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CINCINNATI REVIEW: 27CINCINNATI REVIEW: 27--5151
Original: Otter Aspen, MD
Feb. 20062nd Edition 01/2007 O. Aspen, MD
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Fibrosis in the papillary dermisFibrosis in the papillary dermis
(vertical collagen)(vertical collagen)--lengthening oflengthening of
papillary dermis.papillary dermis.
Hyperorthokeratosis and acanthosisHyperorthokeratosis and acanthosis
+/+/--parakeratosis.parakeratosis.
No lichenoid infiltrate.No lichenoid infiltrate.
27.27. Lichen simplex chronicusLichen simplex chronicus
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DDX: hypertrophic LPDDX: hypertrophic LP
Lichen simplex chronicusLichen simplex chronicus
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Neuts in multilayered scale (notNeuts in multilayered scale (not
mounded).mounded).
Decreased granular layerDecreased granular layer
Superficial papillary vessels withSuperficial papillary vessels with
thinning of epidermal plate.thinning of epidermal plate.
28.28. PsoriasisPsoriasis
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Plugs in the stratum corneum.Plugs in the stratum corneum.
Psoriasiform hyperplasiaPsoriasiform hyperplasia
Acanthosis, parakeratosis inAcanthosis, parakeratosis in
horizontal and vertical arrays.horizontal and vertical arrays.
Granular layer variable.Granular layer variable.
29.29. Pityriasis Rubra PilarisPityriasis Rubra Pilaris
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30.30. Glucagonoma:Glucagonoma: NMENME--
Necrolytic Migratory ErythemaNecrolytic Migratory Erythema
Sandwiched red parakeratosis withSandwiched red parakeratosis with
pallor ( balloon zone) below.pallor ( balloon zone) below.Normal or detached epidermis.Normal or detached epidermis.
Mild inflammation if any.Mild inflammation if any.
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DDX: acrodermatitisDDX: acrodermatitis
enteropathicaenteropathica
EarlyEarly ::
Vacuolar degeneration ofVacuolar degeneration of
the upper spinous layer.the upper spinous layer.
LaterLater::
Acanthosis, increasedAcanthosis, increased
pigment all layers.pigment all layers.
LatestLatest:: AtrophyAtrophy
flattening of the rete ridgesflattening of the rete ridges
and dermal fibrosis.and dermal fibrosis.
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31.
31. Pityriasis RoseaPityriasis Rosea
Parakeratotic mounds overParakeratotic mounds over
spongiosis.spongiosis.
Perivascular lymphocytic infiltratePerivascular lymphocytic infiltrate
w/o interface dermatitis.w/o interface dermatitis.
Extravasated RBCs.Extravasated RBCs.
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Ddx: superficial EAC:Ddx: superficial EAC:
Cuffing lymphocytes w/o interface.Cuffing lymphocytes w/o interface.
No papillary edema or extravasation.No papillary edema or extravasation.
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32.
32. Guttate PsoriasisGuttate Psoriasis
Parakeratotic scale and moundsParakeratotic scale and mounds
with neuts in the scale.with neuts in the scale.
Granular layer present.Granular layer present.
May have small pustules.May have small pustules.
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33.33. PLEVA:PLEVA: or, Muchaor, Mucha--Habermann, if you must.Habermann, if you must.
Necrotic keratinocytes at differentNecrotic keratinocytes at differentlevels of epidermis.levels of epidermis.
WedgeWedge--shaped lymphocyticshaped lymphocytic
infiltrate.infiltrate.
Flat scale +/Flat scale +/-- RBCs.RBCs.
PlatePlate--like parakeratosislike parakeratosis
EMEM--like changes at BM.like changes at BM.
Can have lymphocytic vasculitis.Can have lymphocytic vasculitis.
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34.
34. Impetigo Herpetiformis:Impetigo Herpetiformis:
Small collections of neuts inSmall collections of neuts in
epidermis which may coalesce intoepidermis which may coalesce into
multiple pustules, but no abscesses.multiple pustules, but no abscesses.
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Impetigo Herpetiformis: DdxImpetigo Herpetiformis: Ddx Pustular psoriasisPustular psoriasis
Acrodermatitis continua ofHallopeauAcrodermatitis continua ofHallopeau
CandidaCandida
ReitersReiters
Geographic tongueGeographic tongue
SyphilisSyphilis
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35: Lichen Planopilaris
35: Lichen Planopilaris
Beards of lymphs at follicularBeards of lymphs at follicular
bases.bases.
Lichenoid infiltrate w/ sparingLichenoid infiltrate w/ sparing
between follicles.between follicles.
Involves upper 1/3 of follicles.Involves upper 1/3 of follicles.
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35: Lichen Planopilaris: ddx
35: Lichen Planopilaris: ddx
Alopecia Areata: infiltrate aroundAlopecia Areata: infiltrate around
bulb near adipose layer.bulb near adipose layer.
DLE: interfollicular, vacuolarDLE: interfollicular, vacuolar
change, altered collagen and vessels.change, altered collagen and vessels.
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36: Lichenoid drug reaction
36: Lichenoid drug reaction
Colloid bodiesColloid bodies-- @ BM and upper@ BM and upper
dermis.dermis.
Parakeratosis +/Parakeratosis +/-- spongiosis.spongiosis.
Eos, lymphs.Eos, lymphs.
Pigment incontinence.Pigment incontinence.
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37: Porokeratosis
37: Porokeratosis
Coronoid lamellae overCoronoid lamellae over
hypogranulosis.hypogranulosis.
MildMild--moderate lichenoid infiltrate.moderate lichenoid infiltrate.
Mild degeneration of upperMild degeneration of upper
spinous underneath lamellae.spinous underneath lamellae.
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Note: Atrophic LP
looks just like it,minus coronoid
lamellae.
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Atrophic LPAtrophic LP
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38: Lichen Planus (oral)
38: Lichen Planus (oral)
Mucosal palor.Mucosal palor.
Plasma cells common in all mouthPlasma cells common in all mouthinfiltrates.infiltrates.
Dense lichenoid infiltrate.Dense lichenoid infiltrate.
No hypergranulosis in mouth.No hypergranulosis in mouth.
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Regular LP
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3
9: Lichen Striatus3
9: Lichen Striatus Deep infiltrate around singleDeep infiltrate around single
adnexal structure (eccrine gland),adnexal structure (eccrine gland),
with nothing in dermis.with nothing in dermis.
Variable interface lymphoVariable interface lympho--
histiocytic infiltrate.histiocytic infiltrate.
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4
0.4
0. Halo NevusHalo Nevus Deep and even lichenoid infiltrateDeep and even lichenoid infiltrate
with a bump (on low power).with a bump (on low power).
Thick infiltrate, may obscureThick infiltrate, may obscure
melanocytes.melanocytes.
Larger epithelioid cells withLarger epithelioid cells with
pigment.pigment.
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l
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Mel-5
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4
1: Lichen Nitidus4
1: Lichen Nitidus Ball and ClawBall and Claw
Histiocytic granulomatous infiltrate.Histiocytic granulomatous infiltrate.Sometimes giant cells.Sometimes giant cells.
Ortho or parakeratosisOrtho or parakeratosis..
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42: Lichenoid Keratosis42: Lichenoid Keratosis
Evolve from lentigo into an SK, soEvolve from lentigo into an SK, so
have pigment in basal layer andhave pigment in basal layer and
above.above.
Lichenoid infiltrate.Lichenoid infiltrate.
Parakeratosis and spongiosis.Parakeratosis and spongiosis.
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Lichenoid KeratosisLichenoid Keratosis
MaxMax--Joseph Spaces can be presentJoseph Spaces can be present..
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43.43. Leukocytoclastic VasculitisLeukocytoclastic Vasculitis
Fibrin around vessel walls thatFibrin around vessel walls that
splays out into surrounding collagensplays out into surrounding collagen
Neuts concentrated around vesselsNeuts concentrated around vessels
ExtravasationExtravasation
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44.44. Atrophie blanche: ieAtrophie blanche: ie-- livedolivedo
vasculitis.vasculitis.
Red (more so than LCV) thickRed (more so than LCV) thick
hyaline material adheres to vessels.hyaline material adheres to vessels.
Doesnt splay into collagen.Doesnt splay into collagen.
No neuts.No neuts.
Small vessel proliferation, mostSmall vessel proliferation, most
patent.patent.
Ulceration.Ulceration.
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Atrophie blancheAtrophie blanche
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Atrophie blanche: ddxAtrophie blanche: ddx
ErythropoieticErythropoietic
protoporphyriaprotoporphyria--
hyaline material veryhyaline material very
red, like a crayon.red, like a crayon.
LCVLCV-- not as red.not as red.
EPP
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45.45. CryoglobulinemiaCryoglobulinemia
All vessels occluded by red hyalineAll vessels occluded by red hyaline
material.material.
Deposits within vessels, not inDeposits within vessels, not in
wallswalls (vasculopathy vs. vasculitis).(vasculopathy vs. vasculitis).
Can have mild inflammation.Can have mild inflammation.
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Cryoglobulinemia: ddxCryoglobulinemia: ddx
Purpura fulminansPurpura fulminans
DICDIC
TTPTTP
Lupus anticoagulantLupus anticoagulant
Protein C orS deficiencyProtein C orS deficiency
Antithrombin/ coumadin/ heparin necrosisAntithrombin/ coumadin/ heparin necrosis
PNHPNH-- paroxysmal nocturnal hemoglobulinuria.paroxysmal nocturnal hemoglobulinuria.
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46.46. Pigmented PurpuraPigmented Purpura
Patchy perivascular lymphocyticPatchy perivascular lymphocytic
infiltrate that almost interconnects.infiltrate that almost interconnects.
Shiny orange (Fe) pigment inShiny orange (Fe) pigment in
upper reticular dermis.upper reticular dermis.
Extravasation.Extravasation.
No eos, neuts, or vasculitisNo eos, neuts, or vasculitis..
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Pearls stain
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Pearls stain
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47.47. Granuloma FacialeGranuloma Faciale
Facial skin, Grenz zoneFacial skin, Grenz zone
Small nodules of all inflammatorySmall nodules of all inflammatorycell types.cell types.
Perivascular infiltrate, sometimesPerivascular infiltrate, sometimes
with fibrin around vessels.with fibrin around vessels.
Periadnexal sparing.Periadnexal sparing.
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Granuloma Faciale: ddxGranuloma Faciale: ddx
Grenz zone ddxGrenz zone ddx
GFGF
LeukemiasLeukemias
Lymphomas.Lymphomas.
Lepromatous leprosyLepromatous leprosy
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Granuloma Faciale: ddxGranuloma Faciale: ddx
Eos in the faceEos in the face
GFGF
Angiolymphoid hyperplasia withAngiolymphoid hyperplasia with
eosinophilia/ ALHE/ Epithelioid hemangioma.eosinophilia/ ALHE/ Epithelioid hemangioma.
Follicular mucinosis.Follicular mucinosis.
BugsBugs
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48.48. SweetsSweets
Papillary edemaPapillary edema pseudobullaepseudobullae
Diffuse neuts and debris. Maybe aDiffuse neuts and debris. Maybe afew eos.few eos.
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SweetsSweets
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Sweets: ddxSweets: ddx--
Papillary dermal edema:Papillary dermal edema:
SweetsSweets-- neuts.neuts.
Dermal EMDermal EM-- lymphs.lymphs.
PMLEPMLE-- lymphs.lymphs.
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49.49. PMLEPMLE
Pseudobulla/ marked papillaryPseudobulla/ marked papillary
edema w/ lymphs.edema w/ lymphs.
Superficial and deep (deeper thanSuperficial and deep (deeper than
EM) lymphocytic perivascular infil.EM) lymphocytic perivascular infil.
Some necrotic keratinocytes.Some necrotic keratinocytes.
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PMLE: main ddxPMLE: main ddx
EM:EM:
Mild epidermal hyerplasia withMild epidermal hyerplasia withscattered necrotic keratinocytes.scattered necrotic keratinocytes.
Mild edema initially, significantMild edema initially, significant
lymphohistiocytic infiltrate withlymphohistiocytic infiltrate withmarked edema latermarked edema laterblisters.blisters.
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PMLE: main ddxPMLE: main ddx
EM:EM:
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50.50. TrichotillomaniaTrichotillomania
Follicular melanin casts.Follicular melanin casts.
Catagen hairs (normally only 1%Catagen hairs (normally only 1%of hairs).of hairs).
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Catagen hairs:
Thick red hyaline
sheath along pale
blue cells (w/
apoptotic cells in
between).
Catagen hairsseen in:
1. Traction
(ie- this)
2. AA.
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51.51. Alopecia AreataAlopecia Areata
Small thin hairs w/o scarring.Small thin hairs w/o scarring.
Swarm of bees lymphocyticSwarm of bees lymphocyticinfiltrate around bulbs.infiltrate around bulbs.
Bulbs are deep dermis/ subBulbs are deep dermis/ sub--Q.Q.
Looks like LPP in upper 1/3 ofLooks like LPP in upper 1/3 of
dermis.dermis.
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QUIZQUIZ
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2
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Answers
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1. LSC
2. AA
3. Psoriasis
4. Trichotillomania5. PRP
6. PMLE
7. Glucagonoma
8. Sweets
9. PR
10. GF
11. Guttate psoriasis
12. Pigmented purpura
13. PLEVA
14. Cryoglobulinemia
15. Impetigo herpetiformis
16. Atrophie blanche
17. LPP
18. LCV
19. Lichenoid drug
20. Halo nevus
21. Porokeratosis
22. Lichen striatus
23. Oral LP
24. LPLK