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Histopathological reporting of biopsies taken for the diagnosis of Inflammatory Skin Disease

Dr Sampurna Roy MD   

                                                                                                                      

 

 

The term 'Inflammatory skin disease' is used to described all non-neoplastic conditions.

-A detailed clinical history should be obtained from the clinician which should include age, patient, sex, personal  and family history of skin disease, drug history, allergies, type and distribution of rash.

-Biopsy should be taken from the edge of the lesion. The specimen should include normal tissue and should be deep enough to include subcutaneous adipose tissue. 

(Gross examination of the skin specimen)

- A systematic analysis of the biopsy is necessary starting form keratin layer, epidermis, dermo-epidermal junction, the superficial and deep dermis, the fat and finally the blood vessels. 

(Normal Histology of Skin)

- Decide on the major patterns of involvement .

The inflammatory skin disease is classified according to the type of tissue reaction and nature and distribution of the inflammatory infiltrate.

Types of Tissue Reaction:

Lichenoid (Interface)Tissue Reaction Pattern

Psoriasiform Reaction Pattern

Granulomatous Reaction Pattern

Vesiculobullous Reaction Pattern

Spongiform Reaction Pattern

Vasculopathic Reaction Pattern


Neutrophils: 

Abscess / Folliculitis ;

Vasculitis ;

Superficial dermatophyte infection ;

Psoriasis ; 

Dermatitis Herpetiformis ;

Granuloma faciale ;

Sweet's Syndrome;

Erythema elevatum diutinum.

Lymphocytes 

Lupus erythematosus ;

Lichen planus ;

Erythema multiforme ;

Lichen simplex chronicus ;

Stasis dermatitis ;

Pigmented purpura ;

Viral exanthema ;

Graft versus host disease ;

Polymorphous light eruption ;

Jessner's lymphocytic eruption ;

Lymphoma.

Eosinophils

Drug/allergic reaction ; 

Insect bite reaction ; 

Bullous Pemphigoid ;

Superficial dermatophyte infection ;

Granuloma faciale ;

Well's syndrome.

Mixed Infiltrate   

Urticarial reactions ;

Dermatophyte infection ;

Insect bites ;

Sweet's syndrome ;

Granuloma faciale.

Mast Cells

Urticaria pigmentosa ;

Telangiectasia macularis eruptiva.

Plasma Cells    

Syphilis ;  

Lyme disease;  

Zoon's balanitis ;

Necrobiosis Lipoidica.

Cell Poor

Porphyria/pseudoporphyria ;

Cell poor bullous pemphigoid ;

Cutaneous amyloidosis ; 

Mucinosis.

 

When biopsy looks relatively normal:

-Levels are performed as pathological features may be  present in deeper level.

-Special stains may be required in case of certain "invisible dermatosis".

Examples of invisible dermatosis:   

                    Stain                                 Name of Lesion

Toluidene Blue Urticaria  pigmentosa
Elastic Pseudoxanthoma elasticum
PAS     Dermatophyte infection
Sirius red:   Macular amyloidosis    
Perl's    Pigmented pupura
Alcian blue      Mucinoses

 

Invisible dermatoses with subtle, but diagnostic abnormalities on H&E stain:

- Granuloma annulare (interstitial form)

- Urticarial reactions

- Exanthematous viral and drug reactions

- Morphea

 

Bullous lesions require immunofluorescence for confirmation of diagnosis.

Immunofluorescence plays an important role in the investigation of inflammatory skin disease specially in vesiculo-bullous disorders.

Localisation of antibody in inflammatory skin lesions:

Pemphigus                                 IgG, C3 (IgA)     Inter - epithelial

Pemphigoid                                IgG, C3              Dermo-epidermal junction 
                                                                         
Epidermolysis Bullosa Acquista    IgG, C3                        "

Lupus erythematosus                  IgG, C3                        "
 
Linear IgA dermatosis                 IgA                               "
 
Herpes gestationis                      C3                                 "

Normal skin                                IgM                                " 

Dermatitis herpetiformis             IgA                        Intra-dermal 

                                        
Lichenoid reactions                     IgG , IgM                        "

Vasculitis                                    IgG ; IgA ; IgM ; C3        "
 

 

 

 

Pathology Report should comment on the following features: 

 Glossary

I Epidermis

- Hyperkeratosis ;

- Parakeratosis ;

- Hypergranulosis ;

- Spongiosis and spongiotic vesicles ;

- Acantholysis  ; 

- Papillomatosis  ;

- Acanthosis (irregular, saw-tooth or psoriasiform) ;

- Atrophy ;

- Intraepidermal bulla ; 

- Inflammatory cellular infiltrate ;

- Presence of viral inclusion ;

- Civatte body ;

- Erosions and ulceration.

II Dermoepidermal junction 

Subepidermal bulla formation:

- With eosinophils , neutrophils or little or no inflammatory infiltrate  ;

- Vacuolar degeneration;

- An inflammatory infiltrate (band-like, patchy, plasma cells) ;

- Basement membrane thickening.

III Dermis  

Solar elastosis:

Change in collagen pattern:

- Presence of edema fluid ; 

- Edema fluid and eosinophils ; 

- Edema fluid and mast cells  ; 

- Thickening of bundles ;

- Dense superficial bands of collagen;

- Thickening and obliteration of fibres ;

- Deep extension and entrapment of sweat glands and subcutaneous adipose tissue;

- Hyalinization with swirling pattern ;

- Deposition of mucin ; 

- Presence of flame figures ;

- Destruction of collagen. 

Inflammatory infiltrate:  

Type :

- Neutrophilic ;

- Mast cells ;

- Lymphocytic ; 

- Lymphoplasmacytic ;

- Follicular ;

- Granulomatous ;

- Histiocytic.

Distribution: 

- Band-like ;

- V-shaped ;

- Perivascular inflammation (superficial or superficial and deep) ;

- Neutrophils around hair follicles ;

- Mononuclear inflammatory infiltrate around nerves.

Primary Vasculitis:  

Arterial ; arteriolar ; capillary ; venous

Abnormalities of hair follicle:

Microbes:  Special stains are often used to demonstrate organisms.

IV Subcutis :

Septal Panniculitis or Lobular Panniculitis 

- Presence of calcification 

- Vasculitis 

- Extension of reticular dermis .

 

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


 

 

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