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Granulomatous processes of deeper corium

5  Non-tumorous skin diseases

5.7  Granulomatous processes of deeper corium

Introduction:

Granulomatous inflammations are chronic processes, histologically characterized by aggregations of (often modified) histiocytes. Classification varies, e. g.:

Pyogenic granuloma is benign tumor of blood vessels with variable admixture of inflammatory infiltrate, which is usually not granulomatous (no modified histiocytes are present). This lesion is described in the chapter describing tumours of blood vessels.

5.7.1  Granuloma annulare

Etiology, pathogenesis:

  • unknown

Clinical signs:

  • location: dorsa of hands and feets, skin above the joints, trunk
  • red papules spread into roundish lesions with elevated borders
  • roundish lesions with central depression
  • asymptomatic
  • often involutes following minor trauma
  • chronic, usually self-limiting disease
  • often in children, adults also affected

Histology:

Foci of necrobiosis within the dermis, surrounded by palisading histiocytes.

Deep forms are within the reticular dermis and can reach into the subcutaneous tissue.

Subcutaneous granuloma annulare is situated within the subcutaenous tissue.

5.7.1.2  Granuloma multiforme

Clinical signs:

  • chronic annular eruption
  • location: upper body (arms, chest, back, neck, and head)
  • elderly black people in central Africa

Etiology:

  • unknown

Histology:

Similar to granuloma annulare, but often small tuberculoid granulomas are present.

Pictures

Granuloma multiforme:
Granuloma multiforme, HE 20x (4369)  [zoomify]

5.7.2  Annular elastolytic granuloma

Introduction:

Considered to be a varinat of granuloma annulare. epithelioid granulomas, multinuclear cells, desintegration and phagocytosis of elastic fibres; there are no elastic fibres in affected areas.

5.7.3  Necrobiosis lipoidica

Etiology, pathogenesis:

  • unknown
  • most cases associated with diabetes

Clinical signs:

  • often affected women with diabetes
  • ronud or oval multicolored (red, yellow) plaques on the shins, dorsa of the hands, sometimes forearms
  • chronic disease

Histology:

Large areas of necrobiosis within the dermis, surrounded by palisading histiocytes, usually larger, deeper than in granuloma annulare; often multilayered.

Special staining reveal presence of fat droplets within the necrobiotic areas.

Another signs are epidermal atrophy, loss of elastic fibres within necrobiotic areas and dilatation of superficial blood vessels.

Pictures

Necrobiosis lipoidica:
Necrobiosis lipoidica, HE 10x (328)
Necrobiosis lipoidica, HE 20x (331)
Necrobiosis lipoidica, HE 40x (334)
Necrobiosis lipoidica, HE 40x (333)

Special stain for fat (oil red):
Necrobiosis lipoidica, oil red 10x (329)
Necrobiosis lipoidica, oil red 20x (332)
Necrobiosis lipoidica, HE 40x (335)

Defect of elastic fibres in the necrobiotic area:
Necrobiosis lipoidica, elastic fibres 5x (336)
Necrobiosis lipoidica, elastic fibres 10x (327)
Necrobiosis lipoidica, elastic fibres 20x (330)

Another case:
Necrobiosis lipoidica, HE 10x (337)

Another case:
Necrobiosis lipoidica, HE 5x (326)
Necrobiosis lipoidica, elastic fibres 5x (325)

Another case:
Necrobiosis lipoidica, HE 5x (578)
Necrobiosis lipoidica, HE 20x (577)
Necrobiosis lipoidica, HE 40x (579)

Another case:
Necrobiosis lipoidica granulomatous, HE 5x (580)
Necrobiosis lipoidica granulomatous, HE 20x (581)
Necrobiosis lipoidica, oil red 10x (582)
Necrobiosis lipoidica, oil red 40x (583)

Another case:
Necrobiosis lipoidica, HE 60x (11003)
Necrobiosis lipoidica, HE 20x (4868)  [zoomify]

Another case:
Necrobiosis lipoidica, HE 20x (4869)  [zoomify]

Another case:
Necrobiosis lipoidica, HE 60x (12097)
Necrobiosis lipoidica, HE 20x (4870)  [zoomify]

Another case:
Necrobiosis lipoidica, HE 40x (12831)

Another case:
Necrobiosis lipoidica, HE 40x (12832)

Another case:
Necrobiosis lipoidica, HE 40x (12833)

Another case:
Necrobiosis lipoidica, HE 60x (10792)

Another case:
Necrobiosis lipoidica, HE 60x (13844)
Necrobiosis lipoidica, elastic fibres 60x (13843)

Necrobiosis lipoidica, granulomatous:
Necrobiosis lipoidica granulomatous, HE 60x (14061)
Necrobiosis lipoidica granulomatous, x 60x (14060)

Necrobiosis lipoidica in postphlebectomic scar:
Necrobiosis lipoidica in the scar post phlebectomy, HE 20x (4351)
Necrobiosis lipoidica in the scar post phlebectomy, HE 20x (4349)

5.7.3.1  Granulomatosis disciformis Miescher

Classification:

Now considered to be a variant of necrobiosis lipoidica.

Clinical signs:

  • disc-shaped plaques
  • locations: pretibial regions
  • no asscociation with diabetes

Histology:

Large granulomas with macrophages (often large, multinuclear) and lymphocytes. Necrobiosis is usually minimal.

5.7.4  Rheumatoid nodule

Clinical signs:

  • affect patients with rheumatid arthritis, typically od extensor surfaces
  • nodules several milimeters to several centimeters in size
  • patients have high levels of rheumatoid factor
  • pseudorheumatoid nodule is subcutaneous nodule, histologically similar, but in patients without rheumatoid arthritis, often in children.

Histology:

Irregular, large areas of fibrinoid degeneration of collagen within dermis, surrounded by pallisading histiocytes.

Note: nodules in rheumatic fever are smaller, collagen degeneration is incomplete, neutrophils are present.

5.7.5  Chondrodermatitis nodularis chronica helicis

Etiology, pathogenesis:

  • unknown (vascular deficiency, cold, chronic trauma, process similar to solar elastosis)

Clinical signs:

  • one or sometimes several painful nodules on helix
  • size: several milimeters
  • no tendency to healing

Histology:

Epidermal ulceration above a focus of cartilage degeneration, granulation tissue.

Pictures

Chondrodermatitis nodularis chronica helicis and detail of degenerated cartilage and normal cartilage:
Chondrodermatitis nodularis helicis, HE 5x (282)
Chondrodermatitis nodularis helicis, HE 10x (279)
Chondrodermatitis nodularis helicis, HE 20x (281)
Chondrodermatitis nodularis helicis, HE 20x (280)

Another case of chondrodermatitis helicis:
Chondrodermatitis nodularis helicis, HE 40x (3472)

Another case of chondrodermatitis helicis:
Chondrodermatitis nodularis helicis, HE 40x (12685)

5.7.5.1  Polychondritis recurrens

Clinical signs:

  1. rare disease of autoimmune origin
  2. recurrent inflammation of the cartilage
  3. affects the cartilage of the ears, nose, larynx and trachea
  4. accompanied by arthritis, eye inflammation and other problems
  5. skin is affected in about one third of patients (vasculitis, panniculitis, pigmentation changes and other)
  6. one half of patients survives 10 years

Histology:

Bilateral inlammation, fibrosis, destruction of the cartilage.

Pictures

Polychondritis recurrens:
Polychondritis, HE 20x (4928)  [zoomify]

Another case:
Polychondritis, HE 20x (4949)  [zoomify]

5.7.6  Sarcoidosis

Etiology, pathogenesis:

  • unknown

Clinical signs:

  • skin is affected in about 40% patients with chronic sarcoidosis
  • in about 25%of cases is sarcoidosis limited to skin
  • dark red plaques and papules are the most common variant
  • lupus pernio: infiltration of the nose
  • asymptomatic (no pain, no ulcerations)
  • erythema nodosum in acute mediastinal form: syndrome of Löfgren
  • extracutaneous involvment: mediastinal lymphnodes, bronchi, lungs, liver, bones, eyes etc.
  • (usually) chronic disease

Pictures

Sarcoidosis, lesions of the arm:
Sarcoidosis, CLINIC (911)

Sarcoidosis, larger nodules:
Sarcoidosis, CLINIC (912)

Sarcoidosis, lupus pernio:
Sarcoidosis, CLINIC (913)

Sarcoidosis, lesion of the face:
Sarcoidosis, CLINIC (915)

Further examples of sarcoidosis:

Histology:

Dermal epithelioid granulomas, irregular, often mild lymphocytic infiltrate.

5.7.7  Erythema induratum Bazin

Etiology, pathogenesis:

  • unknown

Clinical signs:

  • chronic disease
  • intradermal nodules
  • affects lower extremities
  • vasculitis, considered to be a deep tuberculid (deep inflammatory necrotizing nodules of the calves)

Pictures

Erythema induratum of Bazin:
Erythema induratum Bazin, CLINIC (1089)

Histology:

Lobular panniculitis, granulomas with giant cells of Langhan's type and epithelioid cells, granulomatous vasculitis (arteries and veins of middle diameter). Vascular occlusion can lead to ulcerations, necrosis and lipophagic granulomas.

5.7.8  Foreign body granulomas

Clinical signs:

  • location: areas of trauma and surgeries (face, wrists, knees etc.)
  • small, firm nodules, often surrounded by inflammation
  • color red, red brown of color of normal skin
  • ulcerations and fistulas are common

Pictures

Foreign body granulomas, posttraumatic, face:
Foreign body granuloma, CLINIC (741)

Granuloma around the suture material:
Foreign body granuloma, CLINIC (742)

Histology:

Foreign bodies (suture material, keratin, hair, traumatic foreign material) lead to chronic inflammation with giant multinuclear histiocytes. Granulocytes are often present. Some of foreign bodies (silica, wood, suture material, glass) are birefringent and easily identifiable using polarized light.

Large lesions in surgical wounds (often with remnants of suture material) are called Schloffer's tumor.

Pictures

Granuloma and inflammation around an epidermal cyst:
Epidermal cyst, inflammation, HE 20x (211)

Detail of the same case:
Epidermal cyst, inflammation, HE 40x (212)

Another case of suture granuloma (ear, after basalioma resection):
Foreign body granuloma, HE 40x (3593)

Another example: deep foreing body demarcated by a capsule of connective tissue:
Foreign body, HE 2x (199)
Foreign body, HE 5x (200)

Capsule, detail:
Foreign body, capsule, HE 20x (198)

Chronic purulent inflammation around suture material:
Suture material, purulent inflammation, HE 20x (278)

Granuloma around suture material:
Foreign body granuloma (fibre), HE 40x (10936)

Granuloma around suture material:
Granuloma near suture, HE 60x (14042)

Granuloma after surgery:
Granuloma after surgery, HE 40x (72473)

Foreign body granuloma:
Foreign body granuloma, HE 20x (1303)

Scar, foreign body:
Scar, foreign body, HE 40x (13007)

Foreign body granuloma, ear, suture material:
Foreign body granuloma (ear; suture material), HE 20x (5331)

Wooden splinter with mostly purulent inflammatory reaction:
Splinter, inflammation, HE 40x (5949)

Splinter, inflammatory reaction:
Splinter, HE 20x (13921)

Granuloma around some plant material:
Foreign body granuloma, HE 20x (2126)

Foreign body granuloma around keratin remnants in squamous cell carcinoma:
Granulomatous reaction on keratin in squamous cell carcinoma, HE 20x (4325)  [zoomify]

Encapsulated and calcified foreign body, cholesterol crystals:
Foreign body granuloma, calcification, HE 20x (5147)

Foreign body of unknown origin:
Foreign body, PAS 20x (13945)

Foreign body:
Foreign body granuloma, HE 60x (13766)

Foreign body, fibrotic capsule, hemosiderin deposits (v.s. it was an iron splinter):
Foreign body, metal splinter, hemosiderosis, HE 20x (13767)
Foreign body, metal splinter, hemosiderosis, HE 20x (13768)

Foreign body, iron splinter, hemosiderin deposits:
Foreign body, siderosis, HE 20x (14002)
Foreign body, siderosis, HE 20x (14003)
Foreign body, siderosis, HE 20x (14004)

Granulomatous reaction after herpes zoster:
Herpes zoster, granulomatous reaction, HE 20x (4326)

Sinus pilonidalis: Sinus tract containing hairs, located in the sacral area, often inflammed: (more details here)
Sinus pilonidalis, inflammed, HE 20x (389)

Schloffer's tumor within the scar after Caesarean section with endometriosis:
Endometriosis and Schloffer't tumor, abdominal wall, HE 40x (10725)
Endometriosis and Schloffer't tumor, abdominal wall, CD10 40x (10723)
Endometriosis and Schloffer't tumor, abdominal wall, Prussian blue 40x (10724)

Supraumbilical suture granuloma with endometriosis, woman 30y:
Endometriosis, suture granuloma, scar above the umbilicus, HE 20x (13710)

Silica granuloma is the chronic reaction to silica crystals, which were traumatically introduced into the dermis. Epithelioid granuloma may resemble sarcoidosis, however, polarized light will show birefringent foreign material.

Histology:

Epithelioid granulomas, birefringent material, artefacts (knife dented by silica crystals)

Pictures

Silica granuloma:
Silica granuloma, HE 5x (387)
Silica granuloma, HE, polarizace 5x (388)

Higher magnification, normal transmitted light and polarization:
Silica granuloma, HE 20x (383)
Silica granuloma, HE, polarizace 20x (384)

Detail (normal transmitted light and polarization):
Silica granuloma, HE 40x (385)
Silica granuloma, HE, polarizace 40x (386)

Zyderm reaction (bovine collagen):
Zyderm, dermal, HE 20x (5433)

Foreign body granuloma (cytoplast):
Granuloma after cytoplast, HE 20x (4324)  [zoomify]

5.7.8.1  Silicone granuloma

Etiology:

  • silicone (from an implantate) is released into the soft tissues

Histology:

Optically empty cavities of variable size and shape, surrounded by inflammation with histiocytic participation.

Pictures

Silicone granuloma:
Silicone granuloma, HE 20x (5999)

Silicone granuloma, female, axillary region:
Silicone granuloma, fat, axilla, female, HE 60x (13683)

Silicone granuloma, preputium:
Silicone granuloma, foreskin, HE 40x (13254)

5.7.9  Cat scratch disease

Etiology:

G negative bacilli can be found in most cases (Bartonella henselae, Afipia fellis).

Clinical signs:

  • location: site of the scratch
  • papule, nodule, sometimes crusted
  • accompanied by lymphadenitis and sometimes by generalized symptoms
  • can run under the picture of erythema nodosum, erythema marginatum, purpura, Sweet-like syndrome

Histology:

Large necrotizing granuloma with neutrophils, tissue debris and a mantle of histiocytes.

5.7.10  Cheilitis granulomatosa Miescher Melkerson Rosenthal

Clinical signs:

  • location: lip
    • swelling of the lip
    • lingua scrotalis
    • facial nerve paralysis

Histology:

Small epithelioid granulomas in the mid and deep dermis, lymphoplasmocytic infiltrate, edema.

5.7.11  Intersticial granulomatous dermatitis

Clinical signs:

  • papules, plaques, cords
  • some cases associated with rheumatoid arthritis
  • other etiology possible (drug reaction, infectious diseases)

Histology:

Interstitial infiltrate with lymphocytes and histiocytes, sometimes with a hint of palisading. Neutrophils are usually present (esp. in rheumatoid arthritis cases). Eosinophils can be seen rather in drug reaction cases.

5.7.12  Crohn's disease, skin changes

Clinical signs:

Crohn's disease has skin changes in abour 80% of cases: fistulae, abscesses, skin tags. Mucous membranes are often affected (oral mucosa). Other lesions:

  • cheilitis granulomatosa
  • erythema elevatum diutinum
  • erythema nodosum
  • acne (fulminans)
  • pyoderma faciei
  • acquired epidermolysis bullosa
  • neutrophilic lobular panniculitis
  • granulomattous dermatitis
  • palisading granulomas (necrobiosis lipoidica and granuloma annulare type)
  • and others

Sometimes granulomatous dermatitis with non-caseating granulomas occurs.

Histology:

Non-caseating granulomas of variable size, mixed inflammatory infiltrate. Changes are usually unspecific, relation to Crohn's disease is necessary for diagnosis.


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