Panniculitis is the inflammation of subcutaneous fat. It poses a diagnostic challenge, both for the clinician as well as the histopathologist owing to its diverse etiologies, overlapping morphological features, and dynamic nature of the lesions. The standard protocol for histopathologic diagnosis is to examine deep skin biopsies after staining with hematoxylin and eosin. Sometimes, however, special stains are also needed to rule out varied etiologies. A thorough histopathologic examination in conjunction with appropriate clinical details is the key to identify different subtypes of panniculitis. In this review, we discuss the classification of panniculitis with salient histopathologic features of the subtypes in each category. We also present a diagnostic algorithm for arriving at a definitive histopathologic diagnosis of different panniculitis subtypes.

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Nonmelanoma skin cancers (NMSCs), which mainly include basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are infrequent in the Indian subcontinent, compared with white skinned individuals. Although BCC in most cases arises de novo on sun-exposed sites, it may rarely develop in photoprotected areas and in the setting of certain risk factors. In contrast to BCC, SCC in dark skin has a tendency to develop in nonhealing ulcers, chronic scars, and inflammatory and infectious dermatoses. Histopathology is the gold standard in confirming the diagnosis and determining the prognosis. As the existing literature on NMSCs in India is limited mostly to case reports and few reviews only, this article is an attempt to create an awareness regarding the premalignant potential of an expanding list of cutaneous lesions, which would help in timely diagnosis and prompt treatment of NMSCs.

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Introduction: Skin tumors are classified as melanocytic and non-melanocytic based on presence of melanocytes and melanin pigment in the tumor. Dermoscopy, being a non-invasive technique, is a proven method in recognizing the non-melanocytic and pink tumors by showing specific patterns. In Indian subcontinent, reports on dermoscopy of non-melanocytic and pink tumors are confined only to case reports. Authors studied dermoscopic features of non-melanocytic and pink skin tumors in dermoscopy. Materials and Methods: Study was carried in a tertiary hospital attached to S.Nijalingappa Medical College, Bagalkot, between January and December 2016. It was a descriptive study. Patients with signs of non-melanocytic and pink tumors were selected. Demographic data, such as age, gender, and clinical variables in terms of site of tumor and duration were documented. Manual DermLite 3 and videodermoscopy were employed. Both polarized and non-polarized versions were used for examination. Results: Totally 128 patients were present with 75 females and 61 males. Study included pyogenic granuloma (39), squamous cell carcinoma (4), basal cell carcinoma (30), keratoacanthoma (3), seborrheic keratosis (15), trichoepithelioma (2), syringoma (5), apocrine hydrocystoma (2), fibrokeratoma (5), dermatofibroma (6), epidermal cyst (7), sebaceous hyperplasia (2), Bowen's disease (1), steatocystoma multiplex (1), Lymphangioma circumscriptum (3) and milia (3). Numbers in parenthesis indicate number of patients. Conclusion: Dermoscopy of non-melanocytic and pink tumors demonstrates characteristic patterns which vary from white, yellow, brown to blue and red color depending on presence of keratin and hemoglobin. Patterns differ based on the type skin color. Recognition of distinctive vascular and keratin related pattern is of great help in the diagnosis of skin tumors. To the best our knowledge, this is first report of dermoscopy of non-melanocytic and pink tumors on a larger scale from Indian subcontinent.

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Introduction: Lichen sclerosus (LS) et atrophicus is an inflammatory disorder of unknown etiology affecting skin and mucosa, especially the genital area. Clinically, its main features are whitish papules which converge to form plaques and atrophic patches. Histopathology of LS et atrophicus is characterized by the constellation of an atrophic epidermis with loss of rete ridges, some lymphocytes in the basal layer, a subepidermal band of sclerosis, and a lichenoid infiltrate of lymphocytes beneath that band is diagnostic of LS. Materials and Methods: Skin specimens from 25 patients with LS were collected from the hospital records for 5 years. The diagnosis of all cases was made on the basis of clinical morphology and histopathologic features. Sections were stained with hematoxylin and eosin, periodic acid-Schiff, and Elastic-Van Gieson. Criteria evaluated included hyperkeratosis, epidermal atrophy, follicular plugging, basal cell vacuolation, vascular ectasia, hyalinosis, inflammatory infiltrate, dermal edema, and deep dermal fibrosis. Results and Conclusion: Of a total of 25 patients, 18 patients had extragenital (EG) LS and 7 had genital manifestations. Mean age of patients with EG was 28 years, and genital was 38 years. To summarize, the main histopathological findings seen in LS are essentially the same as reported in literature, namely, hyperkeratosis, epidermal atrophy, follicular plugging, basal cell vacuolation, vascular ectasia, hyalinosis, inflammatory infiltrate, dermal edema, and deep dermal fibrosis. Moreover, some interesting differences between the EG and genital forms of LS were seen. However, since the figures are too small to comment on, studies comprising larger series of patients are required to bring out a statistical significance.

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Skin metastases are relatively rare but are of important clinical significance because they usually indicate a worse prognosis. The most common sources are lung and colorectal cancers in males and breast and colorectal in females. In this report, we presented a chest wall skin metastasis of gastric origin in a 50-year-old male. Tumor metastasis to unusual locations such as chest wall skin and from unusual origins such as stomach is of great clinical importance.

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Exogenous pigmentation due to arthropods or coloring agents/dyes may be mistaken for melanocytic lesions. Dermoscopy is a useful tool for the evaluation of pigmented lesions. We discuss the dermoscopic and histopathological features in a case of pigmented spots mimicking lentigines caused by burrowing bug and review the pertinent literature on exogenous pigmentation.

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Introduction: Periorbital hyperpigmentation (POH) is a routinely encountered condition in dermatology practice. Studying the clinical features and its correlation with dermoscopy will help in better understanding of patterns of periorbital pigmentation and its evolution. Methodology: Fifty patients attending dermatology outpatient department with POH as presenting complaint were included in the study. A detailed history and proper clinical examination were done. Laboratory tests were advised whenever necessary. Dermoscopy of pigmentation over both lower eyelids was done with ×200 magnification of Oitez e-scope (DP-M17 filter e-scope pro [optical ×200]). Clinical photographs of all patients were taken. Results: POH was multifactorial. The most common clinical type is postinflammatory type. Other associated clinical findings included pigmentation at other anatomical sites (20%), visible bulging (10%), tear trough (8%), and visible superficial vessels in the periorbital region (6%). On dermoscopy, majority of the patients had multicomponent pattern (64%) which included more than one pattern of pigmentation, vasculature, and skin changes. The different patterns of pigmentation were blotches (30%), exaggerated pigment network (28%), coarse speckled (24%), fine speckled (20%), and globules (16%). Pattern of vasculature included telangiectases (18%) and superficial dilated vessels (20%). Patterns of skin changes included atrophy (18%) and exaggerated skin markings (22%). Dermoscopic features can correlate with its etiology. Conclusion: POH is a multifactorial entity. Dermoscopic features can correlate with its etiology.

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Granulomatous disorders comprise a large family sharing the common histological denominator of granuloma formation. Collagenolytic or necrobiotic granuloma is one in which a granulomatous infiltrate develops around a central area of altered collagen and elastic fibers. The altered fibers exhibit new staining patterns, becoming either more basophilic which gives blue appearance (“blue granuloma”) or eosinophilic giving red appearance (“red granuloma”). Conditions which exhibit blue granuloma include granuloma annulare, Wegener's granulomatosis, and rheumatoid vasculitis, whereas red granulomas include necrobiosis lipoidica, necrobiosis xanthogranuloma, rheumatoid nodules, Churg-Strauss syndrome, and eosinophilic cellulitis (Well's syndrome).

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Background: Percutaneous collagen induction (PCI) through dermal roller breaks old collagen strands, promotes removal of damaged collagen and induces more collagen formation. Collagen fibers can be assessed by traditional stains or by polarized light assessment of Picrosirius red stain. Objective: The purpose of the current study is the clinical and histopathological evaluation of percutaneous collagen formation in atrophic acne scars after dermal roller application. Patients and Methods: Total study duration was 26 weeks in which 12 patients received seven sessions of PCI at 3-weeks interval, 3 mm punch biopsy specimens of scars were obtained before and after treatment (at 18 and 26 weeks). Microscopic examination of pre and post operative biopsies were done, using routine stains and Picrosirius red stain. Results: PCI induced notable improvement in the appearance of acne scars with significant reduction in the score from 123.3 ± 24.5 to 74.16 ± 16.49 (P = 0.00) after 26 weeks. Polarized light assessment of Picrosirius red stain clarified the gradual replacement of old thick orange-red birefringent collagen fibers by newly synthesized thin green-yellow birefringent ones postoperatively. Conclusion: Skin needling is a simple and minimally invasive procedure. The polarized light assessment of Picrosirius red stain clarified the change of the optical properties of collagen fibers according to the maturation process.

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Dermatitis herpetiformis (DH), also known as Duhring-Brocq dermatitis, is an autoimmune, chronic subepidermal blistering disorder characterized by an intensely pruritic, papulovesicular eruption. It is linked to gluten sensitivity and considered to be a cutaneous manifestation of celiac disease. It has been demonstrated that sera from most patients with DH demonstrate autoantibodies against epidermal transglutaminase (eTG) and tissue transglutaminase (tTG). Therefore, the aim of the study was to evaluate the diagnostic utility of eTG and tTG immunohistochemistry in identifying patients with DH. A total of 15 skin biopsies from patients with an established diagnosis of DH confirmed by histopathology and direct immunofluorescence (DIF) studies were evaluated. Six cases were used as controls in which the clinical differential included DH and were found to be nondiagnostic by both histopathology and DIF evaluations. Eight (55%) of the DH cases were positive for eTG expression, while none of the controls showed any immunoreactivity (P = 0.0456). All 15 (100%) DH cases showed faint granular staining for tTG in the epidermal basal layers with similar results in all 6 (100%) control cases. Our study indicates eTG immunohistochemistry may aid in identifying patients with DH, with a diagnostic sensitivity and specificity of 55% and 100%, respectively. tTG does not appear to be a useful immunomarker in this setting.

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In this review, we use the term epithelioid cell granuloma for granulomas that show focal collections of epithelioid histiocytes in the absence of additional changes such as acute inflammatory cells and altered collagen or foreign material. Giant cells, lymphocytes, and histiocytes are often seen in these granulomas. Various features are useful in recognizing the specific cause of an epithelioid cell granuloma and include coalescence or discreteness of granulomas, presence and type of necrosis, inclusion bodies within giant cells, and identification of organisms, but the arrangement of granulomas within the dermis may be the single most important feature. Leprosy shows well-circumscribed, oval, oblong, and curvilinear epithelioid cell granulomas in a perivascular and peri-appendageal location involving superficial and deep dermis with minimal interstitial spill. Cutaneous tuberculosis is recognized by a lichenoid granulomatous pattern comprising a dense upper dermal infiltrate with granulomas that impinge on the overlying acanthotic epidermis accompanied by more localized, nodular granulomas in the deep dermis. Sarcoidosis has closely huddled yet discrete granulomas that have a paucity of lymphocytes. Other patterns and clues include follicular/perifollicular granulomas in lichen scrofulosorum and granulomatous rosacea, prominent necrosis in lupus miliaris disseminatus faciei, branching granulomas with plasma cells in granulomatous secondary syphilis, granulomatous lobular panniculitis with vasculitis in erythema induratum, messy granulomas in cutaneous leishmaniasis, and granulomas extending to the muscles in granulomatous cheilitis/Melkersson–Rosenthal syndrome. Histopathological findings, in combination with clinical and laboratory information, can lead to a specific diagnosis in the majority of cases.

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Dermatoscopy is an in vivo noninvasive technique used to examine pigmented and amelanotic skin lesions. The technique is performed using a hand-held self-illuminating device called dermatoscope that visualizes features present under the skin surface that are not normally visible to unaided eye. The images from the dermatoscope can be digitally photographed or recorded for future reference. Nonpolarized dermatoscopy requires contact with the skin surface and interface fluid between glass and skin surface. Polarized light penetrates deeper than the nonpolarized light and does not require contact fluids.

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Onychoscopy is being increasingly used as a diagnostic modality for various nail diseases. Initial research had focused mainly on nail pigmentation and nailfold capillaroscopy; however, it is now being evaluated in various infectious and inflammatory nail disorders as well. The present review aims to summarize current knowledge about onychoscopic diagnostic criteria in nail diseases. The best level of evidence attached to each indication is mentioned to answer the pertinent question: How much can we rely on onychoscopy in confirming diagnosis of nail disease?

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Suppurative granulomatous inflammation is a common histopathological reaction pattern that is encountered in the tropical countries including India. It occurs usually due to infective etiology and identification of the causative pathogen is crucial to initiate appropriate treatment. In this review article, we discuss about certain common and uncommon condition which may present with this reaction pattern.

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Angiomatoid fibrous histiocytoma[AFH] is a rare soft tissue tumour most commonly occurring in children, adolescents, and young adults. It is considered to be a tumour of intermediate malignancy because of its less aggressive course in contrast to conventional malignant fibrous histiocytoma[MFH]. It accounts for approximately 0.3% of soft-tissue neoplasms. The majority of cases occur in the extremities, are slow growing and are typically painless. We report a case of AFH on the scalp of a 40-year old man, locally recurring within two years of the original operation. AFH is a rare condition with the potential of local recurrence and metastasis. It should be considered in the differential diagnosis of a soft tissue mass in a child or adolescent.

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Introduction: Forkhead box protein 3 (Foxp3+) regulatory T-cells (Treg cells) are essential to maintain balance between pro- and anti-inflammatory responses. They play a role in maintaining homeostasis by locally suppressing other skin-resident T-cells thus protecting against autoimmune reactions. Thus, they have been the focus of authors' attention in skin T-cell-mediated diseases in the last decade. The Foxp3 gene encodes a transcription factor thought to be important for the function of Treg cells and represents a reliable marker. Contradictory results have been reported in literature about Treg cell densities in the skin of different inflammatory dermatoses including psoriasis, eczema, pityriasis lichenoides chronica (PLC), and cutaneous lupus erythematosus. Patients and Methods: This was a cross-sectional study on lesional skin biopsies from 10 cases of psoriasis, 10 of spongiotic dermatitis, and 16 cases of lichenoid dermatoses (10 of PLC and 6 of discoid lupus erythematosus. We compared the densities of Foxp3+ Treg cells in relation to CD4+ cells in the epidermis and dermis between these groups using Foxp3 and CD4 monoclonal antibodies.Results: Epidermal Foxp3+ CD4+ Treg cells were lower in psoriasis and lichenoid groups than spongiotic group and dermal Foxp3+ CD4+ Treg cells were lower in psoriasis than lichenoid and spongiotic groups. Conclusions: Treg cells have been proved to suppress other skin-resident T-cells and prevent autoimmunity. Being an autoimmune inflammatory dermatosis, psoriasis showed an overall lower density of Foxp3+ CD4+ Treg cells than spongiotic or lichenoid dermatitis. This supports the theory of Treg cell consumption in psoriatic skin due to conversion to interleukin 17 producers.

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Background: Psoriatic cell kinetic studies attribute psoriatic hyperplasia to increased germinative cell layer and increased mitotic rate causing rapid cell turnover, resulting in suprabasal mitotic activity. The significant Ki-67 and p53 positivity in psoriatic suprabasal layers as opposed to basal layers in normal skin corroborates this finding. Morphology holds importance in differentiating psoriasis among plaque forming lesions as they clinically mimic each other. In this study, the significance of morphologically derived suprabasal mitotic index was evaluated in the diagnosis of psoriatic lesions.Methods: H and E stained paraffin sections of histopathology confirmed cases of psoriasis and its variants (n = 52) were retrieved from archives and studied. For comparison, control group (n = 30) comprising normal skin and other plaque lesions was used. Suprabasal mitoses/100 basal keratinocytes were calculated in both groups and evaluated using Student's t-test and receiver operator characteristics. Results: The suprabasal mitotic index was significantly higher in psoriatic lesions as compared to controls (P < 0.001) with lower counts in palmoplantar psoriasis (n = 14). The cutoff of suprabasal mitoses for non-palmoplantar psoriasis was 1/100 keratinocytes with sensitivity, specificity, positive, and negative predictive value of 94.9%, 86.7%, 90.2%, and 92.9%, respectively. The diagnostic accuracy was 91.3%. Palmoplantar psoriasis had comparatively lower values and a diagnostic accuracy of 70.45%. Conclusion: The morphological evaluation of suprabasal mitoses is a reliable and cost-effective cell kinetic tool in diagnosing psoriasis and its variants. This will aid in the differential diagnosis of plaque forming lesions.

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Background: Dermal melanophages are a common histopathological finding in several inflammatory skin diseases and may be seen even in clinically normal-looking skin. Clinically hyperpigmented and hypopigmented conditions as well as nonpigmented lesions show melanophages which cannot always be correlated with the clinical appearance of the lesion biopsied. No literature exists to help assess the significance of dermal melanophages in inflammatory diseases and correlate their presence with the pathophysiology of the disease biopsied. Methodology: This is a retrospective study of 100 skin biopsies in patients with brown skin, which had mentioned dermal melanophages in the histopathological report. A simple-to-use semi-objective scale (score of 3–10) was used to assess the score of the dermal melanophages. This was done by a dermatopathologist who was blinded to the clinical and histopathological diagnoses. A correlation of the dermal melanophage score was attempted with the clinical/histological diagnoses and known pathogenesis of the diseases. Results: A variety of skin diseases were included in this study which could be broadly grouped into hypopigmented (10 cases, average scores 4), nonpigmented interface diseases (20 cases, average score 6.66), miscellaneous nonpigmented dermatosis (17 cases, average scores 5.3), and hyperpigmented (53). The hyperpigmented group was subdivided into those that were known to show predominantly epidermal melanin (13 cases, average score 4.58) and those who have predominantly dermal melanin following interface dermatitis (29 cases, average score 8.67) and dermal melanosis without interface dermatitis (11 cases, average score 6.18). Conclusions: This scale can be used to determine the significance of dermal melanophages in inflammatory skin diseases. Scores >6 suggest hyperpigmentary conditions due to the presence of dermal melanophages. Low scores of 3–5 are not significant and are seen in epidermal hypermelanoses, hypopigmented conditions, and other varied nonpigmented dermatoses.

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