CORE Metadata, citation and similar papers at core.ac.uk Provided by Elsevier - Publisher Connector THE JOURNAL OF INVESTIOATIVE DERMATOLOOY vol. 49, No. 5 Copyright 1567 by The Williams & Wilkins Co. Printed in U.S.A. COLLOID MILIUM: A HISTOCHEMICAL STUDY* JAMES H. GRAHAM, M.D. AND ANTONIO S. MARQUES, M.D. Wagner (1), in 1866, first reported colloidreaction, with and without diastase digestion; milium in a 54 year old woman who showedcolloidal iron reaction, with and without bovine testicular hyaluronidase digestion for 1 hour at lesions on the forehead, cheeks and nose. In37 C; Movat's pentachrome I stain (2); alcian patients with colloid milium, the involvedblue pH 2.5 and 0.4 (3, 4); aldehyde-fuchsin pH skin is usually hyperpigmented, thickened,1.7 and 0.4 (4), with and without elastase digestion furrowed, nnd covered with multiple 0.5—5(5); Snook's reticulum stain; phosphotungstic acid hematoxylin stain (PTAH); Prussian blue re- mm dome-shaped, discrete papules. The shiny,action for iron; Fontana-Masson stain for ar- pink or orange to yellowish white translucentgentaffin granules; thiofiavine T fluorescent stain lesions have been likened to vesieles, but are(6, 7); Congo red; alkaline Congo red method firm and only after considerable pressure can(8); crystal violet amyloid stain; methyl violet a clear to yellow mueoid substance be ex-stain for amyloid (9, 5); toluidine blue (4); and Giemsa stain. The crystal violet and methyl vio- pressed from the papules. The lesions involvelet stained sections were mounted in Highman's sun exposed sites including the dorsum of theApathy gum syrup (5) which tends to prevent hands, web between the thumb and indexbleeding and gives a more permanent preparation. finger, knuckles, forearms, malar regions, nose,Formalin-fixed tissue from 1 patient with colloid ears, sides and back of the neck, and temporalmilium was used for preparing frozen sections of unstained sections, utilizing the above methods, areas. In 100 years extending from 1866—1966,and for oil red 0 and Sudan black B fat stains. approximately 100 cases of colloid miliumThe majority of the wet and paraffin-blocked tis- have been reported in the literature, but assues were sectioned at 5 e, but some were cut yet there is no uniform agreement with regard10—40 e thick and stained by the listed methods. to the nature of eolloid. All mounted tissue sections were examined polariscopically (5, 10) utilizing polarizer and The purpose of this paper is to record ouranalyzer lenses. The thiofiavine T and Congo red histopathologie, histochemieal, fluorescent mi-stained sections were examined microscopically for croscopic, and polariseopie observations re-fluorescence with a Leitz Ortholux microscope equipped with an Osram HBO 200 W light source, garding the morphologic features and compo-a UGI excitor, and an ultraviolet absorbing bar- sition of colloid. rier filter. The Congo red stained sections were also examined with the same fluorescent micro- MATERIAL ANDMETHODS scope system, but utilizing a darkfield condenser This report is based on observations of one or(11). With the exceptions given, the procedures more biopsies from S patients with typical lesionswere carried out as outlined in the "Manual of of colloid milium. The specimens were obtainedHistologic and Special Staining Technics" (12). with a 4 or 6 mm cutaneous punch and fixed inFor comparative purposes, skin sections prepared 10% neutral buffered formalin. With the exceptionby the various techniques were studied from 4 of 1 specimen (courtesy of P. J. Alfaro, M.D.,adults with lichen amyloidosis and 1 adult with Bayamon, Puerto Rico), all tissues were processedprimary systemic amyloidosis cutis. for paraffin-blocked sections. Multiple sections stained with hematoxylin and eosin (H & E) CLINICAL DATA were examined in all cases, and additional biopsy sections from 3 of the patients were prepared by The biopsy specimens came from 5 Cauca- the following methods: periodic acid-Sehiff (PAS)sian men and all were clinically diagnosed as having eolloid milium. Their ages were 32, This investigation was supported in part by Research Training Grant No. 2A-5289 (C5), from33, 36, 49 and 65 years respectively. The 2 the National Institute of Arthritis and Metabolicpatients who were 32 and 36 years old came Diseases, U. S. Public Health Service, Bethesda, Maryland 20014. from Philadelphia, Pennsylvania; and the Presented at the Twenty-Eighth Annual Meet-remaining 3 had spent most of their lives in ing of the Society for Investigative Dermatology,the region of Columbus, Georgia; Bayamon, June 18—20, 1967, Atlantic City, New Jersey. * From the Departments of Dermatology andPuerto Rico; and Rio de Janiero, Brazil. For Pathology, Temple University School of Medicineoccupational reasons, 4 of the 5 patients had a and The Skin and Cancer Hospital of Philadelphia, 3322 North Broad Street, Philadelphia, Pennsyl-greater than average amount of exposure to vania 19140. sunlight. All patients showed multiple lesions 497 498 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY A Fm. 1. Colloid Milium. Top. Low power view showing elevations of the epidermis with hyperkeratosis, atrophy and effacement of the rete ridges overlying hyaline masses in the papillary corium. H & E, )< 9. Bottom. A higher magnification illustrates the tendency for peripheral collarette formation. grenz zone, and acidophilic, amorphous, smooth, uniform colloid which is fissured with cleft-like retraction spaces. Changes of solar elastosis are present beneath the colloid deposits. H & E, X 5G. typical of colloid milium and these were lim- HiSTOPATHOLOGIC OBSERVATIONS ited to the dorsum of the hands in 2; the malar Microscopically, H & E stained biopsy sec- regions in 1; 1 had involvement of the malartions from the 5 patients showed similar fea- regions and dorsum of the handa; and the re-tures. The epidermis was elevated at irregular maining patient had discrete papuies on theintervals with hyperkeratosis, intact granular dorsum of the hands and posterior neck. Biop- layer, atrophy, hyperpigmentation of the ba- sies from 4 of the patients came from thesal layer, and effacement of the rete ridges hands, and the patient with lesions limited tooverlying hyaline masses in the papillary the face had a biopsy taken from the left zy-corium (Fig. 1—top). Some sections showcd gomatic region. The stated duration of theperipheral eollarette formation which appeared asymptomatic lesions prior to consulting ato localize the colloid to broadened dermal physician varied from 1 to 6 years. All pa-papillae (Fig. 1—bottom). Generally, a grenz tients were in good general health, but 4 ofzone of relatively uninvolved connective tissue the 5 showed aetinic skin changes. separated the epidermis from the eolloid de- COLLOID MILITJM 499 4 Apt .4 1) Fio. 2. High power magnification showing spindle andstellate-shaped fibroblasts throughout the colloid. Ciemsa, >< 655. posits, but focally, the hyalinc material ex-rounding and separating aggregates of colloid, tended to the dermoepidermal junction pro-but the morphologic appearance and staining ducing changes of liquefaction degeneration.characteristics of the 2 substances were dis- The colloid appeared as an acidophilic, amor-tinctly different (Fig. 6—left). In a few areas, phous, smooth, uniform substance replacingsmall clumps of basophilic elastotic tissue the connective tissue (Fig. 1). The homo-appeared entrapped in the hyaline substance, geneous masses were frequently fissured withbut this may be misleading from the plane of cleft-like retraction spaces (Fig. 1). Spindlesingle sections because deeper in the block and stellate shaped fibroblasts are scatteredcontinuity was usually established with larger throughout the colloid and these cells tend tomasses of solar clastosis at the base or periph- arrange their long axis along the lines of fis-ery of the colloid (Fig. 6—left). suring (Fig. 2). Papillary capillaries course through and adjacent to the hyaline masses, HJ5TOCHEMICAL onsxRvATroNs and their walls sometime show infiltration by The significant results of histochemical the acidophilic substance (Fig. 3—bottom).studies were as follows: The Fontana-Masson Vascular ectasia is usually seen in the grenzstain for melanin showed an abundance of zone and beneath the colloid, and some of thepigment in the basal layer of the epidermis, dilated blood vessels extend into the cleftsand lesser amounts free and within mclano- between the hyaline material (Fig. 3). Oc-phages in the region of the colloid deposits. casionally, a few lymphocytes, histiocytes,No hemosidcrin was demonstrated with the and rarely plasma cells were present laterallyPrussian blue reaction for iron. The colloid and at the base adjacent to the collections ofwas PAS-positive anddiastascresistant colloid. Sections from 4 out of the 5 patients(Fig. 3), showed affinity for Congo red, stained showed basophilic changes of solar elastosis atmctachromatically a purplish to red color with the periphery and beneath the colloid substancemethyl violet and crystal violet (Fig. 4), ap- (Figs. 1—bottom and 5). Some sections showedpeared pink with toluidine blue, and exhibited the abnormal elastotic changes completely sur-a variable amount of colloidal iron and alcian 500 THEJOURNAL OF INVESTIGATIVE DERMATOLOGY H p I Fic. 3. Top. The colloid is PAS positive. PAS, X 55. Bottom. The PAS-positive and diastase resistant colloid shows a striking contrast with the epidermis, grenz zone, and underlying corium. At the left, the colloid shows infiltration of the wall of