Cincinnati 27-51 2nd Ed

8/9/2019 Cincinnati 27-51 2nd Ed.

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CINCINNATI REVIEW: 27CINCINNATI REVIEW: 27--5151

Original: Otter Aspen, MD

Feb. 20062nd Edition 01/2007 O. Aspen, MD


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Fibrosis in the papillary dermisFibrosis in the papillary dermis

(vertical collagen)(vertical collagen)--lengthening oflengthening of

papillary dermis.papillary dermis.

Hyperorthokeratosis and acanthosisHyperorthokeratosis and acanthosis

+/+/--parakeratosis.parakeratosis.

No lichenoid infiltrate.No lichenoid infiltrate.

27.27. Lichen simplex chronicusLichen simplex chronicus


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DDX: hypertrophic LPDDX: hypertrophic LP

Lichen simplex chronicusLichen simplex chronicus


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Neuts in multilayered scale (notNeuts in multilayered scale (not

mounded).mounded).

Decreased granular layerDecreased granular layer

Superficial papillary vessels withSuperficial papillary vessels with

thinning of epidermal plate.thinning of epidermal plate.

28.28. PsoriasisPsoriasis


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Plugs in the stratum corneum.Plugs in the stratum corneum.

Psoriasiform hyperplasiaPsoriasiform hyperplasia

Acanthosis, parakeratosis inAcanthosis, parakeratosis in

horizontal and vertical arrays.horizontal and vertical arrays.

Granular layer variable.Granular layer variable.

29.29. Pityriasis Rubra PilarisPityriasis Rubra Pilaris


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30.30. Glucagonoma:Glucagonoma: NMENME--

Necrolytic Migratory ErythemaNecrolytic Migratory Erythema

Sandwiched red parakeratosis withSandwiched red parakeratosis with

pallor ( balloon zone) below.pallor ( balloon zone) below.Normal or detached epidermis.Normal or detached epidermis.

Mild inflammation if any.Mild inflammation if any.


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DDX: acrodermatitisDDX: acrodermatitis

enteropathicaenteropathica

EarlyEarly ::

Vacuolar degeneration ofVacuolar degeneration of

the upper spinous layer.the upper spinous layer.

LaterLater::

Acanthosis, increasedAcanthosis, increased

pigment all layers.pigment all layers.

LatestLatest:: AtrophyAtrophy

flattening of the rete ridgesflattening of the rete ridges

and dermal fibrosis.and dermal fibrosis.


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31.

31. Pityriasis RoseaPityriasis Rosea

Parakeratotic mounds overParakeratotic mounds over

spongiosis.spongiosis.

Perivascular lymphocytic infiltratePerivascular lymphocytic infiltrate

w/o interface dermatitis.w/o interface dermatitis.

Extravasated RBCs.Extravasated RBCs.


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Ddx: superficial EAC:Ddx: superficial EAC:

Cuffing lymphocytes w/o interface.Cuffing lymphocytes w/o interface.

No papillary edema or extravasation.No papillary edema or extravasation.


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32.

32. Guttate PsoriasisGuttate Psoriasis

Parakeratotic scale and moundsParakeratotic scale and mounds

with neuts in the scale.with neuts in the scale.

Granular layer present.Granular layer present.

May have small pustules.May have small pustules.


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33.33. PLEVA:PLEVA: or, Muchaor, Mucha--Habermann, if you must.Habermann, if you must.

Necrotic keratinocytes at differentNecrotic keratinocytes at differentlevels of epidermis.levels of epidermis.

WedgeWedge--shaped lymphocyticshaped lymphocytic

infiltrate.infiltrate.

Flat scale +/Flat scale +/-- RBCs.RBCs.

PlatePlate--like parakeratosislike parakeratosis

EMEM--like changes at BM.like changes at BM.

Can have lymphocytic vasculitis.Can have lymphocytic vasculitis.


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34.

34. Impetigo Herpetiformis:Impetigo Herpetiformis:

Small collections of neuts inSmall collections of neuts in

epidermis which may coalesce intoepidermis which may coalesce into

multiple pustules, but no abscesses.multiple pustules, but no abscesses.


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Impetigo Herpetiformis: DdxImpetigo Herpetiformis: Ddx Pustular psoriasisPustular psoriasis

Acrodermatitis continua ofHallopeauAcrodermatitis continua ofHallopeau

CandidaCandida

ReitersReiters

Geographic tongueGeographic tongue

SyphilisSyphilis


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35: Lichen Planopilaris

35: Lichen Planopilaris

Beards of lymphs at follicularBeards of lymphs at follicular

bases.bases.

Lichenoid infiltrate w/ sparingLichenoid infiltrate w/ sparing

between follicles.between follicles.

Involves upper 1/3 of follicles.Involves upper 1/3 of follicles.


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35: Lichen Planopilaris: ddx

35: Lichen Planopilaris: ddx

Alopecia Areata: infiltrate aroundAlopecia Areata: infiltrate around

bulb near adipose layer.bulb near adipose layer.

DLE: interfollicular, vacuolarDLE: interfollicular, vacuolar

change, altered collagen and vessels.change, altered collagen and vessels.


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36: Lichenoid drug reaction

36: Lichenoid drug reaction

Colloid bodiesColloid bodies-- @ BM and upper@ BM and upper

dermis.dermis.

Parakeratosis +/Parakeratosis +/-- spongiosis.spongiosis.

Eos, lymphs.Eos, lymphs.

Pigment incontinence.Pigment incontinence.


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37: Porokeratosis

37: Porokeratosis

Coronoid lamellae overCoronoid lamellae over

hypogranulosis.hypogranulosis.

MildMild--moderate lichenoid infiltrate.moderate lichenoid infiltrate.

Mild degeneration of upperMild degeneration of upper

spinous underneath lamellae.spinous underneath lamellae.


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Note: Atrophic LP

looks just like it,minus coronoid

lamellae.


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Atrophic LPAtrophic LP


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38: Lichen Planus (oral)

38: Lichen Planus (oral)

Mucosal palor.Mucosal palor.

Plasma cells common in all mouthPlasma cells common in all mouthinfiltrates.infiltrates.

Dense lichenoid infiltrate.Dense lichenoid infiltrate.

No hypergranulosis in mouth.No hypergranulosis in mouth.


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Regular LP


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3

9: Lichen Striatus3

9: Lichen Striatus Deep infiltrate around singleDeep infiltrate around single

adnexal structure (eccrine gland),adnexal structure (eccrine gland),

with nothing in dermis.with nothing in dermis.

Variable interface lymphoVariable interface lympho--

histiocytic infiltrate.histiocytic infiltrate.


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4

0.4

0. Halo NevusHalo Nevus Deep and even lichenoid infiltrateDeep and even lichenoid infiltrate

with a bump (on low power).with a bump (on low power).

Thick infiltrate, may obscureThick infiltrate, may obscure

melanocytes.melanocytes.

Larger epithelioid cells withLarger epithelioid cells with

pigment.pigment.


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l


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Mel-5


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4

1: Lichen Nitidus4

1: Lichen Nitidus Ball and ClawBall and Claw

Histiocytic granulomatous infiltrate.Histiocytic granulomatous infiltrate.Sometimes giant cells.Sometimes giant cells.

Ortho or parakeratosisOrtho or parakeratosis..


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42: Lichenoid Keratosis42: Lichenoid Keratosis

Evolve from lentigo into an SK, soEvolve from lentigo into an SK, so

have pigment in basal layer andhave pigment in basal layer and

above.above.

Lichenoid infiltrate.Lichenoid infiltrate.

Parakeratosis and spongiosis.Parakeratosis and spongiosis.


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Lichenoid KeratosisLichenoid Keratosis

MaxMax--Joseph Spaces can be presentJoseph Spaces can be present..


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43.43. Leukocytoclastic VasculitisLeukocytoclastic Vasculitis

Fibrin around vessel walls thatFibrin around vessel walls that

splays out into surrounding collagensplays out into surrounding collagen

Neuts concentrated around vesselsNeuts concentrated around vessels

ExtravasationExtravasation


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44.44. Atrophie blanche: ieAtrophie blanche: ie-- livedolivedo

vasculitis.vasculitis.

Red (more so than LCV) thickRed (more so than LCV) thick

hyaline material adheres to vessels.hyaline material adheres to vessels.

Doesnt splay into collagen.Doesnt splay into collagen.

No neuts.No neuts.

Small vessel proliferation, mostSmall vessel proliferation, most

patent.patent.

Ulceration.Ulceration.


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Atrophie blancheAtrophie blanche


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Atrophie blanche: ddxAtrophie blanche: ddx

ErythropoieticErythropoietic

protoporphyriaprotoporphyria--

hyaline material veryhyaline material very

red, like a crayon.red, like a crayon.

LCVLCV-- not as red.not as red.

EPP


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45.45. CryoglobulinemiaCryoglobulinemia

All vessels occluded by red hyalineAll vessels occluded by red hyaline

material.material.

Deposits within vessels, not inDeposits within vessels, not in

wallswalls (vasculopathy vs. vasculitis).(vasculopathy vs. vasculitis).

Can have mild inflammation.Can have mild inflammation.


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Cryoglobulinemia: ddxCryoglobulinemia: ddx

Purpura fulminansPurpura fulminans

DICDIC

TTPTTP

Lupus anticoagulantLupus anticoagulant

Protein C orS deficiencyProtein C orS deficiency

Antithrombin/ coumadin/ heparin necrosisAntithrombin/ coumadin/ heparin necrosis

PNHPNH-- paroxysmal nocturnal hemoglobulinuria.paroxysmal nocturnal hemoglobulinuria.


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46.46. Pigmented PurpuraPigmented Purpura

Patchy perivascular lymphocyticPatchy perivascular lymphocytic

infiltrate that almost interconnects.infiltrate that almost interconnects.

Shiny orange (Fe) pigment inShiny orange (Fe) pigment in

upper reticular dermis.upper reticular dermis.

Extravasation.Extravasation.

No eos, neuts, or vasculitisNo eos, neuts, or vasculitis..


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Pearls stain


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Pearls stain


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47.47. Granuloma FacialeGranuloma Faciale

Facial skin, Grenz zoneFacial skin, Grenz zone

Small nodules of all inflammatorySmall nodules of all inflammatorycell types.cell types.

Perivascular infiltrate, sometimesPerivascular infiltrate, sometimes

with fibrin around vessels.with fibrin around vessels.

Periadnexal sparing.Periadnexal sparing.


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Granuloma Faciale: ddxGranuloma Faciale: ddx

Grenz zone ddxGrenz zone ddx

GFGF

LeukemiasLeukemias

Lymphomas.Lymphomas.

Lepromatous leprosyLepromatous leprosy


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Granuloma Faciale: ddxGranuloma Faciale: ddx

Eos in the faceEos in the face

GFGF

Angiolymphoid hyperplasia withAngiolymphoid hyperplasia with

eosinophilia/ ALHE/ Epithelioid hemangioma.eosinophilia/ ALHE/ Epithelioid hemangioma.

Follicular mucinosis.Follicular mucinosis.

BugsBugs


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48.48. SweetsSweets

Papillary edemaPapillary edema pseudobullaepseudobullae

Diffuse neuts and debris. Maybe aDiffuse neuts and debris. Maybe afew eos.few eos.


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SweetsSweets


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Sweets: ddxSweets: ddx--

Papillary dermal edema:Papillary dermal edema:

SweetsSweets-- neuts.neuts.

Dermal EMDermal EM-- lymphs.lymphs.

PMLEPMLE-- lymphs.lymphs.


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49.49. PMLEPMLE

Pseudobulla/ marked papillaryPseudobulla/ marked papillary

edema w/ lymphs.edema w/ lymphs.

Superficial and deep (deeper thanSuperficial and deep (deeper than

EM) lymphocytic perivascular infil.EM) lymphocytic perivascular infil.

Some necrotic keratinocytes.Some necrotic keratinocytes.


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PMLE: main ddxPMLE: main ddx

EM:EM:

Mild epidermal hyerplasia withMild epidermal hyerplasia withscattered necrotic keratinocytes.scattered necrotic keratinocytes.

Mild edema initially, significantMild edema initially, significant

lymphohistiocytic infiltrate withlymphohistiocytic infiltrate withmarked edema latermarked edema laterblisters.blisters.


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PMLE: main ddxPMLE: main ddx

EM:EM:


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50.50. TrichotillomaniaTrichotillomania

Follicular melanin casts.Follicular melanin casts.

Catagen hairs (normally only 1%Catagen hairs (normally only 1%of hairs).of hairs).


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Catagen hairs:

Thick red hyaline

sheath along pale

blue cells (w/

apoptotic cells in

between).

Catagen hairsseen in:

1. Traction

(ie- this)

2. AA.


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51.51. Alopecia AreataAlopecia Areata

Small thin hairs w/o scarring.Small thin hairs w/o scarring.

Swarm of bees lymphocyticSwarm of bees lymphocyticinfiltrate around bulbs.infiltrate around bulbs.

Bulbs are deep dermis/ subBulbs are deep dermis/ sub--Q.Q.

Looks like LPP in upper 1/3 ofLooks like LPP in upper 1/3 of

dermis.dermis.


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QUIZQUIZ


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Answers


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1. LSC

2. AA

3. Psoriasis

4. Trichotillomania5. PRP

6. PMLE

7. Glucagonoma

8. Sweets

9. PR

10. GF

11. Guttate psoriasis

12. Pigmented purpura

13. PLEVA

14. Cryoglobulinemia

15. Impetigo herpetiformis

16. Atrophie blanche

17. LPP

18. LCV

19. Lichenoid drug

20. Halo nevus

21. Porokeratosis

22. Lichen striatus

23. Oral LP

24. LPLK

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Cincinnati 27-51 2nd Ed