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Blistering diseases

5  Non-tumorous skin diseases

5.2  Blistering diseases

5.2.1  Classification

Introduction:

This group of diseases is usually classified according to the location and way of origin of the blisters:

Subcorneal:
in pemphigus foliaceus, staphylococcal impetigo...
Intraepidermal:
within stratum spinosum; further classification according to the way of origin:
Spongiotic:
caused by excessive spongiosis; usually some inflammatory cells are present. Examples: allergic dermatitis, dyshidrotic dermatitis
Cell ballooning:
often caused by viruses (herpes)
Acantholytic:
cellular cohesivness is lost, stratum spinosum desintegrates: pemphigus vulgaris, Darier's disease...
Subepidermal:
epidermolysis bullosa, porphyria cutanea tarda, lichen sclerosus et atrophicus, dermatitis herpetiformis Duhring and others. Subepidermal bullae appear after epidermal necrosis (vascular occlusion, phlegmone etc.).

5.2.2  Impetigo

Clinical signs:

  • often face, esp. perioral; hands
  • vesicles, which quickly change into crusts
  • vesicles, erosions, crusts, staphylococci are detectable

Pictures

Impetigo contagiosa:
Impetigo bullosa, CLINIC (769)

Impetigo, perioral:
Impetigo bullosa, CLINIC (770)

Perioral impetigo:
Impetigo, CLINIC (3016)
Impetigo, CLINIC (3017)
Impetigo, CLINIC (3018)

Impetigo vulgaris:
Impetigo, Macro (3842)

Impetigo:
Impetigo, CLINIC (5973)

Cheilitis impetiginizata:
Cheilitis impetiginisata, CLINIC (5659)

Further examples of impetigo contagiosa:

Histology:

Subcorneal vesicles filled with neutrophils (impetigo contagiosa) or only minimal presence of inflammatory cells (bullous impetigo). Thin roof is often detached. Impetiginization of various inflammatory skin disorders is caused by secondary infection.

Pictures

Impetigo:
Impetigo, HE 20x (67)
Impetigo, HE 40x (68)

Impetigo contagiosa, early, with spongiotic vesicles and only scattered neutrophils:
Impetigo contagiosa, HE 20x (4717)

Impetigo contagiosa:
Impetigo contagiosa, HE 40x (4797)  [zoomify]

Tiny subcornal pustule, etiology v.s. Corynebacteria:
Subcorneal pustule with microorganisms (Corynebacteria), HE 60x (13915)

5.2.3  Staphylococcal scalded skin syndrome

Etiology:

Caused by staphylococcal exotoxin (exfoliatin).

Clinical signs:

  • age: children
  • generalized erythemas, painful skin, large flaccid bullae
  • location: trunk, neck
  • mucous membranes are not involved
  • denudation of large areas after rupture of the bullae
  • good prognosis unless septicaemia develops

Histology:

Large subcorneal bullae, focal subcorneal acantholysis, sparse mixed (lymphocytes, neutrophils) infiltrate.

Direct immunofluorescence is negative.

5.2.4  Subcorneal pustular dermatosis of Sneddon-Wilkinson

Clinical signs:

  • sterile pustules in annular arrangement
  • location: flexural, axillar

Histology:

Subcorneal pustules, neutrophilic spongiosis or spongiform pustules, occassional eosinophils, sometimes slight acantholysis (protelolytic enzymes from neutrophils).

5.2.5  Peeling skin syndrome

Etiology, pathogenesis:

  • rare ausotomal recessive disease
  • abnormal keratinisation

Clinical signs:

  • subcorneal vesicles or bullae
  • no inflammation, asymptomatic
  • several forms exist: generalized, localized (dorsa of the hands, palms)

Histology:

Area of homogenized keratin in the lower parts of stratum corneum, subcorneal bulla. No inflammation.

5.2.6  Acute generalized exanthematous pustulosis (AGEP)

Clinical signs:

  • many small pustules on erythematous background
  • fever, leukocytosis
  • etiology is unknown, possible reasons are many (infections, drugs and other)

Histology:

Superficial, usually subcorneal pustule, slight pustular spongiosis in the margins. Edema of papillary dermis, mixed inflammatory infiltrate. Rarely subepidermal vesicles or leukocytoclastic vasculitis.

Pustules are sterile, no etiological agent can be found.

5.2.7  Pemphigus vulgaris

Etiology, pathogenesis:

  • autoimmune disease: circulating IgG antibodies directed against surface antigens on stratified squamous cells, which are associated with desmosomes
  • antibody binding causes desintegration of epidermis and blister formation

Clinical signs:

  • adults, usually 40 – 60 years old
  • occurs first in the mouth, later affects the entire body
  • flaccid, easily broken blisters, without inflammation
  • erosions, crusts
  • sometimes pain, bleeding
  • heals without scars
  • life threatening disease
  • loss of fluids, proteins, secondary infections
  • test Tzanck is used in clinical diagnostics: cytologic identification of acantholytic keratinocytes within the smear of underside of the fresh bulla.
  • Nikolski sign: pressure of the finger causes formation of a new bulla; pressure of the finger in the vicinity of the bulla causes extension of the bulla and acantholysis (pseudonikolski sign)

Pemphigus vegetans is an longstanding vulgar pemphigus of the intertriginous areas with pustules and vegetations. pemphigus foliaceus (subcorneal acantholysis).

pemphigus erythematosus Senear-Usher, (similar to p. foliaceus, dermo-epidermal deposits similar to those in lupus erythematodes may be present), pareneoplastic and drug induced pemphigus are separate diseases, characterized by acantholysis as well.

Pemphigus herpetiformis is a rare variant of vulgar pemphigus, clinically resembling dermatitis herpetiformis (vesicles, papules, strong pruritus) and histologically is characterized by acantholysis and positive immunofluorescence finding. Inflammatory infiltrate is of variable density, with admixture of eosinophils and/or neutrophils. May affect oral mucosa as well.

Pictures

Pemphigus vulgaris, erosion of the lower lip:
Pemphigus vulgaris, CLINIC (862)

Pemphigus vulgaris:
Pemphigus vulgaris, CLINIC (863)

Pemphigus vulgaris, fresh vesicles and erosions:
Pemphigus vulgaris, CLINIC (864)

Pemphigus vulgaris, detail:
Pemphigus vulgaris, CLINIC (865)

Pemphigus vulgaris:
Pemphigus vulgaris, CLINIC (866)

Pemphigus vulgaris:
Pemphigus vulgaris, CLINIC (868)

Pemphigus vulgaris:
Pemphigus vulgaris, CLINIC (869)

Pemphigus vulgaris, perioral and periorbital lesions:
Pemphigus vulgaris, CLINIC (871)

Pemphigus vulgaris:
Pemphigus vulgaris, CLINIC (872)

Pemphigus herpetiformis:
Pemphigus herpetiformis, CLINIC (1107)

Pemphigus vulgaris, pitva (neglected, home-healed case ending in sepsis; lesions in various stage of healing):
Pemphigus vulgaris, autopsy, CLINIC (1977)
Pemphigus vulgaris, autopsy, CLINIC (1978)
Pemphigus vulgaris, autopsy, CLINIC (1979)

Pemphigus vulgaris, oral lesion:
Pemphigus vulgaris mucosae oris, CLINIC (3208)

Pemphigus vulgaris:
Pemphigus vulgaris, Macro (3898)
Pemphigus vulgaris, Macro (3899)
Pemphigus vulgaris, Macro (3900)
Pemphigus vulgaris, Macro (3902)

Further examples of pemphigus vulgaris:

Histology:

Intraepidermal suprabasal blisters; separated acantholytic cells; chickenwire immunofluorescence in stratum spinosum (very important diagnostic sign); eosinophils.

Pictures

Another case:
Pemphigus vulgaris, HE 20x (71)
Pemphigus vulgaris, HE 40x (72)

Another case:
Pemphigus vulgaris, HE 10x (73)
Pemphigus vulgaris, HE 20x (74)
Pemphigus vulgaris, HE 40x (75)
Pemphigus vulgaris, roof of the bulla, HE 40x (76)
Pemphigus vulgaris, HE 100x (77)

The acantholysis is sometimes inconspicuous:
Pemphigus vulgaris, old bulla, HE 20x (84)

Another case:
Pemphigus vulgaris, HE 20x (78)

Another case:
Pemphigus vulgaris, HE 40x (6025)

Another case:
Pemphigus vulgaris, HE 60x (6414)

Incipient vulgar pemphigus with tiny acantholytic vesicle:
Pemphigus vulgaris, incipient, HE 40x (79)
Pemphigus vulgaris, incipient, HE 40x (80)
Pemphigus vulgaris, HE 100x (81)
Pemphigus vulgaris, HE 100x (82)

Network like fluorescence positivity of the stratum corneum:
Pemphigus vulgaris, net-like intraepidermal anti-IgG positivity, anti-IgG, FITC 40x (83)

Acantholysis may not be present in healing, older blisters:
Pemphigus vulgaris, old bulla, HE 20x (84)

Another case:
Pemphigus vulgaris, HE 20x (1566)

Partially regenerated bulla, pemphigus vulgaris:
Pemphigus vulgaris, HE 40x (5035)  [zoomify]

Another case:
Pemphigus vulgaris, HE 10x (1808)
Pemphigus vulgaris, HE 40x (1569)
Pemphigus vulgaris, HE 40x (1809)

Pemphigus vulgaris:
Pemphigus vulgaris, HE 60x (13446)

Pemphigus vulgaris:
Pemphigus vulgaris, HE 60x (11008)

Pemphigus vulgaris:
Pemphigus vulgaris, HE 60x (12020)

Pemphigus vulgaris:
Pemphigus vulgaris, HE 60x (12515)

Pemphigus vulgaris:
Pemphigus vulgaris, HE 40x (13230)

Fissurated granuloma caused by the pressure of glasses in a patient with pemphigus:
Granuloma fissuratum caused by glasses in patient with pemphigus, HE 20x (4254)  [zoomify]

Pemphigus vulgaris, oral mucosa:
Pemphigus vulgaris, mucous membrane, HE 40x (4295)
Pemphigus vulgaris, mucous membrane, HE 40x (4296)

Another case of pemphigus vulgaris of oral mucosa:
Pemphigus, oral cavity, HE 60x (6210)

Another case of pemphigus vulgaris of oral mucosa:
Pemphigus vulgaris, oral mucosa, HE 60x (13231)
Pemphigus vulgaris, oral mucosa, HE 60x (13232)

Pemphigus herpetiformis:
Pemphigus herpetiformis, HE 20x (4924)  [zoomify]

Pemphigus vulgaris, esophagus:
Pemphigus vulgaris, esophagus, HE 60x (73953)

5.2.7.1  Pemphigus vegetans

Clinical signs:

  • pemphigus vulgaris variant
  • usually intertriginous localization, genital area
  • vegetative oozing lesions forming bigger plaques
  • pustules solitary or in the borders of the vegetative lesions
  • sometimes in the course of pemphigus vulgaris

Pictures

Pemphigus vegetans in the navel:
Pemphigus vegetans, CLINIC (875)

Histology:

Papillomatosis, acanthosis, eosinophilic spongiosis, eosinophilic intradermal accumulations and pustules, focal acantholysis; fluorescence as in pemphigus vulgaris.

5.2.7.2  Neonatal pemphigus

Clinical signs:

  • affects newborns of mothers with pemphigus vulgaris
  • autoantibodies cross the placenta
  • the disease is transient, the condition improves with clearance of the antibodies
  • bullous lesion of variable extent

Pictures

Neonatal pemphigus (the same case of which the histology is shown in this chapter):
Neonatal pemphigus, CLINIC (6132)
Neonatal pemphigus, CLINIC (6133)
Neonatal pemphigus, CLINIC (6134)

Histology:

Acantholytic bullae similar to those in adults with corresponding immunofluorescent finding.

Pictures

Neonatal pemphigus, case with widespread acantholytic bullae on the extremities. Acantholysis affects the epidermis in several layers. Typical immunofluorescence of anti-IgG:
Neonatal pemphigus, HE 40x (72728)
Neonatal pemphigus, AE13 40x (72729)
Neonatal pemphigus, anti-IgG, FITC 20x (72725)
Neonatal pemphigus, anti-IgG, FITC 20x (72726)
Neonatal pemphigus, anti-IgG, FITC 40x (72727)

5.2.8  Pemphigus erythematosus Senear-Usher

Clinical signs:

  • seborrheic localization, face
  • crusts, scales, erosions, seldom flaccid blisters

Pictures

Pemphigus erythematosus:
Pemphigus erythematosus, CLINIC (873)

Pemphigus erythematosus:
Pemphigus erythematosus, CLINIC (874)

Histology:

Acantholysis of superficial epidermal layers, usually subcorneal (as in pemphigus foliaceus). Basal layer alteration similar to that of lupus erythematosus is sometimes present.

5.2.9  Pemphigus foliaceus

Pictures

Pemphigus foliaceus:
Pemphigus foliaceus, CLINIC (1106)

Histology:

Subcorneal acantholysis; in some cases the corneal layer is not present. Eosinophils and neutrophils are usually present.

5.2.10  Paraneoplastic pemphigus

Etiology, pathogenesis:

May accompany malignant neoplastic process (lymphoma, leukemia and others).

Clinical signs:

  • the course depends on the accompanied malignant disease, prognosis is unfavourable
  • macules, papules, vesicles; often widespread
  • lichenoid papules
  • affects mucous membranes with erosions, including bronchial mucosa
  • respiratory mucosa can be affected as well

Histology:

Superficial perivascular lymphocytic infiltrate, vacuolar degeneration of the basal layer, slight spongiosis, suprabasal acantholysis, necrotic keratinocytes, focal parakeratosis, excoriation (mucosa).

5.2.11  IgA pemphigus

Etiology:

  • unknown
  • sometimes followed or accompanied by monoclonal gammapathy, MGUS or myeloma

Clinical signs:

  • subacute disease
  • blisters, erythematous plaques
  • distribution: variable (but does not involve mucous membranes)

Histology:

Subcorneal pustules with IgA positivity of surrounding epidermis (subcorneal pustular dermatosis-like IgA pemphigus) or neutrophils within the epidermis combined with suprabasilar acantholysis (this form resembles common pemphigus).

The diagnosis requires confirmation by immunofluorescence (differential diagnosis against subcorneal pustular dermatosis or pemphigus foliaceus and pemphigus vulgaris).

Pictures

IgA pemphigus, after several years followed by myeloma (HE and anti-IgA immunofluorescence):
IgA pemphigus, HE 40x (4300)
IgA pemphigus, anti-IgA, FITC 20x (6168)

5.2.12  Hailey-Hailey (Familial benign pemphigus)

Etiology, pathogenesis:

  • autosomal dominant inheritance

Clinical signs:

  • benign course
  • vesicles on erythematous base
  • predilection sites: the groins, axillae, perianal area

Histology:

Intraepidermal suprabasal vesicles within the full width of epidermis (dilapidated brickwall appearance), dyskeratosis

5.2.13  Transient acantholytic dermatosis (of Grover)

Etiology, pathogenesis:

  • unknown
  • precipitating factors: heavy exercise, heat, fever

Clinical signs:

  • elder males are usually affected
  • location: trunk, sometimes the thighs
  • small hyperkeratotic papules, sometimes with crusts or vesicles
  • brownish-red colour
  • benign course, several weeks to several years
  • pruritus

Pictures

Grover's disease, papules of the trunk:
Grover's disease, CLINIC (747)

Histology:

Several forms: spongiotic, pemphigus foliaceus like, Darier like, Hailey-Hailey like.

5.2.14  Herpes zoster, varicella, Herpes simplex

Etiology, pathogenesis:

  • viral disease

Pictures

Herpes simplex, virus particles under electron microscope:
Herpes simplex, virus particles, electron microscope (6054)

Herpes, immunosuppressed patient:
Herpes, immunosuppression, HE 60x (6273)

5.2.14.1  Herpes simplex

Clinical signs:

  • Herpes simplex 1: predilection for the lips, face; gingivostomatitis; trunk affected rarely
  • Herpes simplex 2: genital and perigenital area
  • rapidly eroding vesicles, crusts
  • painful lesions, reaction in the regional lymphatic nodes

Pictures

Widespread labial herpes simplex:
Herpes, CLINIC (756)

Herpes simplex labialis impetiginisatus:
Herpes labialis impetiginisatus, CLINIC (2987)
Herpes labialis impetiginisatus, CLINIC (2988)
Herpes labialis impetiginisatus, CLINIC (2989)

Herpes simplex:
Herpes simplex, CLINIC (2990)

Herpes progenitalis of the penis:
Herpes, CLINIC (755)

Herpes progenitalis, penis:
Herpes genitalis, CLINIC (2985)
Herpes genitalis, CLINIC (2986)

Further examples of herpes simplex:

Further examples of herpes genitalis:

Histology:

Intraepidermal vesicles, balloon and reticular degeneration, acantholysis, multinuclear keratinocytes, eosinophilic intranuclear inclusions, leukocytoclastic vasculitis; gradually inflammation (neutrophils)

5.2.14.2  Herpes zoster, varicella

Etiology:

  • virus varicella zoster

Clinical signs:

  • common in adults
  • unilateral eruption along the course of a sensitive nerve (dermatomal): the face, trunk, extremities
  • vesicles, erythema, crusts, sometimes necroses
  • lesions may be very painful, typical is prodromal pain, postherpetic neuralgias are common
  • involvement of several segments, dissemination, necroses, meningoencephalitis may appear in immunocompromised patients

Pictures

Fresh herpes zoster of the upper extremity:
Herpes, CLINIC (757)

Herpes zoster, breast
Herpes, CLINIC (760)

Ophtalmic herpes zoster, first branch of the trigeminus:
Herpes, CLINIC (761)

Herpes zoster cervicobrachialis:
Herpes zoster cervicobrachialis, CLINIC (3451)
Herpes zoster cervicobrachialis, CLINIC (3452)
Herpes zoster cervicobrachialis, CLINIC (3453)

Herpes zoster, bullous:
Herpes zoster, bullous, CLINIC (3448)
Herpes zoster, bullous, CLINIC (3449)
Herpes zoster, bullous, CLINIC (3450)

Herpes zoster:
Herpes zoster, CLINIC (3454)
Herpes zoster, CLINIC (3455)
Herpes zoster, CLINIC (3456)
Herpes zoster, CLINIC (3457)

Another case of herpes zoster:
Herpes zoster, CLINIC (5653)
Herpes zoster, CLINIC (5654)
Herpes zoster, CLINIC (5655)

Herpes zoster:
Herpes zoster, CLINIC (5968)
Herpes zoster, CLINIC (5969)
Herpes zoster, CLINIC (5970)

Herpes zoster, neck of the young man:
Herpes zoster, neck, CLINIC (5971)

Herpes zoster, first branch of the trigeminal nerve:
Herpes zoster, 1st branch of trigeminus, CLINIC (5972)

Herpes zoster thoracoabdominalis:
Herpes zoster thoracoabdominalis, CLINIC (3458)
Herpes zoster thoracoabdominalis, CLINIC (3459)
Herpes zoster thoracoabdominalis, CLINIC (3460)

Generalisation of the herpes zoster; varicela:
Herpes, CLINIC (759)

Varicella in an adult:
Varicella, adult, CLINIC (754)

Varicella:
Varicella, CLINIC (3414)
Varicella, CLINIC (3415)

Hypopigmentations after herpes zoster:
Herpes zoster, residual hypopigmentations, CLINIC (5656)
Herpes zoster, residual hypopigmentations, CLINIC (5657)

Further examples of varicella and herpes zoster:

Histology:

Histology is the same as in herpes simplex.

5.2.15  Bullous pemphigoid

Etiology, pathogenesis:

  • autoimmune disease: circulating IgG antibodies bind to lamina lucida of basement membrane
  • antibody binding causes blister formation

Clinical signs:

  • elder patients (over 70 years)
  • the trunk, extremities, seldom the head, mucous membranes
  • tense blisters on reddened skin
  • chronic urticarial lesions
  • pruritus, healing without scars

Histology:

Subepidermal blisters, roof formed by almost normal epidermis. Vacuolar degeneration of the basal layer. Eosinophils variably admixtured in the superficial dermal infiltrate, often enter the epidermis and usually are present within the bulla (but not in cell poor variant). The base of the blister reepitelises quickly and the blister sometimes becomes intraepidermal. Immunofluorescence: linear deposits of IgG and C3 along the basement membrane.

5.2.16  Cicatricial pemphigoid

Clinical signs:

  • affects mucous membranes of the mouth, pharynx, larynx, esophagus, conjuctiva, genital; the skin involvement is less frequent
  • top of the head: cicatricial pemphigoid of Brunsting-Perry
  • tendency to scarring, strictures, the conjunctiva involvement may lead to blindness
  • blisters on the skin, erosions on the mucous membranes

Pictures

Cicatricing pemphigid, neurofibromas and seborrhoic keratoses are accidental finding:
Pemphigoid cicatrical, CLINIC (771)

Cicatricing pemphigoid, gingivitis:
Pemphigoid cicatrical, CLINIC (772)

Cicatricing pemphigoid, scarring of the buccal mucosa:
Pemphigoid cicatrical, CLINIC (773)

Histology:

Subepidermal vesicles with chronic dermal inflammatory infilrate, proliferation of capillaries (granulation tissue), later fibrosis and scarring. The infiltate contains neutrophils, later eosionphils appear as well.

Erosions are more common than vesicles on mucous membranes.

Pictures

Cicatricial pemfigoid:
Pemphigoid cicatrical, scrotum, HE 40x (2244)

Another case, conjunctiva:
Pemphigoid cicatrical, HE 40x (3581)

Cicatricing pemphigoid of Brunsting-Perry:
Scarring pemphigoid Brunsting-Perry, HE 60x (13785)

5.2.17  Pemphigoid (herpes) gestationis

Clinical signs:

  • extremely rare, 3rd trimestr of pregnancy or postpartum period
  • the periumbilical region, extremities, trunk
  • vesicles, elevated erythemas, urticarial lesions
  • pruritus

Pictures

Pemphigoid gestationis:
Herpes gestationis, CLINIC (753)

Histology:

Closely resembles bullous pemphigoid (may have in addition some necrotic keratinocytes); prominent edema of dermal papillae; immunofluorescence: linear subepidermal depositions of C3.

5.2.18  Porphyria cutanea tarda

Introduction:

A group of defects in heme production. Porphyrins and their precursors are present in tissues and are present in urine or feces. Most of porphyrias are accompanied vy skin problems, some are accompanied by liver disorders, anemia and other symptoms. Porphyria cutanea tarda is the most common group of porphyrias. Its signs are usually limited to skin.

Etiology, pathogenesis:

  • autosomal dominant
  • uroporphyrinogen decarboxylase defect
  • increased concentration of uroporphyrin in urine

Clinical signs:

  • the sun exposed skin: the face, backs of the hands, nape of the neck, ears
  • fragile skin with blisters, erosions, crusts, sclerodermoid changes
  • hyperpigmentation, hypertrichosis, actinic changes
  • healing with scars and milia
  • photosensitivity (photoactivated porphyrins in the skin generate toxic oxygen species)
  • prolonged course, patients aged 30 – 50 years, in younger women using contraceptives
  • iron, drugs, estrogens, alcohol may provoke porphyria
  • porphyrinuria with orange fluorescence in UV light
  • hepatopathy, raised serum iron level

Pictures

Porphyria cutanea tarda:
Porphyria cutanea tarda, CLINIC (883)

Porphyria cutanea tarda, forearm:
Porphyria cutanea tarda, CLINIC (885)

Further examples of porphyria cutanea tarda:

Histology:

the appearance of skin is similar in all types of porphyria: tense subepidermal hemorrhagic bulla in photosensitive areas (dorsa of hands), PAS positive subepidermal deposits, thickened, PAS positive vascular walls

5.2.18.1  Pseudoporphyria

Clinical signs:

  • photosensitivity
  • erythemas, bullous dermatitis
  • usually in patiens with hemodialysis, but may be drug related as well
  • no anomaly of porphyrin metabolism

Histology:

Subepidermal bullae similar to bullae in PCT, but usually there are no changes in blood vessels (no thickening, no deposits).

5.2.18.2  Bulla in diabetes

Clinical signs:

  • large bullae (up to several centimeters)
  • formed suddenly
  • heal spontaneously after several weeks without scarring
  • patients are diabetics

Histology:

Subepidermal bullae, large, no inflammation.

5.2.19  Dermatitis herpetiformis Duhring

Etiology, pathogenesis:

  • autoimmune disease associated with sensitivity to gluten (often associated with celiac sprue — see Malabsorption syndrome)
  • not associated with Herpesvirus infection

Clinical signs:

  • predilection are the elbows, knees, sacral region, scalp or generalized lesions
  • small papules and vesicles, excoriations
  • heavy pruritus
  • rarely blisters and inflammatory halo
  • treatment: gluten free diet, sulfapyridin, Dapsone

Pictures

Dermatitis herpetiformis, buttocks:
Dermatitis herpetiformis Duhring, CLINIC (706)

Dermatitis herpetiformis, vesicles and erosions, inflammation
Dermatitis herpetiformis Duhring, CLINIC (707)

Dermatitis herpetiformis, detail:
Dermatitis herpetiformis Duhring, CLINIC (708)

Dermatitis herpetiformis, elbow:
Dermatitis herpetiformis Duhring, CLINIC (999)

Dermatitis herpetiformis:
Dermatitis herpetiformis Duhring, CLINIC (6351)

Histology:

Neutrophils below basement membrane, papillary edema; subepidermal clefts or vesicles containing neutrophils; immunofluorescence: granular deposits of IgA at tips of dermal papillae along basement membrane.

Pictures

Dermatitis herpetiformis:
Dermatitis herpetiformis Duhring, HE 20x (111)
Dermatitis herpetiformis Duhring, HE 20x (112)
Dermatitis herpetiformis Duhring, HE 20x (113)
Dermatitis herpetiformis Duhring, HE 40x (114)
Dermatitis herpetiformis Duhring, HE 40x (115)

Another case:
Dermatitis herpetiformis Duhring, HE 20x (2386)
Dermatitis herpetiformis Duhring, HE 40x (2387)

Another case:
Dermatitis herpetiformis Duhring, HE 20x (544)
Dermatitis herpetiformis Duhring, HE 40x (545)
Dermatitis herpetiformis Duhring, HE 20x (546)
Dermatitis herpetiformis Duhring, HE 40x (547)

Another case:
Dermatitis herpetiformis Duhring, HE 100x (2660)
Dermatitis herpetiformis Duhring, HE 40x (2661)

Another case:
Dermatitis herpetiformis Duhring, HE 40x (2662)

Another case:
Dermatitis herpetiformis Duhring, HE 10x (1254)
Dermatitis herpetiformis Duhring, HE 10x (1260)
Dermatitis herpetiformis Duhring, HE 20x (1255)
Dermatitis herpetiformis Duhring, HE 40x (1256)

Dermatitis herpetiformis:
Dermatitis herpetiformis Duhring, HE 40x (4020)

Another case, fluorescence:
Dermatitis herpetiformis Duhring, antiiga, FITC, Evans 40x (536)
Dermatitis herpetiformis Duhring, antiiga, FITC, Evans 40x (537)

Another case, fluorescence:
Dermatitis herpetiformis Duhring, anti-IgA, FITC 20x (3657)
Dermatitis herpetiformis Duhring, anti-IgA, FITC 40x (3658)

Dermatitis herpetiformis with large bullae:
Dermatitis herpetiformis Duhring, HE 40x (4055)

Dermatitis herpetiformis with large bullae:
Dermatitis herpetiformis Duhring, HE 60x (12989)

Dermatitis herpetiformis, vesicular:
Dermatitis herpetiformis Duhring, HE 20x (4472)

Another case of m. Duhring, large vesicles:
Dermatitis herpetiformis Duhring, HE 20x (5311)

Bullous dermatitis herpetiformis:
Dermatitis herpetiformis Duhring, HE 60x (13876)

Dermatitis herpetiformis Duhring:
Dermatitis herpetiformis Duhring, HE 60x (12035)
Dermatitis herpetiformis Duhring, HE 20x (4232)

Dermatitis herpetiformis, patient with celiac disease (skin, duodenum):
Dermatitis herpetiformis Duhring, patient with celiac disease, frozen HE 60x (12810)
Dermatitis herpetiformis Duhring, patient with celiac disease, HE 60x (12811)
Celiac disease, duodenum (patient with DHD also), HE 60x (12806)
Celiac disease, duodenum (patient with DHD also), HE 60x (12807)

Dermatitis herpetiformis, frozen section and immunofluorescence (IgA):
Dermatitis herpetiformis Duhring, HE 60x (6423)
Dermatitis herpetiformis Duhring, anti-IgA, FITC 10x (6430)
Dermatitis herpetiformis Duhring, anti-IgA, FITC 20x (6431)
Dermatitis herpetiformis Duhring, anti-IgA, FITC 20x (6432)
Dermatitis herpetiformis Duhring, anti-IgA, FITC 20x (6433)

5.2.20  IgA linear dermatosis

Clinical signs:

  • two forms of the disease:
    • adult type
    • childhood type
  • adult form has clinical features similar to dermatitis herpetiformis, less pruritic; childhood form presents as polycyclic vesicles, distributed over abdomen, genitalia, buttock and periorally.

Histology:

Histology is the same in both forms and resembles dermatitis herpetiformis: subepidermal vesicles, edema, accumulation of neutrophils. The distribution of the neutrophils is not limited to papillae, but is present along the dermo-epidermal border. Similarly, the fluorescence shows linearly arranged subepidermal deposits.

5.2.21  Erythema multiforme

Etiology, pathogenesis:

  • idiopathic, reaction to various infections (Herpes simplex, mycoplasma), drugs (sulphonamides)
  • tissue damage due to humoral and cell mediated immunity

Clinical signs:

  • younger patients, recurrencies in the fall and spring
  • symetric eruption on the trunk, distal extremities, palms, backs of the hands, mucous membranes
  • multiform (target) lesion is often annular with erythematous ring and vesicle in the centre
  • red, cyanotic colour
  • Toxic epidermal necrolysis: generalized confluent lesions with widespread epidermal denudation
  • the most severe form is Lyel's disease, disseminated form with blisters and ulcers especially of mucous membranes is called Stevens-Johnson's syndrome

Pictures

Erythema multiforme, detail:
Erythema multiforme, CLINIC (1043)

Erythema multiforme, large bullae:
Erythema multiforme, CLINIC (1044)

Erythema multiforme:
Erythema multiforme, CLINIC (1045)

Erythema multiforme, typical iris-shape lesions:
Erythema multiforme, CLINIC (1046)

Erythema multiforme:
Erythema multiforme, CLINIC (1047)

Erythema multiforme, palms:
Erythema multiforme, Macro (3791)
Erythema multiforme, Macro (3792)
Erythema multiforme, Macro (3793)
Erythema multiforme, Macro (3794)

Erythema multiforme, conjunctiva:
Erythema multiforme, CLINIC (1050)

Further examples of erythema multiforme:

Histology:

Variable epidermal necrosis; vacuolar degeneration of the basal layer; sometimes subepidermal blisters. In some cases there is a prominent edema of the superficial dermis.

Pictures

Erythema multiforme:
Erythema multiforme, HE 100x (2545)

Another case:
Erythema multiforme, HE 20x (116)
Erythema multiforme, HE 40x (117)

Another case:
Erythema multiforme, HE 10x (118)
Erythema multiforme, HE 40x (119)

Another case:
Erythema multiforme epidermal with bulla, EEM, HE 20x (4659)  [zoomify]

Another case:
Erythema multiforme, HE 10x (552)
Erythema multiforme, HE 40x (553)

Another case:
Erythema exudativum multiforme, HE 20x (1269)

Another case:
Erythema exudativum multiforme, HE 10x (1280)
Erythema exudativum multiforme, HE 20x (1281)
Erythema exudativum multiforme, HE 40x (1282)

Drug related exanthema can be of multiform pattern:
Erythema multiforme, drug induced, HE 20x (120)

Case with prominent dermal edema (so called dermal type):
Erythema multiforme, HE 2.5x (1275)
Erythema multiforme, HE 10x (1274)
Erythema multiforme, HE 40x (1276)

Another example of multiform reaction with prominent dermal edema:
Erythema multiforme, multiform reaction, HE 20x (4863)  [zoomify]

Erythema multiforme:
Erythema multiforme, HE 40x (4190)
Erythema multiforme dermal non bull, HE 40x (4250)

Erythema multiforme:
Erythema multiforme with subepidermal bulla, HE 20x (4234)  [zoomify]

Erythema multiforme:
Erythema multiforme with subepidermal bulla, HE 20x (4239)  [zoomify]

Erythema multiforme:
Acute bullous multiform reaction, HE 40x (12871)

Erythema multiforme:
Erythema multiforme with subepidermal bulla, HE 20x (4240)  [zoomify]

Erythema multiforme, dermal, with tiny vesicle:
Erythema multiforme dermal non bull, HE 20x (4248)  [zoomify]

Erythema multiforme, early, non-bullous:
Erythema multiforme, early, HE 100x (6135)

Erythema multiforme with prominent edema of the papillary corium, without epidermal necroses:
Erythema multiforme, HE 40x (5130)

Erythema multiforme, acute, non-bullous:
Erythema multiforme, HE 60x (10164)

Erythema multiforme:
Erythema multiforme, HE 60x (13002)

Erythema multiforme:
Erythema multiforme, bullous, EEM, HE 40x (12677)

Erythema multiforme:
Erythema multiforme, HE 40x (12877)

Erythema multiforme:
Erythema multiforme, HE 40x (12878)

Erythema multiforme:
Erythema multiforme, HE 40x (12879)

Erythema multiforme, early Lyell's syndrome:
Erythema multiforme, incip. Lyell's syndrome, HE 40x (12880)

5.2.22  Toxic epidermal necrolysis of Lyell

Clinical signs:

  • the most severe drug eruption, TEN can affect up to 100% of the skin surface
  • multiform lesions, blisters, the epidermis peels off, leaving denuded areas
  • erosions and hemorrhagic crusts on the mucous membranes
  • Nikolsky's sign is positive
  • malaise, fever, loss of fluids, danger of infectious complications
  • life threatening disease
  • infectious etiology in some cases (staphyloccocus)

Histology:

Necrosis of the whole epidermis, subepidermal bulla, dermo-epidermal separation.

5.2.23  Stevens-Johnson syndrome

Clinical signs:

  • severe drug eruption, affecting mucous membranes (the lips, oral mucosa, conjunctiva, pharynx, genitals)
  • skin lesions up to 30% of the skin surface
  • infectious etiology in some cases

Pictures

Stevens-Johnson's syndrome:
Stevens-Johnson syndrome, CLINIC (1137)

Erythema multiforme, syndrome of Stevens Johnson:
Erythema multiforme, CLINIC (1048)

Erythema multiforme, syndrome of Stevens Johnson:
Erythema multiforme, CLINIC (1049)

Stevens-Johnson syndrome:
Stevens-Johnson syndrome, CLINIC (3347)
Stevens-Johnson syndrome, CLINIC (3348)
Stevens-Johnson syndrome, CLINIC (3349)
Stevens-Johnson syndrome, CLINIC (3350)
Stevens-Johnson syndrome, CLINIC (3351)

Further examples of Stevens-Johnson syndrome:

Histology:

Epidermal necrosis, full thickness; large subepidermal bullae, necrotic roof; lymphocytic infiltrate, usually slight; variable erythrocytic extravasation

5.2.24  Graft versus host reaction

Clinical signs:

  • affects patients after bone marrow transplantation, rarely after blood transfusion and very rarely in newborns
  • acute forms occur about 3 weeks after the transplantation: skin lesions, diarrhea, liver dysfunction
  • chronic forms occur 3 months after the transplantation: skin lesions (lichenoid lesions, hyperpigmentations, sclerosis, atrophy)

Histology:

Acute forms are graded: grade 1 (vacuolization along the basal layer); grade 2 (dyskeratosis, exocytosis, necrotic keratinocytes); grade 3 (subepidermal clefting); grade 4 (bullae, loss of the epidermis).

Chronic forms there is lichenoid infiltrate, loss of polarization of the epidermis, necrotic keratinocytes, pigment incontinence, atrophy and dermal sclerosis.

5.2.25  Epidermolysis bullosa

Introduction:

About 20 types of this disesase exist; having genetic genetic background (but epidermolysis bullosa acquisita is an autoimmune disorder). See the specialized literature.

5.2.25.1  Epidermolysis bullosa dystrophica

Clinical signs:

  • sites exposed to mechanical trauma
  • blisters after minor trauma or spontaneous
  • healing with atrophic scars and milia
  • mutilations of fingers, contractures, loss of nails
  • in chronically irritated sites risk of squamous cell carcinoma

Pictures

Epidermolysis bullosa dystrophica, localized form with loss of the nails:
Epidermolysis bullosa dystrophica, CLINIC (722)

Epidermolysis bullosa dystrophica, contractures and adhesions of the fingers:
Epidermolysis bullosa dystrophica, CLINIC (723)

Epidermolysis bullosa dystrophica, healing, multiple milia:
Epidermolysis bullosa dystrophica, CLINIC (724)

Epidermolysis bullosa dystrophica, scarred skin of the elbow and fresh vesicles:
Epidermolysis bullosa dystrophica, CLINIC (725)

Epidermolysis bullosa hereditaria Passini:
Epidermolysis bullosa dystrophica, Macro (3764)
Epidermolysis bullosa dystrophica, Macro (3775)
Epidermolysis bullosa dystrophica, Macro (3784)
Epidermolysis bullosa dystrophica, Macro (3785)
Epidermolysis bullosa dystrophica, Macro (3786)
Epidermolysis bullosa dystrophica, Macro (3787)
Epidermolysis bullosa dystrophica, Macro (3788)
Epidermolysis bullosa dystrophica, Macro (3789)
Epidermolysis bullosa dystrophica, Macro (3790)
Epidermolysis bullosa dystrophica, Macro (3765)
Epidermolysis bullosa dystrophica, Macro (3766)
Epidermolysis bullosa dystrophica, Macro (3767)
Epidermolysis bullosa dystrophica, Macro (3768)
Epidermolysis bullosa dystrophica, Macro (3769)
Epidermolysis bullosa dystrophica, Macro (3770)
Epidermolysis bullosa dystrophica, Macro (3771)
Epidermolysis bullosa dystrophica, Macro (3772)
Epidermolysis bullosa dystrophica, Macro (3773)
Epidermolysis bullosa dystrophica, Macro (3774)
Epidermolysis bullosa dystrophica, Macro (3776)
Epidermolysis bullosa dystrophica, Macro (3777)
Epidermolysis bullosa dystrophica, Macro (3778)
Epidermolysis bullosa dystrophica, Macro (3779)
Epidermolysis bullosa dystrophica, Macro (3780)
Epidermolysis bullosa dystrophica, Macro (3781)
Epidermolysis bullosa dystrophica, Macro (3782)
Epidermolysis bullosa dystrophica, Macro (3783)

Histology:

Epidermolysis bullosa dystrophica is characterized by widespread scarring, deformities and loss of fingers and multiple dysplastic lesions turning into squamous carcinoma.

Pictures

Epidermolysis bullosa dystrophica, subepidermal vesicles, fibrin, chronic inflammation, fibrosis of the corium:
Epidermolysis bullosa, bulla, HE 60x (6286)

Case of recessive, generalized, scarring form of EBD with loss of fingers and multiple dysplastic lesions changing into spinocellular carcinoma.
Epidermolysis bullosa dystrophica, HE 5x (121)
Epidermolysis bullosa dystrophica, HE 20x (122)
Epidermolysis bullosa dystrophica, HE 20x (123)
Epidermolysis bullosa dystrophica, HE 40x (124)

The same patient, five years later: infiltrating squamous cell carcinoma (hand), metastasis of well differentiated squamous cell carcinoma into the axillar lymphnode:
Epidermolysis bullosa dystrophica, HE 40x (3521)
Epidermolysis bullosa dystrophica changing into squamous cell carcinoma, HE 40x (3527)
Epidermolysis bullosa dystrophica, HE 40x (3520)

Another case, young female with relatively mild symptoms, lesion on the leg:
Epidermolysis bullosa dystrophica, HE 40x (2666)

The same patient after one year, hyperkeratoses and milia:
Epidermolysis bullosa dystrophica, HE 20x (4059)

The same patient one year later; squamous cell carcinoma:
Epidermolysis bullosa dystrophica, HE 40x (10157)
Epidermolysis bullosa dystrophica, HE 40x (10158)
Epidermolysis bullosa dystrophica, HE 40x (10159)
Epidermolysis bullosa dystrophica, HE 40x (10160)
Epidermolysis bullosa dystrophica, HE 40x (12992)
Epidermolysis bullosa dystrophica, HE 40x (12993)
Epidermolysis bullosa dystrophica, HE 40x (12994)
Epidermolysis bullosa dystrophica, HE 40x (12995)

The same patient after 7 years; another squamous cell carcinoma:
Epidermolysis bullosa dystrophica, HE 40x (10161)
Epidermolysis bullosa dystrophica, HE 40x (10162)
Epidermolysis bullosa dystrophica, HE 40x (10163)

37 year female, widespread squamous cell carcinoma on the background of dystrophic epidermolysis bullosa, upper extremity amputated (macroscopy, microscopy):
Epidermolysis bullosa dystrophica, Macro (6229)
Epidermolysis bullosa dystrophica, Macro (6230)
Epidermolysis bullosa dystrophica, Macro (6231)
Epidermolysis bullosa dystrophica, Macro (6232)
Epidermolysis bullosa dystrophica, Macro (6233)
Epidermolysis bullosa dystrophica, Macro (6234)
Epidermolysis bullosa dystrophica, Macro (6235)
Epidermolysis bullosa dystrophica, Macro (6236)
Epidermolysis bullosa dystrophica, Macro (6237)
Epidermolysis bullosa dystrophica, squamous cell carcinoma, HE 60x (6228)
Epidermolysis bullosa dystrophica, squamous cell carcinoma, HE 40x (6241)
Epidermolysis bullosa dystrophica, squamous cell carcinoma, HE 40x (6242)

Epidermolysis bullosa dystrophica:
Epidermolysis bullosa dystrophica, HE 60x (6411)

Pruritic epidermolysis bullosa dystrophica:
Epidermolysis bullosa dystrophica, HE 60x (6311)

5.2.25.2  Epidermolysis bullosa acquisita

Clinical signs:

  • rare disease, chiefly in the elderly
  • the entire body, backs of the hands, knees, rarely mucous membranes
  • fragile skin
  • blisters, often after trauma
  • healing with scars and milia

Pictures

Epidermolysis bullosa acquisita, healing with a scar on the knee
Epidermolysis bullosa acquisita, CLINIC (716)

Histology:

Subepidermal bullae, cell poor; IgG and C3 linear subepidermal fluorescence.

5.2.26  Artifical clefts in basaliomas

Introduction:

We mention here this fixation artefact for diferential diagnostic reasons. These clefts never contain any cells and are found near (often malignant) skin tumors, especially superficial basaliomas.

Pictures

Artifical clefts, no bazalioma is present in this section:
Subepidermal clefts near basalioma, HE 40x (3642)

The same case, another cutting plane, superficial basalioma is present:
Subepidermal clefts near basalioma, HE 40x (3643)

5.2.27  Allergic contact dermatitis, acute

Etiology, pathogenesis:

  • T-cell mediated type IV. allergic response
  • antigens from outside, e.g. some plants
  • hapten binds to a carrier on the membrane of Langerhans cells, then is presented to T lymphocytes
  • relatively dose independent
  • lesions develop in areas of contact

Clinical signs:

  • it takes 7 days to several years to become sensitized, upon reexposure eczema appears within 48 hours
  • in the beginning only the place of contact, lately generalized lesions
  • Acute allergic contact dermatitis: 1. erythema, 2. papules and/or vesicles, 3. exudation, 4. crusts, 5. scaling
  • Chronic allergic contact dermatitis: erythema, papules, lichenification, scaling
  • pruritus

Contact non allergic dermatitis is caused by various chemical irritants; dose and concentration dependent.

Pictures

Acute photoallergic contact dermatitis:
Eczem dermatitis, CLINIC (718)

Contact allergic dermatitis acute with vesicles:
Eczem dermatitis, CLINIC (1004)

Contact allergic dermatitis:
Eczem dermatitis, CLINIC (1014)

Contact allergic dermatitis:
Eczem dermatitis, CLINIC (1015)

Contact allergic dermatitis caused by eye drops:
Eczem dermatitis, CLINIC (1016)

Contact allergic dermatitis caused by eye drops:
Eczem dermatitis, CLINIC (1017)

Contact allergic dermatitis:
Eczem dermatitis, CLINIC (1018)

Contact allergic dermatitis, nickel:
Eczem dermatitis, CLINIC (1019)

Contact allergic dermatitis around the leg ulcer with dissemination:
Eczem dermatitis, CLINIC (1024)

Hyperkeratotic eczema of the foot:
Eczem dermatitis, CLINIC (1026)

Contact irritative dermatitis caused by antiseptic agent, leg:
Contact allergic dermatitis acute, CLINIC (3034)
Contact allergic dermatitis acute, CLINIC (3035)
Contact allergic dermatitis acute, CLINIC (3039)

Contact dermatitis, watch:
Contact allergic dermatitis acute, CLINIC (3023)

Contact dermatitis caused by plaster, axilla:
Contact allergic dermatitis acute, CLINIC (3024)

Contact dermatitis caused by metal of the belt:
Contact allergic dermatitis acute, CLINIC (3025)
Contact allergic dermatitis acute, CLINIC (3026)
Contact allergic dermatitis acute, CLINIC (3027)

Contact dermatitis (chrome, cobalt):
Contact allergic dermatitis acute, CLINIC (3028)
Contact allergic dermatitis acute, CLINIC (3029)
Contact allergic dermatitis acute, CLINIC (3030)

Contact dermatitis, hands:
Contact allergic dermatitis acute, CLINIC (3031)
Contact allergic dermatitis acute, CLINIC (3032)
Contact allergic dermatitis acute, CLINIC (3033)

Contact dermatitis caused by plaster, leg:
Contact allergic dermatitis acute, CLINIC (3040)
Contact allergic dermatitis acute, CLINIC (3041)

Contact dermatitis caused by plaster, patch test:
Contact allergic dermatitis acute, CLINIC (3042)
Contact allergic dermatitis acute, CLINIC (3043)

Contact dermatitis, leg:
Contact allergic dermatitis acute, CLINIC (3044)
Contact allergic dermatitis acute, CLINIC (3045)

Contact dermatitis, abdomen:
Chronic eczem dermatitis allergic contact, CLINIC (5560)
Chronic eczem dermatitis allergic contact, CLINIC (5561)

Contact dermatitis, metallic string:
Contact eczema in place of metal string, CLINIC (5974)

Acute contact dermatitis:
Acute contact dermatitis, CLINIC (6348)

Further examples of allergic contact dermatitis:

Histology:

Spongiotic intraepidermal vesicles, spongiosis; in urticarial lesions dermal edema and perivascular mixed infiltrate.

Chronic lesions are characterized by plaques of acanthosis, hyperkeratosis, increased granular layer and fibrosis of the upper corium.

Etiology can be often verified by patch tests.

5.2.28  Dyshidrotic dermatitis

Introduction:

Dyshidrotic eczema belongs to the group of superficial dermatitides with spongiosis, affects palms and soles.

Clinical signs:

  • patients of all ages
  • affects lateral aspects of the fingers, palms and soles
  • exacerbations common
  • severe pruritus
  • chronic lesions are impetiginized, with fissures and chronic infections

Histology:

Spongiotic vesicle, lymphocytic exocytosis, prominent acanthosis in chronic cases, slight superficial perivascular infiltrate.

5.2.29  Eczema atopicum (dermatitis atopica)

Clinical signs:

  • affected areas:
    • affected areas differ with age: toddlers — the face, scalp;
    • older children and adolescents — the elbow and knee flexures, reddening of the upper half of the body and face
    • adults — localized and generalized lesions without predilections
  • atopic habitus: cheilitis sicca, wrinkles under the eylids (Dennie-Morgan's lines), loss of lateral parts of the eyebrows (Hertoghe's sign)
  • eczematous, pruriginous, dyshidrotic lesions
  • asteatosis, hyperlinearity of hands
  • severe pruritus, scratches
  • white dermographism
  • nail changes, pitting
  • lichenification
  • allergic rhinitis, conjunctivitis, asthma
  • secondary skin infections
  • raised IgE

Pictures

Atopic eczema of the thumb and nail:
Eczem dermatitis, CLINIC (717)

Crusta lactea: combination of seborrhoeic and atopic eczema:
Eczem dermatitis, CLINIC (1005)

Eczema atopicum: erythroderma
Eczem dermatitis, CLINIC (1006)

Eczema atopicum:
Eczem dermatitis, CLINIC (1007)

Eczema atopicum, impetiginized:
Eczem dermatitis, CLINIC (1008)

Eczema atopicum, prurigo:
Eczem dermatitis, CLINIC (1009)

Eczema atopicum:
Eczem dermatitis, CLINIC (1010)

Eczema atopicum:
Eczem dermatitis, CLINIC (1011)

Eczema atopicum, excoriation, lichenification:
Eczem dermatitis, CLINIC (1012)

Eczema atopicum:
Eczem dermatitis, CLINIC (1013)

Neurodermitis, clinical picture:
Prurigo, CLINIC (1098)

Atopic dermatitis:
Chronic eczem dermatitis atopic, CLINIC (2815)
Chronic eczem dermatitis atopic, CLINIC (2816)
Chronic eczem dermatitis atopic, CLINIC (2817)

Atopic dermatitis, Dennie Morgan folds:
Chronic eczem dermatitis lichenified (atopic), Macro (3742)

Atopic dermatitis, child:
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5536)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5537)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5538)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5539)

Atopic dermatitis:
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5540)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5541)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5542)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5543)
Chronic eczem dermatitis lichenified (atopic), child, CLINIC (5544)

Further examples of atopic dermatitis:

Histology:

Acanthosis, sometimes slight spongiosis, hyperkeratosis, hypergranulosis. Slight lymphocytic infiltration, sometimes with admixture of eosinophils. Fibrosis of the papillary dermis (caused by scratching). The number of mastocytes is sometimes increased.

Chronic atopic eczema corresponds histologically to the lichen simplex chronicus (neurodermitis): chronic scratching causes hyperkeratosis, fibrosis of the papillary dermis and acanthosis and primary cause often cannot be determined.

5.2.30  Subacute and chronic (eczem) dermatitis

Introduction:

Note: to the broad group of superficial dermatides with spongiosis belong nummular dermatitis, fotoallergic dermatitis, stasis dermatitis and other.

Pictures

Dermatitis varicosa:
Dermatitis varicosa, CLINIC (5967)

Histology:

Acute eczematous dermatitis is characterized by spongiosis and spongiotic intraepidermal vesicles. In chronic forms acanthosis dominates. Because these lesions are intensely pruritic, changes caused by (often longlasting] scratching contribute to the picture: excoriations, lichenification, acanthosis, fibrosis of the upper dermis.

Pictures

Subacute eczema dermatitis:
Eczema, subacute, HE 5x (125)

Another case:
Eczem dermatitis, HE 40x (12666)

Another case:
Eczem dermatitis, HE 40x (12667)

Another case:
Eczem dermatitis, HE 40x (12668)

Another case:
Eczem dermatitis, HE 40x (12669)

Another case:
Eczem dermatitis, HE 40x (12670)

Another case:
Eczem dermatitis, HE 40x (12671)

Another case:
Eczema dermatitis, subacute, HE 60x (12366)

Another case:
Subacute eczem dermatitis, HE 40x (13276)

Another case:
Eczema dermatitis, subacute, HE 40x (12367)

Nummular dermatitis:
Nummular eczema, HE 60x (12176)

Nummular dermatitis:
Nummular eczema with vesicles, HE 40x (12927)

Chronic dermatitis:
Chronic eczem dermatitis nonspecific, HE 40x (4765)  [zoomify]

Chronic dermatitis:
Chronic eczem dermatitis, HE 60x (14046)
Chronic eczem dermatitis, HE 60x (14047)

Chronic eczema dermatitis:
Eczema, chronic, HE 20x (126)

Stasis dermatitis is a variant of spongiotic dermatitis of lower extremities (eczema crurum), together with signs of blood stasis (hemosiderin deposits) and blood vessel changes.
Stasis dermatitis, HE 20x (133)
Stasis dermatitis, HE 40x (134)

Stasis dermatitis
Stasis dermatitis, HE 40x (12943)

Another case, in combination with superficial basalioma (shin):
Stasis dermatitis with superficial basalioma, HE 5x (131)
Stasis dermatitis, HE 10x (128)
Stasis dermatitis, HE 20x (127)
Stasis dermatitis with superficial basalioma, Prussian blue 5x (132)
Stasis dermatitis, Prussian blue 10x (129)
Stasis dermatitis, Prussian blue 20x (130)

Impetiginized eczema with neutrophils:
Eczem dermatitis, impetiginized, HE 20x (135)

Another case:
Eczem dermatitis, impetiginized, HE 10x (136)
Eczem dermatitis, impetiginized, HE 20x (137)

Eczema crurum:
Eczema crurum, HE 10x (548)

In remission the inflammation is minimal; siderophages are present:
Stasis dermatitis, HE 40x (2372)
Stasis dermatitis, Prussian blue 40x (2371)

5.2.31  Microbial eczema

Clinical signs:

  • allergic dermatitis caused by microbial allergens ( e.g. staphylococcus)
  • often nummular patches, oozing, crusts
  • usually affects intertriginous areas and skin around secreting wounds (crural ulcerations, otitis, retroauricular lesions)

Pictures

Microbial eczema and lymphedema:
Eczem dermatitis, CLINIC (1020)

Eczema microbiale, nummular lesions:
Eczem dermatitis, CLINIC (1021)

Eczema microbiale, face, generalisation:
Eczem dermatitis, CLINIC (1022)

Eczema microbiale:
Eczem dermatitis, CLINIC (1023)

Nummular eczema:
Nummular eczema, CLINIC (2890)

Another case of nummular eczema:
Nummular eczema with vesicles, Macro (3763)

Further examples of nummular dermatitis:

Histology:

Histology corresponds to eczematous dermatitis, inflammation is usually prominent. Bacteria are found rarely.

5.2.32  Granuloma gluteale infantum

Clinical signs:

  • age: small babies (or adults) in diapers
  • irritant dermatitis, sometimes caused by Candida.

Pictures

Diaper dermatitis:
Diaper dermatitis, CLINIC (3130)
Diaper dermatitis, CLINIC (3131)
Diaper dermatitis, CLINIC (3132)

Further examples of the diaper dermatitis:

5.2.33  Toxic contact (irritative) dermatitis, acute

Clinical signs:

  • skin changes are limited to the area of contact
  • skin changes depend on the concentration of the irritant, duration of contact and individual factors
  • Acute irritant contact dermatitis:
    1. erythema
    2. vesicles
    3. madidation
    4. crusts
    5. scaling

Pictures

Dermatitis contacta irritativa, madidation, caused by hair decolourant:
Dermatitis toxica, CLINIC (713)

Further examples of toxic contact dermatitis:

Histology:

In toxic reaction prevails the necrosis of the epidermis, which in typical cases affects upper epidermal layers (and sometimes follicular epithelium as well).

Pictures

Toxic contact dermatitis:
Toxic contact dermatitis, HE 20x (1736)

Toxic dermatitis with superficial necrosis of the epidermis:
Irritant contact dermatitis, HE 40x (4838)  [zoomify]

5.2.34  Toxic contact (irritative) dermatitis, chronic

Clinical signs:

  • etiology as in the acute form
  • erythema, papules, lichenification, scaling

Pictures

Dermatitis irritativa chronica, hands:
Dermatitis irritativa chronica, hands, CLINIC (1000)

Histology:

Chronic contact dermatitis is characterised by thickenning of the skin, formation of squames and rhagades. Lasts for months and years with alternating exacerbations and remissions.

5.2.35  Seborrhoic dermatitis

Clinical signs:

  • acute or chronic dermatitis
  • location: scalp, central areas of the face, breasts, periumbilical area, eylids, retroauricular region (seborrhoic areas)
  • age: appears usually after puberty
  • severe forms affect patients with AIDS
  • serpiginous, annular, yellow, pink patches covered with yellow squames
  • dandruff is considered a mild form of seborrheic dermatitis of the scalp

Histology:

Variable acanthosis, spongiosis, exocytosis, parakeratosis. Edema of papillary dermis, superficial perivascular infiltrate (lymphocytes, histiocytes, some neutrophils). Parakeratosis is centered on follicular ostia.

Chronic forms show acanthosis with only minimal spongiosis and resemble psoriasis.

Pictures

Seborrhoic dermatitis:
Seborrheic dermatitis, HE 40x (4050)

Another case:
Seborrheic dermatitis, HE 40x (4074)

Chronic seborrhoic dermatitis:
Seborrhoic dermatitis, chronic, HE 20x (5287)

5.2.35.1  Pityriasis amiantacea

Clinical signs:

  • sticky, asbestos-like scales
  • location: scalp
  • may be complicated by alopecia
  • often accompanied by seborrhoic dermatitis

Histology:

Spongiosis of the epidermis and follicular epithelium, parakeratosis around the hair shafts.


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