|CURRENT BEST EVIDENCE
|Year : 2018 | Volume
| Issue : 2 | Page : 106-109
Excerpt of dermatopathology continuous medical education 2018 conducted by Departments of Dermatology and Pathology, Kasturba Medical College, Manipal, on September 15–16, 2018
Manasa Narayan Kayarkatte, Varsha M Shetty, Kanthilatha Pai, B Sathish Pai
Department of Dermatology, Kasturba Medical College, Manipal, Karnataka, India
|Date of Web Publication||19-Dec-2018|
Dr. Varsha M Shetty
Department of Dermatology, Kasturba Medical College, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
Dermatopathology is an indispensable tool for dermatologists as well as pathologists. Hence, continuous medical education (CME) on Dermatopathology was hosted by the departments of Dermatology and Pathology on September 15-16, 2018. This program was a witness to some of the lucid presentations by distinguished faculty. Around 253 delegates attended this academic feast which was a day and a half affair.
Keywords: Continuous medical education, dermatopathology CME, dermatopathology
|How to cite this article:|
Kayarkatte MN, Shetty VM, Pai K, Pai B S. Excerpt of dermatopathology continuous medical education 2018 conducted by Departments of Dermatology and Pathology, Kasturba Medical College, Manipal, on September 15–16, 2018. Indian J Dermatopathol Diagn Dermatol 2018;5:106-9
|How to cite this URL:|
Kayarkatte MN, Shetty VM, Pai K, Pai B S. Excerpt of dermatopathology continuous medical education 2018 conducted by Departments of Dermatology and Pathology, Kasturba Medical College, Manipal, on September 15–16, 2018. Indian J Dermatopathol Diagn Dermatol [serial online] 2018 [cited 2019 Mar 26];5:106-9. Available from: http://www.ijdpdd.com/text.asp?2018/5/2/106/247880
Dermatopathology is a key aspect for a clinician, as many mysterious cases can be solved with the help of a simple biopsy. It may confirm a diagnosis, opens new array of diagnosis, or may sometimes be even misleading. To highlight the importance of dermatopathology with an intention to learn from the eminent dermatopathologists of India, a continuous medical education (CME) was conducted by the Departments of Dermatology and Pathology, Kasturba Medical College, Manipal, on September 15–16, 2018, which was accredited with 3 hours of CME credit points by Karnataka Medical Council. Distinguished speakers like Dr. M Ramam, Dr. Rajiv Joshi, Dr. Rajalakshmi Tirumalae, Dr. I. S. Reddy, Dr. Chirag Desai, and Dr. Venkatram Mysore were successful in quenching the academic thirst of the participants that included 253 trained and aspiring dermatologists and pathologists from across the country.
Dr. I. S. Reddy, Consultant Dermatologist, Apollo Hospitals, Hyderabad, kick-started the session by speaking on “dermatology for pathologists,” wherein he stressed upon the varying histopathological findings seen in different type of skin lesions. The involvement of the layer of skin on histopathology expected with each type of primary lesion was elaborated [Table 1]. He impressed upon to bear in mind that histopathology of a lesion varies with its clinical evolution. Dr. M. Ramam, Professor, Department of Dermatology, AIIMS, New Delhi, introduced the concept of “pathology for dermatologists.”
|Table 1: The primary lesion with the corresponding layer of skin involved on histopathology|
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The sessions continued with Dr. Chirag Desai, from D.Y. Patil Medical College and Hospital, Navi Mumbai, providing a crisp introduction to all the major and minor tissue reaction patterns with classical examples.
He opined that Weedon's approach that includes interpretation by integration of two morphological features, i.e., tissue reaction pattern and pattern of inflammation, is a practical approach to a diagnosis.
| Approach to Psoriasiform Tissue Reaction|| |
Psoriasiform changes are typically characterized by epidermal hyperplasia with elongation of the rete ridges. Dr. Rajiv Joshi, Consultant dermatologist and dermatopathologist, P. D. Hinduja Hospital, Mumbai, pointed out a few classical differentiating features for an easier approach. A few lesser-known points are highlighted in [Table 2].
| Approach to Lichenoid Tissue Reaction|| |
A tissue reaction pattern is considered lichenoid, when the following is seen:
- Epidermal basal cell damage with formation of civatte bodies or apoptotic bodies
- Infiltrate is usually band shaped either just below the epidermis or close to epidermis literally “hugging” it obscuring the dermoepidermal junction (DEJ)
- Melanin incontinence due to damage to melanocytes in the basal layer. Free melanin dropping down into the papillary dermis and phagocytosed by macrophages which are seen as “melanophages” close to superficial vessels.
The key features of lichenoid/interface dermatitis were well highlighted by Dr. Ramam [Table 3].
| Approach to Vasculitis|| |
The topic of vasculitis was simplified by Dr. Rajalakshmi T, Professor of Pathology, St. John's Medical College, Bangalore. She emphasized that the ideal timing of biopsy is 48–72 hour old lesion.
The type of biopsy should be punch biopsy for small-vessel vasculitis (SVV) and incisional or double punch biopsy method for medium-vessel vasculitis. Double punch technique is used to take a piece of subcutaneous tissue. A 6–8 mm punch is inserted to obtain the initial sample, and subsequently, a 4mm punch is inserted into the center of the defect created to obtain the subcutaneous tissue. The site of biopsy in case of an ulcer is its edge and in case of atrophie blanche is the center of the lesion beneath which the vasculitis can be captured for histopathology.
Diagnostic criteria for SVV include identifying two out of three following features:
- Angiocentric/angioinvasive inflammatory infiltrates
- Disruption of the vessel wall by inflammatory infiltrate
- Intramural/intraluminal fibrin deposition (“fibrinoid necrosis”).
Other surrogate markers of SVV include RBC extravasation, nuclear dust, perivascular leukocytoclasia, endothelial swelling, sloughing or necrosis, eccrine gland necrosis, and ulceration.
A few of the other salient points are depicted in [Table 4].
| Approach to Granulomatous Tissue Reaction|| |
This topic was dealt in detail with suitable examples by Dr. Ramam M and some of the important points were discussed [Table 5].
| Approach to Panniculitis|| |
Dr. Rajiv Joshi untangled the complexity of panniculitis, wherein he classified the various reaction patterns that can be encountered in panniculitis such as:
- Architectural: Septal, lobular, mixed, each with or without vasculitis
- Cytological based on cytoplasmic changes:
- Membranous fat necrosis
- Microcyst formation
- Granular fat necrosis.
The entity of erythema nodosum migrans or subacute erythema nodosum of Vilanova, a forgotten entity, was reminded to the dermatopathology enthusiasts. This is seen to affect older women, usually presenting as painless migrating annular plaques. It is not associated with systemic symptoms or any underlying diseases. On histopathology, it shows septal panniculitis associated with patchy lobular involvement with occasional granuloma.
Lupus profundus exhibiting lobular panniculitis without vasculitis histologically mimics subcutaneous panniculitis-like T-cell lymphoma (SPTCL). The overlapping features include atypia, mitosis, and at times, clonality and immunohistochemistry. Rimming of the neoplastic cells around the individual adipocytes classically described in SPTCL may also be found in lupus profundus. The following features provide a cue toward lupus profundus:
- Features of lupus erythematosus (LE) in the skin, especially a thickened basement membrane
- Mucin deposits in the dermis and even in the subcutis
- Sclerotic rims around medium-sized blood vessels in the subcutis
- Lymphocytic nuclear dust amid a dense lymphocytic infiltrate in the panniculus.
| Approach to Alopecia|| |
After a brief insight into anatomy, hair cycle, and clinical classification, Dr. Rajalakshmi T introduced the histopathological classification and key points on tissue handling for histopathology in alopecia were as follows:
Site of biopsy
- Nonscarring alopecia – center of lesion
- Scarring alopecia – active periphery.
Two samples with 4-mm punch are ideal, one each for vertical and horizontal sectioning. In case a single sample is provided, it is ideal to utilize that for a vertical section.
Alopecia is broadly classified into inflammatory and noninflammatory types. Under inflammatory type, discoid lupus erythematosus (DLE), lichen planopilaris (LPP), and alopecia areata show lymphocyte-rich infiltrate, whereas folliculitis decalvans shows neutrophil-rich infiltrate. Trichotillomania and androgenetic alopecia fall under noninflammatory category. A few of the other notable key points are highlighted in [Table 6] and [Table 7].
|Table 7: Differences between lichen planopilaris and discoid lupus erythematosus|
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| Clinicopathological Case Studies|| |
The sessions also included four interesting and rare clinicopathological cases, which was followed by interactive and in-depth discussions. The cases discussed were SPTCL, hypopigmented mycosis fungoides, lymphomatoid papulosis, and amelanotic melanoma.
To pique interest in the young dermatologists and pathologists, postgraduate (PG) quiz and poster presentation competition was conducted. The PG quiz had two rounds, first being Multiple choice questions (MCQ) based and the second was glass slide challenge.
All the speakers pressed one important message home that clinicopathological correlation is the key to making a perfect diagnosis; hence, one should never hesitate to contact the clinician/pathologist when in doubt. This CME brought forth the importance of dermatopathology as an indispensable tool in our day-to-day practice. Hence, in an era with new fields branching out of dermatology, dermatopathology holds its own relevance and stands tall and continues to shine bright among the rest.
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Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]