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Deposition of foreign material in the dermis



5  Non-tumorous skin diseases

5.12  Deposition of foreign material in the dermis

5.12.1  Amyloidosis

Introduction:

Eosinophilic material deposited subepidermally is found in macular amyloidosis and lichen amyloidosus; derived from epidermal keratin. Nodular amyloidosis is associated with immunoglobulin light chains, secondary amyloidosis with acute phase C protein from the serum.

Histology:

Amyloidosis of the skin is characterised by accumulation of eosinophilic, amorphous material (optical microscopy) subepidermally, within the papillary dermis. Usually focal degeneration of keratinocytes in the basal layer is present as well (amyloid is formed by keratin filaments from apoptotic keratinocytes).

In macular amyloidosis the amount of amyloid is low and epidermal reaction is not prominent. In lichen amyloidosus there is hyperkeratosis and acanthosis.

In nodular amyloidosis the light chains of immunoglobulins are accumulated.

In systemic (secondary) amyloidosis the amyloid accumulates within the walls of blood vessels.

Special stains are used for amyloid staining: congo red (brick red in transmitted light, polarisation, fluorescence); thioflavins (fluorescence); in nodular amyloidosis antibodies against light chains may be positive.

5.12.1.1  Systemic (secondary) amyloidosis

5.12.2  Mucinoses

Introduction:

There are 6 types of cutanous mucinosis (generalized myxedema of hypothyreoidism, pretibial myxedema in thyreotoxicosis, lichen myxedematosus , reticular erythematous mucinosis, self-healing juvenile cutaneous mucinosis, scleredema). Mucin is accumulated in some tumors as well (myxoma).

Skleromyxedema is characterized by fibroblastic proliferation within the areas with mucin deposits.

5.12.2.1  Generalized myxedema in hypothyreosis

Clinical signs:

  • associated with hypothyreosis
  • affects large areas of the body (face, eyelids, hands, legs, tongue)
  • small hemorrhages of the skin and mucous membranes (ecchymoses)
  • the skin is dry, rough (sebaceous and sweat production is decreased)
  • other organs are affected as well (the heart, nervous system, GIT, genital organs

Histology:

The increase in dermal mucin is inconspicuous.

5.12.2.2  Pretibial myxedema

Clinical signs:

  • associated with thyreotoxicosis (and exophaltmos), often worsens after therapy
  • limited to pretibial areas and dorsa of feet, rarely other location
  • waxy (pink, yelow) induration of the skin
  • orange peel skin, sometimed nodules

Pictures

Pretibial myxedema, larger nodules:
Pretibial myxedema, CLINIC (840)

Histology:

Large amounts of mucin in the dermis:

Case study:

Pretibial myxedema
Hana Jedličková, PhD.

Introduction:

Pretibial myxedema is observed in patients treated for thyroid gland hyperfunction. The patients are usually euthyroid at the time of the occurrence of myxedema. Excessive thyroid stimulating hormone (TSH) probably stimulates fibroblasts of the lower extremities. Mucinous deposits are formed predominantly by hyaluronic acid and chondroitin sulphate.

Although the shins are the most common site, the deposits can occur on the arms, neck, in the scars, etc.

History:

33-year-old man presented with tough nodules on the anterior aspects of lower legs of 2 months duration. The last year he was treated for thyreotoxicosis by levothyroxium, thiamazolum and bisoprolol and he was preparing for thyroid gland surgery. Further he had exophthalmia and strabismus since childhood (after meningitis) and hepatopathy.

Clinical signs:

Bilaterally on the anterior aspects of the lower legs asymptomatic pink or skin colored tough nodules 2 – 4 cm in diameter, slightly elevated.

Mild edema of the lower legs, excoriations and hyperpigmentations

Palpable enlarged thyroid gland, exophthalmia.

Pictures

Pretibial myxedema:
Pretibial myxedema, CLINIC (6157)

Histology:

Dermis is thickened with mucin deposits (alcian blue strongly positive), collagen fibres are widely separated by mucin. No inflammation.

5.12.2.4  Papular mucinosis

Clinical signs:

  • erythematous papules, sometimes pruritic
  • size: up to 5 mm
  • distribution: localized or generalized
  • lokalisation: face, dorsa of the hands, extensor surfaces of extremities
  • age: adults

Histology:

Prominent accumulation of dermal mucin, plump stellate fibroblasts.

5.12.2.5  Scleredema

Clinical signs:

  • location: neck, upper part of the trunk and arms
  • diffuse, firm, edematous induration of the skin
  • hands and feet are spared
  • the lesions are of skin color; no pitting
  • regression after several months

Pictures

Scleredema adultorum
Scleroderma, CLINIC (1080)

Histology:

Epidermis is normal; dermis is thickened with broad collagen bundles; mucin deposits are inconspicuous and can be demonstrated by special stainings. No proliferation of fibroblasts (as opposed to scleromyxedema).

5.12.2.6  Scleromyxedema

Histology:

Epidermis is usually thinned. Prominent deposits of mucin in the upper part of the dermis accompanied by widespread proliferation of fibroblasts.

5.12.2.7  Myxoma

Clinical signs:

  • papular tumorous lesion

Histology:

Localized accumulation of mucin within the reticular dermis, accompanied with some proliferation of fibroblasts; epidermis is flattened or normal; small cysts are sometimes present.

5.12.3  Calcium deposits

5.12.3.1  Chronic dermatomyositis

Introduction:

Deposits of calcium in dermatomyositis is mentioned in the chapter on dermatomyositis.

5.12.3.2  Subepidermal calcifying nodule

Introduction:

Calcium deposits (dystrophic calcification) of unknown etiology.

5.12.3.3  Calcinosis scroti

Clinical signs:

  • multiple, deep located calcification
  • location: scrotum
  • etiology: unknown (calcified epidermal cysts?)

Histology:

Multiple, roundish calcium deposits, foreign body reaction.

5.12.3.4  Tumoriform calcinosis

Clinical signs:

  • location: usually extremities (over joints)
  • patients are otherwise healthy
  • lesions are several centrimeters large, hard, usually ulcerated

Histology:

Deposits of calcium in the dermis, often with foreign body type reaction.

Pictures

Tumoriform calcinosis, lesion of the neck, 6×10 cm:
Calcinosis cutis, tumoriform, HE 10x (6038)

5.12.3.5  Calciphylaxis

Clinical signs:

  • usually associated with high levels of vitamin D
  • deposits of calcium within blood vessels walls
  • necrosis of surrounding tissue

Histology:

Calcium deposits within the walls of blood vessels.

Pictures

Calciphylaxis:
Calciphylaxis, HE 40x (2221)

Special staining for calcium (von Kossa):
Calciphylaxis, Kossa 40x (2222)

5.12.3.6  Dystrofic dermal calcifications

Histology:

Large masses of calcium deposits with foreign body reaction.

Pictures

Calcifying nodules and plaques of a child, located on the back, with white or yellowish discharge:
Dystrofic dermal calcifications, HE 20x (2663)

Dystrofic dermal calcifications, HE 40x (2664)

5.12.4  Osteoma cutis

Clinical signs:

  • small, round, firm tumor; sometimes multiple

Histology:

Small, roundish intradermal tumors of regular, lamellar bone; usually with fat bone marrow. Sometimes osteoblasts and osteoclasts are present.

Pictures

Osteoma of the skin:
Osteoma, HE 20x (4092)

Osteoma of the skin:
Cutaneous osteoma, HE 60x (10706)

Cutaneous osteoma, HE 60x (10707)

Osteoma of the skin:
Osteoma, HE 20x (13904)

5.12.4.1  Progressive osseous heteroplasia

Clinical signs:

  • age: children
  • genetics: defect of GNAS1 gene
  • widespread ossifications of the skin, subcutanous fat and connective tissue
  • very rare
  • localized variant: plate-like osteoma cutis has the same genetic defect

Histology:

Deposits of calcium and osteomas within the dermis.

Pictures

Progressive osseous heteroplasia:
Progressive osseous heteroplasia, HE 20x (2730)

Plate-like osteoma cutis:
Plate-like osteoma cutis, HE 60x (12836)

5.12.5  Gout, arthritis uratica

Introduction:

Herogenous group of diseases characterized by increased level of uratic acid in the blood, caused by overproduction of purines, increased catabolism of nucleic acids, decreased excretion of uric acid (idiopathic gout, about 80%) or decreased degradation of purines.

Clinical signs:

  • precipitated urates form chalky white deposits on intra-articular structures
  • subcutaneous deposits (tophi), sometimes discharged transcutaneously, sometimes in late stages of the disease
  • location: helix of the ear, elbow, fingers, toes
  • size: up to several centimeters

Histology:

Epidermis normal or ulcerated. Usually large deposits of amorphous, amphophilic or slightly basophilic material with parallel, needle shaped clefts within the dermis and subcutis. Lymphohistiocytic infiltrate, often with granulomatous foreign-body reaction. Sometimes calcifications or ossifications are present as well.

For better visualisation fixation in 100% ethanol is preferred; the crystals are birefingent. If the tissue is fixed with formaldehyde, the crystals usually dissolve. The fixation fluid can be tested for presence of urates (murexid reaction).

Pictures

Gout:
Gout, HE 5x (2066)

Gout, HE 20x (2067)

Gout, HE 40x (2068)

Murexid reaction, result on the bottom of a china dish:
Gout, Macro (2135)

Gout, Macro (2136)

Large deposits (clinically diagnosed as a tumor), crystals are preserved:
Gout, HE 10x (4056)

Gout, HE 40x (4057)

Gout, HE 40x (4058)

Gout:
Gout, HE 20x (4498)
  [zoomify]

Gout:
Gout, HE 40x (13008)

Gout, bursa olecrani:
Gout, bursa olecrani, HE 40x (6113)

Gout, tophi, ear:
Gout, ear, HE 20x (14023)

5.12.6  Hemosiderin

Introduction:

Intradermal deposits of iron (hemosiderin) are usually associated with hemorrhage (purpura, stasis dermatitis), siderosis around foreign bodies. Skin pigmentation in hemochromatosis is caused by epidermal melanin, but hemosiderin is present as well.

Histology:

Hemosiderin deposits within the dermis can be stained by Prussian blue staining.

Pictures

Hemosiderin:
Hemosiderin, HE 10x (265)

Special stain for iron (Perls) — hemosiderin is stained blue:
Hemosiderin, Prussian blue 10x (264)

Similar case in higher magnification:
Hemosiderin, HE 40x (267)

Hemosiderin, Prussian blue 40x (266)

Black heel, hemosiderin within the cornified layer:
Black heel, HE 20x (4222)

Another case:
Black heel, HE 20x (4428)
  [zoomify]

Another case:
Black heel, HE 20x (4790)
  [zoomify]

Another case:
Black heel, HE 20x (5085)
  [zoomify]
Black heel, benzidin 20x (5084)
  [zoomify]

Traumatic hematoma, nail:
Nail hematoma, HE 20x (5214)

Nail hematoma, toe (clinical suspition for melanoma):
Nail hematoma, HE 20x (13900)

Siderosis of the fat in a small child treated for malignancy (etiology unknown):
Siderosis of the fat, after blastoma; chemotherapy, HE 20x (5414)

5.12.7  Tatoo

Introduction:

Blue tatoo is done by introducing carbon into the dermis.

In addition to black (blue) tatoo mercury (red), chromium (green), cadmium (yellow) and cobalt (blue) and many others pigments are used.

Clinical signs:

  • traumatic tatoo occurs most often on the face, palms, knees
  • sometimes foreign body granulomas develop, in artificial tatoo allergic reactions

Pictures

Tatoo, chest:
Tatoo, CLINIC (929)

Traumatic tatoo, face:
Tatoo, CLINIC (1138)

Tatoo, arm:
Tatoo, CLINIC (3354)

Tatoo, CLINIC (3355)

Histology:

Color pigments are deposited within the macrophages or as free tissue deposits.

Carbon does not usually cause any tissue reaction. Granules of carbon are black and cannot be bleached by peroxide (as opposed to melanin).

5.12.7.1  Amalgam tatoo

Clinical signs:

  • location: gums, near the teeth filled with amalgam

Histology:

So called amalgam tatoo are amalgam deposits within the gums, characterised by black pigment granules and dark impregnation of the collagen fibres.

5.12.8  Argyrosis

Clinical signs:

  • silver intoxication
  • occurs especially on insolated areas
  • grayish, grayish black discoloration of the skin, mucous membranes, nails and conjunctivae

Histology:

Tiny black granules of silver in the dermis, especially around sweat glands.

Pictures

Argyrosis:
Argyrosis, HE 100x (4875)

Argyrosis:
Argyrosis, HE 20x (4206)
  [zoomify]

Argyrosis, sweat glands:
Argyrosis, HE 40x (4207)

Argyrosis, HE 63x (4214)

Argyrosis, smooth muscle:
Argyrosis, HE 40x (4210)

5.12.9  Titanium pigmentation

Introduction:

Titanium is common prosthetic material. Titanium particles can be released into surrounding tissues.

Histology:

Histologically appears as black pigmentation.

5.12.10  Deposits of corticosteroids in the dermis

Clinical signs:

  • deposits of injected, low soluble steroids in the dermis

Histology:

Pale, foamy dermal deposits; inflammation is usually slight or none.

5.12.11  Ochronosis

Clinical signs:

  • endogenous ochronosis (alcaptonuria)
    • autosomal recessive metabolic disease
    • generalized deposits of homogentisic acid in soft tissues (esp. cartilage, joints, sclerae)
    • lasts years
  • exogenous ochronosis
    • after topical application of hydroquinone (bleaching)
    • bluish or black hyperpigmentations, papules, milia
    • limited to exposed areas

Histology:

Deposits of yellow brown pigment within the dermis, esp. within the collagen; small granular deposits can be found in endothelium, histiocytes and sweat glands.

Brown pigmentation of cartilage and connective tissue.

5.12.12  Colloid milium

Clinical signs:

  • age: adults (juvenile colloid milium is a different disease)
  • location: face, neck, dorsa of the hands

Histology:

Deposits of amorphous, bluish material within the papillary dermis; thin layer of connective tissue separates the epidermis and the deposits; thin arteficial cleft may separate the colloid from surrounding stroma.

5.12.13  Subcutaneous emphysema

Clinical signs:

Air in the subcutis causes acute swelling, which usually disappears spontaneously.

Pictures

Subcutaneous emphysema:
Subcutaenous emphysema, CLINIC (1982)



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