final version histologic intepretation of bxs for dermatitis

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INTEPRETATION OF PATHOLOGY REPORTS IN BIOPSIES FOR DERMATITIS Jessica Spies, MD Dermatopathologist CTA Lab, Portland, OR

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Page 1: Final version histologic intepretation of bxs for dermatitis

INTEPRETATION OF PATHOLOGY REPORTS IN BIOPSIES FOR

DERMATITIS

Jessica Spies, MD

Dermatopathologist

CTA Lab, Portland, OR

Page 2: Final version histologic intepretation of bxs for dermatitis

Lecture goals

• Biopsy techniques– how to optimize pathologic diagnosis

• Dermatitis--how DPs evaluate biopsies

• Terminology – “buzz words” in DP

• Clinicopathologic nature of diagnosing dermatitis—team effort!

Page 3: Final version histologic intepretation of bxs for dermatitis

Dermatopathology training

• DP fellowships--accept physicians from both pathology and dermatology residencies

• DP training is required in both residencies

• DP training refined in fellowship—50% DP + 50% clinical derm for path trainees, 50% general pathology for derm trainees

Page 4: Final version histologic intepretation of bxs for dermatitis

General surgical pathologists

• DP training/expertise varies widely!

• Most will not use terminology I will describe today (eg “acute” and “chronic” inflammation terminology does not always apply in DP)

• For best results, use a dermatopathologist!

Page 5: Final version histologic intepretation of bxs for dermatitis

When you are sent a patient from a primary care physician with a biopsy report you don’t understand

– Have your DP review the biopsy

– Remember: PCP may not have performed the appropriate bx

– Rebiopsy patient (off treatment 2 weeks)

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Page 7: Final version histologic intepretation of bxs for dermatitis
Page 8: Final version histologic intepretation of bxs for dermatitis

Evaluating a skin biopsy

“Top to bottom approach” mainly: type of epidermal change + type of dermal infiltrate

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Biopsy technique

• Punch not shave biopsy for dermatitis!

• Wedge or incisional bx with a scalpel biopsy if ruling out a subcutaneous process/panniculitis

• Vesicles and bullae should be removed with scalpel, to avoid shearing off the blister

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Biopsy sites to avoid if possible

• Acral sites

• Elbow/knee

• Center of alopetic patch

• Excoriated lesions (delay bx if no primary lesion)

• Treated lesions

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Page 12: Final version histologic intepretation of bxs for dermatitis

Alopecia biopsies

• 4MM PUNCH aligned parallel to hair shaft to include SQ fat

• At ANGLE in Asians and whites, 90 DEGREES in blacks

• One punch—in KEY area—i.e. perifollicularerythema, active border in scarring alopecia, positive hair pull test site

• Avoid the hairline unless only site of hair loss! (where follicles are normally miniaturized and cycle faster)

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Alopecia biopsies

Include as much clinical history and description of the lesions as possible

– Shedding? If so, acute or chronic?

–Pattern of hair loss: diffuse or patchy?

– Location of bx!

–Perifollicular erythema or hyperkeratosis

– Scarring?

Page 14: Final version histologic intepretation of bxs for dermatitis

Alopecia biopsies

• Use lab with experience in alopecia biopsies!!

• Incorrectly processed specimen unlikely to yield a diagnosis

• Experience with alopecia varies widely between DPs (just like in dermatology) –due to critical mass factor

• New patient previously evaluated for alopecia without definitive pathology? Biopsy again!

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Horizontal sections of LPP

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Tangential sections ?LPP

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Biopsy for DIF

• Pemphigus and pemphigoid groups: perilesional skin or mucosa

• Dermatitis herpetiformis: normal appearing skin 0.5-1.0 cm away from lesion

• Collagen vascular disease: involved areas of skin such as active/erythematous borders

• Vasculitis: active/erythematous border of a new lesion; optimally lesions between 18-24 hours old

• Porphyria cutanea tarda: involved skin.

• Avoid old lesions, ulcers and blisters (false +/-)

• Submit in Michel’s media not formalin (frozen within 5 days)

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Bullous pemphigoid DIF

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DIF biopsies

• Include an H&E biopsy if possible!! DIF testing has pitfalls and artifacts which can be avoided if we can correlate with H&E bx

• Clinical history important for us

• DIF another infrequently performed test

• Experience with DIF varies greatly between dermatopathologists

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Dr. Bernard Ackerman

Page 21: Final version histologic intepretation of bxs for dermatitis

“Pattern diagnosis”

• “Pattern diagnosis”-- the examination of a slide at scanning magnification and analysis of the silhouette (or architecture) of lesion rather than of its individual cells

• Although this is used by DPs to some extent in tumor diagnoses, it is most useful in the evaluation of biopsies for dermatitis

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Example of one of Ackerman’s algorithmic flow charts for pattern diagnosis

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Major tissue reaction patterns

• Spongiotic (epidermal intercellular edema)• Lichenoid/interface (basal cell damage)• Psoriasiform (regular epidermal hyperplasia)• Vesiculobullous (blister within or beneath

epidermis)• Granulomatous (chronic granulomatous)

inflammation• Vasculopathic (pathologic changes in

cutaneous blood vessels)

Page 24: Final version histologic intepretation of bxs for dermatitis

Patterns of inflammation

• Superficial dermal

• Superficial and deep dermal

• Perivascular and/or interstitial

• Perifollicular and/or periadnexal

• Involvement of subcutis

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Characterizing the inflammatory cell infiltrate

– Eosinophils

– Neutrophils

– Plasma cells

– Histiocytes

– Lymphocytes

– Mast cells

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Eosinophils• In epidermis---BP, PV,

arthropod bite reactions, drug reactions

• In dermis---all of above + urticarial or “dermal” hypersensitivity

• Not all drug reactions have eosinophils!!

• Unusual for collagen vascular disease (drug induced LE exception)

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Neutrophils• In dermis---

urticaria, infection, DH, bullous LE, LAD, neutrophilicdermatosis, near folliculitis/ruptured cyst

• In epidermis--infection, psoriasis, arthropod bites, AGEP, P. foliaceous, tinea, impetigo, impetiginization

,

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Plasma cells

• Normal in scalp, near mucous membranes

• Dermis-syphillis, near folliculitis, lupus, rosacea

• Syphillis doesn’t always have plasma cells!

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Histiocytes• AKA macrophages,

giant cells, siderophages, melanophages

• Large numbers—think infection, espif neutrophils too

• Can form granulomas--think infection, sarcoidosis (dx of exclusion)

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Mast cells• Party loving!

• Mastocytosis

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Lymphocytes

• Basic inflammatory cell found in all types of dermatitis

• NK cells, T cells, and B cells

• Cannot distinguish between types without immunohistochemical(IHC) staining

• Dense infiltrates—cutaneous lymphoid hyperplasia/pseudolymphoma, cutaneous and systemic lymphomas (IHC panels)

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Page 33: Final version histologic intepretation of bxs for dermatitis

Spongiotic dermatitis

=edema between epidermal keratinocytes which may progress to vesicles/bullae

+ epidermal (“psoriasiform”) hyperplasia when chronic

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Spongiotic dermatitis

When lymphocytic, major ddx is

– allergic/contact dermatitis

– atopic dermatitis

– nummular dermatitis

– id reaction (rare)

– dermatophytosis (PAS-D stain)

– seborrheic dermatitis (scalp and face)

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However…you may also see spongiosisin

• Stasis

• Arthropod bites

• Spongiotic drug eruptions

• Pityriasis rosea

• Light reactions

• Neoplastic infiltrates (Mycosis fungoides)

• Many others..

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How do we narrow down our ddx?

Page 37: Final version histologic intepretation of bxs for dermatitis

The clinical history!

• All DP is clinicopathologic!!

• The more information you give us, the more specific we can be in our diagnosis

• Some diseases have a unique, diagnostic histology while others have a large degree of overlap with other diseases

• A good dermatopathologist tries to narrow the differential diagnosis for you.

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Biopsy of spongiotic/eczematous dermatitis

Stop topical and systemic immunosuppression for 2 weeks prior to the biopsy if possible

– Mutes epidermal spongiosis

– Kills lymphocytes

Page 39: Final version histologic intepretation of bxs for dermatitis

Mycosis fungoides

• Biopsy off steroids after 2 weeks

• Multiple bxs (one container OK)--more definitive diagnosis by histologic and molecular methods (same T cell clone > 1 bx)

• “Spongiotic dermatitis”? call your DP and/or do additional bxs if rash evolves and/or you suspect MF

• Remember: MF is a clinicopathologic diagnosis --early (patch) stage, is very indolent—better to under rather than overdiagnosis it.

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More specific types of spongiosis

• Neutrophilic spongiosis

• Eosinophilic spongiosis

• Follicular spongiosis

• Miliarial spongiosis

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Neutrophilicspongiosis

= neutrophils in epidermis + some degree of spongiosis(often pustular)

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Neutrophilic spongiosis

• Pustular psoriasis• Palmoplantar pustulosis• Dermatophytosis• Pustular contact dermatitis• Reiter’s syndrome• IgA pemphigus• Herpetiform pemphigus• Infantile acropustulosis• Acute generalized exanthematous pustulosis (AGEP)• Impetiginized spongiotic dermatitis

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Eosinophilic spongiosis

= eosinophils in epidermis with some degree of spongiosis

Page 44: Final version histologic intepretation of bxs for dermatitis

Eosinophilic spongiosis

• Allergic contact dermatitis

• Id reaction

• Atopic dermatitis

• Precursor lesions of bullous pemphigoid (or pemphigus)

• Arthropod bite reactions (including scabies)

• Spongiotic drug

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Follicular (or folliculocentric) spongiosis

=when prominent spongiosis in the follicular epithelium

Page 46: Final version histologic intepretation of bxs for dermatitis

Follicular spongiosis

• Atopic dermatitis

• Eosinophilic (suppurative) folliculitis

• Apocrine miliaria (Fox-Fordyce disease)

• Disseminate and recurrent infundibulofolliculitis

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Page 48: Final version histologic intepretation of bxs for dermatitis

Lichenoid/interface dermatitis

• Key feature = epidermal basal layer damage—cell death +/- basal layer vacuolar change

• Terminology confusing-- some use “interface dermatitis” alone when there vacuolar change predominating or “lichenoid dermatitis” when cell death and/or a band-like dermal lymphocytic infiltrate predominates

• Most often used together as most diseases with this pattern will have some of both features

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Lichenoid/interface differential

• Lichen planus and it’s variants• Lichen niditus• Lichen striatus• Lichenoid and fixed drug eruptions• Erythema multiforme• Lupus and it’s variants• Pityriasis lichenoides• Viral reactions• Perniosis• Paraneoplastic pemphigus• Pigmented purpuric dermatitis• Mycosis fungoides• Secondary syphillis• Lichen sclerosus• Many other, less common diseases

Page 50: Final version histologic intepretation of bxs for dermatitis

Lichenoid/interface dermatitis

• Acute or “EM like”

• “LP like”

• Psoriasiform lichenoid

• Atrophic or “LE like”

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Acute or “EM like” --epidermal basal cell death and little other epidermal change

Page 52: Final version histologic intepretation of bxs for dermatitis

“Lichen planus like” --prominent cell death, band like lymphocytic dermal infiltrate

Page 53: Final version histologic intepretation of bxs for dermatitis

“Psoriasiform lichenoid”-- epidermal hyperplasia + band-like inflammatory dermal infiltrate

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Atrophic or “LE like”-prominent vacuolar change + epidermal atrophy

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Lupus• Superficial and deep

infiltrate

• Perifollicullarlymphocytes+plasmacells

• Rare if any eosinophils

• Increased dermal mucindeposition (colloidal iron stain)

• Newly published criteria: increased numbers of CD123+ antigen presenting cells in infiltrate

• DIF studies may or may not be + (50-90%)

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Page 57: Final version histologic intepretation of bxs for dermatitis

Psoriasiformdermatitis

Characterized by epidermal thickening (acanthosis or hyperplasia) with regular elongation of rete ridges

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Psoriasiform dermatitis

• Psoriasis and its variants• Subacute spongiotic dermatitis• Lichen simplex chronicus• Chronic candidiasis and tinea• Mycosis fungoides• Norweigan scabies• Secondary syphillis• Some deficiency states (pellagra, acrodermatitis enteropathica)• Bowen’s disease (squamous cell carcinoma in situ)• Lamellar ichthyosis• Other rare diseases such as Reiter’s syndrome, AIDS associated

psoriasiform dermatitis

Page 59: Final version histologic intepretation of bxs for dermatitis

Thanks!

Come visit!

Jessica Spies, Curtis Thompson and Andrea Chakrapani (all Board certified dermatopathologists)

CTA Lab503-906-7300www.cta-lab.com