cincinnati 01-26 2nd ed

Cincinnati PathCincinnati Path1-261-26

Pamela Norden, MDPamela Norden, MD

01/200601/2006

22ndnd Edition 01/2007 Edition 01/2007 O. Aspen, MDO. Aspen, MD

1.1. Accessory TragusAccessory Tragus

Accessory TragusAccessory Tragus

Polypoid LesionPolypoid Lesion Central focus of superficial fatCentral focus of superficial fat Occassional Central Focus of Occassional Central Focus of

CartilageCartilage Multiple Small Vellus Hairs evenly Multiple Small Vellus Hairs evenly

placedplaced

2.2. Acquired Digital Acquired Digital FibrokeratomaFibrokeratoma

Acquired Digital Acquired Digital FibrokeratomaFibrokeratoma

Acral PolypoidAcral Polypoid Hyperkeratosis, Hypergranulosis, Hyperkeratosis, Hypergranulosis,

AcanthosisAcanthosis Elongated Rete RidgesElongated Rete Ridges Small ectatic vessels in dermal Small ectatic vessels in dermal

papillaepapillae Fibrous stroma with longitudinally Fibrous stroma with longitudinally

oriented collagenoriented collagen

Acquired Digital Acquired Digital FibrokeratomaFibrokeratoma

No neural tissueNo neural tissue No mixoid tissueNo mixoid tissue No koilocytesNo koilocytes

Differential DiagnosisDifferential Diagnosis

WartWart Accessory DigitAccessory Digit Traumatic AmputationTraumatic Amputation Infantile Digital FibromaInfantile Digital Fibroma

3.3. Supernumerary NippleSupernumerary Nipple

Supernumerary NippleSupernumerary Nipple

Mild irregular epidermal hyperplasia Mild irregular epidermal hyperplasia with elongation and broadening of with elongation and broadening of the rete ridgesthe rete ridges

Sebaceous hyperplasiaSebaceous hyperplasia Increased dermal smooth muscleIncreased dermal smooth muscle

May see May see lactiferous lactiferous ducts with ducts with stratified stratified cuboidal cuboidal epitheliumepithelium

4.4. Epidermolytic Epidermolytic HyperkeratosisHyperkeratosis

Clear Spaces in the Granular and Spinous Layers

Epidermolytic Epidermolytic HyperkeratosisHyperkeratosis

Increased granular cell layerIncreased granular cell layer Like a wart but with a higher dropout of Like a wart but with a higher dropout of

nuclei (most cells without nuclei)nuclei (most cells without nuclei) Moth-eaten/FrothyMoth-eaten/Frothy

Cell membranes “falling apart”Cell membranes “falling apart” Stippling of keratohyalin granulesStippling of keratohyalin granules

Differential DiagnosisDifferential Diagnosis

WartWart Benign keratosisBenign keratosis Epidermal neviEpidermal nevi

5.5. Verruca PlanaVerruca Plana

Verruca PlanaVerruca Plana

Hyperkeratosis with epidermal hyperplasiaHyperkeratosis with epidermal hyperplasia Increased granular cell layerIncreased granular cell layer Koilocytes =Owl’s eyes (bunched in 2s)Koilocytes =Owl’s eyes (bunched in 2s)

Clear around nucleusClear around nucleus Vs. Pagets which has perinuclear mucinous Vs. Pagets which has perinuclear mucinous

stromastroma VP involves the upper 1/3 of the epidermisVP involves the upper 1/3 of the epidermis

KoilocytesKoilocytes

Vacuolated cells withVacuolated cells with

Clumped keratohyaline Clumped keratohyaline

Granules and small Granules and small

deeply basophilic nucleideeply basophilic nuclei

Surrounded by a clear Surrounded by a clear

halohalo

6.6. Bowen’s DiseaseBowen’s Disease

Bowen’s DiseaseBowen’s Disease

Every cell in the epidermis is atypicalEvery cell in the epidermis is atypical Dyskeratotic cells in the epidermis Dyskeratotic cells in the epidermis

can be vacuolated with clear haloscan be vacuolated with clear halos Paler in the upper epidermisPaler in the upper epidermis

DDxDDx

Verruca Plana (but Bowen’s has Verruca Plana (but Bowen’s has dyskeratotic cells)dyskeratotic cells)

Paget’s Disease (but Paget’s lacks Paget’s Disease (but Paget’s lacks dyskeratotic cells and Paget’s cells dyskeratotic cells and Paget’s cells are not clear)are not clear)

Paget’sPaget’s

7.7. Tinea VersicolorTinea Versicolor

Tinea VersicolorTinea Versicolor

Invisible Dermatosis at low powerInvisible Dermatosis at low power Mild inflammation on high powerMild inflammation on high power Differs from dermatophyte because Differs from dermatophyte because

you can see TV well on H&Eyou can see TV well on H&E You need to see both spaghetti and You need to see both spaghetti and

meatballsmeatballs

H & E

PAS Stain

DDx for Invisible DermatosisDDx for Invisible Dermatosis

Tinea VersicolorTinea Versicolor Ichthyosis Vulgaris (has no granular Ichthyosis Vulgaris (has no granular

layer)layer) Macular Amyloid (slight pigment Macular Amyloid (slight pigment

incontinence)incontinence) TMEPTMEP ArgyriaArgyria UrticariaUrticaria

8.8. Acanthosis NigricansAcanthosis Nigricans

Acanthosis NigricansAcanthosis Nigricans

Most striking feature is PapillomatosisMost striking feature is Papillomatosis Hyperkeratosis often most evidence in Hyperkeratosis often most evidence in

between church spires (but may be uniform)between church spires (but may be uniform) Acanthosis usually not seen but may be Acanthosis usually not seen but may be

presentpresent Hard to distinguish from epidermal nevusHard to distinguish from epidermal nevus No inflammationNo inflammation May see TV spores in the stratum corneumMay see TV spores in the stratum corneum

DDxDDx

Epidermal Nevus (Hard to Epidermal Nevus (Hard to distinguish)distinguish)

Confluent and Reticulated Confluent and Reticulated PapillomatosisPapillomatosis

99 Porphyria Cutanea Porphyria Cutanea TardaTarda

Porphyria Cutanea TardaPorphyria Cutanea Tarda

Cell poor subepidermal blisterCell poor subepidermal blister Festooning (NOT specific for PCT)Festooning (NOT specific for PCT) Inflammatory cellsInflammatory cells

Lymphs only = PCTLymphs only = PCT Eos and Neuts = BP vs EBAEos and Neuts = BP vs EBA

Acral SkinAcral Skin

Hyaline Thickening of Blood Vessels (rare in PCT common in EPP)

PAS Stain

Caterpillar Bodies, only mentioned in Bhawan CD

DDx for Subepidermal DDx for Subepidermal BlisterBlister

CELL POORCELL POOR CommonCommon

PCTPCT EBEB BPBP

RareRare SuctionSuction Renal FailureRenal Failure Coma/FrictionComa/Friction AmyloidAmyloid DiabetesDiabetes

NOT CELL POORNOT CELL POOR DHDH Linear IgALinear IgA Bullous LupusBullous Lupus BP/HG/CPBP/HG/CP EBAEBA Bullous ScabiesBullous Scabies Bullous MastocytosisBullous Mastocytosis

10.10.Bullous PemphigoidBullous Pemphigoid

PemphigoidPemphigoid

Cell rich subepidermal blisterCell rich subepidermal blister +/- festooning+/- festooning 75% eos and 25% neuts (vs. EBA 75% eos and 25% neuts (vs. EBA

with reverse)with reverse)

PearlsPearls

Look at the papilla to make sure Look at the papilla to make sure there are no neuts there before there are no neuts there before putting EBA or BP as DH can also putting EBA or BP as DH can also have large blisters (and a few eos)have large blisters (and a few eos)

Bullous EM has lymphocytes, no eos Bullous EM has lymphocytes, no eos or neuts and will have epidermal or neuts and will have epidermal necrosisnecrosis

11.11.Erythema MultiformeErythema Multiforme

Erythema MultiformeErythema Multiforme

Classical superficial infiltrate but may Classical superficial infiltrate but may go deepergo deeper

Normal stratum corneumNormal stratum corneum Necrotic Keratinocytes at different Necrotic Keratinocytes at different

levelslevels +/- spongiosis+/- spongiosis Lymphocytic infiltrateLymphocytic infiltrate

DDxDDx

PLEVA (EM has a normal stratum PLEVA (EM has a normal stratum corneum and PLEVA has parakeratosis corneum and PLEVA has parakeratosis and deeper dermal involvement)and deeper dermal involvement)

Lichen Planus (only has necrotic Lichen Planus (only has necrotic keratinocytes at the basal layer vs. EM)keratinocytes at the basal layer vs. EM)

Acute Fixed drug (eos and neuts instead Acute Fixed drug (eos and neuts instead of EM which has lymphs)of EM which has lymphs)

12.12.Graft Versus Host Graft Versus Host DiseaseDisease

GVHDGVHD

Can be variableCan be variable Early = necrotic keratinocytesEarly = necrotic keratinocytes Necrotic cells are also periadnexal Necrotic cells are also periadnexal

(vs. EM)(vs. EM) Mild infiltrateMild infiltrate

Vacuolar Alteration of Basal Cells; mild papillary dermal lymphocytic infiltrate

DDxDDx

EM (necrotic cells don’t go down EM (necrotic cells don’t go down adnexa)adnexa)

Drug rash (has eos)Drug rash (has eos)

13.13.Coma BlisterComa Blister

Coma BlisterComa Blister

Intra and subepidermal blisterIntra and subepidermal blister Necrotic sweat gland epitheliumNecrotic sweat gland epithelium

All red from the hypoxia almost look like All red from the hypoxia almost look like vesselsvessels

Looks like EM of the sweat glandLooks like EM of the sweat gland Minimal inflammatory cellsMinimal inflammatory cells

14.14.Incontinentia PigmentiIncontinentia Pigmenti

Incontinentia PigmentiIncontinentia Pigmenti

Eosinophilic SpongiosisEosinophilic Spongiosis Dyskeratotic Cells/Necrotic Dyskeratotic Cells/Necrotic

KeratinocytesKeratinocytes Pigment incontinence (hence the Pigment incontinence (hence the

name)name)

Stage OneStage One

Stage TwoStage Two

DDx for Eosinophilic DDx for Eosinophilic SpongiosisSpongiosis

PemphigusPemphigus PemphigoidPemphigoid Drug EruptionDrug Eruption Contact DermatitisContact Dermatitis Arthropod BiteArthropod Bite IPIP Erythema Toxicum Neonatorum ( more of Erythema Toxicum Neonatorum ( more of

an abscess)an abscess)

15.15.Acute Fixed Drug Acute Fixed Drug ReactionReaction

Acute Fixed Drug EruptionAcute Fixed Drug Eruption

Normal Stratum CorneumNormal Stratum Corneum Necrotic Keratinocytes at all levelsNecrotic Keratinocytes at all levels Vacuolar Degeneration of the Basal Vacuolar Degeneration of the Basal

LayerLayer Pigment IncontinencePigment Incontinence

*Before answering EM look for eos and *Before answering EM look for eos and neuts. If you find them, think acute neuts. If you find them, think acute fixed drugfixed drug

16: Toxic Epidermal 16: Toxic Epidermal NecrolysisNecrolysis

TENTEN

Confluent wipe-out of epitheliumConfluent wipe-out of epithelium Full thickness necrosisFull thickness necrosis Often little inflammationOften little inflammation * EM is not confluent* EM is not confluent

17.17.Dermatitis Dermatitis HerpetiformisHerpetiformis

DHDH

Subepidermal inflammatory blistersSubepidermal inflammatory blisters Intense neutrophilic infiltrate in the Intense neutrophilic infiltrate in the

papillary dermispapillary dermis Neutrophilic Microabscesses in Neutrophilic Microabscesses in

dermal papillaedermal papillae

Granular IgA deposition in the Papillary Dermis

DDxDDx

Sweet’s Syndrome- Usually edema Sweet’s Syndrome- Usually edema no definite blisterno definite blister

VasculitisVasculitis Bullous Lupus (put this if DH is not a Bullous Lupus (put this if DH is not a

choice)choice) Linear IgALinear IgA

18.18.Darier’s DiseaseDarier’s Disease

Darier’s DiseaseDarier’s Disease

Papillomatous Epidermal HyperplasiaPapillomatous Epidermal Hyperplasia Dyskeratosis starting suprabasally but Dyskeratosis starting suprabasally but

can involve any surfacecan involve any surface ““Dry” –No spongiosisDry” –No spongiosis Corp ronds = swollen cells with halos Corp ronds = swollen cells with halos

located only in the granular layerlocated only in the granular layer Grains are found in the stratum Grains are found in the stratum

corneumcorneum

DDxDDx

Grovers (in general has 2 types of Grovers (in general has 2 types of acantholytic processes on biopsy, acantholytic processes on biopsy, spongiosis and acanthosisspongiosis and acanthosis

Warty dyskeratoma (cup shaped)Warty dyskeratoma (cup shaped)

19: Herpes Simplex19: Herpes Simplex

Herpes SimplexHerpes Simplex

Acantholytic cells with Acantholytic cells with multinucleated giant cellsmultinucleated giant cells

Steel grey nucleusSteel grey nucleus Intraepidermal blisterIntraepidermal blister

BallooningDegeneration Multinucleated

Giant Cell? Steel grey nucleus

20.20.Warty DyskeratomaWarty Dyskeratoma

Warty DyskeratomaWarty Dyskeratoma

Cup-shaped acantholysisCup-shaped acantholysis Endophytic epithelial hyperplasia Endophytic epithelial hyperplasia

involving the hair follicle with involving the hair follicle with hyperkeratosis and suprabasal hyperkeratosis and suprabasal cleftingclefting

Corp ronds limited to granular layerCorp ronds limited to granular layer

21.21.Pemphigus VulgarisPemphigus Vulgaris

Pemphigus VulgarisPemphigus Vulgaris

Intraepidermal blister with Intraepidermal blister with suprabasal acantholysissuprabasal acantholysis

Tombstone arrangement of blister Tombstone arrangement of blister cells at the base of the blistercells at the base of the blister

Process extends down hair follicle Process extends down hair follicle epitheliumepithelium

No corps rondsNo corps ronds

Papillary DermalVilli in the Blister Cavity

Intercellular IgG

22.22.Hailey-HaileyHailey-Hailey

Hailey HaileyHailey Hailey

NO Corps Ronds in Granular LayerNO Corps Ronds in Granular Layer ““Wet”- acantholysis with scale crustWet”- acantholysis with scale crust More continuous, not focal like More continuous, not focal like

Darier’sDarier’s Dilapidated Brick WallDilapidated Brick Wall +/- Tombstoning+/- Tombstoning

Dilapidated Brick Wall

23.23.Pemphigus Pemphigus ErythematosusErythematosus

Pemphigus ErythematosusPemphigus Erythematosus Histopathology = Pemphigus foliaceusHistopathology = Pemphigus foliaceus Split in upper epidermis below corneal Split in upper epidermis below corneal

layerlayer Acantholytic cells stick down and up Acantholytic cells stick down and up

into blisterinto blister Some PMN’sSome PMN’s Superficial epidermis can be missingSuperficial epidermis can be missing If you see lots of neuts think SSSS or If you see lots of neuts think SSSS or

bullous impetigobullous impetigo Few neuts = PemphigusFew neuts = Pemphigus

DDxDDx

Bullous Impetigo/SSSS have more Bullous Impetigo/SSSS have more PMNsPMNs

PV and PF: eos and PMNsPV and PF: eos and PMNs

25.25.EACEAC

EACEAC

Superficial perivascular tight-cuffed Superficial perivascular tight-cuffed lymphohistiocytic infiltratelymphohistiocytic infiltrate

Truncal – No hairsTruncal – No hairs No interfaceNo interface No papillary dermal edemaNo papillary dermal edema May see extravasated RBC due to May see extravasated RBC due to

endothelial swellingendothelial swelling

DDxDDx

Lupus (Similar but with interface)Lupus (Similar but with interface) PMLE and CLL ( Similar but with PMLE and CLL ( Similar but with

papillary dermal edema)papillary dermal edema) Jessners (on the face so you will see Jessners (on the face so you will see

hair follicles)hair follicles) Arthropod bites (Eos)Arthropod bites (Eos) Syphilis (Plasma Cells)Syphilis (Plasma Cells) Gyrate erythemaGyrate erythema

26.26.Secondary SyphilisSecondary Syphilis

Secondary SyphilisSecondary Syphilis

Often presents as lichenoid, look for Often presents as lichenoid, look for plasma cellaplasma cella

May be lichenoid + granulomatousMay be lichenoid + granulomatous HypergranulosisHypergranulosis Lymphs and plasma cellsLymphs and plasma cells Colloid bodiesColloid bodies

QuizQuiz