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Panniculitis: A dermatopathologist's perspective and approach to diagnosis
Parikshaa Gupta, Uma Nahar Saikia, Sandeep Arora, Dipankar De, Bishan Das Radotra
July-December 2016, 3(2):29-41
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.
  74,106 6,359 12
Epithelioid cell granuloma
Deepika Yadav, M Ramam
January-June 2018, 5(1):7-18
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.
  32,433 1,237 3
Histopathological spectrum of lichen sclerosus Et atrophicus
Varsha Dalal, Manveen Kaur, Chandra Bhushan Rai, Avninder Singh, V Ramesh
January-June 2017, 4(1):8-13
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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Histopathologic approach to alopecia
Inchara Kalegowda Yeliur, Rajalakshmi Tirumalae
July-December 2018, 5(2):79-88
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.
  24,826 2,556 2
An overview of suppurative granuloma
Mary Thomas, Raghavendra Rao, G Nanda Kumar
January-June 2018, 5(1):19-26
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.
  23,837 1,159 3
Histopathologic approach to cutaneous vasculitis
Rajalakshmi Tirumalae
January-June 2014, 1(1):2-6
Cutaneous vasculitis encompasses a varied clinicopathologic spectrum, some of them with grave systemic consequences. A skin biopsy is often part of the first-line investigations done in the workup of such patients. A pathologist confronted with a biopsy for vasculitis has to be cognisant of the variations in morphology of these lesions with the course of the disease, overlaps in clinical and histologic features, use of ancillary tests like direct immunofluorescence (DIF), and its limitations. This review outlines a practical histopathologic approach to cutaneous vasculitis and emphasizes features that help in differential diagnosis.
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Necrobiotic granuloma: An update
Achyut Pokharel, Isha Poudel Koirala
January-June 2018, 5(1):27-33
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).
  21,359 1,169 3
Epidermal reaction patterns
Aanchal Panth, M Ramam
January-June 2015, 2(1):1-7
Changes in the epidermis serve as important histopathological clues to the diagnosis of skin disorders. These peculiar changes are referred to as epidermal reaction patterns. Certain epidermal reaction patterns such as acantholytic dyskeratosis, epidermolytic hyperkeratosis, cornoid lamellae and papillomatosis point towards a specific diagnosis and hence it is important to recognise them. In this article, we have reviewed the histopathological appearance of these reaction patterns as well as their etiology and the conditions in which they are seen.
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Utility of trichoscopy
Rachita S Dhurat
July-December 2018, 5(2):89-96
Trichoscopy is evolving as an indispensable aid to the dermatologist by providing valuable clues on dermatoscopy of the scalp and hair. Trichoscopy presents as a bridging tool between clinical and histological diagnosis. It is useful to distinguish congenital atrichia from other forms of childhood hair loss such as alopecia universalis. There are a set of women who present with chronic hair loss without any discernible reduction in hair density over the crown. Such early forms are often overlooked, and clinical evaluation may not be adequate to make the right diagnosis. Trichoscopy has been widely used as a diagnostic as well as a prognostic tool to measure anisotrichosis in cases of overt androgenetic alopecia and female pattern hair loss (FPHL) and to distinguish them from telogen effluvium. It can be used to distinguish FPHL from diffuse and subtotal alopecia areata (AA) as well as trichotillomania from AA which can have similar clinical presentations. Trichoscopy also helps in monitoring treatment response in patients of AA. It is also useful in diagnosing infectious conditions such as noninflammatory tinea capitis, seborrheic dermatitis, piedra, and pediculosis. Trichoscopy represents a valuable, noninvasive and low-cost technique, still underutilized, to rapidly differentiate clinically frequent hair disorders.
  17,444 1,095 1
Idiopathic scrotal calcinosis: A case series
Sainath K Andola, Shabnam Karangadan, Suresh Patil
July-December 2014, 1(2):86-89
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.
  17,158 674 2
“Interface” Dermatoses: Revisited
Sasi Kiran Attili
January-June 2019, 6(1):14-24
“Interface dermatoses” are defined as inflammatory dermatoses primarily affecting the interface elements along the dermoepidermal junction, resulting in epidermal basal cell damage. This epidermal basal cell damage can be of two forms: vacuolar/hydropic degeneration and filamentous degeneration (resulting in Civatte bodies). This may be associated with a range of secondary epidermal (atrophy to hypertrophy) and dermal changes (varying from simple effacement of the rete ridges to the diffuse dermal fibrosis/sclerosis). With so many variables, “Interface dermatitis” per se is not a diagnosis by itself but simply a reaction pattern, similar to “psoriasiform dermatitis” or “spongiotic dermatitis.” One should never use these terms as the final sign out diagnosis in reports, though in difficult cases one may allude to the reaction pattern and discuss the possible differentials. This article analyzes and discusses in detail, the basic pathogenesis behind the primary/secondary features associated with interface dermatoses and the steps involved in their histopathological evaluation; thorough knowledge of which may help one arrive at a specific diagnosis.
  16,027 1,275 2
Dermatoscopy: Physics and principles
Balakrishnan Nirmal
July-December 2017, 4(2):27-30
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.
  15,167 1,463 5
Histopathological approach to cutaneous lymphoid infiltrate
Uma Nahar Saikia, Manoj Gopal Madakshira
January-June 2019, 6(1):1-13
Cutaneous lymphoid infiltration is common histology seen in the day-to-day practice of dermatopathology. The reasons for this infiltration can range from a spontaneously remitting pseudolymphoma such as Jessner's infiltration to a sinister and aggressive cytotoxic T-cell lymphoma. Before analyzing the slide, the clinical perspective needs to be borne in mind as a diagnosis can never be made in isolation, especially in dermatopathology. In this article, we discuss in brief the various common cutaneous lymphoid infiltrative entities encountered in routine practice, discuss the differentiating features, and suggest an algorithmic approach to arrive at the possible diagnosis.
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Dermoscopy of non-melanocytic and pink tumors in brown skin: A descriptive study
Balachandra S Ankad, Punit S Sakhare, Mural H Prabhu
July-December 2017, 4(2):41-51
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.
  13,753 859 9
Nonmelanoma skin cancers: An Indian perspective
Geeti Khullar, Uma Nahar Saikia, Dipankar De, Bishan Das Radotra
July-December 2014, 1(2):55-62
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.
  12,321 1,738 6
Dermal melanophages: Does quantitative assessment play a role in the diagnosis of inflammatory skin diseases?
Sasi Kiran Attili
July-December 2018, 5(2):133-134
  12,562 376 1
A case of benign lichenoid keratosis
Amita Mhatre, Nitin Nadkarni, Sharmila Patil, Shweta Agarwal
July-December 2015, 2(2):49-51
  12,148 437 2
Acquired cutaneous perforating disorders: Clues to diagnosis by silhouette
Asha Kubba, Meenakshi Batrani, Tanvi Pal
July-December 2016, 3(2):42-44
Inflammatory dermatoses are interpreted by pattern recognition. Primary perforating disorders including reactive perforating collagenosis, elastosis perforans serpiginosa, perforating folliculitis, and Kyrle's disease show clinical and histopathological overlap. This article highlights the importance of architectural based analysis by “silhouette” observed under scanning magnification for diagnosis of primary perforating disorders.
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Verrucous hyperplasia of amputation stump
Amit Kumar Dhawan, Chander Grover, Kavita Bisherwal, Vinod Kumar Arora, Reena Tomar
January-June 2015, 2(1):23-24
  11,336 558 -
Role of histochemical stains in differentiating hemangioma and vascular malformation
Ruchir Jitendra Patel, Archana Chirag Buch, Shirish S Chandanwale, Harsh Kumar
January-June 2016, 3(1):1-6
Background: Benign vascular lesions such as vascular malformation and hemangioma at times pose difficulty in diagnosis both for clinicians and pathologists. Vascular malformations are difficult to treat while hemangiomas resolve spontaneously in most instances. There are instances when vascular malformations, especially arteriovenous malformations (AVMs) have been misdiagnosed as hemangiomas and vice-versa. Clinical and radiological correlation with histopathological confirmation of these anomalies is important for the management of these lesionsAim: The aim was to study the histological characteristics of hemangiomas and vascular malformations and to study the utility of histochemical stains in their diagnosis. Materials and Methods: We retrospectively studied fifty cases retrieved from the records of Department of Pathology which were diagnosed as hemangioma (n=32) and vascular malformation (n=18) on Hematoxylin and Eosin (H and E) stain over a period of 18 months. The cases were analyzed based on findings of histochemical stains such as Verhoeff-van Gieson (VVG), Masson's trichrome (MT), and toluidine blue. Results: After reviewing all the cases with the use of histochemical stains, two of the three cases originally diagnosed as hemangioma turned out to be AVM and one to be venous malformation. An increased number of intra-lesional nerves were found in 16 of 19 cases of AVM and in both cases of venous and lymphatic malformation. Hemangiomas did not show increase in nerve bundles. Mast cells were found to be increased in proliferating hemangiomas and pyogenic granulomas as compared to AVMs. Conclusion: Hemangiomas and vascular malformations should be clearly differentiated to reduce the risk of treatment failure and recurrence. With the use of histochemical stains such as VVG, MT and toluidine blue, the diagnostic difficulty can be reduced and definitive diagnosis is possible.
  10,834 938 -
Diagnostic utility of onychoscopy: Review of literature
Chander Grover, Deepak Jakhar
July-December 2017, 4(2):31-40
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?
  10,601 1,034 4
Clinical and dermoscopic evaluation of periorbital hyperpigmentation
Mithali Jage, Sunanda Mahajan
January-June 2018, 5(1):42-47
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.
  10,694 910 5
Subcutaneous granuloma annulare in a child: A rare presentation
Kumar Parimalam, Jayakar Thomas
January-June 2014, 1(1):39-41
We present a rare case of subcutaneous granuloma annulare (SGA) of the palm in a 3-year-old girl disappearing on removal of a SGA of the dorsum of foot. Though GA is more common in children, subcutaneous type is rare and poses diagnostic difficulty. Very few cases of SGA over the palm have so far been reported. Disappearance of SGA of the palm following removal of a nodule from the foot represents remote reverse Koebner's phenomenon.
  9,902 470 -
Emerging inflammatory dermatoses: New entities, novel observations, and concept review of selected established conditions
Kristofer Holte, Asok Biswas
July-December 2018, 5(2):71-78
There has been relatively little change during the past four decades in the way dermatopathologists approach and interpret biopsies obtained from inflammatory skin disorders. If anything, there has been a stronger emphasis on clinicopathologic correlation as an aid to arrive at a clinically meaningful diagnosis. Nevertheless, new and novel observations made under the microscope have improved our understanding of several existing conditions and paved the way toward recognition of newer entities. This review looks at a selection of inflammatory dermatoses which are either newly recognized or where unique microscopic findings published in recent years have refined our understanding of some established conditions.
  9,441 699 -
Preparing for a dermatopathology quiz
Biju Vasudevan, Manas Chatterjee, Nikhil Moorchung, Shekar Neema
July-December 2014, 1(2):63-67
Dermatopathology is one of the key aspects in dermatological diagnosis and is of immense value to the practicing dermatologist as well as residents pursuing dermatology as a career. It is a visual medium of understanding the subject, and is therefore ideal to be tested similarly. Dermatopathology quiz has become a part and parcel of most scientific deliberations, and is therefore an essential requirement of the postgraduate curriculum. Preparing for a dermatopathology quiz is tougher than preparing for a normal clinical quiz because of the lesser importance given for it in the syllabus of postgraduation and also due to the lack of resources either in getting microscopic sessions arranged or due to lack of flair of the subject compared to cosmetology or dermatosurgery. This review was done with the purpose of educating both the students and quizmasters as to how to prepare for a dermatopathology quiz. It is a unique proposal and, therefore, is gathered from more of personal experience, experience gained from watching quizzes conducted by experienced quizmasters, and also from the advice gained from masters of the subject in relation to the quiz.
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