DermatopathologyDermatopathology--

WeWe’’veve OnlyOnly JustJust BegunBegun PaulPaul K.K. Shitabata,Shitabata, M.D.M.D. DermatopathologyDermatopathology InstituteInstitute PatternsPatterns

Epidermis

Dermis/Vessels/Hair Follicles

Fat/Vessels

AcantholysisAcantholysis

„ LossLoss ofof cohesioncohesion betweenbetween epidermalepidermal oror adnexaladnexal keratinacyteskeratinacytes „ GroverGrover’’ss disease,disease, PemphigusPemphigus,, DarierDarier’’ss disease,disease, HaileyHailey--HaileyHailey

AcanthosisAcanthosis

„ TheThe increaseincrease inin thethe thicknessthickness ofof thethe stratumstratum malpighiimalpighii „ AcanthosisAcanthosis nigricansnigricans,, PalePale cellcell acanthomaacanthoma

ApoptosisApoptosis

„ Dropping off of colloid bodies from the epidermis into the dermis „ Occurs in disorders in which basal cell damage occurs, such as lichenoid tissue reactions „ Lichen planus, LPLK, DLE

BullaBulla

„ CavityCavity ofof atat leastleast 55 mmmm inin diameterdiameter formingforming withinwithin oror belowbelow thethe epidermisepidermis „ BullousBullous pemphigoidpemphigoid,, EBA,EBA, DHDH

CornoidCornoid LamellaLamella

„ TheThe cornoidcornoid lamellalamella isis tiltedtilted towardtoward thethe centercenter ofof suchsuch aa lesionlesion „ PeripherallyPeripherally migratingmigrating cloneclone ofof abnormalabnormal keratinocyteskeratinocytes formingforming thethe cornoidcornoid lamellalamella „ PorokeratosisPorokeratosis

EpidermolyticEpidermolytic HyperkeratosisHyperkeratosis

„ VacuolationVacuolation ofof thethe keratohyalinekeratohyaline granulargranular layerlayer „ RuleRule outout CongenitalCongenital IchthyosiformIchthyosiform erythrodermaerythroderma „ AssociationAssociation withwith dysplasticdysplastic nevinevi

LichenoidLichenoid (Interface)(Interface)

„ Epidermal basal cell damage manifested with cell death or liquefactive degeneration (basal vacuolar change) „ Interface sometimes applied only to poikilodermatous reactions with mild basal damage with vacuolar change „ Lichen planus, Fixed drug eruption, LPLK

ParakeratosisParakeratosis

„ RetentionRetention ofof nucleinuclei inin thethe stratumstratum corneumcorneum „ NormalNormal findingfinding onon mucousmucous membranesmembranes „ SpongioticSpongiotic dermatitisdermatitis (Eczema)(Eczema)

PsoriasiformPsoriasiform

„ EpidermalEpidermal hyperplasiahyperplasia withwith regularregular elongationelongation ofof reterete ridgesridges „ SeveralSeveral layerslayers ofof scalescale resultingresulting fromfrom boutsbouts ofof activityactivity „ Psoriasis,Psoriasis, PRP,PRP, LichenLichen striatusstriatus,, MFMF

SpongioticSpongiotic

„ IntraepidermalIntraepidermal intercellularintercellular edemaedema withwith widenedwidened intercellularintercellular spacesspaces andand elongationelongation ofof intercellularintercellular bridgesbridges „ SubclassifySubclassify byby inflammatoryinflammatory cellcell typetype „ EczemaEczema

UlcerUlcer

„ ObliterationObliteration ofof aa mucosalmucosal surfacesurface „ UsuallyUsually fibrinopurulentfibrinopurulent basebase EpidermalEpidermal ReactionReaction PatternsPatterns

Orthokeratosis

Hyperkeratosis Spongiosis

Modify by Inflammatory Cell type

Parakeratosis Acanthosis Spongiosis

Parakeratosis Acanthosis Hyperkeratosis Orthokeratosis

Hyperkeratosis Acanthosis Epidermal/DermalEpidermal/Dermal ReactionReaction PatternsPatterns

„ SuperficialSuperficial perivascularperivascular „ SuperficialSuperficial andand deepdeep perivascularperivascular „ NodularNodular andand diffusediffuse „ IntraepidermalIntraepidermal vesicularvesicular andand pustularpustular „ SubepidermalSubepidermal vesicularvesicular

AbscessAbscess

„ ObliterationObliteration ofof tissuetissue byby suppurativesuppurative necrosisnecrosis „ MayMay havehave foreignforeign bodybody giantgiant cellscells „ ConsiderConsider correlationcorrelation withwith culturescultures „ ConsiderConsider specialspecial stainsstains

CaseationCaseation NecrosisNecrosis

„ Identical to coagulation necrosis and ischemic necrosis „ Affected tissue has lost its structural outline and appears as pale eosinophilic, amorphous and finely granular „ Tuberculosis, Necrobiotic xanthogranuloma

FibrinoidFibrinoid NecrosisNecrosis

„ FibrinFibrin depositiondeposition inin thethe wallwall ofof smallsmall vesselsvessels „ CommonlyCommonly associatedassociated withwith leukocytoclasticleukocytoclastic vasculitisvasculitis

FlameFlame FiguresFigures

„ EncrustationEncrustation ofof eosinophiliceosinophilic granulesgranules aroundaround collagencollagen „ FrequentFrequent inin conditionsconditions withwith dermaldermal eosinophiliaeosinophilia „ WellWell’’ss syndrome,syndrome, arthropod,arthropod, drugdrug reactionsreactions

GranulationGranulation TissueTissue

„ Newly formed dermis arising in healing wounds and characterized by numerous fibroblasts and new capillaries and an infiltrate consisting of lymphoid cells, macrophages, and plasma cells „ Decubitus ulcer

GranulomaGranuloma

„ Chronic proliferative lesion consisting of mononuclear cells and epithelioid cells or multinucleated giant cells or both „ Cells lie in groups and are often surrounded by lymphoid cells „ "Naked" granulomas have few to none of these surrounding lymphoid cells „ Sarcoidosis, foreign body

GrenzGrenz ZoneZone

„ AA narrownarrow areaarea ofof uninvolveduninvolved dermisdermis betweenbetween thethe epidermisepidermis andand aa dermaldermal inflammatoryinflammatory oror neoplasticneoplastic infiltrate.infiltrate. ““GrenzGrenz”” isis GermanGerman forfor ““borderborder”” „ SomeSome lymphomas,lymphomas, granulomagranuloma facialefaciale

NecrobiosisNecrobiosis

„ AlteredAltered collagencollagen thatthat losesloses itsits normalnormal eosinophiliceosinophilic colorationcoloration andand fibrillarfibrillar appearance,appearance, becomingbecoming slightlyslightly bluishbluish andand "smudged"smudged““ „ NecrobiosisNecrobiosis lipoidicalipoidica,, somesome infectionsinfections

NuclearNuclear DustDust

„ FragmentedFragmented nucleinuclei scatteredscattered inin thethe dermis,dermis, predominantlypredominantly aroundaround bloodblood vesselsvessels „ LeukocytoclasticLeukocytoclastic vasculitisvasculitis,, granulomagranuloma facialefaciale,, SweetSweet’’ss syndromesyndrome No Epidermal Changes Perivascular Intestitial

Superficial/Deep Epidermal Changes Spongiotic Epidermal Changes Ballooning Interface Psoriasiform/Lichenoid Lichenoid/Interface

Spongiotic Psoriasiform

Psoriasiform Lichenoid SuperficialSuperficial PerivascularPerivascular NoNo EpidermalEpidermal ChangesChanges

„ Tinea versicolor Dermatophytosis Erythrasma Pitted keratolysis Vitiligo Schamberg's disease Viral exanthems Drug eruption (one type) Urticaria, late Erythema figuratum, superficial SuperficialSuperficial PerivascularPerivascular/Interstitial/Interstitial NoNo EpidermalEpidermal ChangesChanges

„ Schamberg's disease PUPPP „ Dermatitis herpetiformis Linear IgA dermatosis Dermatitis herpetiformis-like drug eruptions Acute discoid lupus erythematosus/SLE Leukocytoclastic vasculitis Erythema marginatum SuperficialSuperficial PerivascularPerivascular/Interstitial/Interstitial NoNo EpidermalEpidermal ChangesChanges

„ Bullous pemphigoid/Herpes gestationis, urticarial Pemphigus vulgaris, urticarial Arthropod PUPPP „ Urticaria „ Postinflammatory pigmentary alteration Macular amyloidosis „ Urticaria pigmentosa Brachioradial pruritis SuperficialSuperficial PerivascularPerivascular PsoriasiformPsoriasiform „ Psoriasis Allergic contact dermatitis Nummular dermatitis Dyshidrotic dermatitis Pityriasis rubra pilaris Seborrheic dermatitis SuperficialSuperficial PerivascularPerivascular PsoriasiformPsoriasiform „ Dermatophytosis Candidiasis „ Lichen simplex chronicus Prurigo nodularis Acanthoma fissuratum Pressure papule from prosthesis Surfer's nodules Chondrodermatitis nodularis helicis SuperficialSuperficial PerivascularPerivascular SpongioticSpongiotic PsoriasiformPsoriasiform „ AllergicAllergic contactcontact dermatitisdermatitis „ NummularNummular dermatitisdermatitis DyshidroticDyshidrotic dermatitisdermatitis IdId reactionreaction SeborrheicSeborrheic dermatitisdermatitis „ NonbullousNonbullous congenitalcongenital ichthyosiformichthyosiform erythrodermaerythroderma LichenLichen striatusstriatus SuperficialSuperficial PerivascularPerivascular LichenoidLichenoid/Interface/Interface

„ LichenLichen planusplanus LichenoidLichenoid drugdrug PityriasisPityriasis lichenoideslichenoides chronicachronica „ DLEDLE DermatomyositisDermatomyositis GVHGVH EMEM SuperficialSuperficial PerivascularPerivascular Psoriasiform/LichenoidPsoriasiform/Lichenoid

„ LichenLichen striatusstriatus BullousBullous pemphigoidpemphigoid HerpesHerpes gestationisgestationis,, urticarialurticarial „ MycosisMycosis fungoidesfungoides Superficial/DeepSuperficial/Deep NoNo EpidermalEpidermal ChangesChanges

„ Polymorphous light eruption, early Erythema figuratum Erythema chronicum migrans Pernio „ Erythema nodosum PMLE DLE, tumid CLL „ B-cell lymphoma Superficial/DeepSuperficial/Deep NoNo EpidermalEpidermal ChangesChanges

„ Arthropod insult „ Erythema chronicum migrans Scleroderma „ Leprosy, indeterminate Superficial/DeepSuperficial/Deep PerivascularPerivascular andand InterstitialInterstitial „ Suppurative folliculitis, periphery „ Neutrophilic eccrine hidradenitis „ Flea bite „ Cellulitis „ Erythropoietic protoporphyria „ Arthropod „ Erythema chronicum migrans „ Well's syndrome Superficial/DeepSuperficial/Deep PerivascularPerivascular andand InterstitialInterstitial

„ Granuloma annulare „ Necrobiosis lipoidica „ Interstitial granulomatous dermatitis with arthritis „ Mycosis fungoides, granulomatous Superficial/DeepSuperficial/Deep EpidermalEpidermal LichenoidLichenoid--InterfaceInterface „ PLEVAPLEVA FixedFixed drugdrug eruptioneruption DermatophytosisDermatophytosis „ LyPLyP GVHGVH DLEDLE „ AcrodermatitisAcrodermatitis chronicachronica atrophicansatrophicans „ MycosisMycosis fungoidesfungoides,, plaqueplaque Nodular/DiffuseNodular/Diffuse DermatitisDermatitis

Lymphocytes

Histiocytes Neutrophils (Granulomas)

Plasma cells Eosinophils Nodular/DiffuseNodular/Diffuse DermatitisDermatitis

„ HistiocytesHistiocytes ((GranulomasGranulomas)) „ Sarcoidal „ Tuberculoid „ Palisaded „ Suppurative Nodular/DiffuseNodular/Diffuse DermatitisDermatitis

„ HistiocytesHistiocytes ((GranulomasGranulomas)) „ Tuberculoid „ Suppurative Nodular/DiffuseNodular/Diffuse DermatitisDermatitis

CellCell TypeType DiagnosisDiagnosis

NeutrophilsNeutrophils SweetsSweets EosinophilsEosinophils WellWell’’s,s, HypersensitivityHypersensitivity PlasmaPlasma cellscells LymeLyme diseasedisease HistiocytesHistiocytes GranulomatousGranulomatous diseasesdiseases MixedMixed GranulomaGranuloma facialefaciale

Intraepidermal Vesicular and Pustular Dermatitis

Vesicular Pustular

Ballooning Spongiosis Acantholysis Cleaving Intracorneal Subcorneal IntraepidermalIntraepidermal VesicularVesicular DermatosisDermatosis

Spongiosis

Intraepidermal vesicle

Intraepidermal bullae IntraepidermalIntraepidermal SpongiosisSpongiosis

„ Allergic contact dermatitis Nummular dermatitis Dyshidrotic dermatitis „ Id reaction Photoallergic dermatitis, early Dermatophytosis Miliaria rubra Gianotti-Crosti syndrome Pityriasis rosea Erythema annulare centrifugum Seborrheic dermatitis „ Lichen striatus Pityriasis alba „ Mycosis fungoides, macule/patch IntraepidermalIntraepidermal SpongiosisSpongiosis

„ PUPPP Allergic contact dermatitis Nummular dermatitis Dyshidrotic dermatitis „ Id reaction Bullous pemphigoid Herpes gestationis Pemphigus vulgaris, urticarial Incontinentia pigmenti „ Toxic erythema of newborn Arthropod assault IntraepidermalIntraepidermal BallooningBallooning

„ HerpesHerpes OrfOrf ParapoxParapox infectioninfection „ MeaslesMeasles „ HydroaHydroa aestivale/Hydroaaestivale/Hydroa vacciniformevacciniforme IntraepidermalIntraepidermal withwith AcantholysisAcantholysis

„ PemphigusPemphigus vulgarisvulgaris PemphigusPemphigus vegetansvegetans PemphigusPemphigus erythematosuserythematosus PemphigusPemphigus foliaceusfoliaceus FogoFogo selvagemselvagem „ GroverGrover’’ss diseasedisease IntraepidermalIntraepidermal SpongioticSpongiotic Psoriasiform/LichenoidPsoriasiform/Lichenoid

„ Allergic contact dermatitis „ Nummular dermatitis „ Dyshidrotic dermatitis „ Id reaction „ Seborrheic dermatitis „ Nonbullous congenital ichthyosiform erythroderma „ Lichen striatus IntraepidermalIntraepidermal SpongioticSpongiotic Psoriasiform/LichenoidPsoriasiform/Lichenoid

„ Lichen striatus „ Bullous pemphigoid „ Herpes gestationis, urticarial „ MF SubepidermalSubepidermal VesicularVesicular DermatosisDermatosis

Subepidermal

Minimal Mixed Lymphocytes

Neutrophils Neuts/Eos Mast Cells SubepidermalSubepidermal VesicularVesicular DermatosisDermatosis

„ Bullous pemphigoid/Herpes gestationis „ Cicatricial pemphigoid „ Dermatitis herpetiformis/Linear IgA disease SubepidermalSubepidermal VesicularVesicular DermatosisDermatosis

„ EBA „ Bullous LE „ Bullous mastocytosis „ Bullous amyloidosis „ Drug reactions „ LP SpecialSpecial CategoriesCategories

„ VasculitisVasculitis „ AlopeciaAlopecia „ Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis „ FibrosingFibrosing dermatitisdermatitis „ PanniculitisPanniculitis VasculitisVasculitis

Small Vessel

Large Vessel

Mixed VasculitisVasculitis

„ LeukocytoclasticLeukocytoclastic vasculitisvasculitis „ MicroscopicMicroscopic arteritisarteritis „ PolyarteritisPolyarteritis nodosanodosa „ ErythemaErythema induratuminduratum Alopecia

Non-Inflammatory Inflammatory

Follicle density normal Follicle density decreased Lymphocytes Mixed AlopeciaAlopecia NonNon--InflammatoryInflammatory

„ FollicleFollicle densitydensity normalnormal „ Androgenic alopecia Telogen effluvium Trichotillomania „ FollicleFollicle densitydensity decreaseddecreased „ Traction alopecia AlopeciaAlopecia InflammatoryInflammatory „ Alopecia areata Lichen planopilaris DLE Scleroderma „ Folliculitis decalvans Tinea capitis Majocchi's granuloma Burns/Radiation „ Syphilis „ Scar „ LPP Scleroderma DLE Spongiotic

Folliculitis

Suppurative Perifolliculitis Lymphocytes

Perifolliculitis

Granulomatous Fibrosing Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis

„ Infectious (Staph, Strep, Dermatophytosis Endothrix/Ectothrix) „ Acne vulgaris Acne rosacea Perforating disorders Folliculitis/PerifolliculitisFolliculitis/Perifolliculitis

„ Infundibulofolliculitis Alopecia mucinosa „ Perifolliculitis „ Scurvy Lichen planopilaris DLE Rosacea Keratosis pilaris FibrosingFibrosing DermatitisDermatitis

Fibrosing Dermatitis

Fibrocytes Increased Fibrocytes Decreased Antecedents to Fibrosis

Ulcer Scar Sclerosis Granulation tissue Scleroderma/Morphea Radiation Granulomas Sclerosis

Fibrosis

Antecedent to Fibrosis FibrosingFibrosing DermatitisDermatitis

„ ScarScar „ ChronicChronic lymphedemalymphedema „ KeloidKeloid „ DermatofibromaDermatofibroma „ AnetodermaAnetoderma „ AcrodermatitisAcrodermatitis chronicachronica atrophicansatrophicans „ LSEA/LSEA/MorpheaMorphea „ RadiationRadiation sclerosissclerosis PanniculitisPanniculitis

Septal Lobular With or without vasculitis With or without Vasculitis PanniculitisPanniculitis

„ ErythemaErythema nodosumnodosum ErythemaErythema induratuminduratum „ LupusLupus panniculitispanniculitis InfectiousInfectious PancreaticPancreatic fatfat necrosisnecrosis LympohmaLympohma SubQSubQ fatfat necrosisnecrosis PoststeroidPoststeroid panniculitispanniculitis

QuestionsQuestions

„ PeoplePeople talktalk fundamentalsfundamentals andand superlativessuperlatives andand thenthen makemake somesome changeschanges ofof detail.detail.

Oliver Wendell Holmes Jr. (1841 - 1935)