Original Research Article

A study of pathological and clinical parameters of non-infectious, erythematous papulosquamous disorders of skin in a tertiary care hospital in central India

Bimal Patel1*, Karan S Chandraker2

1Assistant Professor, Department of Pathology, GAIMS, Bhuj, Gujrat, INDIA. 2Assistant Professor, Department of Pathology, Government Medical College, Rajnandgaon, Chattisgarh, INDIA. Email: [email protected]

Abstract Background: The papulosquamous skin disorders are heterogeneous group of disorders the diagnosis of which is based on a descriptive morphology of clinical lesions characterized by scaly plaques and along with correlation with histomorphological features. Aims and Objectives: Study the histopathological features of the various subcategories of papulosquamous disorders along with age and sex distribution pattern and to assess the agreement of clinical and histological diagnosis. Material and methods: This was an observational study including 120 cases of all age groups and both sexes over a period of 18 months. Prediagnosed cases already on treatment or patient not willing to be part of study or denying skin were excluded. Results: Among a total of 120 cases, there was a slight male predominance with distribution in a wide range of age group. The most common lesion was (44.1%) followed by (21.6%), prurigo nodularis (11.6%), while rosea, lichen amyloidosis, , , and chronica constituted a smaller fractions (<10% each). Conclusion: Classification of these skin lesions into broad categories revealed that the psoriasiform lesions were most frequently encountered 60% followed by the lichenoid lesions. There is considerable overlap of both clinical pattern and distribution of papulosquamous skin disorders, hence a proper clinical observation and histomorphological study will give a conclusive diagnosis. Key Words: Papulosquamous lesion, scaly plaques, papules, psoriasiform, lichenoid

*Address for Correspondence: Dr. Bimal Patel, Assistant Professor, Department of Pathology, GAIMS, Bhuj, Gujarat, Pin 370001. Email: [email protected] Received Date: 02/06/2019 Revised Date: 23/06/2019 Accepted Date: 11/08/2019 DOI: https://doi.org/10.26611/10151128

nutritional status and climatic conditions1,2. Eczema and Access this article online are the most prevalent skin disorders reported Quick Response Code: from developed countries, whereas skin infections are 1 Website: predominant in developing African and Asian countries .

www.medpulse.in The papulosquamous skin lesions are heterogeneous group of disorders constituting one of the largest groups

of diseases seen by the dermatopathologist. The nosology of these disorders is based on a descriptive morphology of Accessed Date: clinical lesions characterized by scaly plaques and 12 August 2019 2 papules . In addition, the expertise of dermatologists and availability of the latest diagnostic facilities play a crucial 1 role .The diagnostic approach of the skin is INTRODUCTION based on the tissue reaction patterns3,4. The latter depends The prevalence of skin diseases in any region or country on the various pathological stimuli producing different depends on various factors, such as genetics, racial lesions clinically, however may show similar histological constitution, social and hygienic standards, customs, picture3. Therefore, to obtain the precise diagnosis of the

How to cite this article: Bimal Patel, Karan S Chandraker. A study of pathological and clinical parameters of non-infectious, erythematous papulosquamous disorders of skin in a tertiary care hospital in central India. MedPulse International Journal of Pathology. August 2019; 11(2): 99-104. https://www.medpulse.in/Pathology/ MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 11, Issue 2, August 2019 pp 99-104 skin biopsy, it should be accompanied by all clinical fixed in 10% formalin and processed using automatic details. Epidemiological surveys are important to tissue processor. Three to 4micron sections were cut and determine the burden of dermatological disorders in an stained with hematoxylin and eosin (HandE). Other area 4.The purpose of this study was to find out the special stains like PAS and Congo red were done as pattern of papulosquamous skin diseases in patients required. The slides were reviewed with appropriate attending the Department of , at a tertiary clinical details for final diagnosis. care hospital in central India. This study mainly includes an interpretation of two major tissue reaction patterns, the RESULTS psoriasiform and the lichenoid reactions; with The cohort in the present study comprised of 120 patients clinicopathological correlation. newly diagnosed with papulosquamous lesions. The total skin biopsies received in the department of Pathology MATERIAL AND METHODS were 378(7.26%) of which 120 skin biopsies (2.31%) The present study was an observational study, undertaken were of patients with papulosquamous diseases. Out of to study clinical and histopathological parameters in total 120 cases, Psoriasis (53 cases) was the commonest patients with papulosquamous disorders of skin. Patient lesion, followed by Lichen planus (26 cases). Details of cohort consisted of those who consented for skin biopsy the distribution of skin lesion are mentioned in Table 1. while attending Out Patient Department or in wards of There was a slight male predominance (Figure1) with sex Department of Dermatology with clinically diagnosis of distribution in various papulosquamous lesions shown in papulosquamous lesions, over a period of 18 months at a Table 1. Among various lesions, there was male tertiary care hospital in the central India. Patients who predominance in psoriasis, lichen amyloidosis, were already under treatment or did not consented for a parapsoriasis and pityriasis lichenoides chronica. Female skin biopsy or to be a part of this study were excluded predominance was seen in lichen planus and pityriasis from the study. A 4mm skin punch biopsy was taken rosea while equal sex distribution was seen in pityriasis under aseptic conditions from an active lesion, which was rubra pilaris and prurigo nodularis.

Table 1: Distribution of papulosquamous skin diseases (n=120) with sex distribution Disease No. of cases (%) Males Females Psoriasis (PSO) 53 (44.2%) 33 20 Lichen planus (LP) 26 (21.7%) 12 14 Prurigo nodularis (PN) 14 (11.7%) 07 07 (PR) 08 (6.7%) 02 06 Lichen amyloidosis (LA) 06 (5.0%) 04 02 Parapsoriasis (PP) 05 (4.1%) 03 02 Pityriasis rubra pilaris (PRP) 04 (3.3%) 02 02 Pityriasis lichenoid chronica (PLC) 04 (3.3%) 03 01 TOTAL 120 66 54

Figure 1: Sex distribution of papulosquamous lesions Figure 2: Histogram showing the the age group wise distribution of papulosquamous lesions Psoriasis was seen more commonly in 3rd, 4th and 5th decade of life. Lichen planus occurred in all age groups but was common in 2nd to 5th decade. Prurigo nodularis was seen in middle age group (31-40 years). Pityriasis rubra pilaris was seen in less than 10 years and middle age group (21-40years). Parapsoriasis and lichen amyloidosis was seen in middle and older age group (31-40years). Pityriasis rosea and pityriasis lichenoides chronic was seen in young age group in 2nd

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 11, Issue 2, August 2019 Page 100 Bimal Patel, Karan S Chandraker to 4th decades. The most common clinical presentation of patients with psoriasis was scaly plaques (98.1%) followed by papules, flat topped papules, scaly patches and thin scales. In lichen planus, papules and scaly plaques was the commonest type, followed by flat topped papules. Among prurigo nodularis, nodule was the commonest presentation followed by hyperkeratotic plaque, scaly patch and thin scales. Among pityriasis rosea, the common presentations were papular (87.5%), scaly plaque and thin scales. In lichen amyloidosis, parapsoriasis and pityriasis rubra pilaris, the most common presentation was papules. In pityriasis lichenoides chronica, scaly plaques and patches were most commonly seen. The histological features observed in each lesion are tabulated in Table 2.

Table 2: Histopathological changes seen in various papulosquamous lesions PSO LP PN PR LA PP PRP PLC Histological changes (n) (n) (n) (n) (n) (n) (n) (n) Epidermal changes 51 25 14 05 05 05 04 03 03 08 02 41 - 01 03 04 (focal) (focal) (focal) Acanthosis 34 23 13 07 02 05 04 - Orthokeratosis - - 07 - - - - - - - 12 - - - - - Hypogranulosis 39 ------ - 21 13 - - - - - Granular layer thinning - 08 - - - - 8 - - 07 - 03 - - Psoriasiform hyperplasia 49 - 14 - - - - - Suprapapillary thinning 37 ------Spongiform pustule 12 ------Munro microabscessses 17 ------Saw toothed rete ridges - 23 ------Rete ridges - elongated - - - 02 06 05 - - Rete ridges- short and broad ------03 21 04 Degeneration of basal cells - - - 01 - - (vacuolar) (vacuolar) Max Joseph spaces - 04 - - - - - Civatte bodies ------Lymphocytic exocytosis - - - 08 - - - - Erythrocyte extravasation ------03 Follicular plugging ------02 - Dermal changes Papillary edema 09 - 04 - 03 - - - Vascular changes 07 - 04 - - - - - 23(Band like) 06 Dermal inflammation 44 14 08 05 05 04 3(Spotty) (sparse) Pigment incontinence - 07 ------Erythrocyte extravasation - - - 05 - - - - Amyloid deposition - - - - 06 - - -

DISCUSSION The present study was carried out in the Department of Pathology, at a tertiary care hospital over a period of one and a half year. One hundred and twenty newly diagnosed cases of non-infectious, erythematous papulosquamous disorders were included in our study. The comparison of case distribution is shown in the Table 3.

Table3: Comparison of Distribution of cases in various studies Pramod Alakliby Dogra et al D’Costa Present Disease (1997)5 (2005)6 (2005)7 (2010)2 study Psoriasis 127 37 1975 38 53 Lichen planus 29 18 724 72 26 Prurigo nodularis NR NR NR 11 14 Pityriasis rosea 22 2 120 22 08

Copyright © 2019, Medpulse Publishing Corporation, MedPulse International Journal of Pathology, Volume 11, Issue 2 August 2019 MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 11, Issue 2, August 2019 pp 99-104

Lichen amyloidosis NR NR 214 NR 06 Parapsoriasis NR 01 NR 3 05 Pityriasis rubra pilaris NR 02 9 7 04 Pityriasis lichenoid chronica NR NR 46 7 04 annulare centrifugum NR NR NR 1 NR Reiter’s Disease NR NR NR 2 NR PLEVA NR NR NR 2 NR ILVEN NR NR NR 1 NR The peak age of presentation and sex ratio among patient diagnosed with psoriasis in present study was 21-30 years and 1.6 respectively, which is comparable to studies by Agrawal S8, Alakliby9, Shobanili6, D’Costa et al2, however the peak age group affected in study by Alexander et al10 was 40-50. L.Y.T. Chiam et al11 found plaques as the most common presentation which was similar to that found by Morris A et al12, Seyhan M et al13, Nanda A et al14. In present study, scaly plaque was the most common presentation. The histological findings were in concordance with those found in studies by Gordon M15, Cox AJ16 and Grower C.17 In lichen planus, most of the case had a peak between 21-40 years of age, which was similar to that in Singh and Kumar18, Kumar et al19, Rahnama et al20 and D’Costa et al.2 The most common clinical presentation as mentioned in several studies2,18-20 and found in present study was flat topped or plaques. Table 4 shows the comparison of various subtypes of LP in present study and others.

Table 4: Comparison of subtypes of lichen planus Subtypes Bhattacharya et al22 Sharma et al21 Nnoruka et al23 Present study Classical LP 44 30 8 14 Hypertrophic LP 1 13 3 5 Follicular LP 3 2 1 - Pigmented LP 5 4 4 6 Actinic LP 1 1 2 1 Total 54 50 18 26 Tanaka M et al24, Payne R et al25, Amer et al26 and Soter NA27 had observed that prurigo nodularis was common in older age group with mean age of presentation at 50 years. In present study, most cases were seen in the age groups of 31-50 years. The histopathological picture in present study was similar to those mentioned in the aforementioned studies.Egwin AS et al28, Parija M et al29 and Allen RA30 showed that pityriasis rosea is most commonly seen young adults in the age group of 21-40 years. In the above studies scaly patch was the most common presentation, while in present study, thin scaly lesion was the most common lesion followed by papular lesion. Histomorphological features were similar among the various studies.Vijaya et al31, Wang32, Tay et al33 and Al Ratrout et al34 had observed 45-50 years of age group to be affected the most among the patients with primary cutaneous amyloidosis. In the present study, most of the cases were seen in 51-60 years. Hyperpigmented hyperkeratotic plaques was the chief presentation in the present study which was similar to that in studies by Jhingan A et al36 and Salim T et al37. The histomorphological picture was similar to the studies by Vijaya et al31, Black M et al35, Salim T et al37 and Padhiar B et al38.In present study parapsoriasis was seen most commonly in age group of 41-50 years with a male predominance. The cases of PRP were seen in 1st and 3rd decade of life in the present study which is similar to that observed by Griffiths W39 and Mary LW40. The clinical presentation of PRP in above two studies was follicular hyperkeratotic papule while in present study the most common clinical presentation was papules with scaly patches and thin scales.In studies by Bowers and Warshaw41, Fernandes et al42 and Ersoy-Evans S et al43 PLC was common in 3rd decade of life and in present study it was seen in the age group of 11-20 years with similar clinical presentation and histomorphological features. Table 5 shows a correlation of clinical diagnosis with that of histopathological diagnosis. Among the clinically suspected cases of psoriasis, there were 18 cases which had a different histopathological diagnosis. In clinically suspected 28 cases of lichen planus, there were 10 cases which had other final diagnosis. There were 12 cases of clinically non specific dermatitis, which on histopathology diagnosed as PSO(7), PN(3), PR(1) and PRP(1).

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 11, Issue 2, August 2019 Page 102 Bimal Patel, Karan S Chandraker

Clinical diagnosis Histopathological 2 or more

A LP LP LA LA PP PP Diagnosis PR

PN differential AD PLC PRP PRP PSO PLEV atitis atitis Derm diagnosis PSO 41 2 1 - 1 1 - - - 7 - 8 LP 7 18 - - 1 1 - - 1 - - 5 PN 6 2 5 ------3 - 3 PR 1 2 - 3 - 2 - - - 1 - 3 LA - 2 - - 2 3 - - - - - 4 PP 2 2 - 1 - 2 - - - - - 3 PRP ------3 - - 1 - 2 PLC 2 - - - - 3 - 2 - - - 3

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