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| '''Non-malignant skin disease''' is relatively common. The pathology may or may not be specific. Some diseases require clinical information to diagnose. | | '''Non-malignant skin disease''' is relatively common. The pathology may or may not be specific. Some diseases require clinical information to diagnose. |
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| An introduction to dermatopathology is in the ''[[dermatopathology]]'' article. [[Nevi]] (moles) and other melanocytic lesions are dealt with in the article ''[[melanocytic lesions]]''. Inflammatory skin conditions are dealt with in ''[[inflammatory skin disorders]]''. | | An introduction to dermatopathology is in the ''[[dermatopathology]]'' article. [[Nevi]] (moles) and other melanocytic lesions are dealt with in the article ''[[melanocytic lesions]]''. Inflammatory skin conditions are dealt with in ''[[inflammatory skin disorders]]''. |
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| =Other= | | =Other= |
| ==Lichen simplex chronicus== | | ==Lichen simplex chronicus== |
| *Abbreviated ''LSC''.
| | {{Main|Lichen simplex chronicus}} |
| *[[AKA]] ''squamous cell hyperplasia''.<ref name=Ref_PBoD1011>{{Ref PBoD8|1011}}</ref>
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| ===General===
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| *May be considered a variant of ''spongiotic dermatitis''.<ref name=Ref_DCHH296>{{Ref DCHH|296}}</ref>; more specifically, some think it is an ''atopic dermatitis'' (which fits in the large ''[[spongiotic dermatitis]]'' category).<ref name=Ref_Derm26>{{Ref Derm|26}}</ref>
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| *It is lumped with the [[psoriasiform dermatitides]].
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| Etiology:<ref>URL: [http://emedicine.medscape.com/article/1123423-overview http://emedicine.medscape.com/article/1123423-overview]. Accessed on: 20 August 2010.</ref>
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| *Pruritus (itchness) -> mechanical trauma -> lichenification (thickened/leathery<ref>URL: [http://www.medterms.com/script/main/art.asp?articlekey=10131 http://www.medterms.com/script/main/art.asp?articlekey=10131]. Accessed on: 20 August 2010.</ref>.
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| ===Microscopic===
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| Features:<ref name=Ref_PBoD1065-6>{{Ref PBoD|1065-6}}</ref>
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| *Acanthosis (epithelial thickening) - irregular.
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| *Hyperkeratosis.
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| Other features:<ref>URL: [http://emedicine.medscape.com/article/1123423-diagnosis http://emedicine.medscape.com/article/1123423-diagnosis]. Accessed on: 20 August 2010.</ref>
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| *[[Spongiosis]] (epidermal intercellular edema -- cells appear to have a clear halo around 'em).
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| *[[Parakeratosis]] = retention of nuclei in the stratum corneum.
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| DDx:
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| *[[Prurigo nodularis]] - focal process (nodule or papule).
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| *Benign alveolar ridge keratosis ([[AKA]] oral lichen simplex chronicus<ref name=pmid18158926>{{Cite journal | last1 = Natarajan | first1 = E. | last2 = Woo | first2 = SB. | title = Benign alveolar ridge keratosis (oral lichen simplex chronicus): A distinct clinicopathologic entity. | journal = J Am Acad Dermatol | volume = 58 | issue = 1 | pages = 151-7 | month = Jan | year = 2008 | doi = 10.1016/j.jaad.2007.07.011 | PMID = 18158926 }}</ref>) - see [[oral pathology]].
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| Images:
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| *[http://commons.wikimedia.org/w/index.php?title=File:Lichen_simplex_chronicus_-_low_mag.jpg LSC - low mag. (WC)].
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| *[http://commons.wikimedia.org/w/index.php?title=File:Lichen_simplex_chronicus_-_high_mag.jpg LSC - high mag. (WC)].
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| ===Sign-out===
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| <pre>
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| SKIN, PUNCH BIOPSY:
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| - LICHEN SIMPLEX CHRONICUS.
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| - NEGATIVE FOR MALIGNANCY.
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| </pre>
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| ====Oral====
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| <pre>
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| RETROMOLAR PAD, RIGHT, PUNCH BIOPSY:
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| - ORAL LICHEN SIMPLEX CHRONICUS.
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| - NEGATIVE FOR MALIGNANCY.
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| </pre>
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| ====Micro====
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| The sections show a squamous mucosa with irregular psoriasiform change, parakeratosis, and focal hypergranulosis. There is no inflammation at the interface. Epidermal intercellular bridges are easily seen. There is no significant nuclear atypia. Mitoses are not evident.
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| ==Prurigo nodularis== | | ==Prurigo nodularis== |
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| *[[Exocytosis]] - blood cell infiltrate the epidermis. | | *[[Exocytosis]] - blood cell infiltrate the epidermis. |
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| Images: | | ====Images==== |
| *[[WC]]:
| | <gallery> |
| **[http://commons.wikimedia.org/wiki/File:Dermatomycosis_-_intermed_mag.jpg Dermatomycosis - intermed. mag. (WC)].
| | Image:Dermatomycosis_-_intermed_mag.jpg | Dermatomycosis - intermed. mag. (WC) |
| **[http://commons.wikimedia.org/wiki/File:Dermatomycosis_-_high_mag.jpg Dermatomycosis - high mag. (WC)].
| | Image:Dermatomycosis_-_high_mag.jpg | Dermatomycosis - high mag. (WC) |
| **[http://commons.wikimedia.org/wiki/File:Dermatomycosis_-_gms_-_low_mag.jpg Dermatomycosis - GMS stain - low mag. (WC)].
| | Image:Dermatomycosis_-_gms_-_low_mag.jpg | Dermatomycosis - GMS stain - low mag. (WC) |
| **[http://commons.wikimedia.org/wiki/File:Dermatomycosis_-_gms_-_high_mag.jpg Dermatomycosis - GMS stain - high mag. (WC)].
| | Image:Dermatomycosis_-_gms_-_high_mag.jpg | Dermatomycosis - GMS stain - high mag. (WC) |
| *www:
| | </gallery> |
| **[http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Histo%20Images/tinea_pas.jpg Dermatophytosis (ucsf.edu)].<ref>URL: [http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html]. Accessed on: 25 February 2013.</ref>
| | www: |
| | *[http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Histo%20Images/tinea_pas.jpg Dermatophytosis (ucsf.edu)].<ref>URL: [http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html]. Accessed on: 25 February 2013.</ref> |
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| ===Stains=== | | ===Stains=== |
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| ==Cicatrix== | | ==Cicatrix== |
| *[[AKA]] ''scar'', ''dermal scar''.
| | {{Main|Dermal scar}} |
| ===General===
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| *Previous surgery, biopsy, trauma.
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| ===Microscopic===
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| Features:
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| *Loss of dermal papilla.
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| *Dense collagen - fibers run parallel to the dermal-epidermal (DE) junction<ref name=Ref_Derm499>{{Ref Derm|499}}</ref> - '''key feature'''.
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| *Loss of adnexal structures.
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| Other feature:
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| *Thin-walled blood vessels.
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| **Described as running perpendicular to the surface<ref name=Ref_Derm499>{{Ref Derm|499}}</ref> - this may not be apparent.
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| Note:
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| *There should not be any nuclear hyperchromasia or pleomorphism.<ref name=Ref_Derm479>{{Ref Derm|479}}</ref>
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| DDx:
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| *[[Malignant melanoma]], desmoplastic-neurotropic type - nuclear pleomorphism and/or hyperchromasia; may be focal.<ref name=Ref_Derm479>{{Ref Derm|479}}</ref>
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| *[[Dermatofibroma]].
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| *Desmoplastic [[Spitz nevus]].
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| *Sclerosing [[blue nevus]].
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| Image:
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| *[http://commons.wikimedia.org/wiki/File:ScarHistology.JPG Scar (WC)].
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| ===IHC===
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| *S100 focal/scattered +ve.
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| **Desmoplastic melanoma strong +ve.
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| *HMB-45 -ve.
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| **Sclerosing blue nevus +ve.
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| ===Sign out===
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| <pre>
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| SKIN, LOWER MID BACK, RE-EXCISION:
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| - DERMAL SCAR.
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| - SOLAR ELASTOSIS.
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| </pre>
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| ====Micro====
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| The sections show skin with a dermis with dense collagen fibres that run parallel to the skin surface without adnexal structures. The overlying dermal-epidermis interface lacks the typical undulation.
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| ==Fibroepithelial polyp== | | ==Fibroepithelial polyp== |
| *[[AKA]] ''acrochordon''.
| | {{Main|Fibroepithelial polyp}} |
| *[[AKA]] ''skin tag''.
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| ===General===
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| *Benign.
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| *Older people.
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| *May be associated with pregnancy, [[diabetes]], [[intestinal polyposis]].<ref name=Ref_PCPBoD8|596>{{Ref PCPBoD8|596}}</ref>
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| *Can be a component of ''[[Birt–Hogg–Dubé syndrome]]''.
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| ===Gross===
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| *Raised skin-coloured lesion.
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| Image:
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| *[http://commons.wikimedia.org/wiki/File:Skintagblemish.jpg Skin tag (WC)].
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| ===Microscopic===
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| Features:
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| *On a stalk / epithelium on three sides.
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| *Benign epidermis.
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| DDx:
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| *Pedunculated [[seborrheic keratosis]] - typically have epidermal hyperplasia, hyperkeratosis, horn cysts.<ref name=Ref_Derm342>{{Ref Derm|342}}</ref>
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| *Regressing [[melanocytic lesions]].
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| **[[Intradermal melanocytic nevus]].
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| *[[Nevus lipomatosus superficialis]] - abundant adipocytes in the superficial dermis.
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| *[[Neurofibroma]].
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| Images:
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| *[http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1767547949 Fibroepithelial polyp (dermatlas.med.jhmi.edu)].<ref>URL: [http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=1196583692 http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=1196583692]. Accessed on: 1 September 2011.</ref>
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| *[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=20080802171929218 Fibroepithelial polyp (surgicalpathologyatlas.com)].
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| *[http://dermatology-s10.cdlib.org/143/case_presentations/skintags/3.jpg Inflamed fibroepithelial polyp (cdlib.org)].<ref>URL: [http://dermatology-s10.cdlib.org/143/case_presentations/skintags/allegue.html http://dermatology-s10.cdlib.org/143/case_presentations/skintags/allegue.html]. Accessed on: 9 January 2013.</ref>
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| ===Sign out===
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| <pre>
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| SKIN ("SKIN TAG"), THIGH, EXCISION:
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| - FIBROEPITHELIAL POLYP.
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| </pre>
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| ====Micro====
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| The sections show a fragment of skin with epithelium on three sides. The epithelium matures and is not hypertrophic. Orthokeratosis is present. The core of the lesion has fibrous tissue. There is no significant inflammation. No melanocytic nests are identified.
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| =====Inflamed=====
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| The sections show a fragment of skin with epithelium on three sides. The epithelium matures
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| and is acanthotic. Minimal parakeratosis is present. The core of the lesion consists of
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| fibrous tissue with a mild lymphocyte-predominant dermal infiltrate. Rare siderophages are
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| present.
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| There is mild basal nuclear enlargement. No significant nuclear atypia is apparent. The
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| dermal-epidermal interface is well-demarcated. Rare basal mitotic activity is identified.
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| ==Actinic keratosis== | | ==Actinic keratosis== |
| :''Bowenoid actinic keratosis'' redirects to here.
| | {{Main|Actinic keratosis}} |
| *Abbreviated ''AK''.
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| *[[AKA]] ''solar keratosis''.<ref name=pmid18393780>{{Cite journal | last1 = Weinberg | first1 = JM. | title = Topical therapy for actinic keratoses: current and evolving therapies. | journal = Rev Recent Clin Trials | volume = 1 | issue = 1 | pages = 53-60 | month = Jan | year = 2006 | doi = | PMID = 18393780 }}</ref><ref name=pmid18067626>{{Cite journal | last1 = Roewert-Huber | first1 = J. | last2 = Stockfleth | first2 = E. | last3 = Kerl | first3 = H. | title = Pathology and pathobiology of actinic (solar) keratosis - an update. | journal = Br J Dermatol | volume = 157 Suppl 2 | issue = | pages = 18-20 | month = Dec | year = 2007 | doi = 10.1111/j.1365-2133.2007.08267.x | PMID = 18067626 }}</ref>
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| ===General===
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| *Considered a precursor of [[squamous cell carcinoma of the skin]].<ref name=pmid18067626>{{Cite journal | last1 = Roewert-Huber | first1 = J. | last2 = Stockfleth | first2 = E. | last3 = Kerl | first3 = H. | title = Pathology and pathobiology of actinic (solar) keratosis - an update. | journal = Br J Dermatol | volume = 157 Suppl 2 | issue = | pages = 18-20 | month = Dec | year = 2007 | doi = 10.1111/j.1365-2133.2007.08267.x | PMID = 18067626 }}</ref>
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| Risk factors:<ref name=Ref_PBoD8_1180>{{Ref PBoD8|1180}}</ref>
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| *Sun exposure.
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| *Immune suppression (e.g. organ transplant recipients).
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| ===Gross===
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| Features:
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| *Yellow-brown scaly, patches.
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| *Sandpaper sensation - on touching.
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| *May be pigmented.<ref>URL: [http://www.dermoscopy-ids.org/index.php/newest-case/79-lentigo-maligna-vs-pigmented-actinic-keratosis http://www.dermoscopy-ids.org/index.php/newest-case/79-lentigo-maligna-vs-pigmented-actinic-keratosis]. Accessed on: 23 August 2012.</ref>
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| ===Microscopic===
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| Features:<ref>URL: [http://emedicine.medscape.com/article/1099775-workup#a0723 http://emedicine.medscape.com/article/1099775-workup#a0723]. Accessed on: 1 September 2011.</ref>
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| *Epidermal nuclear atypia:
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| **Variation is size, shape and staining - must involve basilar layer.
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| ***Nuclear enlargement - '''key feature'''.
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| ***Hyperchromasia.
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| *Abnormal epidermal architecture:
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| **Palisading.{{Fact}}
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| *+/-Parakeratosis - may alternate with orthokeratosis, esp. early lesions.<ref name=Ref_Derm353>{{Ref Derm|353}}</ref>
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| *+/-Irregular acanthosis.
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| Note:
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| *May be full thickness - known as ''bowenoid actinic keratosis''.<ref name=pmid19515076>{{Cite journal | last1 = Bagazgoitia | first1 = L. | last2 = Cuevas | first2 = J. | last3 = Juarranz | first3 = A. | title = Expression of p53 and p16 in actinic keratosis, bowenoid actinic keratosis and Bowen's disease. | journal = J Eur Acad Dermatol Venereol | volume = 24 | issue = 2 | pages = 228-30 | month = Feb | year = 2010 | doi = 10.1111/j.1468-3083.2009.03337.x | PMID = 19515076 }}</ref>
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| DDx:
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| *[[Actinic cheilitis]] - the same lesion on the lip.<ref name=pmid3305604>{{Cite journal | last1 = Picascia | first1 = DD. | last2 = Robinson | first2 = JK. | title = Actinic cheilitis: a review of the etiology, differential diagnosis, and treatment. | journal = J Am Acad Dermatol | volume = 17 | issue = 2 Pt 1 | pages = 255-64 | month = Aug | year = 1987 | doi = | PMID = 3305604 }}</ref>
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| *[[Bowen's disease]] - full thickness involvement - with involvement of adnexal epithelium and follicular epithelium.<ref name=pmid19515076/>
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| *[[Paget disease of the breast]].
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| *[[Squamous cell carcinoma of the skin]].
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| *[[Lentigo maligna]] (melanoma in situ on sun damaged skin) - esp. for ''pigmented AK''.<ref name=Ref_Derm353>{{Ref Derm|353}}</ref>
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| *[[Seborrheic keratosis]] - should not have basilar nuclear atypia.
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| Images:
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| *[http://commons.wikimedia.org/wiki/File:Actinic_Keratosis,_H%26E.jpg Actinic keratosis (WC)].
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| *[http://commons.wikimedia.org/wiki/File:SkinTumors-P5280065.JPG Actinic keratosis (WC)].
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| *[http://commons.wikimedia.org/wiki/File:SkinTumors-P5280055.JPG Actinic keartosis (WC)].
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| *[http://commons.wikimedia.org/wiki/File:Bowenoid_actinic_keratosis_-_high_mag.jpg Bowenoid actinic keratosis - high mag. (WC)].
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| *[http://commons.wikimedia.org/wiki/File:Bowenoid_actinic_keratosis_-_very_high_mag.jpg Bowenoid actinic keratosis - very high mag. (WC)].
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| ====Histologic subtypes of actinic keratosis====
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| Like most common things, there are several variants:<ref name=Ref_Derm353>{{Ref Derm|353}}</ref>
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| *Hypertrophic actinic keratosis.
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| **Increased thickness of: (1) epidermis and, (2) stratum corneum.<ref name=Ref_Derm352>{{Ref Derm|352}}</ref>
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| *Acantholytic actinic keratosis.
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| *Proliferative actinic keratosis - downward finger-like projections of the epidermis.
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| *Pigmented actinic keratosis.
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| **DDx: [[lentigo maligna]].
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| *Lichenoid actinic keratosis.
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| ===Sign out===
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| <pre>
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| SKIN LESION, RIGHT THIGH, BIOPSY:
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| - HYPERTROPHIC ACTINIC KERATOSIS.
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| - SOLAR ELASTOSIS.
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| - NEGATIVE FOR MALIGNANCY.
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| </pre>
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| ====Bowenoid====
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| <pre>
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| SKIN LESION, RIGHT DISTAL FOREARM, BIOPSY:
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| - BOWENOID ACTINIC KERATOSIS, COMPLETELY EXCISED IN PLANE OF SECTION.
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| - EXTENSIVE SOLAR ELASTOSIS.
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| - NEGATIVE FOR MALIGNANCY.
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| </pre>
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| ====Micro====
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| =====General=====
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| The sections show skin with basilar epidermal nuclear enlargement and hyperchromasia with irregular nuclear palisading. Hyperkeratosis and parakeratosis is present. A granular layer is present. The dermal-epidermal interface is sharply-demarcated. There is focal inflammation at the interface. Extensive solar elastosis is present.
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| There is no clefting of the lesion from the surrounding stroma. The surrounding stroma does not have a myxoid quality.
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| =====Bowenoid=====
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| The sections show skin with epidermal nuclear enlargement and hyperchromasia with irregular nuclear palisading. The lesion involves the full thickness of the epidermis; however, it spares adnexal and follicular epithelium. Proliferative activity is present. Hyperkeratosis and parakeratosis is present. A granular layer is present. The dermal-epidermal interface is sharply-demarcated. There is focal inflammation at the interface. Extensive solar elastosis is present.
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| There is no clefting of the lesion from the surrounding stroma. Intercellular bridges are identified.
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| ==Actinic cheilitis== | | ==Actinic cheilitis== |
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| ==Pilomatricoma== | | ==Pilomatricoma== |
| {{Main|Pliomatricoma}} | | {{Main|Pilomatricoma}} |
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| ==Dermatofibroma== | | ==Dermatofibroma== |
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| *Dermal mucin (as my be seen in [[lupus erythematosus]]) is a possible mimic - but it isn't spaghetti-like and the "background" (an [[interface dermatitis]]) is different. | | *Dermal mucin (as my be seen in [[lupus erythematosus]]) is a possible mimic - but it isn't spaghetti-like and the "background" (an [[interface dermatitis]]) is different. |
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| Images: | | ====Images==== |
| *[[WC]]:
| | <gallery> |
| **[http://commons.wikimedia.org/wiki/File:Solar_elastosis_-_intermed_mag.jpg Solar elastosis - intermed. mag. (WC)].
| | Image:Solar_elastosis_-_intermed_mag.jpg | Solar elastosis - intermed. mag. (WC) |
| **[http://commons.wikimedia.org/wiki/File:Solar_elastosis_-_high_mag.jpg Solar elastosis - high mag. (WC)].
| | Image:Solar_elastosis_-_high_mag.jpg | Solar elastosis - high mag. (WC) |
| *www:
| | </gallery> |
| **[http://dermpathexpert.com/id88.html Solar elastosis - several images (dermpathexpert.com)].
| | www: |
| | *[http://dermpathexpert.com/id88.html Solar elastosis - several images (dermpathexpert.com)]. |
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| ===Sign out=== | | ===Sign out=== |
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| =Very common - viral= | | =Very common - viral= |
| ==Verruca vulgaris== | | ==Verruca vulgaris== |
| *[[AKA]] common wart.
| | {{Main|Verruca vulgaris}} |
| ===General===
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| *Etiology - [[HPV]].
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| *Very common.
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| Notes:
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| *Related to [[condyloma acuminatum]].
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| ===Gross===
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| Features:
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| *[[Papule]] or [[plaque]] with granular surface.
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| *Classic location: hand.
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| Images:
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| *[http://commons.wikimedia.org/wiki/File:Porea_doet_djin_wi.jpg Wart (WC)].
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| *[http://commons.wikimedia.org/wiki/File:Wart_ASA_animated.gif Wart - animated (WC)].
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| ===Microscopic===
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| Features:<ref>URL: [http://missinglink.ucsf.edu/lm/DermatologyGlossary/verruca_vulgaris.html http://missinglink.ucsf.edu/lm/DermatologyGlossary/verruca_vulgaris.html]. Accessed on: 14 July 2010.</ref>
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| *Hyperkeratosis (more keratin - thick stratum corneum) - in "columns"; keratin in separate towers - ''not'' a flat thick sheet.
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| *Hypergranulosis (thicker stratum granulosum).
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| *''Papillomatous hyperplasia'':
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| **Rete ridge lengthening (~7-10x normal) and thickening.
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| **Rete ridge curvature toward the centre of the lesion (like the roads to the ''Palace of Versailles'') - '''important'''.
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| *Large blood vessels at the dermal-epidermal junction - between the rete ridges.
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| *+/-Viral changes - perinuclear halo, nucleus small and hyperchromatic<ref name=Ref_Derm106-7>{{Ref Derm|106-7}}</ref> - virtually '''diagnostic''' when present.
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| **+/-Binucleation.
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| Memory device: there is more of everything - more s. corneum, s. granulosum, s. spinosum, longer rete ridges, more (larger) blood vessels.
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| DDx:
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| *[[Squamous cell carcinoma of the skin|Squamous cell carcinoma]] - nuclear atypia full thickness and often more pronounced.
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| *Hypertrophic [[actinic keratosis]] - often accompanied by solar elastosis.
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| **Actinic keratosis with superimposed [[lichen simplex chronicus]].<ref name=Ref_Derm353>{{Ref Derm|353}}</ref>
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| *[[Seborrheic keratosis]] - may have focal clear cell changes.
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| *[[Condyloma accuminatum]] - genital region.
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| Images:
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| *[[WC]]:
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| **[http://commons.wikimedia.org/wiki/File:Verruca_vulgaris_-_very_low_mag.jpg Verruca vulgaris - very low mag. (WC)].
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| **[http://commons.wikimedia.org/wiki/File:Verruca_vulgaris_-_intermed_mag.jpg Verruca vulgaris - intermed mag. (WC)].
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| *www:
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| **[http://alf3.urz.unibas.ch/pathopic/getpic-fra.cfm?id=4528 Verruca vulgaris (unibas.ch)].
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| ===Sign out===
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| <pre>
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| SKIN LESION, RIGHT LOWER LEG, SHAVE BIOPSY:
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| - VERRUCA VULGARIS.
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| </pre>
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| ====Micro====
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| The sections show skin with elongated rete ridges, acanthosis, hypergranulosis, hyperkeratosis in vertical columns, focal parakeratosis, dilated blood vessels at the dermal-epidermal junction and koilocytic change. Mild basilar nuclear atypia is present.
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| =====Without koilocytes=====
| |
| The sections show skin with elongated rete ridges that curve toward the centre of the lesion, acanthosis, hypergranulosis, hyperkeratosis in vertical columns, and dilated blood vessels at the dermal-epidermal
| |
| junction. Minimal basilar nuclear enlargement is present. No definite koilocytic change is
| |
| apparent.
| |
| | |
| No parakeratosis is identified. Mild solar elastosis is identified. No melanocytic nests
| |
| are apparent. Mitotic activity is not apparent.
| |
|
| |
|
| ==Verruca plana== | | ==Verruca plana== |
| Line 502: |
Line 238: |
| *Viral keratohyaline. | | *Viral keratohyaline. |
| *Koilocytes. | | *Koilocytes. |
| *Acanthosis - yet flat surface and base. | | *[[Acanthosis]] - yet flat surface and base. |
|
| |
|
| Notes: | | Notes: |
| *It differs from verruca vulgaris... (1) orthokeratosis, (2) flat surface and base. | | *It differs from [[verruca vulgaris]]... (1) orthokeratosis, (2) flat surface and base. |
|
| |
|
| =Less common= | | =Less common= |
| Line 525: |
Line 261: |
| **Lymphocytes - usu. predominant. | | **Lymphocytes - usu. predominant. |
| *+/-Chronic changes: | | *+/-Chronic changes: |
| **Acanthosis. | | **[[Acanthosis]]. |
| **Hyperkeratosis. | | **Hyperkeratosis. |
| **Hypergranulosis. | | **Hypergranulosis. |
| Line 546: |
Line 282: |
|
| |
|
| ==Clear cell acanthoma== | | ==Clear cell acanthoma== |
| ===General===
| | {{Main|Clear cell acanthoma}} |
| *Benign.
| |
| *Elderly.
| |
| *Classically on the leg.<ref name=pmid18583817>{{Cite journal | last1 = Akin | first1 = FY. | last2 = Ertam | first2 = I. | last3 = Ceylan | first3 = C. | last4 = Kazandi | first4 = A. | last5 = Ozdemir | first5 = F. | title = Clear cell acanthoma: new observations on dermatoscopy. | journal = Indian J Dermatol Venereol Leprol | volume = 74 | issue = 3 | pages = 285-7 | month = | year = | doi = | PMID = 18583817 | URL = http://www.ijdvl.com/text.asp?2008/74/3/285/41396 }}</ref>
| |
| *Rare.
| |
| *Clinically not distinct.
| |
| **Suspected clinically in only ~3% of cases.<ref name=pmid20931670>{{Cite journal | last1 = Morrison | first1 = LK. | last2 = Duffey | first2 = M. | last3 = Janik | first3 = M. | last4 = Shamma | first4 = HN. | title = Clear cell acanthoma: a rare clinical diagnosis prior to biopsy. | journal = Int J Dermatol | volume = 49 | issue = 9 | pages = 1008-11 | month = Sep | year = 2010 | doi = | PMID = 20931670 }}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:<ref>URL: [http://www.drmihm.com/cases/case.cfm?CaseID=45 http://www.drmihm.com/cases/case.cfm?CaseID=45]. Accessed on: 7 February 2012.</ref>
| |
| *Psoriasiform pattern - epidermal thickening (acanthosis).
| |
| *Keratinocytes:
| |
| **Pale or light pink cytoplasm (when compared to surrounding non-lesional keratinocytes).
| |
| **Separated from one another (spongiosis).
| |
| *+/-Stratum corneum [[neutrophil]]s.
| |
| | |
| DDx:
| |
| *[[Psoriasis vulgaris]].
| |
| | |
| Images:
| |
| *[http://www.drmihm.com/cases/casefigure.cfm?figID=906&CaseID=45 CCA (drmihm.com)].
| |
| *[http://www.dermatlas.com/derm/IndexDisplay.cfm?ImageID=-327718365 CCA - low mag. (dermatlas.com)].
| |
| *[http://www.dermatlas.com/derm/IndexDisplay.cfm?ImageID=546460717 CCA - high mag. (dermatlas.com)].
| |
|
| |
|
| ==Chondrodermatitis nodularis chronica helicis== | | ==Chondrodermatitis nodularis chronica helicis== |
| *[[AKA]] ''chondrodermatitis nodularis helicis''. | | *[[AKA]] ''chondrodermatitis nodularis helicis''. |
| *Abbreviated ''CNCH''. | | *Abbreviated ''CNCH''. |
| ===General===
| | *[[AKA]] ''Winkler disease''.<ref>URL: [http://www.head-face-med.com/content/4/1/2 http://www.head-face-med.com/content/4/1/2]. Accessed on: 16 January 2014.</ref> |
| *Tender/painful - '''key clinical feature'''. | | {{Main|Chondrodermatitis nodularis chronica helicis}} |
| *Typically right [[ear]] - people more often sleep on this one.<ref name=pmid17879469>{{Cite journal | last1 = Devani | first1 = A. | last2 = Barankin | first2 = B. | title = Dermacase. Chondrodermatitis nodularis chronica helicis. | journal = Can Fam Physician | volume = 53 | issue = 5 | pages = 821, 837 | month = May | year = 2007 | doi = | PMID = 17879469 }}</ref>
| |
| *Usually >40 years old.
| |
| | |
| Etiology:
| |
| *Trauma/mechanical.
| |
| | |
| ===Gross===
| |
| *[[Papule]] on ear.
| |
| *+/-Erythematous.
| |
| *+/-Crust.
| |
| | |
| Clinical DDx:<ref name=pmid17879469/>
| |
| *[[BCC]].
| |
| *[[SCC]].
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:Chondrodermatitis.jpg CNCH (WC)].
| |
| *[http://www.dermnetnz.org/lesions/chondrodermatitis.html CNCH (dermnetnz.org)].
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=pmid17879469/>
| |
| *Dermal inflammation.
| |
| *Epithelial hyperlasia.
| |
| *Fibrosis.
| |
| *Cartilaginous pathology:
| |
| **Perichondrial inflammation - '''key feature'''.
| |
| **Perichondrial disruption.
| |
| **+/-Necrosis.
| |
| **+/-Hemorrhage.
| |
| | |
| Images:
| |
| *[http://www.dermpedia.org/case/chondrodermatitis-nodularis-chronica-helicis CNCH (dermpedia.org)].
| |
| *[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?s=20080802171837514 CNCH (surgicalpathologyatlas.com)].
| |
| *[http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=2140701395 CNCH (dermatlas.med.jhmi.edu)].
| |
| | |
| ===Sign out===
| |
| ====Superficial biopsy====
| |
| <pre>
| |
| SKIN LESION, LEFT ANTIHELIX OF EAR, BIOPSY:
| |
| - SUPERFICIAL SKIN WITH ACANTHOSIS, HYPERKERATOSIS, MODERATE SOLAR ELASTOSIS,
| |
| HYPERGRANULOSIS AND A MILD LYMPHOCYTIC PERIVASCULAR INFILTRATE.
| |
| - NO CARTILAGE IS IDENTIFIED.
| |
| - NEGATIVE FOR DYSPLASIA AND MALIGNANCY.
| |
| | |
| COMMENT:
| |
| The findings are non-specific. Chondrodermatitis cannot be excluded.
| |
| </pre>
| |
|
| |
|
| ==Cutaneous calcinosis== | | ==Cutaneous calcinosis== |
| *[[AKA]] ''calcinosis cutis''. | | *[[AKA]] ''calcinosis cutis''. |
| ===General===
| | {{Main|Cutaneous calcinosis}} |
| *Benign in itself; underlying cause may not be benign.
| |
| *May be a [[scrotum|scrotal]] lesion - known as ''scrotal calcinosis''.<ref name=pmid20178701>{{Cite journal | last1 = Dubey | first1 = S. | last2 = Sharma | first2 = R. | last3 = Maheshwari | first3 = V. | title = Scrotal calcinosis: idiopathic or dystrophic? | journal = Dermatol Online J | volume = 16 | issue = 2 | pages = 5 | month = | year = 2010 | doi = | PMID = 20178701 }}</ref>
| |
| | |
| Subtypes:<ref name=emed>URL: [http://emedicine.medscape.com/article/1103137-overview http://emedicine.medscape.com/article/1103137-overview]. Accessed on: 21 September 2011.</ref>
| |
| #Dystrophic - due to death of cells; may be related to a tumour.
| |
| #Metastatic - due to chronic renal failure; hyperkalemia; paraneoplastic phenomenon.
| |
| #Iatrogenic - post surgical.
| |
| #Idiopathic.
| |
| | |
| ===Microscopic===
| |
| Features:
| |
| *Dermal calcification:
| |
| **Acellular purple blobs on [[H&E]].
| |
| ***+/-Artefactual tearing of surrounding tissue due to processing (cutting).
| |
| ***+/-Small artefactual lines ~1-2 micrometers due to processing (cutting).
| |
| ***+/-Greyish rim of paucicellular material.
| |
| **Usu. well-circumscribed.
| |
| ***May be surrounded by a palisading granuloma & [[giant cell]]s.
| |
| | |
| Images:
| |
| *[http://www.dermatopathonline.com/calcinosis%20cutis2.html Calcinosis cutis (dermatopathonline.com)].
| |
| | |
| ===Sign out===
| |
| <pre>
| |
| SKIN AND SUBCUTANEOUS LESION, LEFT HIP, EXCISION:
| |
| - SUBCUTANEOUS CALCIFICATION SURROUNDED BY BENIGN FIBROUS TISSUE.
| |
| - DERMAL SCAR.
| |
| - NEGATIVE FOR MALIGNANCY.
| |
| </pre>
| |
| | |
| <pre>
| |
| SUBCUTANEOUS MASS, OVER BURSA OF ELBOW, EXCISION:
| |
| - CALCINOSIS CUTIS.
| |
| </pre>
| |
| | |
| ====Micro====
| |
| The sections show subcutaneous calcifications surrounded by macrophages and giant cells. No nuclear atypia is apparent. The overlying skin is unremarkable.
| |
|
| |
|
| ==Dilated pore of Winer== | | ==Dilated pore of Winer== |
| ===General=== | | ===General=== |
| *Benign. | | *Benign. |
| *Looks like zit. | | *Looks like a zit. |
|
| |
|
| ===Microscopic=== | | ===Microscopic=== |
| Features:<ref name=Ref_WMSP486>{{Ref WMSP|486}}</ref> | | Features:<ref name=Ref_WMSP486>{{Ref WMSP|486}}</ref> |
| *Dilated hair follicle with keratin. | | *Dilated hair follicle with keratin. |
| *Acanthosis. | | *[[Acanthosis]]. |
| *Budding of epidermis (into dermis). | | *Budding of epidermis (into dermis). |
|
| |
| ==Lichenoid keratosis==
| |
| *[[AKA]] ''lichen planus-like keratosis''.
| |
| *[[AKA]] ''lichenoid keratosis''.
| |
|
| |
| ===General===
| |
| *Caucasians - middle age or older.
| |
| *May be a variant of [[seborrheic keratosis]] (with marked inflammation).<ref name=Ref_Derm346>{{Ref Derm|346}}</ref>
| |
|
| |
| Clinical DDx:<ref name=Ref_Derm346>{{Ref Derm|346}}</ref>
| |
| *[[Basal cell carcinoma]], [[squamous cell carcinoma of the skin]], melanocytic neoplasm.
| |
|
| |
| ===Microscopic===
| |
| Features:<ref name=Ref_Derm347>{{Ref Derm|347}}</ref>
| |
| *Hyperkeratosis.
| |
| *Parakeratosis.
| |
| *Band of inflammatory cells at DE junction (lichenoid inflammation).
| |
| *Dead keratinocytes (Civatte bodies).
| |
| *Dermal melanophages.
| |
|
| |
|
| DDx: | | DDx: |
| *[[Lichen planus]] - need clinical correlation (mucosal lesions). | | *[[Pilar sheath acanthoma]]. |
| *[[Drug reaction]].
| |
| *[[Cutaneous T-cell lymphoma]].
| |
| *Regressed melanocytic lesion, esp. [[malignant melanoma]].
| |
| *Lichenoid [[actinic keratosis]] - has atypical hyperchromatic basal cells - esp. at edge of lesion, usu. in the context of [[solar elastosis]].
| |
|
| |
|
| Images:
| | Image: |
| *[http://www.dermpathexpert.com/id57.html Lichenoid keratosis (dermpathexpert.com)]. | | *[http://dermpathexpert.com/id90.html Dilated pore of Winer (dermpathexpert.com)]. |
|
| |
|
| ===Sign out=== | | ==Lichenoid keratosis== |
| <pre>
| | *[[AKA]] ''lichen planus-like keratosis''. |
| SKIN LESION, MID-MIDDLE BACK, PUNCH BIOPSY:
| | {{Main|Lichenoid keratosis}} |
| - LICHENOID KERATOSIS. | |
| </pre>
| |
|
| |
|
| ==Granuloma annulare== | | ==Granuloma annulare== |
| Line 714: |
Line 319: |
|
| |
|
| ==Necrobiosis lipoidica== | | ==Necrobiosis lipoidica== |
| ===General===
| | {{Main|Necrobiosis lipoidica}} |
| Associated with:
| |
| *[[Diabetes mellitus]] - known as ''necrobiosis lipoidica diabeticorum''.
| |
| *[[Rheumatoid arthritis]].
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_Derm51>{{Ref Derm|51}}</ref>
| |
| *Dermal palisading [[granuloma]] around:
| |
| **Necrotic collagen - '''key feature'''.
| |
| ***Nuclei "missing" - have undergone karyolysis.
| |
| *Little mucin, no normal dermis between foci.
| |
| *Plasma cells - common.<ref name=dermnetnz_nl>URL: [http://dermnetnz.org/pathology/necrobiosis-lipoidica-path.html http://dermnetnz.org/pathology/necrobiosis-lipoidica-path.html]. Accessed on: 24 January 2012.</ref>
| |
| *May involve adipose tissue.
| |
| | |
| DDx:
| |
| *[[Granuloma annulare|Granuloma a'''nn'''ulare]] - '''m'''ore '''m'''ucin, normal dermis between foci,<ref name=Ref_Derm51>{{Ref Derm|51}}</ref> plasma cells uncommon,<ref name=dermnetnz_nl/> no fat involvement - usu. more superficial.
| |
| *[[Rheumatoid nodule]].
| |
| | |
| Images:
| |
| *[http://dermatology.cdlib.org/103/NYU/case_presentations/042004n10.html Necrobiosis lipoidica (dermatology.cdlib.org)].
| |
| *[http://www.drmihm.com/cases/case.cfm?CaseID=53 Necrobiosis lipoidica (drmihm.com)].
| |
| *[http://dermnetnz.org/pathology/necrobiosis-lipoidica-path.html Necrobiosis lipoidica (dermnetnz.org)].
| |
|
| |
|
| ==Keloid== | | ==Keloid== |
| *''Hypertrophic scar'' redirects to this section.
| | {{Main|Keloid}} |
| ===General===
| |
| *Sites of previous trauma/surgery, esp. in dark skinned individuals.<ref name=Ref_WMSP492>{{Ref WMSP|492}}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_WMSP492>{{Ref WMSP|492}}</ref>
| |
| *Thick collagen bundles - surrounded by paler staining fibroblasts - '''key feature'''.
| |
| *Lesion replaces adnexal structures, e.g. hair, sweat glands.
| |
| | |
| DDx:
| |
| *Hypertrophic scar.<ref name=pmid20927486>{{Cite journal | last1 = Gauglitz | first1 = GG. | last2 = Korting | first2 = HC. | last3 = Pavicic | first3 = T. | last4 = Ruzicka | first4 = T. | last5 = Jeschke | first5 = MG. | title = Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. | journal = Mol Med | volume = 17 | issue = 1-2 | pages = 113-25 | month = | year = | doi = 10.2119/molmed.2009.00153 | PMID = 20927486 | PMC = 3022978 }}</ref>
| |
| | |
| NB:
| |
| *'''Reported as "keloidal-type collagen"'''; the clinician decides between ''hypertrophic scar'' and ''keloid''.
| |
| | |
| ====Images====
| |
| <gallery>
| |
| Image:Keloid_-_add_-_low_mag.jpg | Keloid - low mag. (WC/Nephron)
| |
| Image:Keloid_-_add_-_intermed_mag.jpg | Keloid - intermed. mag. (WC/Nephron)
| |
| Image:Keloid_-_high_mag.jpg | Keloid - high mag. (WC/Nephron)
| |
| </gallery>
| |
| www:
| |
| *[http://missinglink.ucsf.edu/lm/DermatologyGlossary/keloids.html Keloid (ucsf.edu)].
| |
| | |
| ===Sign out===
| |
| <pre>
| |
| SKIN LESION, LEFT SCAPULA, EXCISION:
| |
| - DERMAL SCAR WITH KELOIDAL-TYPE COLLAGEN, SEE COMMENT.
| |
| | |
| COMMENT:
| |
| The findings are consistent with a hypertrophic scar or keloid; clinical correlation is required.
| |
| </pre>
| |
| | |
| ====Clinical provided====
| |
| <pre>
| |
| SKIN LESION, LEFT NIPPLE AREOLA, EXCISION:
| |
| - DERMAL SCAR WITH KELOIDAL-TYPE COLLAGEN, CONSISTENT WITH HYPERTROPHIC SCAR.
| |
| </pre>
| |
|
| |
|
| ==Angiofibroma== | | ==Angiofibroma== |
| :See also: ''[[nasopharyngeal angiofibroma]]''. | | :See also: ''[[nasopharyngeal angiofibroma]]''. |
| :Should '''not''' be confused with ''[[angiokeratoma]]''. | | :Should '''not''' be confused with ''[[angiokeratoma]]''. |
| ===General===
| | {{Main|Angiofibroma}} |
| *May be seen in the context of [[tuberous sclerosis]] - especially "butterfly area of the face".<ref name=Ref_WMSP492>{{Ref WMSP|492}}</ref>
| |
| *Solitary lesions in adults are known as ''[[fibrous papules]]'' and classically arise on the nose.<ref name=Ref_Derm505>{{Ref Derm|505}}</ref>
| |
| | |
| Clinical:
| |
| *Firm, dome-shaped, flesh coloured.
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_WMSP492>{{Ref WMSP|492}}</ref>
| |
| *Dome-shaped.
| |
| *Fibrotic dermis.
| |
| **Enlarged fibroblasts.
| |
| *Dilated small vessels.
| |
| | |
| DDx:
| |
| *[[Benign fibrous papule]] - solitary, nose lesion.
| |
| | |
| Image:
| |
| *[http://www.drdittmar.lu/images/sce/angiofibroma-s.jpg Angiofibroma (drdittmar.lu)].<ref>URL: [http://www.drdittmar.lu/Services.aspx http://www.drdittmar.lu/Services.aspx]. Accessed on: 1 September 2011.</ref>
| |
|
| |
|
| ==Benign fibrous papule== | | ==Benign fibrous papule== |
| Line 824: |
Line 353: |
| Note: | | Note: |
| *Several variants exist.<ref name=pmid18032900>{{Cite journal | last1 = Jacyk | first1 = WK. | last2 = Rütten | first2 = A. | last3 = Requena | first3 = L. | title = Fibrous papule of the face with granular cells. | journal = Dermatology | volume = 216 | issue = 1 | pages = 56-9 | month = | year = 2008 | doi = 10.1159/000109359 | PMID = 18032900 }}</ref> | | *Several variants exist.<ref name=pmid18032900>{{Cite journal | last1 = Jacyk | first1 = WK. | last2 = Rütten | first2 = A. | last3 = Requena | first3 = L. | title = Fibrous papule of the face with granular cells. | journal = Dermatology | volume = 216 | issue = 1 | pages = 56-9 | month = | year = 2008 | doi = 10.1159/000109359 | PMID = 18032900 }}</ref> |
| | |
| | ===Images=== |
| | *[http://www.dermaamin.com/site/histopathology-of-the-skin/58-f/1739-fibrous-papule-angiofibroma-.html Fibrous papule (dermaamin.com)]. |
|
| |
|
| ===Sign out=== | | ===Sign out=== |
| Line 832: |
Line 364: |
|
| |
|
| ==Molluscum contagiosum== | | ==Molluscum contagiosum== |
| *Abbreviated ''MC''.
| | {{Main|Molluscum contagiosum}} |
| ===General===
| |
| *Etiology: caused by ''molluscum contagiosum virus''.
| |
| *May be abundant in immune deficient individuals, e.g. [[HIV]]/AIDS.
| |
| | |
| ===Gross===
| |
| Features:<ref name=Ref_Derm115>{{Ref Derm|115}}</ref>
| |
| *Dome-shaped papules, flesh coloured or pearly.
| |
| *Usually face or trunk.
| |
| *+/-Central umbilication.
| |
| **Central depression.
| |
| | |
| DDx - gross:
| |
| *[[Skin tag]].
| |
| | |
| Image:
| |
| *[http://commons.wikimedia.org/wiki/File:Molluscaklein.jpg Molluscum contagiosum (WC)].
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_Derm115>{{Ref Derm 115}}</ref>
| |
| *A suprabasilar epidermal lesion consisting of "molluscum bodies" -- in other words "molluscum bodies" are found above the stratum basale +/- extension to the skin surface.
| |
| **Molluscum bodies - '''key feature''':
| |
| ***Large cells with (granular) eosinophilic cytoplasmic inclusions.
| |
| ****The inclusions usually fill the cytoplasm.
| |
| ****Inclusions are usually one per cell... but may be multiple.
| |
| ***Small peripheral nucleus.
| |
| *+/-Lymphocytes.
| |
| | |
| Notes:
| |
| *Molluscum bodies very vaguely resemble ''[[signet ring cell]]s'' -- but:
| |
| **Cytoplasm is eosinophilic and granular.
| |
| **Nucleus usually smaller than in signet ring cells.
| |
| **''Molluscum bodies'' are only in the epidermis - an uncommon place to find SRCs without finding them elsewhere.
| |
| *The granular eosinophilic cytoplasmic inclusions represents accumulated virons.
| |
| *Molluscum bodies "grow" toward the surface
| |
| | |
| DDx:
| |
| *Nothing really - it is very distinctive.
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:Molluscum_contagiosum_high_mag.jpg Molluscum contagiosum - high mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Molluscum_contagiosum_low_mag.jpg Molluscum contagiosum - low magnification (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Molluscum_contagiosum_1.jpg Molluscum contagiosum (WC)].
| |
| | |
| ===Sign out===
| |
| <pre>
| |
| SKIN LESION ("SKIN TAG"), EXCISION:
| |
| - MOLLUSCUM CONTAGIOSUM.
| |
| </pre>
| |
| | |
| ====Micro====
| |
| The section shows fragments of skin with epithelium on three sides. Large suprabasilar cells with eosinophilic intracytoplasmic inclusions (molluscum bodies) and small eccentric nuclei are present, and extend to the skin surface. The epithelium is acanthotic; however, it matures to the surface. There is no significant inflammation.
| |
|
| |
|
| ==Superficial dermal infiltrates== | | ==Superficial dermal infiltrates== |
| Line 916: |
Line 397: |
|
| |
|
| ==Mastocytosis== | | ==Mastocytosis== |
| ===General===
| | {{Main|Mastocytosis}} |
| *Abundance of [[mast cell]]s.
| |
| | |
| Classification:<ref name=pmid21083038>{{Cite journal | last1 = Arock | first1 = M. | last2 = Valent | first2 = P. | title = Pathogenesis, classification and treatment of mastocytosis: state of the art in 2010 and future perspectives. | journal = Expert Rev Hematol | volume = 3 | issue = 4 | pages = 497-516 | month = Aug | year = 2010 | doi = 10.1586/ehm.10.42 | PMID = 21083038 }}</ref>
| |
| #Cutaneous (only) - usually children.
| |
| #*Urticaria pigmentosa.
| |
| #*Others.
| |
| #Systemic - usually adults.
| |
| #*Indolent subvariant.
| |
| #*Aggressive subvariant.
| |
| #*Leukemic subvariant.
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_PBoD8|1185>{{Ref PBoD8|1185}}</ref>
| |
| *Cells in the superficial/mid dermis that are:
| |
| **Lymphocyte-like with more cytoplasm that is granular.
| |
| ***Cells may have spindled or stellate morphology.
| |
| ***Tend to be more abundant around vessels.
| |
| *+/-Eosinophils (common).
| |
| *+/-Edema - often prominent; gives cells a white halo.
| |
| | |
| Notes:
| |
| *Lymphocyte vs. mast cell:
| |
| **Lymphocytes = round; mast cells = ovoid.
| |
| | |
| Images:
| |
| *www:
| |
| **[http://www.jameswpattersonmd.com/case_studies/index.cfm?CFID=387434 Mastocytosis - low res. (jameswpattersonmd.com)].
| |
| **[http://path.upmc.edu/cases/case366.html Mastocytosis - bone marrow - several images (upmc.edu)].
| |
| *[[WC]]:
| |
| **[http://commons.wikimedia.org/wiki/File:Mastocytosis_-_high_mag.jpg Mastocytosis - high mag. (WC)].
| |
| **[http://commons.wikimedia.org/wiki/File:Mastocytosis_-_cropped_-_very_high_mag.jpg Mastocytosis - very high mag. (WC)].
| |
| **[http://path.upmc.edu/cases/case409.html Systemic mastocytosis - several images (upmc.edu)].
| |
| | |
| ===Stains===
| |
| *[[Toluidine blue stain|Toluidine blue]] -- highlights the granules.
| |
| | |
| ===IHC===
| |
| *CD117 +ve.
| |
| *Tryptase +ve.<ref name=pmid21866466>{{Cite journal | last1 = Rudzki | first1 = Z. | last2 = Sotlar | first2 = K. | last3 = Kudela | first3 = A. | last4 = Starzak-Gwóźdź | first4 = J. | last5 = Horny | first5 = HP. | title = Systemic mastocytosis (SM) and associated malignant bone marrow histiocytosis - a hitherto undescribed form of SM-AHNMD. | journal = Pol J Pathol | volume = 62 | issue = 2 | pages = 101-4 | month = | year = 2011 | doi = | PMID = 21866466 }}
| |
| </ref>
| |
|
| |
|
| ==Ichthyosis== | | ==Ichthyosis== |
| Line 974: |
Line 415: |
|
| |
|
| ==Palmar fibromatosis== | | ==Palmar fibromatosis== |
| {{Main|Fibromatosis}}
| |
| *[[AKA]] ''Dupuytren's contracture''. | | *[[AKA]] ''Dupuytren's contracture''. |
| *[[AKA]] ''Dupuytren disease''. | | *[[AKA]] ''Dupuytren disease''. |
| ===General===
| | {{Main|Palmar fibromatosis}} |
| Clinical:<ref>URL: [http://www.humpath.com/palmar-fibromatosis http://www.humpath.com/palmar-fibromatosis]. Accessed on: 6 January 2011.</ref>
| |
| *Usually older - 60s or 70s (years old).
| |
| *Male > female.
| |
| *Associated with:
| |
| **[[Alcohol abuse]].
| |
| *May be familial.
| |
| | |
| ===Gross===
| |
| *Ring finger - classic location.{{fact}}
| |
| *Nodular.
| |
| *Poorly demarcated.
| |
| | |
| Image:
| |
| *[http://commons.wikimedia.org/wiki/File:Morbus_dupuytren_fcm.jpg Palmar fibromatosis (WC)].
| |
| | |
| ===Microscopic===
| |
| Features:<ref>URL: [http://surgpathcriteria.stanford.edu/softfib/plantar_fibromatosis/printable.html http://surgpathcriteria.stanford.edu/softfib/plantar_fibromatosis/printable.html]. Accessed on: 6 January 2011.</ref><ref name=standford_pf_ddx>URL: [http://surgpathcriteria.stanford.edu/softfib/palmar_fibromatosis/differentialdiagnosis.html http://surgpathcriteria.stanford.edu/softfib/palmar_fibromatosis/differentialdiagnosis.html]. Accessed on: 9 November 2012.</ref>
| |
| *Poorly demarcated, usu. multiple lesions/multiple nodules.
| |
| *Composed of bland spindle cells in dense collagen.
| |
| **Pale grey cytoplasm (moderate quantity).
| |
| **Pale ovoid nuclei with small round nucleoli.
| |
| *Giant cells - rare.
| |
| | |
| Note:
| |
| *No nuclear atypia.
| |
| *Mitotic figures - rarely present, none atypical.
| |
| *May see Pacinian corpuscle ([[AKA]] lamellar corpuscle) as an incidental finding.
| |
| | |
| DDx:<ref name=standford_pf_ddx>URL: [http://surgpathcriteria.stanford.edu/softfib/palmar_fibromatosis/differentialdiagnosis.html http://surgpathcriteria.stanford.edu/softfib/palmar_fibromatosis/differentialdiagnosis.html]. Accessed on: 9 November 2012.</ref>
| |
| *[[Calcifying aponeurotic fibroma]] - calcification, chondroid differentiation, usu. < 20 years old.
| |
| *Extra-abdominal desmoid [[fibromatosis]] - extremely rare on hands and feet, muscle infiltrative.
| |
| *Inclusion body [[fibromatosis]].
| |
| *[[Fibrosarcoma]] - atypia, necrosis, herring-bone pattern.
| |
| *[[Synovial sarcoma]] - one mass.
| |
| *[[Epithelioid sarcoma]] - necrosis, atypia.
| |
| *[[metastasis|Metastatic]] metaplastic carcinoma, e.g. [[metaplastic breast carcinoma]] - extremely uncommon.
| |
| | |
| Images:
| |
| *[http://www.biomedsearch.com/attachments/display/00/16/69/68/16696857/1479-5876-4-21-2.jpg Palmer fibromatosis (biomedsearch.com)].<ref name=pmid16696857>{{cite journal |author=Wang L, Zhu H |title=Clonal analysis of palmar fibromatosis: a study whether palmar fibromatosis is a real tumor |journal=J Transl Med |volume=4 |issue= |pages=21 |year=2006 |pmid=16696857 |pmc=1488873 |doi=10.1186/1479-5876-4-21 |url=http://www.biomedsearch.com/nih/Clonal-analysis-palmar-fibromatosis-study/16696857.html}}</ref>
| |
| *[http://alf3.urz.unibas.ch/pathopic/e/getpic-fra.cfm?id=8235 Palmar fibromatosis (unibas.ch)].
| |
| *[http://commons.wikimedia.org/wiki/File:WVSOM_Pacinian_Corpuscle.JPG Pacinian corpuscle (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Tendon_-_intermed_mag.jpg Tendon without fibromatosis - intermed. mag. (WC)].
| |
| | |
| ===IHC===
| |
| *Beta-catenin +ve (cytoplasmic & nuclear).<ref name=pmid18958538>{{Cite journal | last1 = Degreef | first1 = I. | last2 = De Smet | first2 = L. | last3 = Sciot | first3 = R. | last4 = Cassiman | first4 = JJ. | last5 = Tejpar | first5 = S. | title = Beta-catenin overexpression in Dupuytren's disease is unrelated to disease recurrence. | journal = Clin Orthop Relat Res | volume = 467 | issue = 3 | pages = 838-45 | month = Mar | year = 2009 | doi = 10.1007/s11999-008-0590-z | PMID = 18958538 }}</ref>
| |
| | |
| ===Sign out===
| |
| ====Left====
| |
| <pre>
| |
| PALMAR FASCIA, LEFT, FASCIECTOMY:
| |
| - PALMAR FIBROMATOSIS.
| |
| </pre>
| |
| | |
| ====Right====
| |
| <pre>
| |
| PALMAR FASCIA, RIGHT, FASCIECTOMY:
| |
| - PALMAR FIBROMATOSIS.
| |
| </pre>
| |
| | |
| =====Micro=====
| |
| The sections show multiple poorly-demarcated nodules composed of bland spindle cells with moderate pale grey cytoplasm and pale ellipsoid nuclei with small round nucleoli. The poorly-demarcated nodules are completely surrounded by dense collagen. Calcification is not present. There is no nuclear atypia or necrosis. Mitotic activity is not identified. Benign fibroadipose tissue is present.
| |
| | |
| ====Missed fibromatosis====
| |
| <pre>
| |
| PALMAR FASCIA, LEFT, FASCIECTOMY:
| |
| - PALMAR FASCIA WITHIN NORMAL LIMITS AND BENIGN FIBROADIPOSE TISSUE -- IN AN
| |
| INDIVIDUAL WITH A CLINICAL HISTORY OF PALMAR FIBROMATOSIS.
| |
| - NEGATIVE FOR MALIGNANCY.
| |
| </pre>
| |
| | |
| ======Micro======
| |
| The sections show dense collagen (tendon) without an apparent pathology. Calcification is not present. There is no nuclear atypia or necrosis. Mitotic activity is not identified. Benign fibroadipose tissue is present. Lamellar corpuscles are present. The tissue was submitted in toto and levels were cut.
| |
| | |
| =====Straight=====
| |
| <pre>
| |
| PALMAR FASCIA, RIGHT, FASCIECTOMY:
| |
| - PALMAR FASCIA WITHIN NORMAL LIMITS.
| |
| - NEGATIVE FOR FIBROMATOSIS.
| |
| | |
| COMMENT:
| |
| The tissue was submitted in toto and levels were cut.
| |
| </pre>
| |
| | |
| ======Micro======
| |
| The sections show dense collagen (tendon) without an apparent pathology. Calcification is not present. There is no nuclear atypia or necrosis. Mitotic activity is not identified. Benign fibroadipose tissue is present. Lamellar corpuscles are present.
| |
|
| |
|
| ==Angiomyoma== | | ==Angiomyoma== |
| Line 1,081: |
Line 436: |
|
| |
|
| ==Angiokeratoma== | | ==Angiokeratoma== |
| ===General===
| | {{Main|Angiokeratoma}} |
| *Rare.
| |
| *May be seen in the context of [[Fabry disease]].<ref name=pmid16403380/>
| |
| | |
| Notes:
| |
| *Shouldn't be confused with ''[[angiofibroma]]'' which is associated [[tuberous sclerosis]].
| |
| | |
| ===Gross===
| |
| *Dark lesions.
| |
| | |
| Clinical DDx:
| |
| *[[Melanocytic lesions]].
| |
| ====Images====
| |
| <gallery>
| |
| Image:Angiokeratoma_of_the_Scrotum_7.jpg | Angiokeratoma. (WC)
| |
| </gallery>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=pmid16403380>{{Cite journal | last1 = Karen | first1 = JK. | last2 = Hale | first2 = EK. | last3 = Ma | first3 = L. | title = Angiokeratoma corporis diffusum (Fabry disease). | journal = Dermatol Online J | volume = 11 | issue = 4 | pages = 8 | month = | year = 2005 | doi = | PMID = 16403380 }}</ref>
| |
| #Ectatic superficial dermal vessels.
| |
| #Overlying hyperkeratosis (thick stratum corneum).
| |
| *Should have "epidermal collarette".<ref name=Ref_Derm548>{{Ref Derm|548}}</ref>
| |
| **Vascular space surrounded by epidermis on three sides.
| |
| | |
| Others features:{{fact}}
| |
| *Irregular acanthosis.
| |
| *Longer rete ridges.
| |
| | |
| DDx:
| |
| *[[Venous lake]].
| |
| | |
| ====Images====
| |
| <gallery>
| |
| Image:Angiokeratoma_-_low_mag.jpg | Angiokeratoma - low mag. (WC/Nephron)
| |
| Image:Angiokeratoma_-_intermed_mag.jpg | Angiokeratoma - intermed. mag. (WC/Nephron)
| |
| </gallery>
| |
| www:
| |
| *[http://www.pathologyoutlines.com/images/skintumorangiokerat1.jpg Angiokeratoma (pathologyoutlines.com)].
| |
| | |
| ===Sign out===
| |
| <pre>
| |
| SKIN LESION, LEFT POPITEAL FOSSA, PUNCH BIOPSY:
| |
| - ANGIOKERATOMA.
| |
| </pre>
| |
|
| |
|
| ==Inverted follicular keratosis== | | ==Inverted follicular keratosis== |
| Line 1,191: |
Line 503: |
| :'''''Not''' to be confused with [[nodular fasciitis]]''. | | :'''''Not''' to be confused with [[nodular fasciitis]]''. |
| *[[AKA]] ''flesh-eating disease''. | | *[[AKA]] ''flesh-eating disease''. |
| ===General===
| | {{Main|Necrotizing fasciitis}} |
| *High mortality.
| |
| *May be diagnosed at [[frozen section]].<ref name=pmid9386043>{{Cite journal | last1 = Majeski | first1 = J. | last2 = Majeski | first2 = E. | title = Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. | journal = South Med J | volume = 90 | issue = 11 | pages = 1065-8 | month = Nov | year = 1997 | doi = | PMID = 9386043 }}</ref>
| |
| *Classically associated with ''Group A streptococcus''.
| |
| | |
| Treatment:
| |
| *Operative debridement.
| |
| | |
| ===Microscopic===
| |
| Features:
| |
| *Necrosis of fascia - '''key feature'''.<ref name=pmid15735411>{{Cite journal | last1 = Wong | first1 = CH. | last2 = Wang | first2 = YS. | title = The diagnosis of necrotizing fasciitis. | journal = Curr Opin Infect Dis | volume = 18 | issue = 2 | pages = 101-6 | month = Apr | year = 2005 | doi = | PMID = 15735411 | URL = http://www.sepeap.org/archivos/pdf/9859.pdf }}</ref>
| |
| **[[PMN]]s and necrotic debris (amorphous grey or pink material).
| |
| | |
| Note:
| |
| *Fat lobules between septae may be normal.
| |
| | |
| DDx:
| |
| *[[Cellulitis]].
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:Necrotizing_fasciitis_-_intermed_mag.jpg Necrotizing fasciitis - intermed. mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Necrotizing_fasciitis_-_high_mag.jpg Necrotizing fasciitis - high mag. (WC)].
| |
|
| |
|
| ==Porokeratosis== | | ==Porokeratosis== |
| ===General===
| | {{Main|Porokeratosis}} |
| *Genetic.
| |
| *Several subtypes.
| |
| | |
| Notes:
| |
| *Not the same as ''punctate porokeratotic keratoderma''.<ref name=pmid20137755>{{Cite journal | last1 = Alikhan | first1 = A. | last2 = Burns | first2 = T. | last3 = Zargari | first3 = O. | title = Punctate porokeratotic keratoderma. | journal = Dermatol Online J | volume = 16 | issue = 1 | pages = 13 | month = | year = 2010 | doi = | PMID = 20137755 | URL = http://dermatology.cdlib.org/1601/case_presentations/ppk/alikhan.html }}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:
| |
| *Cornoid lamella (pathognomonic) - '''key feature''':
| |
| **Compact keratosis over a hair follicle.
| |
| *+/-Rete ridge loss.
| |
| | |
| Images:
| |
| *[[WC]]:
| |
| **[http://commons.wikimedia.org/wiki/File:Porokeratosis_-_intermed_mag.jpg Porokeratosis - intermed. mag. (WC)].
| |
| **[http://commons.wikimedia.org/wiki/File:Porokeratosis_-_very_high_mag.jpg Porokeratosis - very high mag. (WC)].
| |
|
| |
|
| ==Nevus sebaceous== | | ==Nevus sebaceous== |
| *[[AKA]] ''nevus sebaceous of Jadassohn''. | | *[[AKA]] ''nevus sebaceous of Jadassohn''. |
| ===General===
| | {{Main|Nevus sebaceous}} |
| *Congenital - considered a [[hamartoma]].<ref name=pmid23217958/>
| |
| *Usually sporadic - may be transmitted autosomal dominant.<ref name=pmid23217958/>
| |
| *Malignant tumours may arise within a ''nevus sebaceous''.
| |
|
| |
| ===Gross===
| |
| Features:<ref name=pmid23217958>{{Cite journal | last1 = West | first1 = C. | last2 = Narahari | first2 = S. | last3 = Kwatra | first3 = S. | last4 = Feldman | first4 = S. | title = Autosomal dominant transmission of nevus sebaceous of Jadassohn. | journal = Dermatol Online J | volume = 18 | issue = 11 | pages = 17 | month = Nov | year = 2012 | doi = | PMID = 23217958 }}</ref><ref name=pmid19171988>{{Cite journal | last1 = Simi | first1 = CM. | last2 = Rajalakshmi | first2 = T. | last3 = Correa | first3 = M. | title = Clinicopathologic analysis of 21 cases of nevus sebaceus: a retrospective study. | journal = Indian J Dermatol Venereol Leprol | volume = 74 | issue = 6 | pages = 625-7 | month = | year = | doi = | PMID = 19171988 }}</ref>
| |
| *Head and neck [[plaque]] or [[papule]] with:
| |
| **Well-circumscribed borders.
| |
| **Waxy, yellow appearance.
| |
| *Area usu. devoid of hair.<ref name=pmid22148058>{{Cite journal | last1 = Kim | first1 = JH. | last2 = Park | first2 = HY. | last3 = Ahn | first3 = SK. | title = Nevus sebaceous accompanying secondary neoplasms and unique histopathologic findings. | journal = Ann Dermatol | volume = 23 | issue = Suppl 2 | pages = S231-4 | month = Oct | year = 2011 | doi = 10.5021/ad.2011.23.S2.S231 | PMID = 22148058 }}</ref>
| |
| | |
| DDx - gross:
| |
| *[[Seborrheic keratosis]].
| |
| | |
| Image:
| |
| *[http://www.dermnet.com/images/Nevus-Sebaceous/picture/17082?imgNumber=14 NS (dermnet.com)].
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=pmid19171988/>
| |
| *Abundant sebaceous glands.
| |
| *Immature/abortive hair follicles.
| |
| **No normal terminal hair follicles.
| |
| *Papillomatous epidermal hyperplasia.
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:SkinTumors-P6260391.JPG NS (WC)].
| |
| *[http://www.dermnet.com/images/Nevus-Sebaceous/picture/17087 NS (dermnet.com)].
| |
|
| |
|
| ==Nevus lipomatosus superficialis== | | ==Nevus lipomatosus superficialis== |
| Line 1,268: |
Line 516: |
| *[[AKA]] ''nevus lipomatosus cutaneous superficialis'', abbreviated ''NLCS''. | | *[[AKA]] ''nevus lipomatosus cutaneous superficialis'', abbreviated ''NLCS''. |
| *[[AKA]] ''nevus lipomatosus''.<ref name=pmid15677959>{{Cite journal | last1 = Kaw | first1 = P. | last2 = Carlson | first2 = A. | last3 = Meyer | first3 = DR. | title = Nevus lipomatosus (pedunculated lipofibroma) of the eyelid. | journal = Ophthal Plast Reconstr Surg | volume = 21 | issue = 1 | pages = 74-6 | month = Jan | year = 2005 | doi = | PMID = 15677959 }}</ref> | | *[[AKA]] ''nevus lipomatosus''.<ref name=pmid15677959>{{Cite journal | last1 = Kaw | first1 = P. | last2 = Carlson | first2 = A. | last3 = Meyer | first3 = DR. | title = Nevus lipomatosus (pedunculated lipofibroma) of the eyelid. | journal = Ophthal Plast Reconstr Surg | volume = 21 | issue = 1 | pages = 74-6 | month = Jan | year = 2005 | doi = | PMID = 15677959 }}</ref> |
| ===General===
| | {{Main|Nevus lipomatosus superficialis}} |
| *Rare.
| |
| *Congenital - considered a [[hamartoma]].<ref name=pmid22984661/>
| |
| *Usually young adults.<ref>URL: [http://www.dermpedia.org/dermpedia-textbook/nevus-lipomatosus http://www.dermpedia.org/dermpedia-textbook/nevus-lipomatosus]. Accessed on: 8 January 2013.</ref>
| |
| | |
| Clinically separated into:<ref name=pmid17288284>{{Cite journal | last1 = Triki | first1 = S. | last2 = Mekni | first2 = A. | last3 = Haouet | first3 = S. | last4 = Mokni | first4 = M. | last5 = Kchir | first5 = N. | last6 = Ben Osman Dhahri | first6 = A. | last7 = Zitouna | first7 = M. | title = [Nevus lipomatosus cutaneous superficialis: a clinico-pathological study of 13 cases]. | journal = Tunis Med | volume = 84 | issue = 12 | pages = 800-2 | month = Dec | year = 2006 | doi = | PMID = 17288284 }}</ref>
| |
| *''Solitary'' - one lesion.
| |
| *''Multiple'' - more than one lesion.
| |
| | |
| ===Gross===
| |
| Features:<ref name=pmid22984661>{{Cite journal | last1 = Goucha | first1 = S. | last2 = Khaled | first2 = A. | last3 = Zéglaoui | first3 = F. | last4 = Rammeh | first4 = S. | last5 = Zermani | first5 = R. | last6 = Fazaa | first6 = B. | title = Nevus lipomatosus cutaneous superficialis: Report of eight cases. | journal = Dermatol Ther (Heidelb) | volume = 1 | issue = 2 | pages = 25-30 | month = Dec | year = 2011 | doi = 10.1007/s13555-011-0006-y | PMID = 22984661 | PMC = 3437641 }}</ref>
| |
| *Pedunculated lesion.
| |
| *Soft.
| |
| *Usually lower trunk or gluteal region.<ref name=pmid1235780>{{Cite journal | last1 = Jones | first1 = EW. | last2 = Marks | first2 = R. | last3 = Pongsehirun | first3 = D. | title = Naevus superficialis lipomatosus. A clinicopathological report of twenty cases. | journal = Br J Dermatol | volume = 93 | issue = 2 | pages = 121-33 | month = Aug | year = 1975 | doi = | PMID = 1235780 }}</ref>
| |
| | |
| Image:
| |
| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437641/figure/Fig1/ NLS (nih.gov)].<ref name=pmid22984661/>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=pmid19495497>{{Cite journal | last1 = Yap | first1 = FB. | title = Nevus lipomatosus superficialis. | journal = Singapore Med J | volume = 50 | issue = 5 | pages = e161-2 | month = May | year = 2009 | doi = | PMID = 19495497 | URL = http://smj.sma.org.sg/5005/5005cr3.pdf }}</ref>
| |
| *Benign adipose tissue in the dermis.
| |
| **Adipocytes in [[reticular dermis]] +/- [[papillary dermis]].<ref name=pmid20673540>{{Cite journal | last1 = Ghosh | first1 = SK. | last2 = Bandyopadhyay | first2 = D. | last3 = Jamadar | first3 = NS. | title = Nevus lipomatosus cutaneous superficialis: An unusual presentation. | journal = Dermatol Online J | volume = 16 | issue = 7 | pages = 12 | month = | year = 2010 | doi = | PMID = 20673540 }}</ref>
| |
| | |
| DDx:
| |
| *[[Lipoma]].
| |
| *[[Fibroepithelial polyp]] (skin tag).
| |
| *[[Intradermal nevus]] with adipocytes.<ref name=pmid9810886>{{Cite journal | last1 = Eng | first1 = W. | last2 = Cohen | first2 = PR. | title = Nevus with fat: clinical characteristics of 100 nevi containing mature adipose cells. | journal = J Am Acad Dermatol | volume = 39 | issue = 5 Pt 1 | pages = 704-11 | month = Nov | year = 1998 | doi = | PMID = 9810886 }}</ref>
| |
| | |
| Images:
| |
| *[http://www.dermaamin.com/site/images/histo-pic/n/nevus-lipomatosus-superficialis/nevus-lipomatosus-superficialis1.jpg NLS (dermamin.com)].<ref>URL: [http://www.dermaamin.com/site/histopathology-of-the-skin/66-n/1971-nevus-lipomatosus-superficialis----.html http://www.dermaamin.com/site/histopathology-of-the-skin/66-n/1971-nevus-lipomatosus-superficialis----.html]. Accessed on: 7 March 2012.</ref>
| |
| *[http://www.humpath.com/IMG/jpg/nevus_superficialis_lipomatosus_01_1.jpg NLS (humpath.com)].<ref>URL: [http://www.humpath.com/spip.php?article8134 http://www.humpath.com/spip.php?article8134]. Accessed on: 17 December 2012.</ref>
| |
| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437641/figure/Fig3/ NLS (nih.gov)].<ref name=pmid22984661/>
| |
| *[http://www.dermpedia.org/dermpedia-textbook/nevus-lipomatosus Nevus lipomatosus (dermpedia.org)].
| |
| | |
| ===Sign out===
| |
| <pre>
| |
| SKIN LESION ("SKIN TAG"), LEFT HIP, EXCISION:
| |
| - NEVUS LIPOMATOSUS SUPERFICIALIS.
| |
| </pre>
| |
|
| |
|
| =Bullous disease= | | =Bullous disease= |
