Tissue Reaction Patterns in Dermatopathology
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by Dr. Nishkarsh Chugh
Tissue Reaction Patterns in Dermatopathology
- 1. Tissue Reaction Patterns DR. NISHKARSH CHUGH PG RESIDENT DERMATOLOGY distinctive morphological patterns which categorize a group of cutaneous diseases.
- 2. 2 WEEDON’S SCHEME 1. Major Patterns a) Eczematous (spongiotic) reactions b) Psoriasiform reactions c) Lichenoid reactions d) Vasculopathies e) Granulomatous reactions f) Vesiculobullous reactions 2. Minor Patterns a) Epidermolytic hyperkeratosis b) Acantholytic dyskeratosis c) Cornoid lamella d) Papillomatosis e) Eosinophilic cellulitis f) Transepidermal elimination 3. Cellular Patterns a) Superficial perivascular dermatitis b) Superficial and deep perivascular dermatitis Tissue Reaction Patterns by Dr. Nishkarsh Chugh
- 3. 3 Also known as Eczematous Tissue Reaction and is characterized by: 1. Spongiotic Vesicles 2. Exocytosis of inflammatory cells 3. Parakeratosis 4. Dilated BV in upper dermis 5. Widened intercellular spaces with elongation of intercellular bridges Tissue Reaction Patterns by Dr. Nishkarsh Chugh The Spongiotic Reaction Pattern Time Intraepidermal intercellular edema These 3 changes are spotty or focal
- 4. 4 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Lymphocytic/Pityriasiform • All forms of dermatitis • Sup. fungal infections • P. Rosea • PLEVA • Pityriasiform Drug Reaction • EM • EAC • Insect Bite Reaction Eosinophilic • Pemphigus (Precursor Lesions) • Pemphigoid • Pemphigoid gestationis • Insect Bite Reaction • Dermatophytes • IP • ACD • AD Neutrophilic • Pustular Psoriasis • Pustular CD • Reiter’s Disease • Prurigo Pigmentosa • Pemphigus foliaceus • IgA Pempigus • Pedrous Dermatitis Follicular • Eosinophilic Pustular Folliculitis • Follicular Eczema • SD • AD (follicular lesions) • Apocrine Milaria • Infundibulofolliculitis Milarial/Acrosyringial • Milaria Rubra Haphazard • ICD • ACD • AD • SD • Papular Dermatitis • Nummular Dermatitis Epidermal Spongiosis with Subepidermal Edema • ACD (dermal type) • Contact Urticaria • Papular Urticaria • Milaria Rubra • PMLE • Dermatophytosis • Dermal Hypersensitivity/Urticarial Dermatitis Spongiform • Psoriasis (Kogoj) • Candidiasis • Geographic Tongue • Halodermas • SC Fungal Infections
- 5. 5 1. Elongation of rete ridges in a regular pattern 2. Acanthosis 3. Presence of inflammatory cells in dermis Tissue Reaction Patterns by Dr. Nishkarsh Chugh The Psoriasiform Reaction Pattern Time ↑ Mitotic activity Epidermal Hyperplasia
- 6. 6 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Polymorphs in Epidermis Munro’s Abscess Psoriasis Sandwich Sign Dermatophytosis Follicular polymorphs Seborrheic Dermatitis No Polymorphs Spongiosis Chronic Dermatitis Mite in S. Corneum Scabies Vertical collagen bundles LSC Vertical parakeratosis, checker board pattern PRP Mound-like parakeratosis Parapsoriasis Plasma Cell Secondary Syphillis
- 7. 7 Also known as Interface dermatitis because of prominent cellular and tissue changes at the DEJ. • 1. Basal cell vacuolation • 2. Apoptosis of cells resulting in colloid/civatte bodies and necrotic keratinocytes • 3. Infiltrate at DEJ which often obscures it. Tissue Reaction Patterns by Dr. Nishkarsh Chugh The Lichenoid Reaction Pattern previously k/a liquefactive degeneration shrunken eosinophilic cells with pyknotic nuclear remnants mostly lymphocytic
- 8. 8 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Interface Dermatitis Prominent Infiltrate Lichenoid Type Vacuolation of Cells Vacuolar Type Orthokeratosis Sup infiltrate EM Mixed infiltrate, pigment incontinence FDE Parakeratosis, mild infiltrate PLC Wedge-like infl, RBCs in epidermis PLEVA
- 9. 9 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Prominent Infiltrate Lichenoid Type Band-like infiltrate Classical - Many rete ridges LP Parakeratosis – 3-4 ridges Lichen Striatus Ball Socket – 2 rete ridges Lichen Nitidus Dyskeratosis LP like keratoses Eosinophil Drug induced LP Plasma cell Secondary Syphilis Patchy infiltrate PAS + BMZ DLE Pigment incontinence Ashy Dermatoses Deep infiltrate, pigment incontinence FDE Hemosiderin Lichenoid LPP Satellite cell necrosis GVHD Plasma cell Secondary Syphilis
- 10. 10 Clinically heterogeneous group of diseases which have in common pathological changes in blood vessels. Major groups are: Tissue Reaction Patterns by Dr. Nishkarsh Chugh The Vasculopathic Reaction Pattern 1. Non inflammatory purpuras: characterized by the extravasation of erythrocytes into the dermis without inflammation or occlusion of blood vessels. 2. Vascular Occlusive Diseases: narrowing or obliteration of the lumina of small vessels by fibrin or platelet thrombi, cryoglobulins, cholesterol, or other material 3. Urticarias: leakage of plasma and some cells from dermal vessels 4. Vasculitis: inflammation of walls of BV 5. Neutrophilic Dermatoses: prominent dermal infiltrate of neutrophils, but usually without the fibrinoid necrosis of vessel walls that typifies acute (leukocytoclastic) vasculitis
- 11. 11 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Vasculitis Capillary-Venule Small Vessel Capillary Papillary Dermis PMN Septic Vasculitis Lymphocyte PPP Venule+Capillary, Pap+Mid Dermis PMN Microthrombi Septic Vasculiitis No thrombi LCV Acute PMNs IgA on DIF HSP IgG on DIF Others Eosinophil Chronic Localized G. faciale Generalized EED Lymphocyte Papillary Dermis Viral Erythema Reticular Dermis PLEVA Arteriole, Artery Large Vessel PMN PAN Atypical lymphocyte Ly Granulomatosis Granulomatous Eosinophils Churg-Strauss Necrotizing Wegener’s
- 12. 12 Distinctive inflammatory pattern characterized by the presence of granuloma which is defined as a focal collection of inflammatory cells—eosinophils, lymphocytes, macrophages, epithelioid cells, giant cells, plasma cells—with connective tissue and blood vessels Tissue Reaction Patterns by Dr. Nishkarsh Chugh The Granulomatous Reaction Pattern Tuberculoid Granuloma
- 13. Tissue Reaction Patterns by Dr. Nishkarsh Chugh 13 Granuloma Epithelioid Granuloma Macrophage Granuloma Palisading/Necrobiotic Granuloma Ring-shaped necrobiosis GA Plate-like necrobiosis Necrobiosis Lipoidica Subcutaneous necrobiosis Rheumatoid Nodule With nuclear dust and neutrophils PGND necrobiosis is defined as presence of focal degeneration of collagen (which may appear either bluish due to mucin in GA or pinkish due to fibrinoid in Rh nodule), surrounded by palisading (lying side by side) of histiocytes
- 14. 14 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Macrophage Granuloma Diffuse macrophage infiltration LD Bodies Cutaneous Leishmaniasis M. leprae LL Mixed Cell/Suppurative Granuloma Infective Fungal, ATM, Cut Leishmaniasis Non infective FB, PG, Ruptured Cyst Xanthogranuloma Touton Giant Cells Juvenile Xanthogranuloma Reticulohistiogranuloma Halogenodermas, Follicular Occlusion LGV, Malakolakia, Cat Scratch Disease Mixed-cell infiltrate which may be present as focal abscesses In addition to mixed cell infiltrate, predominant cell type is the foam cell which represents macrophage filled with foamy cytoplasm due to accumulation of lipids. These fuse to form Touton body giant cell having a foamy cytoplasm in the center surrounded by a wreath of nuclei
- 15. 15 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Epitheloid Granuloma Lymphocyte Cuff Tuberculoid With necrosis Infective Cutaneous TB Non infective LMDF Without necrosis Infective TT, Cutaneous TB Non infective FB, Rosacea Naked Granuloma Sarcoidal Infective Fungal, Syphilis Non infective FB, Sarcoidosis Cutaneous Leishmaniasis Fungal (Sporotrichosis) presence of masses of epithelioid cells which appear as a symplasmic mass of pale pink cells with indistinct cell margins and vesicular nuclei Has Langhan’s giant cells which are giant cells, 20–30 microns in size, with nuclei arranged circumferentially or in a horseshoe pattern. They are usually, but not invariably, indicative of good host immunity.
- 16. 16 The presence of vesicles, bullae or pustules at any level within the epidermis or at the DEJ. A specific diagnosis can usually be made in a particular case by assessing three features – 1. the anatomical level of the split 2. the underlying mechanism responsible for the split 3. the nature of the inflammatory infiltrate in the dermis (in the case of subepidermal lesions) 9/3/20XX Tissue Reaction Patterns by Dr. Nishkarsh Chugh The Vesiculobullous Reaction Pattern
- 17. 17 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Intraepidermal bullae Subcorneal Polymorphs SCPD Kogoj’s pustule Psoriasis Culture positive for bacteria Bullous Impetigo Acantholysis PF, P. erythematosus Suprabasal Spongiosis Dermatitis EHK Ballooning degeneration Viral Blister Acantholysis Row of tombstones PV Dilapidated brick wall HHD Dyskeratosis Darier’s Disease Basal LP
- 18. 18 1. Intraepidermal bulla/cleft in the basal layer and lower layers of stratum malpighii 2. Basal cells line the floor of the bulla as a row of tombstones 3. Acantholytic/ Tzanck cells in bulla cavity are cells that have become detached 4. Dermis shows few mononuclear cells Tissue Reaction Patterns by Dr. Nishkarsh Chugh due to loosening of connections and separation of cells, without complete detachment. the squamoid or polygonal keratinocyte changes its shape after losing the desmosomal attachments and becomes round and large abundant basophilic cytoplasm at the periphery and perinuclear halo central pyknotic nucleus with hazy/absent nucleoli Pemphigus Vulgaris
- 19. 19 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Subepidermal Bullae Cellular Lymphocyte EM PMNs DH/CBDC Eosinophils BP/HG Mast cell mastocytosis Mixed BP/EBA/IgABD Acellular Congenital EBA Acquired EBA/BP/BSLE PAS-positive material PCT
- 20. 20 1. Subepidermal bulla 2. Roof consists of intact viable epidermis 3. Predominantly eosinophilic infiltrate, with few mast cells in dermis. Occasionally, polymorphs/lymphocytes can occur In non inflammatory bulla, dermis appears acellular. Tissue Reaction Patterns by Dr. Nishkarsh Chugh Bullous Pemphigoid
- 21. 21 Tissue Reaction Patterns by Dr. Nishkarsh Chugh Lichenoid Spongiotic Vasculopathic Granulomatous Lichenoid contact dermatitis Nummular dermatitis Spongiotic drug reactions Pityriasis lichenoides Polymorphic light eruption (some cases) Pigmented purpuric dermatoses (PPD) Persistent viral reactions, particularly to herpes virus Drug reactions (allopurinol) Rare reactions to viruses Rare drug reactions Lichen nitidus Tinea capitis Mycobacterial infections HIV infection Combined Reaction Patterns
- 22. 22 Tissue Reaction Patterns by Dr. Nishkarsh Chugh • Gross Hyperkeratosis • Lysed App. (extensive and severe vacuolation of keratinocytes) • Granular App. (parakeratosis and hypergranulosis • Seen in BCIE and PPK Epidermolysis Hyperkeratosis • Acantholysis + Dyskeratosis • Seen in Darier’s Disease, Gower’s Disease and Warty Dyskeratoma Acantholytic Dyskeratosis • Parakeratosis • Agranulosis • Seen in Porokeratosis Cornoid lamella • Church Spire Sign (Hyperkeratosis, Acanthosis, Elongated Dermal Papillae pushing up the entire epidermis • Seen in inflammatory diseases and tumours Papillomatosis • Edema in both upper and lower dermis • Prominent eosinophilic infiltrate • Flame Figures • Late Stages – Fibrosis Eosinophilic cellulitis • Elimination of dermal material through channels in epidermis which cause perforation. • Seen in perforating diseases, FB and fungal disases Transepidermal elimination Minor Tissue Patterns
- 23. 23 Patterns of Inflammation Superficial perivascular dermatitis usually a/w spongiotic, psoriasiform or lichenoid reaction patterns Seen in drug rxn, tinea, viral exanthems chronic urticaria erythrasma Superficial and deep perivascular dermatitis Also may accompany a major reaction pattern Seen in light reactions, leprosy, syphilis, lichen striatus, lupus erythematosus, drug rxn, tinea, urticaria, lipodica Septal Panniculitis inflammation confined to the interlobular septa of the subcutis Seen in EN, MPAN, Necrobiosis lipoidica, Scleroderma, Cellulitis Lobular Panniculitis inflammation involves the entire fat lobule and often the septa as well Seen in Erythema induratum – nodular vasculitis, SC fat necrosis of the newborn, traumatic fat necrosis, Infective panniculitis
- 24. 24 Patterns of Inflammation Folliculitis and perifolliculitis Inflammation of the hair follicle (folliculitis) usually extends into the adjacent dermis, producing a perifolliculitis subclassified into ‘infective’ and ‘non- infective’ groups and this etiological classification is used in conjunction with the anatomical level of the follicle most affected by the inflammation Superficial Infective Folliculitis • Impetigo • Fungal Infections • Herpes Simplex Folliculitis • Folliculitis Of Secondary Syphilis Superficial Non- infective Folliculitis • Infundibulofolliculitis • Actinic Folliculitis • AV • Eosinophilic Pustular Folliculitis Deep Infective Folliculitis • Kerion • Favus • Pityrosporum Folliculitis • Furuncle • Herpes Simplex Folliculitis Deep Non-infective Folliculitis • Hidradenitis Suppurativa • Dissecting Cellulitis Of The Scalp • AC • Perforating Folliculitis Tissue Reaction Patterns by Dr. Nishkarsh Chugh
- 25. 25 THANK YOU Dr. Nishkarsh Chugh PG Resident, Dermatology Tissue Reaction Patterns by Dr. Nishkarsh Chugh
Editor's Notes
- #2: Cellular patterns along with panniculitis and folliculitis/perifolliculitis are also known as pattern of inflammation which refers to the distribution of the inflammatory cell infiltrate within the dermis and/or the subcutaneous tissue
- #3: Schematic diagram of evolutionary stages of spongiotic dermatitis: (A) initial perivascular infiltrate; (B-ACUTE) papillary dermal edema, spongiosis = vesicle, vasodilation = erythema; (C-SUBACUTE) parakeratosis due to altered keratinization=scaling and change in colour with (D) progressive epidermal hyperplasia; and (E) chronic lesions showing vertically oriented fibrosis of dermal papilla with hyperkeratosis = lichenification (thickening and pigmentation of skin) Parakeratosis: retention of nuclei in s. corneum
- #4: 1: classical form, lymphocytes + langerhan cells + histiocytes Sup fungal: dermatophytes and candiadisis PLEVA: pityriasis lichenoides et varioliformis acuta EAC: Erythema annular centrifugum 2: eisonophilic microabcesses 3: neutrophils within foci of spongiosis 4: intercellular edema in the follicular infundibulum 5: edema in the Acrosyringium: the distal intraepithelial end portion of a duct of an adnexal gland (not limited to the eccrine gland, the duct of which spirals through surface epidermis) 6: no particular pattern 7: subtype of haphazard 8: spongiosis associated with polymorphs
- #5: Acanthosis – thickened malphigi Malphigi – basale+spinosum Shortcoming is that the histologic picture varies with the stage of the lesion, no significant epidermal hyperplasia in their early stage Temporal evolution of a lesion of psoriasis from pinpoint papule to hypertrophic psoriasis. (A) Earliest manifestation: dilatation of blood vessels and few perivascular inflammatory cells. (B) Initial stage: mild parakeratosis and few neutrophils in the stratum corneum. (C) Parakeratosis with hypogranulosis. (D) Established lesion: Munro’s microabscesses in stratum corneum with regular elongation of rete ridges. (E) Hypertrophic psoriasis: thick hyperkeratosis with parakeratosis, tortuous capillary loops
- #6: Other diseases: Psoriasiform Keratosis, AIDS associated psoriasiform dermatitis, pustular psoriasis, reiter’s syndrome Sandwich sign: fungal hyphae being found in the stratum corneum, sandwiched between a superficial zone with a basket-weave configuration and a deeper zone of compact orthokeratosis
- #7: Schematic diagram of lichen planus showing (a) hyperkeratosis, (b) wedge-shaped hypergranulosis, (c) saw-tooth elongation of rete ridges, (d) basal cell degeneration, (e) pigment incontinence, and (f) band-like lymphocytic infiltrate.
- #8: Pityriasis lichenoides chronica Pityriasis lichenoides et varioliformis acuta Orthokeratosis = hyperkeratosis with normal str corneum
- #9: Satellite cell necrosis: finding of lymphocytes closely associated with a necrotic keratinocyte in the spinous layers DLE: Pas +ve and IgG band at BMZ
- #10: 1: seen in ITP, senile purpura, autoerythrocyte sensitization syndrome(psychogenic purpura), traumatic (including factitious) purpura and drug purpuras 2: Purpura and sometimes ulceration and necrosis may be clinical features of this group 4: In subsiding lesions there may only be an inflammatory infiltrate in close contact with vessel walls 5: seen in acute generalized exanthemous pustulosis, sweets sx, behcets, pg, lepra reaction, bowel bypass sx
- #11: PPP palpable puroyra EED rythema elevatum diutinum Ly granulomatosis lymphomatoid granulomatosis
- #13: PGND Palisading granulomatous neutrophilic dermatitis Histiocyte: broad term encompassing cells of both the macrophage and dendritic cell lineages
- #14: Follicular Occlusion: Acne, Rosacea and HS Cat Scratch d/s: bacterial infection caused by Bartonella henselae, typically transmitted through cat scratches or bites, leading to swollen lymph nodes and sometimes a small, crusted bump at the site of the injury
- #15: Symplasmic = continuous system of cytoplasm LMDF Lupus Miliaris Disseminatus et Faciei (consistently shows caseous necrosis but it is neither tb not tuberculid, its considred a form of rosacea) Sarcoidosis remains a diagnosis of exclusion Foreign body granulomas such as silicon, zirconium, and aluminium
- #17: Epidermolytic hyperkeratosis (EHK), also known as bullous congenital ichthyosiform erythroderma Subcorneal pustular dermatosis (SCPD) Acantholysis loss of cohesion of keratinocytes Dyskeratosis abnormal premature keratinization (deep pink cells with small dark blue nucleus)
- #18: Schematic diagram of pemphigus vulgaris showing (a) suprabasal cleft with (b) acantholytic cells and (c) tombstone appearance of basal cells with minimal dermal infiltrate. Malphigi – basale+spinosum Pyknotic = condensation of chromatin
- #19: EBA epidermolysis bullous aquisita BSLE, bullous systemic lupus erythematosus CBDC, chronic bullous dermatosis of childhood; HG, herpes gestationis;
- #20: (A) subepidermal cleft; (B) subepidermal bulla with eosinophilic infiltrate; and (C) re-epithelization resulting in subepidermal bulla becoming intraepidermal bulla.
- #22: 1. That’s why also known as granular degenration Bullous congenital ichthyosiform erythroderma (BCIE) 4. Infl d/s- : Verrucous skin lesions such as verrucous tuberculosis, subcutaneous fungal infections, pemphigus vegetans, pyoderma vegetans, milker’s nodule, viral warts and acrokeratosis verruciformis of Hopf Tumours - Seborrheic keratosis, hypertrophic form of actinic keratosis, some cases of intradermal nevi, epidermal nevi, and nevus sebaceous 5. Flame figures - flame-shaped, or triangular amorphous, homogenous eosinophilic bodies in dermis consisting of a major basic protein (derived from eosinophils), collagen, and serum proteins
- #23: 2. lipoidica (includes necrobiosis lipoidica and incomplete forms of granuloma annulare) urticaria (chronic urticaria and the urticarial stages of bullous pemphigoid and herpes gestationis)