Skin pathology pigmented lesions neoplasms immune mediated lesions and infections
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Skin Pathology: Pigmented lesions, neoplasms, immune-mediated lesions, and infections. Lecture 5 Thursday, January 25, 2007 Refs. Basic Pathology Chapter 22 Wheater’s Basic Histopathology Chapter 21 Pathologic Basis of Disease 7th ed Chapter 25.

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Skin pathology pigmented lesions neoplasms immune mediated lesions and infections

Skin Pathology:Pigmented lesions, neoplasms, immune-mediated lesions, and infections

Lecture 5

Thursday, January 25, 2007

Refs. Basic Pathology Chapter 22

Wheater’s Basic Histopathology Chapter 21

Pathologic Basis of Disease 7th ed Chapter 25


Removing the Mystery of Eyelid Lesion Differential Diagnosis:Beyond Papilloma and Basal Cell Carcinoma

Thomas F. Freddo, O.D., Ph.D., F.A.A.O.

Professor of Ophthalmology, Pathology and Anatomy

Boston University School of Medicine

and

Adjunct Professor of Optometry

New England College of Optometry


Terms to describe skin lesions
Terms to describe skin lesions Diagnosis:

  • Gross Lesions

    • Macule

    • Papule, nodule, plaque

    • Vesicle, bulla (blister)

    • Pustule

    • Wheal

    • Scale

    • Lichenification

    • Excoriation


Terms to describe skin lesions1
Terms to describe skin lesions Diagnosis:

  • Microscopic lesions

    • Hyperkeratosis, parakeratosis

    • Acanthosis,

    • Acantholysis, spongiosis

    • Lentiginous

    • Papillomatosis

  • Both gross and microscopic

    • Ulceration-complete loss of epidermis, ±defect in underlying dermis and subcutis

    • Erosion-incomplete loss of epidermis


Surface keratin wbp 21 1
Surface keratin wbp 21-1 Diagnosis:

Normal Hyperkeratosis Parakeratosis

(orthokeratosis)


Response of skin to disease
Response of skin to disease Diagnosis:

  • Limited repertoire

  • Few pathognomonic lesions

  • Acute dermatitis

    • Spongiosis

    • ± inflammatory infiltrate

    • If lesions are red, papulovesicular, oozing and crusted, the clinical term eczema can be used.

  • Chronic dermatitis

    • Acanthosis

    • Hyperkeratosis




Pigmented lesions
Pigmented lesions Diagnosis:

  • Variation from benign to malignant

  • Benign conditions:

    • Vitiligo (loss of melanocytes and thus pigment from affected area) may be autoimmune, neurohumoral, toxic intermediates …..

    • Freckles (melanocyte number is normal but increased amount of melanin), melasma (hyperpigmentation on face)

    • Nevocellular nevus “mole”

      • Junctional, compound, intradermal

  • Dysplastic nevus may progress to malignant melanoma.

  • Malignant melanoma has tendency to metastasize.





Malignant melanoma bp 22 21c d vertical growth c increases probability of metastasis
Malignant melanoma BP 22-21C&D Diagnosis:Vertical growth (C) increases probability of metastasis.


Other skin tumors
Other skin tumors Diagnosis:

  • Benign epithelial tumors-hundreds of kinds

    • Seborrheic keratoses, epithelial cysts, etc.

  • Actinic keratoses

    • Hyperkeratosis associated with chronic exposure to sunlight may become SCC.

  • Squamous cell carcinoma (SCC)

    • Sun exposure, rarely metastasizes, locally invasive

    • May present as non-healing ulcer.

  • Basal cell carcinoma

    • Slow growing, usually does not metastasize

    • Sun exposure is a predisposing factor.


Papillomatous masses seborrheic keratosis
Papillomatous Masses: Diagnosis:Seborrheic keratosis

Sessile

Papillomatous

nodule/tumor

Usually

pigmented,

with greasy

scale



Actinic keratosis
Actinic Keratosis Diagnosis:


Actinic keratosis - Diagnosis:can also appear as a scaly papule. Again note blotchy appearance of surrounding skin.


Actinic keratosis - the scaly appearance is actually parakeratosis indicating rapid turnover of the epithelium. The basal half of the epithelium looks worrisome, with lateral budding of the rete pegs, but the apical half looks OK. Squamous cell CA-Grade 1/2.


Rounded, symmetric dome with central nidus of keratin vs non-domed irregular border with larger central crater of keratin

Squamous cell

Carcinoma

Keratoacanthoma

The other major clue to this differential is how long the lesion has been present.


Squamous cell carcinoma bp 22 17b c
Squamous cell carcinoma BP 22-17b&c non-domed irregular border with larger central crater of keratin


Basal cell carcinoma
Basal Cell Carcinoma non-domed irregular border with larger central crater of keratin

  • Commonest form of skin cancer

  • Typically seen on sun-exposed areas such as the face and neck.

  • Originate from the basal keratinocyte

  • Histologically reminiscent of skin adnexal structures such as hair follicles.

  • Locally invasive, but rarely metastasize


Basal cell carcinoma1
Basal Cell Carcinoma non-domed irregular border with larger central crater of keratin

  • Age of onset: >40 years of age.

  • Sex: Males > females.

  • Incidence: In US, 500-1,000 per 100,000; >400,00 new cases each year.

  • Race: Higher in Caucasians, rare in brown and black skinned people.

  • Predisposing factors:  White-skin with poor tanning capacity, albinos, exposure to x-rays for facial acne, arsenic ingestion, heavy sun exposure before age 14.


Basal cell carcinoma types
Basal Cell Carcinoma - Types non-domed irregular border with larger central crater of keratin

  • 1) Nodular (and nodulo-ulcerative): Most common.  Begins as a small, skin-colored papule which shows fine telangiectasia and a glistening pearly edge.  Frequently, there is central necrosis that leaves a small ulcer with an adherent crust.  They are usually less than 1 cm in diameter (I.e. NODULES), but grow larger if present for several years.


Nodular basal cell ca
Nodular non-domed irregular border with larger central crater of keratinBasal Cell CA


Basal cell carcinoma2
Basal Cell Carcinoma non-domed irregular border with larger central crater of keratin

Nodulo-ulcerative type


Nodulo ulcerative basal cell ca
Nodulo-ulcerative Basal Cell CA non-domed irregular border with larger central crater of keratin

Note

telangiectatic

vessels near

central

ulceration.


Differential diagnosis nodulo ulcerative basal cell ca vs squamous cell carcinoma
Differential Diagnosis: non-domed irregular border with larger central crater of keratinNodulo-ulcerative Basal Cell CA vs Squamous cell carcinoma

Squamous cell - Central crater dry, filled with brown-yellow, scaly, greasy keratin

Basal Cell - Central crater ulcerated and moist, often with hemorrhage and translucent border


Cystic basal cell carcinoma
Cystic Basal Cell Carcinoma non-domed irregular border with larger central crater of keratin

  • Cystic: Become tense and translucent, and show cystic spaces on histology


Basal cell carcinoma bp 22 18b c
Basal cell carcinoma BP 22-18b,c non-domed irregular border with larger central crater of keratin


Dermatitis dermatosis
Dermatitis/Dermatosis non-domed irregular border with larger central crater of keratin

  • Infectious

    • Secondary to systemic disease

    • Primary infections

      • Bacterial - impetigo usually Staph or Strep

      • Viral- warts due to human papillomavirus

        • Molluscum contagiosum caused by pox virus

      • Fungal due to dermatophytes-tinea capitis, barbae, pedis, corporis


Erythema multiforme bp 22 3 a hypersensitivity to infections and drugs
Erythema multiforme BP 22-3 non-domed irregular border with larger central crater of keratina hypersensitivity to infections and drugs


Psoriasis bp 22 4 and 22 5 current evidence mediated by t cells
Psoriasis BP 22-4 and 22-5 non-domed irregular border with larger central crater of keratinCurrent evidence: mediated by T cells


Papillomatous masses verruca vulgaris
Papillomatous Masses: non-domed irregular border with larger central crater of keratinVerruca vulgaris

  • Scaly

    nodule with

    “Spikey”

    papillomatosis

    Sometimes in

    Clusters.

    At lid margin, can give rise to follicular conjunctivitis, like mollsucum.


Wart verruca vulgaris whp 21 9
Wart (Verruca vulgaris) Whp 21-9 non-domed irregular border with larger central crater of keratin


Acne vulgaris
Acne vulgaris non-domed irregular border with larger central crater of keratin

  • Physiological hormonal variations and alterations in hair follicle maturation

    • Androgens

    • Dilation of follicle with sebum and keratin

  • Comedones

    • Open- has black keratin plug

    • Closed- can rupture- severe inflammation



Blistering diseases
Blistering diseases with inflammation) PBD 25-42

  • Group of diseases with vesicles and/or bullae as major features

  • Location of vesicles varies (see fig. 22-7)

  • Subcorneal vesicles are more superficial

    • Pemphigus foliaceus

  • Suprabasal vesicles are above the stratum basale.

    • Pemphigus vulgaris

  • Subepithelial vesicles are at junction of basal cells and basement membrane.

    • Bullous pemphigoid and dermatitis herpetiformis


Pemphigus vulgaris bp 22 8 b
Pemphigus vulgaris BP 22-8 B with inflammation) PBD 25-42


Pemphigus vulgaris. Direct immunofluorescence shows antibody and complement at intercellular junctions of keratinocytes. BP 22-9


Bullous pemphigoid bp 22 10
Bullous Pemphigoid BP 22-10 and complement at intercellular junctions of keratinocytes. BP 22-9


Bullous pemphigoid bp 22 11a
Bullous Pemphigoid BP 22-11A and complement at intercellular junctions of keratinocytes. BP 22-9



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