Psoriasiform reaction pattern

Comments

Transcription

Psoriasiform reaction pattern
Psoriasiform dermatitis
Nathan C. Walk, M.D.
Interpretation of inflammatory skin biopsies:
– Identifyy and integrate
g
2 morphological
p
g
features
Tissue reaction pattern
– Distinctive morphologic patterns that allow grouping diseases
– Majority of inflammatory dermatoses can be categorized into
six different patterns
Lichenoid
Psoriasiform
Spongiotic
Vesiculobullous
Granulomatous
Vasculopathic
Pattern of inflammation
Psoriasiform reaction pattern
*Psoriasis
AIDS--associated psoriasiform dermatitis
AIDS
*Pustular psoriasis
*Reiter’s syndrome
– Histology indistinguishable from pustular psoriasis
*Pityriasis rubra pilaris
*Parapsoriasis
– Small p
plaque
q = chronic superficial
p
dermatitis
– Large plaque = pre MF
*Lichen simplex chronicus
The psoriasiform reaction pattern -- Other
*Subacute and chronic spongiotic dermatitides
Erythroderma
Mycosis fungoides
Chronic candidiasis and dermatophytoses
Inflammatory linear verrucous epidermal nevus
Norwegian scabies
Bowen’s disease
Clear cell acanthoma
Lamellar ichthyosis
y
Pityriasis rosea (herald patch)
Pellagra
Acrodermatitis enteropathica
Glucagonoma syndrome
Secondary syphilis
Always reference normal…
normal
Cases 1 & 2
Psoriasis
2% p
population
p
All racial groups
Mean age 25, 2 peaks – 20
20--30, 40
40--60; less
severe if develops in elderly
Children – most common is guttate form
Strong genetic factors
factors…HLA
HLA Cw6 confers RR 13
in Caucasians
– Identical twin studies….
Triggers: trauma (Koebbner), infection, drugs,
HIV
Psoriasis
Clinical ((Bolognia):
g )
– Basically - erythema,
thickened skin, and scale
– Sharply
p y demarcated
papules and/or plaques,
depending on variant
– Auspitz sign – remove
scale
l and
d gett bl
blood
d
– Extensor surfaces of
extremities, elbows, knees,
sacral region
region, scalp
scalp, nails
– Oral lesions rare
– Often pruritic, esp during
exacerbation
Psoriasis
Histology:
– Varies
V i d
depending
di on age off
lesion.
– Vascular dilation, spongiosis,
mounds of parakeratosis,
exocytosis of neutrophils into
parakeratosis
– **Loss of granular layer
– Acanthosis - regular
– PVLI – usually not many
neutrophils here
– With time…confluent
parakeratosis, Munro
microabscesses
i
b
(PMN
(PMNs iin s.
corneum), pustules of Kogoj
(s. spinosum)
– Psoriasiform hyperplasia
(regular acanthosis) and thin
suprapapillary plates
Clinical Differential ((Bolognia):
g )
–
–
–
–
–
LSC
Seborrheic dermatitis
SCCIS
CTCL
Hypertrophic LP – when on shins…psoriasis w/ scalp,
intergluteal
g
fold involvement
– With erythroderma: Sezary Sx, PRP, drug.
– With g
guttate form: small p
plaque
q p
parapsoriasis,
p
, PLC,, secondary
y
syphilis, PR, tinea
– With pustules: AGEP (drug), tinea, SneddonSneddon-Wilkinson
Pustular psoriasis
p
– Intraepidermal pustules at various stages of development.
– Early, epidermis only slightly acanthotic.
– Psoriasiform hyperplasia
yp p
seen only
y in older,, p
persistent lesions.
Reiter’s syndrome
– Triad: non
non--gonoccocal urethritis, arthritis, uveitis
– Mucocutaneous lesions – a 4th feature!
– Indistinguishable histology from Pustular psoriasis
G tt t psoriasis
Guttate
i i
– Guttate form – changes milder…like evolving lesion,
parakeratosis a/w loss of granular layer is limited to small foci
Guttate psoriasis
p
Cases 3 & 4
Pityriasis rubra pilaris
Clinical:
– Follicular hyperkeratosis on
erythematous base is KEY
– Results in rough papules
that coalesce to form large
red to orangeorange-red plaques
with distinctive “islands of
sparing”
– May become erythrodermic
– Orange
Orange--red waxy
keratoderma of palms and
soles
– Scalp, nail involvement
– Usually begins in H/N (may
look like seb derm) and
progresses caudally –
acute disorder
– Pruritus/burning 20%
Pityriasis rubra pilaris
Histology:
– Biopsy @ site of erythema,
not plugs….
plugs
– Parakeratosis at lips of
follicles, follicular plugging
– Alternating orthokeratosis and
parakeratosis in both vertical
and horizontal directions
– Irregular acanthosis
– Irregular HYPERKERATOSIS
– THICK suprapapillary plates
– RETAINS g
granular layer,
y , mayy
be hypergranulosis
– SPLI
– May have focal acantholytic
dyskeratosis**
Clinical Differential:
– Usually easily recognized
– Psoriasis – family hx, nail involvement, no
islands of sparing
sparing, not follicular based
– Seborrheic dermatitis – may mimic early PRP
– Kawasaki’s
Kawasaki s disease – if child with acute onset
Case 5
Necrolytic migratory erythema
Glucagonoma syndrome
– Necrolytic migratory erythema
– Glossitis
– Stomatitis
– Glucose intolerance
– Anemia
– Weight
g loss
– a/w islet cell tumor of pancreas
Necrolytic migratory erythema
Clinical:
– Waves of extending
annular erythema and
superficial epidermal
necrosis.
– Shedding of skin leading to
flaccid bullae and crusted
erosions.
– Resolution within 10
10--14
days.
days
– Primarily affect trunk, groin,
perineum, thighs and
buttocks.
buttocks
Necrolytic migratory erythema
Pale,, vacuolated
keratinocytes in the upper
epidermis, leading to
focal and eventual
confluent necrosis.
– “necrolysis”
Psoriasiform hyperplasia
with overlying confluent
parakeratosis vascular
parakeratosis,
dilatation.
PVLI
Case 6
Lichen simplex chronicus
Persistent rubbing
Atopy, other reason?
Clinical:
– Almost never in children;;
>60
– Hyperpigmented,
lichenified, leathery
plaques
– Well circumscribed
– Predilection for the occipital
and nuchal areas in
women; perineum,
i
scrotum
t
in men
– Other favored areas
include wrists,, extensor
surfaces of forearms, and
lower legs
Lichen simplex chronicus
Histology:
– Thick, compact orthokeratosis
– like acral skin
– Hypergranulosis
– ***?parakeratosis
?parakeratosis
– Psoriasiform hyperplasia with
thick rete of less even length
g
than psoriasis
– Epidermal thickness and
volume greater than in
psoriasis
– Thick papillary dermis with
vertical collagen
– Inflammation
Case 7
Prurigo nodularis
Clinical:
– Numerous persistent,
intensely pruritic nodules.
– Involve predominantly
extensor aspects of the
limbs, symmetrically.
– Range from few in number
to >100
>100.kk
– ?underlying cause for
pruritus
Metabolic disorder
Arthropod bites
Folliculitis
Atopy
py
Prurigo nodularis
Histology:
– Prominent
hyperkeratosis, focal
parakeratosis
– Marked irregular
acanthosis
– Tends to be
folliculocentric
– Pseudoepitheliomatous
hyperplasia
Case 8
Seborrheic dermatitis
Clinical:
Erythematous, scaling papules
and plaques, sometimes with a
greasy
g
y yyellow appearance.
pp
“Seborrheic areas”
– Scalp, ears, eyebrows,
eyelid margins
margins, nasolabial
area.
Changes those of an acute,
subacute or chronic spongiotic
subacute,
dermatitis.
Chronic spongiotic
dermatitis looks
psoriasiform!
Seborrheic dermatitis
Histology:
gy
– Spongiosis
– Psoriasiform
hyperplasia – less so
than psoriasis, usually.
– Folliculocentric
parakeratosis and
scale crusts
– PVLI
3 features help differentiate…
Case 9
Mycosis fungoides
Most common
primary cutaneous
lymphoma.
T cells:
– CD2+, CD3+, CD4+,
CD8- and CD7-
Patch – plaque –
tumor
Histology: (plaque stage)
– Compact hyperkeratosis,
parakeratosis, psoriasiform
hyperplasia.
– Variably dense infiltrate of
mononuclear cells in the papillary
dermis.
– Epidermotropism
– Pautrier’s microabcesses
– Lymphocytes with a clear
perinuclear halo, aligned along
the basal layer – “beading”
beading
– Lymphocytes with
hyperconvoluted nuclei –
“cerebriform”
– Epidermal lymphocytes larger
than dermal lymphocytes
Psoriasis versus:
– LSC/Prurigo
– Seborrheic dermatitis
– SCCIS
– CTCL
– Hypertrophic LP – when on shins…psoriasis w/ scalp,
intergluteal fold involvement
– With erythroderma:
y
Sezary
y Sx,, PRP,, drug.
g
– With guttate form: small plaque parapsoriasis, PLC, secondary
syphilis, PR, tinea
– With pustules: AGEP (drug), tinea, SneddonSneddon-Wilkinson

Similar documents

Psoriasiform Dermatitis

Psoriasiform Dermatitis • Clinically, presents as large erythematous patches and plaques • Often progresses to poikilodermatous lesions • Histology: mild psoriasiform hyperplasia with spongiosis and few atypical lymphocyt...

More information

Spongiotic and psoriasiform reaction pattern

Spongiotic and psoriasiform reaction pattern Focal hyperkeratosis (multi)focal parakeratosis Slight irregular acanthosis Vesiculation rare Superficial perivascular mononuclear inflammatory cell infiltrate • Extravasation of erythrocytes

More information