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Panniculitis: A dermatopathologist's perspective and approach to diagnosis
Parikshaa Gupta, Uma Nahar Saikia, Sandeep Arora, Dipankar De, Bishan Das Radotra
July-December 2016, 3(2):29-41
Panniculitis is the inflammation of subcutaneous fat. It poses a diagnostic challenge, both for the clinician as well as the histopathologist owing to its diverse etiologies, overlapping morphological features, and dynamic nature of the lesions. The standard protocol for histopathologic diagnosis is to examine deep skin biopsies after staining with hematoxylin and eosin. Sometimes, however, special stains are also needed to rule out varied etiologies. A thorough histopathologic examination in conjunction with appropriate clinical details is the key to identify different subtypes of panniculitis. In this review, we discuss the classification of panniculitis with salient histopathologic features of the subtypes in each category. We also present a diagnostic algorithm for arriving at a definitive histopathologic diagnosis of different panniculitis subtypes.
  7 56,760 5,534
Nonmelanoma skin cancers: An Indian perspective
Geeti Khullar, Uma Nahar Saikia, Dipankar De, Bishan Das Radotra
July-December 2014, 1(2):55-62
Nonmelanoma skin cancers (NMSCs), which mainly include basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are infrequent in the Indian subcontinent, compared with white skinned individuals. Although BCC in most cases arises de novo on sun-exposed sites, it may rarely develop in photoprotected areas and in the setting of certain risk factors. In contrast to BCC, SCC in dark skin has a tendency to develop in nonhealing ulcers, chronic scars, and inflammatory and infectious dermatoses. Histopathology is the gold standard in confirming the diagnosis and determining the prognosis. As the existing literature on NMSCs in India is limited mostly to case reports and few reviews only, this article is an attempt to create an awareness regarding the premalignant potential of an expanding list of cutaneous lesions, which would help in timely diagnosis and prompt treatment of NMSCs.
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Dermoscopy of non-melanocytic and pink tumors in brown skin: A descriptive study
Balachandra S Ankad, Punit S Sakhare, Mural H Prabhu
July-December 2017, 4(2):41-51
Introduction: Skin tumors are classified as melanocytic and non-melanocytic based on presence of melanocytes and melanin pigment in the tumor. Dermoscopy, being a non-invasive technique, is a proven method in recognizing the non-melanocytic and pink tumors by showing specific patterns. In Indian subcontinent, reports on dermoscopy of non-melanocytic and pink tumors are confined only to case reports. Authors studied dermoscopic features of non-melanocytic and pink skin tumors in dermoscopy. Materials and Methods: Study was carried in a tertiary hospital attached to S.Nijalingappa Medical College, Bagalkot, between January and December 2016. It was a descriptive study. Patients with signs of non-melanocytic and pink tumors were selected. Demographic data, such as age, gender, and clinical variables in terms of site of tumor and duration were documented. Manual DermLite 3 and videodermoscopy were employed. Both polarized and non-polarized versions were used for examination. Results: Totally 128 patients were present with 75 females and 61 males. Study included pyogenic granuloma (39), squamous cell carcinoma (4), basal cell carcinoma (30), keratoacanthoma (3), seborrheic keratosis (15), trichoepithelioma (2), syringoma (5), apocrine hydrocystoma (2), fibrokeratoma (5), dermatofibroma (6), epidermal cyst (7), sebaceous hyperplasia (2), Bowen's disease (1), steatocystoma multiplex (1), Lymphangioma circumscriptum (3) and milia (3). Numbers in parenthesis indicate number of patients. Conclusion: Dermoscopy of non-melanocytic and pink tumors demonstrates characteristic patterns which vary from white, yellow, brown to blue and red color depending on presence of keratin and hemoglobin. Patterns differ based on the type skin color. Recognition of distinctive vascular and keratin related pattern is of great help in the diagnosis of skin tumors. To the best our knowledge, this is first report of dermoscopy of non-melanocytic and pink tumors on a larger scale from Indian subcontinent.
  4 8,969 626
Histopathological spectrum of lichen sclerosus Et atrophicus
Varsha Dalal, Manveen Kaur, Chandra Bhushan Rai, Avninder Singh, V Ramesh
January-June 2017, 4(1):8-13
Introduction: Lichen sclerosus (LS) et atrophicus is an inflammatory disorder of unknown etiology affecting skin and mucosa, especially the genital area. Clinically, its main features are whitish papules which converge to form plaques and atrophic patches. Histopathology of LS et atrophicus is characterized by the constellation of an atrophic epidermis with loss of rete ridges, some lymphocytes in the basal layer, a subepidermal band of sclerosis, and a lichenoid infiltrate of lymphocytes beneath that band is diagnostic of LS. Materials and Methods: Skin specimens from 25 patients with LS were collected from the hospital records for 5 years. The diagnosis of all cases was made on the basis of clinical morphology and histopathologic features. Sections were stained with hematoxylin and eosin, periodic acid-Schiff, and Elastic-Van Gieson. Criteria evaluated included hyperkeratosis, epidermal atrophy, follicular plugging, basal cell vacuolation, vascular ectasia, hyalinosis, inflammatory infiltrate, dermal edema, and deep dermal fibrosis. Results and Conclusion: Of a total of 25 patients, 18 patients had extragenital (EG) LS and 7 had genital manifestations. Mean age of patients with EG was 28 years, and genital was 38 years. To summarize, the main histopathological findings seen in LS are essentially the same as reported in literature, namely, hyperkeratosis, epidermal atrophy, follicular plugging, basal cell vacuolation, vascular ectasia, hyalinosis, inflammatory infiltrate, dermal edema, and deep dermal fibrosis. Moreover, some interesting differences between the EG and genital forms of LS were seen. However, since the figures are too small to comment on, studies comprising larger series of patients are required to bring out a statistical significance.
  4 20,307 730
Clinical and dermoscopic evaluation of periorbital hyperpigmentation
Mithali Jage, Sunanda Mahajan
January-June 2018, 5(1):42-47
Introduction: Periorbital hyperpigmentation (POH) is a routinely encountered condition in dermatology practice. Studying the clinical features and its correlation with dermoscopy will help in better understanding of patterns of periorbital pigmentation and its evolution. Methodology: Fifty patients attending dermatology outpatient department with POH as presenting complaint were included in the study. A detailed history and proper clinical examination were done. Laboratory tests were advised whenever necessary. Dermoscopy of pigmentation over both lower eyelids was done with ×200 magnification of Oitez e-scope (DP-M17 filter e-scope pro [optical ×200]). Clinical photographs of all patients were taken. Results: POH was multifactorial. The most common clinical type is postinflammatory type. Other associated clinical findings included pigmentation at other anatomical sites (20%), visible bulging (10%), tear trough (8%), and visible superficial vessels in the periorbital region (6%). On dermoscopy, majority of the patients had multicomponent pattern (64%) which included more than one pattern of pigmentation, vasculature, and skin changes. The different patterns of pigmentation were blotches (30%), exaggerated pigment network (28%), coarse speckled (24%), fine speckled (20%), and globules (16%). Pattern of vasculature included telangiectases (18%) and superficial dilated vessels (20%). Patterns of skin changes included atrophy (18%) and exaggerated skin markings (22%). Dermoscopic features can correlate with its etiology. Conclusion: POH is a multifactorial entity. Dermoscopic features can correlate with its etiology.
  3 6,194 628
Cutaneous metastasis of gastric carcinoma: A rare case with unusual presentation site
Fariba Abbasi, Ata Abbasi, Rahim Mahmodlou, Elnaz Mehdipour
January-June 2018, 5(1):54-56
Skin metastases are relatively rare but are of important clinical significance because they usually indicate a worse prognosis. The most common sources are lung and colorectal cancers in males and breast and colorectal in females. In this report, we presented a chest wall skin metastasis of gastric origin in a 50-year-old male. Tumor metastasis to unusual locations such as chest wall skin and from unusual origins such as stomach is of great clinical importance.
  2 2,926 232
Chondroid syringoma: Histopathology a cornerstone tool in diagnosis
Kanathur Shilpa, Budamakuntla Leelavathy, Gorur Divya, DV Lakshmi
January-June 2016, 3(1):20-21
  2 4,220 281
Picrosirius red staining assessment of collagen after dermal roller application: A minimally invasive percutaneous collagen induction therapy
Fatma El-Zahraa Salah El-Deen Yassin, Reham Ezz El-Dawela, Mohammad Abel Kerim
July-December 2014, 1(2):68-74
Background: Percutaneous collagen induction (PCI) through dermal roller breaks old collagen strands, promotes removal of damaged collagen and induces more collagen formation. Collagen fibers can be assessed by traditional stains or by polarized light assessment of Picrosirius red stain. Objective: The purpose of the current study is the clinical and histopathological evaluation of percutaneous collagen formation in atrophic acne scars after dermal roller application. Patients and Methods: Total study duration was 26 weeks in which 12 patients received seven sessions of PCI at 3-weeks interval, 3 mm punch biopsy specimens of scars were obtained before and after treatment (at 18 and 26 weeks). Microscopic examination of pre and post operative biopsies were done, using routine stains and Picrosirius red stain. Results: PCI induced notable improvement in the appearance of acne scars with significant reduction in the score from 123.3 ± 24.5 to 74.16 ± 16.49 (P = 0.00) after 26 weeks. Polarized light assessment of Picrosirius red stain clarified the gradual replacement of old thick orange-red birefringent collagen fibers by newly synthesized thin green-yellow birefringent ones postoperatively. Conclusion: Skin needling is a simple and minimally invasive procedure. The polarized light assessment of Picrosirius red stain clarified the change of the optical properties of collagen fibers according to the maturation process.
  2 6,364 576
Verocay bodies and myxoid change in fibrosarcomatous variant of dermatofibrosarcoma protuberans: A case report and review of literature
Mary Theresa Sylvia, Bhawana Ashok Badhe
January-June 2015, 2(1):14-17
Dermatofibrosarcoma protuberans (DFSP) is a fibro-histiocytic tumor of intermediate malignant potential. Unusual morphologic patterns can be misleading. Sarcomatous change in DFSP is a rare occurrence. Presence of Verocay bodies and myxoid change in DFSP is uncommon. We report a case where the trucut biopsy was initially reported as neurogenic tumor based on prominent Verocay bodies, myxoid change and increased mitoses. Resection specimen had classic areas of DFSP with foci of Verocay bodies, prominent myxoid change, myofibroblastic differentiation, sarcomatous transformation and a satellite nodule. We also briefly discuss the relevant literature.
  1 2,890 238
Unusual manifestation of isolated cutaneous toxoplasmosis in an immunocompetent patient
Shirish Nandedkar, Trupti Bajpai, Kamal Malukani, Ganesh S Bhatambare
January-June 2015, 2(1):18-22
A rare and probably the first documented case of isolated cutaneous toxoplasmosis is being reported in a 50-year-old, vegetarian, immunocompetent man. The granulomatous nodule located on the scrotal skin was excised, and the sections and crushed material of the nodule were subjected to different staining techniques. Demonstration of crescentic structures and PAS-positive material confirmed the presence of Toxoplasma gondii. The significantly raised titer of anti-toxoplasma antibodies further supported the diagnosis. The case was successfully managed surgically. No further treatment was advised since the patient was immunocompetent and it was assumed that cell-mediated immunity would further control the proliferation of organisms.
  1 5,146 286
Annular elastolytic giant cell granuloma: An atypical presentation
Vinitha Gopalakrishnan, Thonduparambil Pappan Thankappan, Gopalan Sulochana
January-June 2018, 5(1):51-53
Annular elastolytic giant cell granuloma is a rare granulomatous disease with unknown pathogenesis. It clinically presents as single or multiple well-defined erythematous annular arciform serpiginous polycyclic plaque with indurated elevated borders and central atrophy in sun-exposed areas. It is found to have a causal association with conditions such as diabetes mellitus, T-cell leukemia, CD4 lymphoma, cutaneous amyloidosis, squamous cell carcinoma lung, sarcoidosis, and monoclonal gammopathy. On histopathology, characteristic “elastophagocytosis” of dermal elastic fibers by the multinucleated giant cells is seen. The presence of horizontally oriented fragmented elastic fibers is characteristic. There is no necrobiosis or mucin deposition, thus differentiating from granuloma annulare. We herein report a case of elderly male with type 2 diabetes mellitus who presented with asymptomatic multiple discrete erythematous shiny dome-shaped papules over anterior chest, abdomen, and back of 2-month duration. The diagnosis was confirmed by biopsy and thorough workup for associations was done. This case is reported due to the rarity of the disease, the atypical presentation, and the characteristic histopathology which lead to the diagnosis.
  1 4,195 243
Angiomatoid fibrous histiocytoma
Sunil Yogiraj Swami, BD Baste, VV Narhire, SS Shashikant, GF D'Costa
January-June 2016, 3(1):17-19
Angiomatoid fibrous histiocytoma[AFH] is a rare soft tissue tumour most commonly occurring in children, adolescents, and young adults. It is considered to be a tumour of intermediate malignancy because of its less aggressive course in contrast to conventional malignant fibrous histiocytoma[MFH]. It accounts for approximately 0.3% of soft-tissue neoplasms. The majority of cases occur in the extremities, are slow growing and are typically painless. We report a case of AFH on the scalp of a 40-year old man, locally recurring within two years of the original operation. AFH is a rare condition with the potential of local recurrence and metastasis. It should be considered in the differential diagnosis of a soft tissue mass in a child or adolescent.
  1 3,083 269
Pyogenic granuloma: Adiagnostic dilemma
Seema Rani, Preeti Sharma, Arvind Kumar Ahuja
January-June 2016, 3(1):22-23
  1 2,444 211
Epidermolytic blaschkoid verrucous epidermal nevus: Report of two cases
Anupam Das, Indrashis Podder, Anirban Das, Anupama Ghosh, Kaushik Shome
July-December 2015, 2(2):46-48
  1 5,507 321
A case of benign lichenoid keratosis
Amita Mhatre, Nitin Nadkarni, Sharmila Patil, Shweta Agarwal
July-December 2015, 2(2):49-51
  1 7,613 324
Lipoblastoma: An uncommon soft tissue tumor
Rashmi Patnayak, Anima Hota, Antaryami Pradhan, Debahuti Mahapatra, Kumudini Devi
July-December 2017, 4(2):56-57
  1 1,750 184
Morphea-like dermal sclerosis: A pitfall in the evaluation of persistent and residual lesions of treated leprosy
Rajiv Joshi, Sudhanshu Mehta
July-December 2017, 4(2):58-59
  1 1,641 166
Accuracy and reliability of Tzanck test compared to histopathology for diagnosis of basal cell carcinoma
Vivek Kumar Dey, Manasi Thawani, Neha Dubey
January-June 2015, 2(1):8-13
Background: Histopathology is considered the gold standard for diagnosis of basal cell carcinoma (BCC) but is time consuming and needs expertise to make a correct diagnosis. On the other hand, Tzanck test is a simple, easy, inexpensive and rapid test which uses exfoliative cytology to make a diagnosis. Objective: To compare the results of Tzanck test with histopathology in the diagnosis of BCC and to evaluate the diagnostic reliability and accuracy of Tzanck test in BCC. Materials and Method: Twenty-six patients with clinical suspicion of BCC were recruited. Samples for Tzanck test and histopathology were taken and diagnoses made independently. Results of Tzanck test were compared with histopathology. Results: Twenty-three cases were histopathologically proved to be BCC. Tzanck test correlated in 12 cases of BCC and could exclude all three non-BCC lesions. In 11 cases it failed to diagnose BCC. The sensitivity and specificity of Tzanck test were 52.2% and 100%, respectively, and positive and negative predictive values were 100% and 21.4%. Conclusion: Tzanck test can be recommended for initial, rapid evaluation of a clinically diagnosed case of BCC. Under experienced hands, it reliably confirms BCC. The limitation is low negative predictive value. Since it does not give information about subtypes of BCC which is of great value in therapeutic planning, histopathological confirmation is mandatory.
  1 5,420 442
Paucity of forkhead box protein 3+ regulatory T-cells in psoriatic skin compared to other inflammatory dermatoses
Marwa Zohdy, Laila Ahmed Sharaf, Samia E Abdelnaby, Khaled Refaat Zalata, Hanan Fathy Mohamed
July-December 2016, 3(2):52-56
Introduction: Forkhead box protein 3 (Foxp3+) regulatory T-cells (Treg cells) are essential to maintain balance between pro- and anti-inflammatory responses. They play a role in maintaining homeostasis by locally suppressing other skin-resident T-cells thus protecting against autoimmune reactions. Thus, they have been the focus of authors' attention in skin T-cell-mediated diseases in the last decade. The Foxp3 gene encodes a transcription factor thought to be important for the function of Treg cells and represents a reliable marker. Contradictory results have been reported in literature about Treg cell densities in the skin of different inflammatory dermatoses including psoriasis, eczema, pityriasis lichenoides chronica (PLC), and cutaneous lupus erythematosus. Patients and Methods: This was a cross-sectional study on lesional skin biopsies from 10 cases of psoriasis, 10 of spongiotic dermatitis, and 16 cases of lichenoid dermatoses (10 of PLC and 6 of discoid lupus erythematosus. We compared the densities of Foxp3+ Treg cells in relation to CD4+ cells in the epidermis and dermis between these groups using Foxp3 and CD4 monoclonal antibodies.Results: Epidermal Foxp3+ CD4+ Treg cells were lower in psoriasis and lichenoid groups than spongiotic group and dermal Foxp3+ CD4+ Treg cells were lower in psoriasis than lichenoid and spongiotic groups. Conclusions: Treg cells have been proved to suppress other skin-resident T-cells and prevent autoimmunity. Being an autoimmune inflammatory dermatosis, psoriasis showed an overall lower density of Foxp3+ CD4+ Treg cells than spongiotic or lichenoid dermatitis. This supports the theory of Treg cell consumption in psoriatic skin due to conversion to interleukin 17 producers.
  1 2,477 182
Suprabasal mitotic index: A cell kinetic aid in psoriasis diagnosis
Susan Maria Mendonca, Sumanth Devaraju
January-June 2017, 4(1):2-7
Background: Psoriatic cell kinetic studies attribute psoriatic hyperplasia to increased germinative cell layer and increased mitotic rate causing rapid cell turnover, resulting in suprabasal mitotic activity. The significant Ki-67 and p53 positivity in psoriatic suprabasal layers as opposed to basal layers in normal skin corroborates this finding. Morphology holds importance in differentiating psoriasis among plaque forming lesions as they clinically mimic each other. In this study, the significance of morphologically derived suprabasal mitotic index was evaluated in the diagnosis of psoriatic lesions.Methods: H and E stained paraffin sections of histopathology confirmed cases of psoriasis and its variants (n = 52) were retrieved from archives and studied. For comparison, control group (n = 30) comprising normal skin and other plaque lesions was used. Suprabasal mitoses/100 basal keratinocytes were calculated in both groups and evaluated using Student's t-test and receiver operator characteristics. Results: The suprabasal mitotic index was significantly higher in psoriatic lesions as compared to controls (P < 0.001) with lower counts in palmoplantar psoriasis (n = 14). The cutoff of suprabasal mitoses for non-palmoplantar psoriasis was 1/100 keratinocytes with sensitivity, specificity, positive, and negative predictive value of 94.9%, 86.7%, 90.2%, and 92.9%, respectively. The diagnostic accuracy was 91.3%. Palmoplantar psoriasis had comparatively lower values and a diagnostic accuracy of 70.45%. Conclusion: The morphological evaluation of suprabasal mitoses is a reliable and cost-effective cell kinetic tool in diagnosing psoriasis and its variants. This will aid in the differential diagnosis of plaque forming lesions.
  1 3,266 268
The utility of tissue and epidermal transglutaminase immunohistochemistry in dermatitis herpetiformis
Aida Valencia-Guerrero, Karen Dresser, Kristine M Cornejo
July-December 2018, 5(2):97-100
Dermatitis herpetiformis (DH), also known as Duhring-Brocq dermatitis, is an autoimmune, chronic subepidermal blistering disorder characterized by an intensely pruritic, papulovesicular eruption. It is linked to gluten sensitivity and considered to be a cutaneous manifestation of celiac disease. It has been demonstrated that sera from most patients with DH demonstrate autoantibodies against epidermal transglutaminase (eTG) and tissue transglutaminase (tTG). Therefore, the aim of the study was to evaluate the diagnostic utility of eTG and tTG immunohistochemistry in identifying patients with DH. A total of 15 skin biopsies from patients with an established diagnosis of DH confirmed by histopathology and direct immunofluorescence (DIF) studies were evaluated. Six cases were used as controls in which the clinical differential included DH and were found to be nondiagnostic by both histopathology and DIF evaluations. Eight (55%) of the DH cases were positive for eTG expression, while none of the controls showed any immunoreactivity (P = 0.0456). All 15 (100%) DH cases showed faint granular staining for tTG in the epidermal basal layers with similar results in all 6 (100%) control cases. Our study indicates eTG immunohistochemistry may aid in identifying patients with DH, with a diagnostic sensitivity and specificity of 55% and 100%, respectively. tTG does not appear to be a useful immunomarker in this setting.
  1 5,458 210
Epithelioid cell granuloma
Deepika Yadav, M Ramam
January-June 2018, 5(1):7-18
In this review, we use the term epithelioid cell granuloma for granulomas that show focal collections of epithelioid histiocytes in the absence of additional changes such as acute inflammatory cells and altered collagen or foreign material. Giant cells, lymphocytes, and histiocytes are often seen in these granulomas. Various features are useful in recognizing the specific cause of an epithelioid cell granuloma and include coalescence or discreteness of granulomas, presence and type of necrosis, inclusion bodies within giant cells, and identification of organisms, but the arrangement of granulomas within the dermis may be the single most important feature. Leprosy shows well-circumscribed, oval, oblong, and curvilinear epithelioid cell granulomas in a perivascular and peri-appendageal location involving superficial and deep dermis with minimal interstitial spill. Cutaneous tuberculosis is recognized by a lichenoid granulomatous pattern comprising a dense upper dermal infiltrate with granulomas that impinge on the overlying acanthotic epidermis accompanied by more localized, nodular granulomas in the deep dermis. Sarcoidosis has closely huddled yet discrete granulomas that have a paucity of lymphocytes. Other patterns and clues include follicular/perifollicular granulomas in lichen scrofulosorum and granulomatous rosacea, prominent necrosis in lupus miliaris disseminatus faciei, branching granulomas with plasma cells in granulomatous secondary syphilis, granulomatous lobular panniculitis with vasculitis in erythema induratum, messy granulomas in cutaneous leishmaniasis, and granulomas extending to the muscles in granulomatous cheilitis/Melkersson–Rosenthal syndrome. Histopathological findings, in combination with clinical and laboratory information, can lead to a specific diagnosis in the majority of cases.
  1 19,758 882
Dermatoscopy: Physics and principles
Balakrishnan Nirmal
July-December 2017, 4(2):27-30
Dermatoscopy is an in vivo noninvasive technique used to examine pigmented and amelanotic skin lesions. The technique is performed using a hand-held self-illuminating device called dermatoscope that visualizes features present under the skin surface that are not normally visible to unaided eye. The images from the dermatoscope can be digitally photographed or recorded for future reference. Nonpolarized dermatoscopy requires contact with the skin surface and interface fluid between glass and skin surface. Polarized light penetrates deeper than the nonpolarized light and does not require contact fluids.
  1 8,776 992
Diagnostic utility of onychoscopy: Review of literature
Chander Grover, Deepak Jakhar
July-December 2017, 4(2):31-40
Onychoscopy is being increasingly used as a diagnostic modality for various nail diseases. Initial research had focused mainly on nail pigmentation and nailfold capillaroscopy; however, it is now being evaluated in various infectious and inflammatory nail disorders as well. The present review aims to summarize current knowledge about onychoscopic diagnostic criteria in nail diseases. The best level of evidence attached to each indication is mentioned to answer the pertinent question: How much can we rely on onychoscopy in confirming diagnosis of nail disease?
  1 6,653 784
An overview of suppurative granuloma
Mary Thomas, Raghavendra Rao, G Nanda Kumar
January-June 2018, 5(1):19-26
Suppurative granulomatous inflammation is a common histopathological reaction pattern that is encountered in the tropical countries including India. It occurs usually due to infective etiology and identification of the causative pathogen is crucial to initiate appropriate treatment. In this review article, we discuss about certain common and uncommon condition which may present with this reaction pattern.
  1 13,805 872
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