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Appearances in Dermatopathology: the Diagnostic and the Deceptive

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Appearances in Dermatopathology: the Diagnostic and the Deceptive Symposium Appearances in dermatopathology: 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 syringoma). 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 Histopathology 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 pathogenesis, 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 disease (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 epidermis layer with melanocytic hyperplasia 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 sarcoma, desmoplastic melanoma, scleroderma) is squared off at the edges, giving the leukemia cutis, interstitial granulomatous drug appearance of box‑shaped (or boxed dermis appearance) reaction, mastocytosis and subtle breast carcinoma biopsy under scanner view[3] [Figure 2]. This boxing of the metastasis[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 tissue diseases, 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 immunofluorescence study of pemphigus 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 hyperkeratosis along with papillomatosis 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, hypergranulosis 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: Histology 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 nevus, 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
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