Pathologie Prof. Dr. med. Katharina Glatz

Inflammatory Skin Disease

Pattern: superficial perivascular inflammation & epidermal changes

2014-01-16

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

• 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

Pattern Analysis

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

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

Subacute Dermatitis

Subacute-Chronic Dermatitis

Spongiotic-psoriasiform dermatitis

Spongiotic-psoriasiform hyperplasia Perivascular inflammation with exocytosis

Subacute-Chronic Dermatitis

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

– Vacuolar Erythema multiforme

– Lichenoid Lichen ruber planus

Interface Dermatitis

Civatte bodies

apoptotic keratinocyte

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

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

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

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

• Postinflammatory hyperpigmentation

– Fibrosis

– Civatte bodies (Colloid bodies)

– Melanophages (iron-, Masson-Fontana+)

Residues of Lichenoid Dermatitis