis and subtle biopsy under scanner view[3] [Figure 2]. This boxing of the [4] [Figure 3]. dermis probably happens due to the marked sclerosis of collagen throughout the reticular dermis and extending CAMEL FOOT APPEARANCE to the septa of subcutaneous fat. Morphea‑lichen sclerosus overlap and scleredema can also similarly It is a descriptive terminology for epidermal show squared off edges of biopsy specimen. hyperplasia (regular acanthosis) seen in histopathology of plaque‑type psoriasis. Normally, only 10% of the BUSY DERMIS APPEARANCE basal cells are in the proliferative phase, whereas in psoriasis about 90% of the basal cells are in the It is a descriptive term for changes seen on scanning replicative phase. As a result, to accommodate the magnification, and is due to inflammatory infiltrate increasing population of basal cells, rete pegs take a present in the interstitial dermis rather than around plunge in the dermis in the form of regular elongation the superficial and deep perivascular location. It of rete ridges, giving the “camel foot” appearance to can be considered as a separate pattern seen in dermal rete ridges[5] [Figure 4]. inflammatory or infiltrative dermatoses. Depending on the nature of infiltrate present in the dermis: CANNON BALL APPEARANCE (i) histiocytes‑granuloma annulare, histiocytoma, interstitial granulomatous dermatitis of connective Classically seen in acquired tufted angioma , interstitial granulomatous dermatitis (angioblastoma), a subtype of lobular capillary with cutaneous cords and (ii) neutrophils‑vasculitis, hemangioma (LCH) that shows clusters of angiomatous tufts and lobules scattered in the dermis in a “cannon ball” pattern.[6,7] However, similar tufts of thick‑walled capillaries are frequently seen in pseudo‑Kaposi’s sarcoma or angiodermatitis of Mali.

Figure 1: Rete ridges showing antler-like downgrowth with pigmentation at the tip in a case of Dowling Degos disease (H and E, ×40)

Figure 2: Biopsy from an indurated plaque showing boxed off appearance at the edges (H and E, ×40)

Figure 3: Hematoxylin and eosin section showing subtle interstitial infiltrate giving the whole specimen a “busy dermis” appearance Figure 4: Regular acanthosis with rete peg elongation giving rete (H and E, ×100) ridges a “camel foot” appearance (H and E, ×100)

Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 339 Madke, et al. Appearances in dermatopathology

CHICKEN WIRE/FISH NET PATTERN

It is a descriptive terminology seen on direct study of vulgaris, where intercellular deposition of IgG and C3 between epidermal cells give a “chicken wire” or “fish net” appearance[8] [Figure 5]. Myxoid liposarcoma is a low‑grade tumor composed of hypocellular bland Figure 5: Direct immunofluorescence studies showing intercellular fusiform to ovoid cells in a myxoid stroma with deposition of immune complexes giving a “chicken wire/fish net” look (×100) a prominent plexiform capillary network and scattered signet‑ring lipoblasts. Myxoid liposarcoma shows prominent branching pattern of capillaries throughout the tumor in a so‑called chicken‑wire pattern.[9]

CHURCH SPIRE APPEARANCE

Described in the histopathology of “hyperkeratotic seborrheic keratosis” and “acrokeratosis Figure 6: Biopsy from a seborrheic keratosis showing along with resembling the verruciformis of Hopf” (an allelic disorder to Darier’s epidermal changes as “church spire” (H and E, ×40) disease). Both these entities show a distinctive pattern of epidermal features with hyperkeratosis, and acanthosis together with papillomatosis. These epidermal changes frequently lead to numerous digitate upward extensions of epidermis‑lined papillae, giving the appearance of “church spires.”[10,11] Other conditions where “church spire” appearance can be seen are verruca vulgaris, epidermodysplasia verruciformis, verruca plana, Figure 7: of lichen nitidus showing well-defined actinic keratosis, arsenic keratosis, tar keratosis, granuloma enclosed by rete pegs giving the appearance of “claw clutching a ball” on scanning magnification (H and E, ×40) acanthosis nigricans, epidermal , confluent and reticulate papillomatosis of Gougerot‑Carteaud, CLOCK FACE/CART WHEEL APPEARANCE hyperkeratosis lenticularis and verrucous carcinoma[12] [Figure 6]. Plasma cell has a characteristic cart‑wheel appearance owing to its typical nuclear configuration. The plasma CLAW CLUTCHING BALL APPEARANCE cell is round or oval, with an eccentrically placed nucleus and chromatin arranged in a pyramidal block The histological appearance of lichen nitidus is against the nuclear membrane, giving the characteristic commonly referred to as ball and claw configuration “cart wheel” appearance.[14] for the infiltrate and epidermis, respectively. The ball is comprised of well‑circumscribed granulomatous COAT SLEEVE APPEARANCE infiltrate composed of lymphocytes, epithelioid cells and occasional Langhans giant cells that are clutched by Historically, coat sleeve appearance was described in surrounding hyperplastic rete ridges, giving the overall the histopathology of primary and secondary lesions “claw clutching ball” appearance[13] [Figure 7]. Similar of syphilis, where the inflammatory infiltrate of resemblance can be seen in histology of early lesions lymphocytes and plasma cells are located in a perivascular of juvenile xanthogranuloma (JXG) and lichenoid coat sleeve‑like pattern.[15] A similar picture can also be eruptive histiocytoma. Occasionally, micropapular seen in the histology of erythema annulare centrifugum, and tuberculoid leprosy may show such where dermal perivascular infiltrate of lymphocytes appearance, although with shorter “claws.” is arranged in a “coat sleeve” pattern.[16] Several other

340 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 Madke, et al. Appearances in dermatopathology inflammatory diseases with lymphoplasmocytic shows prominent suprabasal clefting and extensive infiltrate may show perivascular coat sleeve pattern. loss of intercellular bridges () with However, the thickened endothelial lining contributes to partial coherence of cells between keratinocytes, the coat sleeve appearance in syphilis. giving the whole epidermis a “dilapidated brick wall” appearance.[18] It has also been described in cases of CRIBRIFORM APPEARANCE bullous Darier’s disease and Hailey‑Hailey variant of Grover disease[19,20] [Figure 9]. Literally, cribriform means a structure having resemblance to a sieve akin to cribriform plate of FESTOONED PAPILLAE APPEARANCE (SEE the ethmoid bone through which pass the fibers of UNDECORATED TOMB STONING) the olfactory nerve. Trichoepithelioma is a benign showing mostly follicular germinative Classically described in the histopathology of [17] differentiation. Five different histopathologic porphyria cutanea tarda, wherein a biopsy from patterns have been described columnar (desmoplastic a fresh blister shows a subepidermal bulla with trichoepithelioma), retiform, racemiform, minimal dermal inflammatory infiltrate and adamantenoid and cribriform (trichoepithelioma). dermal papillae protruding upward into the blister cavity (festooning) and hence the name “festooned Histology of trichoepithelioma of the cribriform pattern papillae” appearance[21] [Figure 10]. shows presence of horn of varying sizes and basaloid epithelial cribriform nests and a few elongated strands embedded in a fibroblastic stroma [Figure 8]. FLAME‑THROWER‑LIKE APPEARANCE Papillary mesenchymal bodies formed by stromal fibroblastic aggregation are seen typically adjacent to It is a histopathological description of the vertical epithelial islands. However, cribriform pattern may section of telogen hair shaft. Telogen club hairs have a also be seen with basal cell carcinoma, glomus tumor non‑pigmented bulb with an irregular shaggy border. and several other benign and malignant . The presence of bright red trichilemmal keratin bordering the club hair results in a “flame‑thrower DILAPIDATED BRICK WALL APPEARANCE like” appearance in vertical hematoxylin and eosin sections[22] [Figure 11]. It is a well known appearance in dermatopathology. It is classically seen in Hailey‑Hailey disease, which

Figure 9: Biopsy from a representative lesion of Hailey-Hailey disease showing partial acantholytic giving the whole epidermis a “dilapidated brick wall resemblance” (H and E, ×100) Figure 8: Hematoxylin and eosin-stained section of trichoepithelioma showing epithelial islands in a cribriform pattern (H and E, ×100)

Figure 11: Vertical section from scalp biopsy showing telogen Figure 10: Biopsy from a blister in a case of porphyria showing hair lined with eosinophilic trichilemmal keratin giving “flame subepidermal blister along with festooning of dermal papillae (×100) thrower” appearance (H and E, ×200)

Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 341 Madke, et al. Appearances in dermatopathology

FRIED EGG APPEARANCE

Mast cells are found in small numbers (up to 10 mast cells per 40X field) in a perivascular location in the dermis and larger number in some neoplasms (e.g., ) and certain forms of mastocytosis. These cells are commonly oval with a centrally located dark round nucleus, giving a “fried egg” appearance[23] [Figure 12]. Figure 12: Histology of mastocytosis showing numerous mast HOBNAIL (MATCHSTICK) APPEARANCE cells having centrally located nuclei (H and E, ×200)

Retiform hemangioendothelioma is a rare variant of low‑grade angiosarcoma characterized by indolent clinical behavior. Histologically, it bears a close resemblance to the architecture of rete testis on scanning magnification. The tumor is composed of elongated, arborizing blood vessels lined by monomorphic bland endothelial cells with prominent apical nuclei and scanty cytoplasm. These endothelial cells have been described to have a “match stick” or Figure 13: Histological section of cylindroma showing numerous hobnail appearance.[24,25] Similar is the appearance of tumor islands molded into each other giving a “jigsaw puzzle” endothelial cells lining the vessels of angiolymphoid appearance (H and E, ×100) hyperplasia.[26]

JIGSAW PUZZLE APPEARANCE

Cylindroma is a of hair follicle origin. The tumor is composed of irregularly shaped islands of basaloid cells arranged in a mosaic‑like mass molding together in a “jigsaw puzzle” pattern[27] [Figure 13]. A rim of densely eosinophilic, Periodic acid

Schiff‑positive ‑like material Figure 14: Gomori methenamine silver stain showing the tissue commonly envelops the individual nests. A similar phase of paracoccidioidomycosis resembling the so-called jigsaw puzzle appearance of tumorous mass was also “Mariner’s pilot wheel” appearance (×1000) reported in eccrine spiradenomas.[28] of the genus Prototheca, an achlorophyllic alga. Olecranon bursitis and localized cutaneous MARINER’S PILOT WHEEL APPEARANCE are the most common presentation seen in immunocompetent patients.[30] Prototheca species It is description of the tissue phase of divide by symmetrical endosporulation. Lactophenol paracoccidioidomycosis (also known as Brazilian cotton blue or calcofluor white mount of culture reveals blastomycosis, South American blastomycosis, the morula‑like appearance of sporangia containing Lutz‑Splendore‑de Almeida disease) caused by multiple endospores; however, the endospores are less the thermally dimorphic fungus Paracoccidioides brasiliensis. In biopsy specimens, the tissue phase as compared with that seen in rhinosporidiosis and [31] of the fungus is seen as multiple buds surrounding coccidioidomycosis. the whole surface of the mother yeast cell. This configuration is described as “Mariner’s pilot wheel” ONION SKIN APPEARANCE or “Mickey mouse” appearance[29] [Figure 14]. Pacinian corpuscle is a specialized type of touch MORULA‑LIKE APPEARANCE receptor present in the deeper layers of the skin. Each corpuscle is composed of the end of a sensory Protothecosis is a rare caused by members nerve fiber with layers of connective tissue wrapped

342 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 Madke, et al. Appearances in dermatopathology around it, resembling “onion skin” appearance.[32‑34] palisading appearance can be seen are: Palisading Mycobacterial infiltration of the nerve in cases of neutrophilic and granulomatous dermatitis,[45,46] borderline and polar lepromatous leprosy leads to rheumatoid , necrobiosis lipoidica,[47] syphilis proliferation of perineurium of the nerve bundles and foreign body reaction[48] [Figure 17]. leading to “onion peel appearance”[35] [Figure 15]. Eosinophilic angiocentric fibrosis (mucosal variant PICKET FENCE APPEARANCE of granuloma faciale) and chronic fibrosing vasculitis could lead to a similar “onion skin” appearance due to This appearance is seen on direct extensive fibrosis of blood vessels.[36] immunofluorescence (DIF) studies of . DIF of non‑involved perilesional skin OWL’S EYE APPEARANCE shows deposit of IgA alone or in combination with C3, which are arranged in a granular pattern at the Histopathology of verruca plana shows, in addition to dermoepidermal junction. These granular deposits hyperkeratosis and acanthosis, diffuse vacuolization may be vertically elongated, giving a “picket‑fence” of cells in the upper spinous and granular layer. appearance[49] [Figure 18]. The nuclei of the vacuolated cells lie at the centers of the cells with empty shells around the nucleus. RAVELLED WOOL APPEARANCE This appearance of vacuolated cells is referred to as Owl eye appearance[37] [Figure 16]. These vacuolated Literally, ravelled means tangled mass of threads. It cells should be differentiated from Paget cells. Similar is a classical histopathological description seen in “owl’s eye” appearance of Reed Sternberg cell (cells pseudoxanthoma elasticum (PXE). Biopsy from a having either multinucleated or bilobed nucleus) is lesion will show small, fragmented, wavy and clumped considered pathognomonic for classical Hodgkin’s eosinophilic elastic fibers, giving a “ravelled wool” lymphoma.[38] appearance[50] [Figure 19]. Similar appearance of elastic fibers can also be seen in D‑penicillamine‑induced PAINT BRUSH‑LIKE APPEARANCE PXE and periumbilical PXE.[51]

The name Penicillium comes from the word “brush.” SAFETY PIN APPEARANCE Penicilliosis is a systemic fungal infection caused by a dimorphic fungus, Penicillium marneffei, common in In granulomatous lesions of donovanosis, the bacterium HIV patients whose CD4 count is less than 50/mm,3 Calymmatobacterium granulomatis (C. granulomatis) and was first isolated from bamboo rats in Vietnam.[39] displays characteristic bipolar staining, giving a “safety Fungal culture shows grey–white colonies surrounded pin appearance.”[52] These bacilli are found in large by diffusible red pigment, and lactophenol cotton number in the cytoplasm of mononuclear cells of the blue stain preparation of the culture specimen shows monocyte/macrophage lineage forming Donovan bodies. brush‑like clusters of septate hyphae with terminal conidiospores.[40] SAW‑TOOTH APPEARANCE

PALISADING APPEARANCE Yet another well‑known histopathological finding seen in lichen planus. Histology of lichen planus shows Palisade means a wall or fence made from either irregular hyperplasia of the malpighian (spinous) wooden stakes or iron plates, and is built to defend layer (irregular acanthosis) in a triangular pattern a structure. In dermatopathology, palisading means giving a saw‑tooth appearance[53] [Figure 20]. Similar typical arrangement of cells of either tumorous origin saw tooth appearance may be seen in some cases of as in basal cell carcinoma,[41] where basal layer of lichenoid drug eruptions and in lichen planus‑like cells lies perpendicular to the basement membrane keratoses. giving a palisaded appearance or histiocytes surround a deposit or area of collagen alteration in granuloma SEPTATE TOMATO APPEARANCE annulare.[42,43] Benign tumors like palisaded and encapsulated also show palisading by spindle In Molluscum contagiosum, scanner view of cells of neural origin.[44] Other conditions where hematoxylin and eosin‑stained sections shows

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Figure 15: Histology of pacinian corpuscle showing the classical Figure 16: Histopathology of verruca plana showing the typical onion peel appearance (H and E, ×200) cytopathic effect on keratinocytes called as having a perinuclear halo referred to as “owl-eye appearance” (H and E, ×200)

Figure 17: Specimen obtained from nodular basal cell carcinoma showing the classical arrangement of peripheral basaloid cells in a palisading configuration (H and E, ×200)

Figure 18: Direct immunofluorescence showing deposition of IgA along the tips of dermal papilla giving a “picket fence” appearance. (×100) (Photo contributed by Dr. Raghavendra Rao, Kasturba Medical College, Manipal)

Figure 19: Biopsy from a papular lesion of pseudoxanthoma elasticum showing fragmented and calcified elastic fibers forming a tangled mass resembling woolen threads, the so-called “ravelled wool appearance” (H and E, ×200) an epidermal invagination with several closely Figure 20: Histology of a of lichen planus showing the spaced lobules of epidermal proliferation leading typical saw tooth morphology of rete ridges (H and E, ×100) to a septate tomato appearance. The septum of this appearance is formed by normal dermis and not by SPAGHETTI AND MEATBALL APPEARANCE (BANANA epidermal proliferation. In the lower epidermis, these AND GRAPE APPEARANCE) viral bodies appear as minute, ovoid eosinophilic structures. At the level of granular layer, these bodies Hematoxylin and eosin‑stained biopsy from the change their staining pattern from eosinophilic to lesions of pityriasis versicolor shows slender septate basophilic [Figure 21]. hyphae and spores resembling the sphagetti and meat ball appearance[55] [Figure 22]. SIEVE‑LIKE APPEARANCE STORIFORM APPEARANCE Kaposi sarcoma (KS) is a low‑grade malignant tumor of vascular origin associated with human herpes simplex This is classically described in dermatofibrosarcoma virus 8 (HHV‑8) infections. Biopsy from the plaque protuberans (DFSP), but is also seen in the frequently stage of KS shows spindle cells arranged in fascicles seen dermatofibroma. DFSP is a rare, locally aggressive with slit‑like dense and irregular vascular spaces, dermal tumor composed of interwoven bundles of creating a sieve‑like appearance.[54] spindle cells with plump nuclei arranged in a “storiform

344 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 Madke, et al. Appearances in dermatopathology or pinwheel pattern”[56] [Figure 23]. Storiform appearance composed of two lobes connected by a band of nuclear is also seen in dermatofibroma, where histiocytes material, and resembles the old‑fashioned “telephone are arranged in a storiform or whorled pattern in the receiver”[62] [Figure 26]. reticular dermis with evidence of entrapped collagen bundles at its peripheral margins (c.f. DFSP). In DFSP, TISSUE CULTURE‑LIKE APPEARANCE the proliferation extends into the fibrous septae of subcutaneous tissue forming pseudoseptae. Nodular fasciitis is a self‑limiting benign reactive fibroblastic growth, and is often mistaken for malignant SWARM OF BEES APPEARANCE neoplasm with its feature of rapid growth and histological appearance. Clinically, it usually presents as a solitary, It is a characteristic histopathological picture seen rapidly developing, sometimes tender, subcutaneous in active alopecia areata, where the perifollicular nodule that reaches its ultimate size of 1-5 cm. Histology , in particular peribulbar infiltrates, is from a well‑developed nodular lesion shows plump composed of predominantly lymphocytes around fibroblasts growing haphazardly in a vascular, myxoid anagen hair follicles. This pattern of infiltrate is referred stroma presenting a “tissue culture‑like” appearance.[63] to as “swarm of bees” appearance[57] [Figure 24]. Similar appearance has been reported in leishmaniasis, wherein TOMB STONE APPEARANCE giemsa stain of tissue material shows numerous amastigote (20-30 in number) arranged in a “swarm of Classically described in the histopathology of fresh bees” fashion within the cytoplasm of macrophages.[58] blister of or drug‑induced pemphigus. Suprabasal splitting of the epidermis SWISS CHEESE APPEARANCE leads to blister formation, with the basal layer still remaining adherent to the basement membrane, This appearance is reported in cases of and gives the resemblance to the row of the tomb paraffinoma (sclerosing lipogranuloma). Paraffin is stone[64,65] [Figure 27]. Ackerman and colleagues have a mineral oil and is not hydrolyzed by tissue lipases classified tomb stoning into two broad categories: and, hence, is treated by the body as a foreign Decorated tomb stone (discrete dermal papillae covered substance. The most common site of injecting paraffin by a single row of basal keratinocytes that project oil is the penis and breast.[59,60] Biopsy obtained from into an intraepidermal blister) and undecorated tomb the infiltrated area shows presence of numerous ovoid stone (discrete, well‑preserved dermal papillae beneath or round cavities where the paraffin resided prior to a subepidermal blister).[1] Decorated tombstones have processing, giving the “Swiss cheese” appearance. been described apart from pemphigus in Grover’s disease, Darier’s disease, Hailey‑Hailey disease, TADPOLE/COMMA‑SHAPED APPEARANCE warty dyskeratoma and solar keratosis, whereas undecorated tomb stone has been described in Classically seen at scanning magnification in histology suction blister, porphyria, pseudoporphyria, bullous of syringoma. This benign tumor of eccrine lineage pemphigoid, herpes gestationis and epidermolysis comprises of numerous ducts lined by two rows of bullosa junctional and dystrophic variant. epithelial cells embedded in a fibrous stroma. The epithelial component is arranged in nests, cords TRILAYERED/STRIPED APPEARANCE or tubules of relatively uniform size. Depending upon the plane of section, some nests of syringoma The histology picture of lichen sclerosus is commonly can assume a morphology that closely resembles a referred to as “tri‑layered or striped” appearance. The comma or tadpole.[61] Similar tadpole appearance established lesion of lichen sclerosis shows three of epitheial strands is also reported in desmoplastic distinct zones: (i) epidermal with surface trichoepithelioma, sclerosing basal cell carcinoma and hyperkeratosis, (ii) an underlying broad zone of microcystic adnexal carcinoma [Figure 25]. subepidermal edema in the papillary dermis and (iii) homogenization and ground glass appearance of TELEPHONE HANDLE APPEARANCE collagen, which becomes more sclerotic over time.[67]

Another well known cellular appearance among A similar trilayered appearance can be seen in the hematologist. The deep red nucleus of an eosinophil is histology of soft chancre (chancroid) caused by

Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 345 Madke, et al. Appearances in dermatopathology

Figure 22: Numerous fungal elements of malasezzia species seen as elongated hyphae and spores, familiarly called as “spaghetti and meat-ball” appearance (×200)

Figure 21: Molluscum contagiosum showing the epidermal invagination and numerous eosinophilic viral inclusion bodies resembling a septate tomato on scanner view (H and E, ×40)

Figure 24: Lymphocytic infiltrate around anagen follicle resembling a “swarm of bees” (H and E, ×200 and 100)

Figure 23: Hematoxylin and eosin-stained specimen showing “storiform/whorled” appearance of dermatofibroma sarcoma protuberans (H and E, ×200)

Figure 26: Bilobed nucleus of eosinophil resembling an old “telephone receiver” (H and E, ×200)

Figure 25: Histology of syringoma showing typical “tadopole/ comma shaped” epithelial tumor strand (H and E, ×200)

Figure 28: Haphazard orientation of keratinocytes seen in Bowen’s disease commonly referred to as “windblown” appearance of dysplastic cells (H and E, ×100) Figure 27: Suprabasal acantholysis in pemphigus showing the characteristic “row of tombstone” appearance (H and E, ×100) infiltrate, (ii) the mid‑zone containing new blood Hemophilus ducreyi: (i) superficial zone consisting vessels and regenerating granulation tissue on one of necrotic tissues and an acute inflammatory hand and degenerative changes on the other and

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(iii) the deeper zone shows a chronic inflammatory 18. Narbutt J, Chrusciel A, Rychter A, Fijuth J, Lesiak A, infiltrate of plasma cells and lymphocytes.[68] Sysa‑Jedrzejowska A. Persistent improvement of previously recalcitrant Hailey‑Hailey disease with electron beam radiotherapy. Acta Derm Venereol 2010;90:179‑82. WINDBLOWN APPEARANCE 19. Kakar B, Kabir S, Garg VK, Bhushan P. A case of bullous Darier›s disease histologically mimicking Hailey‑Hailey disease. Dermatol Online J 2007;13:28. A descriptive term for the enlarged, crowded, 20. Weaver J, Bergfeld WF. Grover disease (transient acantholytic haphazardly arranged neoplastic cells that show loss dermatosis). Arch Pathol Lab Med 2009;133:1490‑4 21. Welsh B. Blistering skin conditions. Aust Fam Physician of polarity, enlarged and hyperchromatic nuclei and 2009;38:484‑90. atypical mitoses in the epithelium of Bowen’s disease 22. James WD, Berger TG, Elston DM, editors. Skin: Basic th and bowenoid papulosis of the genitalia. 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