CM- Inflammatory Dermatoses Flashcards
What physical exam finding will you see if there is non-granulomatous inflammation and vascular dilation?
Erythema
What finding correlates with hyperkeratosis, parakeratosis?
scales
What correlates with:
- spongiosis
- subsequent serum/inflammatory cells in stratum corneum
- loss of epidermal barrier protection
serous crust
What correlates with induration [hardened skin]?
deep inflammation
What correlates to purpura?
Extravasated erythrocytes
What correlates to flaccid blister?
Tense blisters?
Flaccid blister = intraepidermal vesicle
Tense = subepidermal vesicle
What correlates with “hide-bound skin”?
sclerotic abundant collagen extending through the dermis
If there are ill-defined borders on the skin lesion, where is the inflammation most likely occuring?
subcutaneous inflammation
What is pattern analysis?
What are the two key facts that must be established first?
It is systemic approach to making accurate/reproducible dermatopathologic diagnoses by recognizing low-power changes to skin structure.
- what anatomic region the biopsy was taken from?
- regional differences
- certain diseases favor certain anatomic sites - what method was used to get the biopsy?
What is the histology of superficial perivascular dermatitis without epidermal change?
How does this correlate to clinical presentation?
- epidermis is normal
- infiltrate surrounds superifical plexus [in papillary dermis]
- blood vessels are dilated
Clinical correlation:
- dilated vessels –> erythema
- mild increases in vascular permeability make LITTLE or NO dermal edema–> flat lesions [macules, patches]
- IF dermal edema is present–> papules, plaques
- normal epidermis–> smooth skin surface
What skin diseases manifest as superficial perivascular dermatitis without epidermal change?
- Viral exanthems - measles, rubella, erythema infectiosum
2. drug eruptions [morbilliform type]
Describe the histology of superficial perivascular dermatitis with interface change.
- vascular dilation with inflammation around superficial plexus
- altered dermoepidermal junction causing the epidermis to mature abnormally –> hyperkeratosis, parakeratosis
What are the 2 subtypes of interface dermatitis?
- vacuolar - vacuolated basal cells as a result of inflammation
- lichenoid - “lichen-planus like”
How would you describe the color, elevation and surface for superficial perivascular dermatitis with interface change?
Color:
- erythema due to vasodilation
- violaceous - lichen planus has combo of red and blue-brown which is the color of dermal melanin, [epidermal melanocytes drop their color in response to inflammation]
Elevation:
Papules/plaques due to dermal and epidermal involvement
surface:
Scale due to hyperkeratosis and parakeratosis
What skin diseases show superficial perivascular dermatitis with interface change?
- erythema multiforme
- dermatomyositis
- lichen planus
- mycosis fungoides, the most common cutaneous T cell lymphoma
Describe the histology of superficial perivascular dermatitis with spongiosis/
Epidermis:
- edema between keratinocytes
- pale areas–> intraepidermal vesicle formation - serum and inflammatory infiltrate in stratum corneum
- acanthosis and parakeratosis
Dermis:
1. superficial perivascular infiltrate
Describe the clinical presentation of superficial perivascular dermatitis with spongiosis in terms of color, elevation and suface.
Color:
Erythema due to vasodilation
Elevation:
Papules/Plaques due to epidermal and dermal changes
Surface:
Crust - serum/inflammatory infiltrate in stratum corneum
What diseases demonstrate superficial perivascular dermatitis with spongiosis?
- allergic contact dermatitis
- nummular dermatitis [coin shaped]
- tinea
Describe histology of superficial perivascular dermatitis with psoriasiform hyperplasia.
Epidermis:
- psoriasiform hyperplasia with even elongation of rete ridges
- diminished granular layer
- parakeratosis
- suprapapillary thinning above where the widened capillaries are
- neutrophils in the stratum corneum [Munro abscess]
- neutrophils in the spinous layer [spongiform pustule of Kogoj]
Dermis:
- superficial perivascular inflammation
- tortuous capillaries
Describe the clinical presentation of superficial perivascular dermatitis with psoriasiform hyperplasia in terms of color, elevation, surface.
Color:
1. erythema due to dilated vessels
elevation:
- papules/plaques due to epidermal and dermal changes
- sharp circumscription of the lesion due to transition from psoriasiform epidermus to surrounding normal
Surface:
silver scale - parakeratosis
What are the skin diseases associated with superficial perivascular dermatitis with psoriasiform hyperplasia?
- psoriasis
2. lichen simplex chronicus [more thick, uneven psoriasiform hyperplasia; no neutrophils in stratum corneum]
What is the histology of superficial and deep perivascular dermatitis?
Dermis:
- inflammatory infiltrate around superficial and deep plexus
- lymphocytes, histiocytes, neutrophils
Epidermis:
Variable but could be spongiosis, psoriasiform, interface
Describe the clinical presentation of superficial and deep perivascular dermatitis in terms of color and elevation.
Color:
erythema - dilated vessels
Elevation:
- papules and plaques
- induration due to deeper inflammation
What are the 3 common skin diseases that show superficial and deep perivascular dermatitis?
What epithelial changes are associated with each?
- lupus erythematous and dermatomyositis - interface
- secondary syphilis - psoriasiform, lichenoid
- arthropod bite reaction - spongiosis
Describe the histology [epidermis and dermis] for nodular and diffuse dermatitis.
Epidermis = non-specific changes
Dermis [nodular]
Perivascular aggregates of inflammatory cells in superficial and deep plexus [lympho, neutro, histo]
Dermis [diffuse]
coalescing nodular aggregates to form sheets
*granulomas are nodular infiltrates of histiocytes
What will nodular/diffuse dermatitis look like clinically in terms of color and elevation?
Color:
- non-granulomatous [not nodular/histocytes] = erythema
- granulomas = red/brown by routine, yellow-brown when compressed on a glass slide [diascopy]
Elevation:
1. thicker lesion [papule, plaque, annular plaque, nodule]
What are the 5 major skin diseases associated with nodular or diffuse dermatitis?
Tell what cell is in each and if it is nodular or diffuse.
- Hansen’s disease [leprosy]
- nodular or diffuse depending on stage
- granuloma = histiocyte - TB
- nodular histiocytes
- granulmona - Sarcoidosis
- nodular histiocytes
- granuloma - Sweet syndrome
- nodular or diffuse
- neutrophils - B-cell lymphoma
- nodular or diffuse
- lymphocytes
How is vasculitis distinguished from perivascular dermatitis?
Vasculitis has histiologic evidence of blood vessel injury/destruction
What are the 4 histiologic signs of cutaneous small-vessel vasculitis [post-capillary in papillary dermis]?
- leukocytoclasis - perivascular neutrophil fragments
- extravasated RBCs- in tissue out of lumen
- fibrinoid degeneration - fibrin in vessel wall
- endothelial cell necrosis
What are the histiologic signs of cutaneous medium to large-vessel vasculitis?
Inflammatory cells in the wall or in the subendothelial space
Describe the clinical appearance of vasculitis in terms of color and elevation.
Color:
1. purpura - bright to violaceous erythema that DOES NOT blanch because erythrocytes are in the dermis outside circulation
Elevation:
- small-vessel = macules, patches, papules, plaques
- medium-vessel = papulonodules
What are 3 common causes of vasculitis?
Are they small-vessel or medium vessel?
- Leukocytoclastic vasculitis
- small-vessel
- HSP, connective tissue disorders - Polyarteritis nodosa
- medium - Wegener’s granulomatous vasculitis
- medium
What are the 3 different histologic appearances of intraepidermal vesicular dermatitis?
They all involve vesicles entirely within the epidermis [no dermal involvement]
- acantholysis - loss of intercellular adhesions –> detached and rounding up of keratinocytes.
- herpes, pemphigus - ballooning degeneration - keratinocytes swell due to intracellular edema
- herpes simplex, orf - spongiosis- intercellular edema resulting in coalescing spongiotic foci to form vesicles, bullae
- allergic contact dermatitis
Describe the clinical appearance of intraepidermal vesicular dermatitis in terms of color.
What will the surface of the blister be like?
Color:
- translucent vesicle/bullae = serum»_space;inflammatory cells
- erythema at the base = dermal inflammation and dilated vessels
Surface:
- roof formed by SOME of the epidermis –> flaccid lesion
- higher in cleavage plane, more fragile
- removal of room –> moist erosion
What are 4 skin diseases that are intraepidermal vesicular dermatitis?
does each demonstrate acantholysis, spongiosis, or ballooning degeneration?
- pemphigus vulgaris
- acantholysis
- bullae - herpes simplex
- ballooning and acantholysis
- vesicle - impetigo
- acantholytic pustule from staph - allergic contact dermatitis
- spongiosis
- vesicle
On clinical exam, you notice a translucent vesicle or bullae containing serum. There is erythema at the base of the blister. There is a thick, tense roof.
What type of lesion is this?
Supepidermal vesicular dermatitis
Translucent = serum»>inflammatory cells
Erythema if inflammatory, no erythema if bullous pemphigoid
thick roof = entire thickness of epidermis
What 3 skin diseases cause subepidermal vesicular dermatitis?
What inflammatory cell predominates in each
- bullous pemphigoid
- eosinophils - dermatitis herpetiformis
- neutrophils - porphyria cutanea tarda
- few inflammatory cells
Describe the histology of fibrosing and/or sclerosing dermatitis.
Alterations in quantity OR quality of collagen.
- Fibrosis
- collagen has fibrous quality and is densely crowded in bundles
- increase in fibrocytes - Sclerosis
- collagen is homogenized, smudged with smooth color
- decrease in fibrocytes
What color, elevation and consistency is associated with fibrosing/sclerosing dermatitis?
Color:
- erythema - increased vascularity
- violaceous - active border of inflammation which precedes sclerosis in morpha and scleroderma
Elevation:
- papules/ plaques with increased total collagen
- depressed plaques with decreased total collagen
Consistency:
- Firm - increased abnormal collagen [keloid, hypertrophic scars]
- Bound down skin - sclerosis into subcutis and deep fascia [morphea, scleroderma]
What 4 diseases commonly show fibrosing or sclerosing dermatitis?
- Scar- fibrosis
- Keloid- dense fibrosis
- Morphea - sclerosis
- scleroderma- sclerosis
What is the histology of folliculitis?
- inflammatory cells WITHIN hair follicle
- follicular spongiosis, ballooning, acantholysis
- pustule when neutrophils cluster and distend/rupture the follicle
What is the histology of perifolliculitis?
What are the 2 major types?
inflammation around the follicle
- granulomatous
- histiocytes [rosacea] - lymphocytic
- around bulb = alopecia areata
- interface changes along length of follicle = lupus
What skin diseases have folliculitis and perifolluculitis?
- acne vulgaris and hidradenitis suppurativa
- folliculitis and peri - rosacea
- both - alopecia areata
- peribulbar, perifolliculitis
Describe the histology of the 2 different types of panniculitis.
- Septal
- inflammatory cells in the fibrous septa
- some cells “spill over” into periphery of lobules - Lobular panniculitis
- inflammatory cells in the lobules AND septa
- more extensive fat degeneration
- foamy macrophages
A patient presents with erythema that is slightly violaceous and red-brown. The nodules/plaques have ill-defined boundaries and are fixed. What is the problem?
Panniculitis
What are the 2 clinical conditions that are associated with panniculitis?
- erythema nodosum - septal
2. lupus profundus - lobular
