Inflammatory Skin Disease - PathoBasic [PDF]

Inflammatory Skin Disease Pattern: superficial perivascular inflammation & epidermal changes

2014-01-16

Prof. Dr. med. Katharina Glatz

Pathologie

Clinical Information Always ask for a working diagnosis !

Dermatomyositis

«invisible dermatosis»

Inflammatory Skin Disease

Shit in =

Inflammatory Skin Disease

Shit in = Shit out

Algorithms

Dr Albert Bernard "Bernie" Ackerman 1936-2008

Pattern Analysis • Superficial perivascular inflammation & • Epidermal changes: – Spongiotic  Eczema – Spongiotic-psoriasiform – Psoriasiform  Psoriasis – Interface dermatitis  Lichen ruber planus • vacuolar  Acute systemic lupus, erythema multiforme • Lichenoid  Lichen ruber planus, GvHD

Spongiotic Dermatitis  Eczema • • • • • • •

Contact eczema, nummular eczema Dishydrotic dermatitis ID reaction Pityriasis rosea Seborrheic dermatitis Stasis dermatitis Dermatophytosis: Always stain PAS!

Life of Lesions

«Eczema» • Acute: spongiotic – Spongiosis

• Subacute: spongiotic-psoriasiform – Epidermal hyperplasia – Parakeratosis

• Chronic: psoriasiform – Epidermal hyperplasia – Thickened compact horny layer – Little spongiosis

Acute Contact Dermatitis

Acute Spongiotic Dermatitis Superficial perivascular inflammation with Exocytosis Spongiosis Normal corneal layer

Subacute Contact Dermatitis

Subacute Dermatitis

Parakeratosis Spongiotic vesicles Spongiosis Psoriasiform epidermal hyperplasia Superficial perivascular inflammation with exocytosis

Subacute-Chronic Dermatitis

Spongiotic-psoriasiform dermatitis

Subacute-Chronic Dermatitis

Spongiotic-psoriasiform hyperplasia Perivascular inflammation with exocytosis

Chronic Dermatitis/Eczema

Chronic Dermatitis/Eczema

Irregular psoriasiform hyperplasia Hyper(para)keratosis Little spongiosis Dermal fibrosis Superficial perivascular infiltrate

Dermatophytosis

Superficial perivascular dermatitis Psoriasiform hyperplasia of the epidermis Hyphae in the cornified layer

Always perform a PAS stain in inflammatory skin disease

Subsided Dermatitis or Dermatophytosis

Intermittent tissue damage 7-10 days ago: Parakeratosis above normally maturing epidermis

Clue to dermatophytosis: neutrophils

Lichen Simplex Chronicus

Lichen Simplex Chronicus • Pattern – Superficial perivascular dermatitis

• Subpattern – Psoriasiform epidermal changes – Predomonantly lymphocytic infiltrate

• Specific characteristics – Hyper(para)keratosis, hypergranulosis – Fibrosis of the papillary dermis with thick perpendicular collagen fibers

Lichen Simplex Chronicus Impetiginisation: serocrust with neutrophils Subepithelial fibrin Superficial perivascular inflammation Hyperkeratosis, hypergranulosis

Fibrosis of the papillary dermis with perpendicular fibers

Prurigo Nodularis

Prurigo Nodularis

Seborrheic Dermatitis Superficial perivascular dermatitis Psoriasiform epidermal hyperplasia Ortho- and parakeratosis with infundibular parakeratotic crust Folliculocentric spongiosis Perivascular lymphocytic infiltrat

Psoriasis vs. psoriasiform

Psoriasis

Psoriasiform: chronic eczema

Psoriasis vulgaris

Regular psoriasiform hyperplasia Neutrophilic parakeratosis No stratum granulosum No spongiosis Thin suprapapillary epidermis Dilated capillaries Superficial perivascular infiltrate

Interface Dermatitis • Interface dermatitis – Vacuolar  Erythema multiforme – Lichenoid  Lichen ruber planus

apoptotic keratinocyte

Civatte bodies

Lichen planus-like keratosis

Interface Vacuolar • Erythema multiforme • GvHD • Lupus erythematosus, discoid, Dermatomyositis • Lichen sclerosus • Postinflammatory pigmentary alteration

Erythema multiforme Normal horny layer  acute change Vacuolar interface change Spongiosis with lymphocytic exocytosis Often numerous apoptotic keratinocytes Papillary dermal edema Superficial mild perivascular inflammatory infiltrate with scattered eosinophils

Acute Graft versus Host Disease Histologic staging for acute GVHD of the skin: Grade 0 - Normal skin Grade 1 - Basal cell layer diffuse or focal vacuolar alteration Grade 2 - Grade 1 with epidermis and/or hair follicle dyskeratotic squamous cells Grade 3 - Grade 2 with subepidermal vesicle Formation Grade 4 - Complete dermal and epidermal separation Hymes SR, Alousi AM, Cowen EW. Graft-versus-host disease: part I. Pathogenesis and clinical manifestations of graft-versus-host disease. J Am Acad Dermatol. April 2012;66:e1-18

Chronic Discoid Lupus Dense hyperorthokeratosis Epidermal atrophy Thickened basal membrane Vacuolar interface change Apoptotic keratinocytes Superficial and deep periadnexial lymphocytic inflammation Dermal mucin

Lichen Sclerosus Life of lesions! Early: lichenoid lymphohistiocytic inflammation with epidermal hyperplasia, sawtoothing, compact Hyperkeratosis, and inderface change

Late: Papillary dermal homogenization, teleangiectasia, epidermal atrophy, residual interface change.

Interface Lichenoid • Lichen ruber planus • Lichenoid keratosis/Lichen planus like keratosis • Lichenoid drug reaction • GvHD, late

Lichen Ruber Planus

Lichen Planus Hyperkeratosis Irregular sawtooth acanthosis Wedge-shaped hyergranulosis Basal cell hydropic degeneration Band like lymphohistiocytic infiltrate Apoptotic (cytoid/Civatte/colloid) bodies

Lichenoid Keratosis Syn. Lichen planus like keratosis Solitary lesion Parakeratosis Eosinophils & plasma cells

Lichenoid Keratosis

St.n. lichenoider Dermatitis Residues of Lichenoid Dermatitis • Postinflammatory hyperpigmentation – Fibrosis – Civatte bodies (Colloid bodies) – Melanophages (iron-, Masson-Fontana+)