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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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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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: 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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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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Hodgkin's disease with skin involvement is a rare entity with a reported incidence of 0.5-3.5%. Various routes of skin involvement may include retrograde lymphatic spread, direct extension from underlying nodes, or hematogenous spread. Prognosis is usually determined by the degree of visceral involvement and the stage of disease. We report our experience with four cases of Hodgkin's disease with varying presentations, mimicking other malignant or inflammatory conditions.

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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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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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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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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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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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Context: Lichenoid disorders are diverse, and the use of a noninvasive tool like dermoscopy could highlight the pathology in the deeper skin. The present study aimed to compare the accuracy of clinical and dermoscopic findings with histopathology in making a diagnosis of lichenoid dermatoses. Settings and Design: This is a prospective cross-sectional observational study of consecutive, clinically suspected cases of lichenoid skin eruption. Subjects and Methods: Forty patients with various clinical features and dermoscopic features were enrolled. Skin biopsy was taken from all the cases, and the clinical, dermoscopic, and the histopathological correlation was made. Results: Classical lichen planus (CLP) was the most common entity reported (30%), followed by hypertrophic LP (HLP) (15%) and lichen nitidus (15%). Radiating lines were the most common structures seen in as compared with HLP. Comedo-like lesions were significantly seen in HLP than CLP. Compact hyperkeratosis was seen in 66.67% of CLP and in all cases of HLP. There was a significant association in HLP, between blue and black structures on dermoscopy as compared with pigmented melanophages in dermoscopy. Chi-square test was used as a method of comparison, and SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. was used. Conclusion: Dermoscopic findings give a vital clue about the underlying histopathology which can aid a physician in his/her diagnosis.

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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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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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Annular elastolytic giant cell granuloma is a rare granulomatous disease with unknown pathogenesis. It clinically presents as single or multiple well-defined erythematous annular arciform serpiginous polycyclic plaque with indurated elevated borders and central atrophy in sun-exposed areas. It is found to have a causal association with conditions such as diabetes mellitus, T-cell leukemia, CD4 lymphoma, cutaneous amyloidosis, squamous cell carcinoma lung, sarcoidosis, and monoclonal gammopathy. On histopathology, characteristic “elastophagocytosis” of dermal elastic fibers by the multinucleated giant cells is seen. The presence of horizontally oriented fragmented elastic fibers is characteristic. There is no necrobiosis or mucin deposition, thus differentiating from granuloma annulare. We herein report a case of elderly male with type 2 diabetes mellitus who presented with asymptomatic multiple discrete erythematous shiny dome-shaped papules over anterior chest, abdomen, and back of 2-month duration. The diagnosis was confirmed by biopsy and thorough workup for associations was done. This case is reported due to the rarity of the disease, the atypical presentation, and the characteristic histopathology which lead to the diagnosis.

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Idiopathic calcinosis of the scrotum is a rare benign local condition, characterized by multiple, painless, hard scrotal nodules, in the absence of any systemic metabolic disorder. We report nine cases of this rare entity diagnosed over a five-year period (2009-2013). The patients' age ranged from 26 to 65 years (Mean 42 years). The majority presented with scrotal swellings (8/9) and were clinically diagnosed as sebaceous cysts (7/9). Two cases also gave history of white chalky discharge from the swelling. Associated features of right inguinal hernia and left hematocele were seen in two cases. Five cases presented with a solitary nodule, with the size ranging from 0.5 to 3 cm (Mean 1.89 cm). The histopathological examination revealed dermal calcified masses with prominent foreign body reaction. All cases underwent surgical excision and showed no recurrence in follow up. This case series attempts to create an awareness of this rare pathology, which has an obscure pathogenesis and is often misdiagnosed.

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A rare and probably the first documented case of isolated cutaneous toxoplasmosis is being reported in a 50-year-old, vegetarian, immunocompetent man. The granulomatous nodule located on the scrotal skin was excised, and the sections and crushed material of the nodule were subjected to different staining techniques. Demonstration of crescentic structures and PAS-positive material confirmed the presence of Toxoplasma gondii. The significantly raised titer of anti-toxoplasma antibodies further supported the diagnosis. The case was successfully managed surgically. No further treatment was advised since the patient was immunocompetent and it was assumed that cell-mediated immunity would further control the proliferation of organisms.

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Spiny keratoderma is a rare disease; first described by Brown as “punctuate keratoderma”. It is characterized by asymptomatic keratotic pin point papules over palms and soles, resembling the old fashioned music box spine. The spiny spicules are often misdiagnosed and has a very subtle histopathological difference from punctate porokeratosis. With only less than 40 cases reported worldwide, we report our case as the very few mentioned in Indian literature.

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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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Background: Onychomycosis can resemble other nail dystrophies and hence the clinical diagnosis should be supplemented with a laboratory diagnosis. Rapid diagnosis of onychomycosis is the necessary to initiate early therapy. In this study, the efficacy of Chicago Sky Blue (CSB) stain in comparison with that of routine potassium hydroxide (KOH) preparation in the diagnosis of onychomycosis was evaluated. Methods: A prospective study of 42 nails with a clinical diagnosis of distal lateral subungual onychomycosis. KOH mount followed by direct microscopic examination of the subungual debris was performed. This was followed by microscopic examination after addition of 1% CSB. Results were interpreted by two experienced dermatologists. Results: 18 (42.9%) nails showed KOH positivity and 37 (88.1%) were positive for CSB stain. Conclusions: CSB staining was more sensitive and was more accurate in the rapid diagnosis of onychomycosis. Colour contrast provided by the CSB made it easier identification of fungal elements.

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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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Alopecia is a common condition that frequently poses a challenge to pathologists and dermatologists alike. Its' classification is still evolving, and there are several areas of overlap. From the therapeutic and prognostic point of view, it is vital to discriminate between scarring and nonscarring alopecia. Histopathology is the most valuable tool in diagnosis. This review attempts to give an overview of hair anatomy and histology and discusses a simple, practical, microscopy-based classification of the commonly encountered diseases. It emphasizes the importance of examining the biopsy under scanning magnification, which is often overlooked and can provide vital clues. Some of the diagnostic challenges are also highlighted.

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