Perivascular dermatitis in human skin.pptx

types of perivascular dermatitis in surgical pathology

1. Perivascular Dermatitis

2. Perivascular Dermatitis Introduction This chapter covers diseases that consist of perivascular (and interstitial) infiltrates of inflammatory cells devoid of marked changes in the epidermis. Clinically, these diseases usually present with smooth surfaced macules , patches, papules, and plaques without either the crust, scale, or both. Some of The diseases in this chapter are characterized by the infiltrates.eg, neutrophils ( urticaria , erysipelas), numerous eosinophils ( pruritic urticarial papules and plaques of pregnancy), or plasma cells ( erythema migrans ), etc. Still others are typified by sparse infiltrates of inflammatory cells accompanied by very subtle, but highly characteristic changes in epidermis or dermis ( postinflammatory pigmentary alteration, vitiligo , tinea versicolor , erythrasma ).

3. Perivascular Dermatitis Contents Urticaria Erysipelas Pruritic Urticarial Papules and Plaques of Pregnancy Erythema Migrans Persistent Pigmented Purpuric Dermatitis Viral Exanthems Polymorphous Light Eruption Tumid Lupus Erythematosus Pernio Erythema Figuratum Postinflammatory Pigmentary Alteration Vitiligo TineaVersicolor Erythrasma

4. Clinical Presentation : Edematous papules and plaques, discrete or confluent Localized, regional, or widespread Individual lesions disappear in hours Lesions are intensely pruritic URTICARIA

5. Histopathology: Early, Perivascular infiltrate of neutrophils and eosinophils Later, perivascular lymphocytes, neutrophils , and eosinophils . Resolving lesion, sparse perivascular infiltrate of lymphocytes and a few eosinophils URTICARIA Perivascular and interstitial dermatitis without epidermal changes Lymphocytes and eosinophils perivascular and numerous neutrophils interstitial

6. Perivascular and interstitial dermatitis without epidermal changes. Dilated vessels. Dermal edema URTICARIA

7. Clinicopathologic Correlation : Clinical Feature Pathologic Feature Edematous papules and plaques Edema located mostly in the reticular dermis (mostly not visualizable in H+E) Erythema Dilated vessels Differential Diagnosis : Insect Bites : Wedge-shaped infiltrate of lymphocytes and eosinophils Spongiosis , a spongiotic vesicle sometimes Urticarial Lesions of Bullous Pemphigoid or Pemphigus Vulgaris : Bandlike infiltrate housing numerous eosinophils Eosinophilic spongiosis sometimes Urticarial Lesions of Prurigo Pigmentosa : Superficial perivascular infiltrate of neutrophils (mostly) Scattered neutrophils in the epidermis URTICARIA

8. ERYSIPELAS Clinical Presentation : Sharply demarkated erythematous or purpuric patch or plaque, sometimes covered by vesicles and/or bullae Often accompanied by edema, lymphangitis , lymphadenitis, and fever Face and lower extremities involved commonly, usually unilateral Lesion is painful Sharply demarcated purpuric erythema on the leg, a bulla is seen in the uppermost part of the lesion

9. ERYSIPELAS Histopathology : Sparse to moderately dense perivascular and interstitial mixed-cell infiltrate of lymphocytes, neutrophils , and few eosinophils Erythrocytes extravasated in number Widely dilated venules and lymphatics Edema of the papillary dermis Spongiosis and ballooning of the epidermis (sometimes) Perivascular and interstitial dermatitis without epidermal changes. Lymphocytes and neutrophils perivascular and interstitial accompanied by numerous extravasated erythrocytes.

10. PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY (PUPPP) Synonyms : polymorphic eruption of pregnancy, Bourne’s toxemic rash of pregnancy, toxic erythema of pregnancy, nurse’s late onset prurigo of pregnancy. Clinical Presentation Urticarial papules and plaques Abdomen, buttocks, and thighs especially, often beginning in abdominal striae Lesions usually disappear shortly after term Lesions are itchy Primigravidas late in the third trimester

11. PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY (PUPPP) Histopathology : Superficial perivascular infiltrate of lymphocytes Eosinophils scattered interstitially Focal spongiosis and parakeratosis (sometimes) Perivascular and interstitial dermatitis without epidermal changes. Lymphocytes and few eosinophils around vessels Eosinophils scattered interstitially.

12. PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY (PUPPP) Clinicopathologic Correlation : Clinical Feature Pathologic Feature Papules and plaques Sparse perivascular and interstitial infiltrates of inflammatory cells and slight edema in the upper part of the dermis Erythema Dilated blood vessels Subtle scale Parakeratosis Differential Diagnosis : Urticaria : Perivascular and interstitial infiltrate Neutrophils and eosinophils No changes in the epidermis Insect Bites Dense, wedge-shaped infiltrates, perivascular and interstitial Lymphocytes and eosinophils Spongiosis in the center of the lesion

13. ERYTHEMA MIGRANS (Lyme disease) Clinical Presentation : Macules, patches, or plaques Centrifugal extension with healing in the center leads to formation of annular shapes hemorrhagic or scaly lesions Erythematous patch on the thigh with a bright red slightly elevated border and a paler red in the center

14. ERYTHEMA MIGRANS Histopathology : Perivascular and sometimes interstitial infiltrate of lymphocytes and plasma cells Eosinophils in the vicinity of the “bite” of the tick in an early lesion Spongiosis and parakeratosis (rarely) Perivascular dermatitis without epidermal changes Infiltrate consisting of lymphocytes and plasma cells.

15. ERYTHEMA MIGRANS A normal cornified layer and epidermis Edema of the papillary dermis A moderately dense, well- marginated lymphohistiocytic infiltrate with a few plasmocytes around the superficial and deep vessels A few histiocytes , solitary eosinophils and lymphocytes between collagen bundles in the interstitium Spirocettes demonstrated in the subepidermal region by the Warthin Starry stain

16. ERYTHEMA MIGRANS Clinicopathologic Correlation : Clinical Feature Pathologic Feature Annular plaque Perivascular and sometimes interstitial infiltrate Scale Parakeratosis Differential Diagnosis : 1- Insect Bites: Wedge- shapedinfiltrate Numerouseosinophils Interstitial mucin sometimes 2- Erythema Figuratum /Deep Gyrate Erythema Perivascular infiltrate, no involvement of the interstitium Lymphocytesmonopolize No mucin 3-Tumid Lupus Erythematosus Perivascular and interstitial infiltrate Lymphocytes monopolize Interstitial mucin always

17. PERSISTENT PIGMENTED PURPURIC DERMATITIS Synonyms : Pigmented purpuric dermatitis; progressive pigmented prupura . Clinical Presentation : Purpuric macules and papules, sometimes scaly Symmetrically involving legs and thighs, rarely the trunk and the upper extremities Variations include Schamberg’s disease ( purpuric and pigmented macules ), lichenoid purpura of Gougerot -Blum ( lichenoid papules ), lichen aureus ( yellow or brown patches ), purpura of Doucas and Kapetanakis ( scaly papules ), and purpura annularis telangiectodes of Majocchi ( annular purpuric macules ) Pigmented macules

18. PERSISTENT PIGMENTED PURPURIC DERMATITIS Histopathology: Superficial perivascular and interstitial, sometimes lichenoid , infiltrate of lymphocytes Dermoepidermal junction often spared but sometimes lymphocytes scattered in the epidermis accompanied by slight spongiosis and parakeratosis Extravasated erythrocytes and/or siderophages in the upper part of the dermis Wiry bundles of collagen in the upper part of the dermis,(sometimes) Superficial perivascular dermatitis Infiltrate of lymphocytes and extravasated erythrocytes

19. PERSISTENT PIGMENTED PURPURIC DERMATITIS Superficial perivascular dermatitis infiltrate of lymphocytes and extravasated erythrocytes

20. PERSISTENT PIGMENTED PURPURIC DERMATITIS Clinicopathologic Correlation : Clinical Feature Pathologic Feature Purpuric macules Extravasated erythrocytes in the dermis Yellow or brownmacules Multiple siderophages in the dermis Lichenoid papules Bandlike infiltrates of lymphocytes Scale Parakeratosis Differential Diagnosis : Drug Eruption Perivascular or lichenoidinfiltrate Eosinophils in the infiltrate Vacuolar alteration, necrotic keratinocytes No changes of collagen Focal parakeratosis Mycosis Fungoides Lichenoid or psoriasiform-lichenoid infiltrate Lymphocytes monopolize Lymphocytes in the epidermis accompanied by subtle spongiosis Wiry bundles of collagen Elongated mounds of parakeratosis

21. PERSISTENT PIGMENTED PURPURIC DERMATITIS Clinicopathologic Correlation : Clinical Feature Pathologic Feature Purpuric macules Extravasated erythrocytes in the dermis Yellow or brownmacules Multiple siderophages in the dermis Lichenoid papules Bandlike infiltrates of lymphocytes Scale Parakeratosis Hemosiderophages in the dermis are staining blue in an iron stain.

22. VIRAL EXANTHEMS Clinical Presentation : Exanthem of macules and/or papules Children, especially Variations include erythema infectiosum (appearance of cheeks that have been slapped), or discrete, small macules and papules similar to those of rubella Exanthem of red macules and papules.

23. VIRAL EXANTHEMS Histopathology: Sparse perivascular infiltrate of lymphocytes Few eosinophils , (sometimes) Extravasate erythrocytes, (sometimes) Differential Diagnosis : Drug Eruption Persistent Pigmented Purpuric dermatitis Perivascular dermatitis without epidermal changes Infiltrate of lymphocytes and few eosinophils

24. VIRAL EXANTHEMS Clinicopathologic Correlation : Clinical Feature Pathologic Feature Red macules and papules Sparse superficial perivascular infiltrate and vasodilation Differential Diagnosis : Drug Eruption Perivascular or lichenoid infiltrate Eosinophils in the infiltrate Vacuolar alteration and necrotic keratinocytes often No changes of collagen Persistent Pigmented Purpuric Dermatitis Perivascular and interstitial,sometimes lichenoid , infiltrate Lymphocytes, erythrocytes, and Siderophages No changes in the epidermis or slight spongiosis Wiry bundles of collagen

25. POLYMORPHOUS LIGHT ERUPTION Clinical Presentation : Scattered edematous papules and plaques Sites exposed to sunlight, mostly the face, chest, and arms Young women (especially) Urticarial papules on the chest, some of them excoriated

26. POLYMORPHOUS LIGHT ERUPTION Histopathology : Sparse to moderately dense infiltrate of lymphocytes Extravasated erythrocytes (often) Marked edema of the papillary dermis Spongiosis of variable extent (sometimes) Perivascular and interstitial dermatitis with tremendous edema of the papillary dermis. Infiltrate of lymphocytes and extravasated erythrocytes, extensive edema of the papillary dermis may simulate a subepidermal blistering disease

27. POLYMORPHOUS LIGHT ERUPTION Clinicopathologic Correlation : Clinical Feature Pathologic Feature Papules Perivascular infiltrates of lymphocytes and edema in the papillary dermis Scale crust Parakeratosis above spongiosis Differential Diagnosis : Tumid Lupus Erythematosus Superficial and deep infiltrate oflymphocytes Abundant mucin in the reticular dermis No edema in the papillary derms No changes in the epidermis Hydroa Vacciniforme Superficial and deep infiltrate of lymphocytes No mucin Edema of the papillary dermis Ballooning and reticular alteration of the epidermis

28. TUMID LUPUS ERYTHEMATOSUS Synonyms : Lymphocytic infiltration of Jessner , tumidus lupus erythematosus . Clinical Presentation : Smooth surfaced red macules , papules, and plaques Often localized on sun-exposed sites such as the face, chest, and arms Smooth surfaced erythematous papules and plaques on the face

29. TUMID LUPUS ERYTHEMATOSUS Superficial and deep perivascular and periadnexal dermatitis Infiltrates of lymphocytes are accompanied by mucin in abundance in the interstitium Histopathology : Perivascular and periadnexal infiltrate of lymphocytes, superficial and deep Mucin in abundance in the reticular dermis

30. Jessner Lymphocytic infiltration

31. TUMID LUPUS ERYTHEMATOSUS Clinicopathologic Correlation : Clinical Feature Pathologic Feature Papules and plaques Superficial and deep infiltrate of lymphocytes and deposits of mucin Erythema Dilation of vessels in the dermis Smooth surface No changes in the epidermis Differential Diagnosis : Polymorphous LightEruption Infiltrate of normal lymphocytes Edema of the papillary dermis Spongiosis Erythema Figuratum /Deep Gyrate Erythema Infiltrate of normal lymphocytes,no involvement of the interstitium No edema of the papillary dermis No changes in theepidermis Chronic LymphocyticLeukemia Infiltrate of lymphocytes that may have abnormal nuclei No edema of the papillary dermis No changes in the epidermis

32. PERNIO Synonyms : Dermatitis congelationis ; chilblains ; perniosis ; erythema pernio . Clinical Presentation : Papules, papulovesicles , nodules, and ulcerations Fingers, toes, nose, and ears Young persons usually purple papules and nodules

33. PERNIO Histopathology : Superficial and deep perivascular infiltrate of lymphocytes Extravasated erythrocytes Edema of the papillary dermis Lymphocytes at the dermoepidermal junction often Thrombi in the lumen and/or fibrin in the wall of vessels sometimes Mucin in the reticular dermis Superficial and deep perivascular infiltrate of lymphocytes Epidermis covered by compact orthokeratosis indicates an acral site of the lesion. Extravasated erythrocytes are housed in an edematous papillary dermis

34. PERNIO Clinicopathologic Correlation : Clinical Feature Pathologic Feature Edematous papules and nodules Perivascular infiltrate of lymphocytes, deposits of mucin in the reticular dermis, and edema in the papillary dermis Papulovesicles Extensive subepidermal edema Differential Diagnosis : 1- Erythema Multiforme Lichenoid infiltrate of lymphocytes No deposits of mucin in the dermis Numerous individual necrotic keratinocytes Ballooning and reticular alteration 2- Hydroa Vacciniforme Superficial and deep perivascular infiltrate of lymphocytes No deposits of mucin in the dermis 3- Polymorphous Light Eruption Superficial and deep perivascular infiltrate of lymphocytes No deposits of mucin in the dermis Spongiosis

35. ERYTHEMA FIGURATUM Synonyms : Deep gyrate erythema ; “deep type” of erythema annulare centrifugum of Darier ; palpable migratory and arciform erythema ; figurate erythema . Clinical Presentation : Annular, arcuate , polycyclic, and serpentine papules and plaques devoid of scale Localized or widespread, trunk and proximal extremities especially Adults Figurate erythematous macules and slightly elevated plaques on the back

36. ERYTHEMA FIGURATUM Histopathology : Superficial and deep perivascular infiltrate of lymphocytes, the interstitium of the reticular dermis, usually being spared No increase in mucin in the reticular dermis No edema of the papillary dermis No changes in the epidermis Strictly perivascular infiltrate Monomorphic lymphocytes monopolize, mucin is not increased in the interstitium .

37. ERYTHEMA FIGURATUM Clinicopathologic Correlation : Clinical Feature Pathologic Feature Red papules and plaques Moderately dense infiltrates of lymphocytes around dilated venules Differential Diagnosis : 1- Erythema Migrans Perivascular and sometimes interstitial infiltrate Normal lymphocytes and plasma cells No increase in mucin 2- Chronic Lymphocytic Leukemia Dense perivascular infiltrate Lomphocytes may have abnormal nuclei No increase in mucin 3- Tumid Lupus Erythematosus Perivascular and interstitial infiltrate Normal lymphocytes monopolize Abundant mucin in the reticular dermis

38. POSTINFLAMMATORY PIGMENTARY ALTERATION( Change) Clinical Presentation : Pigmented macules and patches Sites of a previous dermatitis More prominent in dark-skinned individuals Fading gradually over months or years This bizarre shaped pigmented macule developed consequent to a phototoxic dermatitis

39. POSTINFLAMMATORY PIGMENTARY ALTERATION (Change) Histopathology: Little or no infiltrate of lymphocytes around venules of the superficial plexus and along the dermoepidermal junction Hints of vacuolar alteration sometimes Melanophages in the papillary dermis and in the upper part of the reticular dermis range from few to many Papillary dermis thickened sometimes by subtle fibroplasia Very subtle infiltrate of lymphocytes in the dermis.. Numerous melanophages in the papillary dermis.

40. VITILIGO Clinical Presentation : Depigmented macules and patches Localized, segmental, or widespread; often symmetric Association, episodically, with alopecia areata , Hashimoto’s thyroiditis , diabetes mellitus, Addison’s disease, lupus erythematosus , myasthenia gravis, primary biliary cirrhosis, or Vogt- Koyanagi -Harada’s syndrome Depigmented macules distributed rather symmetrically on trunk and extremities

41. VITILIGO Histopathology : Sparse superficial perivascular infiltrate of lymphocytes Few lymphocytes sprinkled in the lower half of the epidermis sometimes Melanocytes at the dermoepidermal junction decreased markedly in number or absent entirely Melanin in the epidermis decreased in amount Very subtle infiltrate of lymphocytes in the dermis. Melanocytes are lacking from the epidermis

42. VITILIGO Clinicopathologic Correlation : Clinical Feature Pathologic Feature Hypopigmented macules Absence of melanocytes Differential Diagnosis: Pityriasis Alba Perivascular dermatitis, lymphocytes monopolize Melanocytes present in theepidermis Hypopigmented Scar No or sparse infiltrate, collagen bundles arranged horizontally Melanocytes present in the epidermis

43. TINEA VERSICOLOR Synonyms: Pityriasis versicolor ; dermatomycosis furfuracea . Clinical Presentation : Slightly scaly macules and patches Hypopigmented in dark-skinned and hyperpigmented in light-skinned persons Symmetrical on the trunk, sometimes involving proximal extremities Recurrences are the rule Pigmented macules distributed rather symmetrically on trunk

44. TINEA VERSICOLOR Histopathology: Sparse superficial perivascular infiltrate of lymphocytes Short branching septate hyphae and spores in the cornified layer Slight hyperkeratosis in basket-weave fashion Slight spongiosis and parakeratosis rarely Sparse perivascular and interstitial dermatitis consisting of lymphocytes. Numerous hyphae and spores in an orthokeratotic cornified layer stain blue in H+E

45. TINEA VERSICOLOR Clinicopathologic Correlation : Clinical Feature Pathologic Feature Hypopigmented macules Malassezia furfur in the cornified layer produces a sun-protection factor Hyperpigmented macules Colored hyphae of Malassezia furfur in the cornified layer ( visualizable in H ‏ E) Scale Orthokeratosis Differential Diagnosis : None

46. ERYTHRASMA Clinical Presentation : Solitary patches and subtle red plaques covered by fine scales Coral-red fluorescence when exposed to Wood’s light Intertriginous regions Elderly persons of both sexes, especially those with diabetes mellitus Recurrences are common Well-demarcated red patches in the groins show coral red fluorescence in Wood’s light (inset).

47. ERYTHRASMA Histopathology: Sparse superficial perivascular infiltrate of lymphocytes Slight orthokeratosis Blue-staining organisms in the form of delicate rods and filaments in the cornified layer Gram stain shows delicate gram-positive rods and filaments in the cornified layer Subtle infiltrate of lymphocytes in the dermis Corynebacterium minutissimum in the orthokeratotic cornified layer stains blue in H+E.

48. ERYTHRASMA Clinicopathologic Correlation Clinical Feature Pathologic Feature Red macules , patches, Sparse superficial perivascular and subtle plaques infiltrateof lymphocyte Scale Orthokeratosis which houses corynebacteria Differential Diagnosis : Candidiasis Pseudohyphae in the cornified layer oriented both vertically and horizontally on all levels of the cornified layer Intraepidermal and infundibular pustules often Mixed infiltrate containing neutrophils Tinea Corporis Hyphae in the lowermost part of the cornified layer, oriented horizontally Intraepidermal and infundibular pustules often Mixed infiltrate containing neutrophils