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Dermatopathologists base their diagnostic approach on the tissue reaction pattern. This study mainly includes the interpretation of two major tissue reaction patterns, the psoriasiform and the lichenoid reactions, with clinicopathological correlation.
To analyze the spectrum of non-infectious erythematous papular and squamous lesions of the skin at our institute, study the age, sex and anatomic distribution pattern and classify the lesions into major categories; determine the incidence of each subcategory.
Study period: two years; prospective, sample size: 161 cases, proforma filled.
The lesions comprised 15.80% of the total load of surgical pathology and 30.99% of total number of skin biopsies. The highest percentage was in the 30-40 year age group (28.6%) with a male preponderance of 60.25%. The extremities were most frequently involved (67.79%). Lichenoid lesions were the commonest (46.57%) with lichen planus 26.7% and psoriasis vulgaris-19.88% being the most frequent. There were 5.6% seropositive cases. Correlation with the histopathological diagnosis was positive in 97.52% cases and negative in 2.48% cases.
The contribution of histopathology to the final diagnosis was significant. It confirmed the diagnosis in 92.55% and gave the diagnosis in 4.97% cases.
The skin has a limited number of reaction patterns with which it can respond to various pathological stimuli; clinically different lesions may show similar histological patterns. Therefore, to obtain the precise diagnosis of the skin biopsy, it should be accompanied by all clinical details. The interpretation of many skin biopsies requires the identification and integration of two different morphological features- the tissue reaction pattern and the pattern of inflammation. The experienced dermatopathologist sees these two aspects simultaneously, integrating and interpreting the findings in a matter of seconds.
This study mainly includes an interpretation of two major tissue reaction patterns, the psoriasiform and the lichenoid reactions; with clinicopathological correlation.
This was a prospective two-year study in which the total sample size was 161 cases. The following proforma was filled out in each case.
Surgical Pathology Number.
Gross photos of some of the lesions were taken before a punch or excision biopsy was done; 10% formalin was the fixative used. Specimens of > 3 mm were bisected. Excision biopsies were inked and sectioned and sections were 2-3µm. Hematoxylin and Eosin stain was used and special stains were used when necessary.
Non-infectious erythematous papulosquamous disorders constituted 15.80% of the total surgical pathology load and 30.99% of the total number of skin biopsies at the institute. The age distribution pattern revealed that the maximum biopsies (28.6%) were in the age range of 30-40 years and the least number were in the youngest age range of 0-10 years (5.6%). The sex distribution pattern revealed that most of the patients were males (60.25%). The anatomic distribution pattern revealed that the limbs were involved in the maximum number of cases (67.79%) followed by the trunk (19.94%) and head, neck and face (12.27%).
An analysis of the broad categories revealed that the most frequently encountered lesion was the lichenoid group - 46.57%, followed by psoriasiform lesion - 23.60%. Amongst the lichenoid group of lesions, lichen planus was the most frequent at 57.33% followed by hypertrophic lichen planus 18.67% and lichen planus pigmentosus 12%. The next category was of the psoriasiform lesions- 23.60% in which psoriasis vulgaris was the most frequent- 84.21%. This was followed by an equal number of lesions of chronic plaque psoriasis, guttate psoriasis and pustular psoriasis- 5.26%.
About 5.6% patients were HIV positive and psoriasis was the most common lesion encountered in HIV positive patients - 0.44%. There was a positive correlation of clinical diagnosis with histopathological diagnosis in 97.52% cases. Histopathology confirmed the clinical diagnosis in 92.55% cases; gave the diagnosis in 4.97% cases and was non contributory in only 2.48% cases.
Non-infectious erythematous papulosquamous disorders constituted 15.80% of the total surgical pathology load of the department and 30.99% of the total number of skin biopsies at our institute.
The age distribution pattern of skin biopsies revealed that the maximum number of biopsies (28.6%) was seen in the 30-40 year age range, and the minimum number in the youngest age range of 0-10 years: 5.6%. Lichen planus was most frequently seen in the 20-40 year age range - 50%. It has, however, been reported in the middle aged adults in the 5th- 6th decades. Childhood occurrence is unusual, except in the familial cases, yet other authors have reported it in young to middle aged adults. The next most frequently seen lesion – psoriasis was most commonly seen in the 30-40 year age range. Most authors, however, have cited a younger or older age range in the literature. Fry mentioned that two-thirds occurred before the age of 30 years, 22% in the age range of 30-50 years. Griffiths mentions that classic psoriasis is seen in the older age range of 55-60 years; but clarifies that there are two types of lesions. Type I occurs before 40 years of age and type II after 40 years of age. Bell et al. also described an older age range of 60-69 years. Generalized pustular psoriasis is described well past middle age.[6,7] Juvenile generalized pustular psoriasis has been described in children less than 11 years. We had two cases in the 10-20 year age range. We had two cases of parapsoriasis both in the older age ranges of 40-50 years and > 60 years age range. Similar age ranges has been documented in the literature.
The sex distribution pattern of cases revealed that most of the patients were male 60.25%. Lichen planus showed female preponderance in our series and has been also described as such in the literature.[1,10] We found a male preponderance in our cases of psoriasis, however Bell et al. found a female preponderance and Fry found no sex predilection.
The anatomical distribution pattern of the lesions revealed that the limbs were involved in the maximum number of cases 67.79%, followed by the trunk 19.94% and head, neck and face 12.27%. Most of our cases of lichen planus occurred on the limbs followed by the trunk and head, neck and face. Other authors have also found the arms and legs to be the most frequently involved.[1,2,10] Most of our cases of psoriasis were seen in the limbs. Different morphological types have been described at different locations.
An analysis of the broad categories revealed that the most frequently encountered lesion was the lichenoid group of lesions constituting 46.58% followed by psoriasis forming 23.60% of cases. Amongst the lichenoid group of lesions, which accounted for 46.58% of total cases, lichen planus constituted the highest percentage of cases i.e. (57.33%), followed by hypertrophic lichen planus (18.67%) and lichen planus pigmentosus (12%). The next category was of psoriasiform lesions forming 23.59% cases. Within this group, psoriasis vulgaris had the highest number of lesions (81.58%). This was followed by an equal number of lesions of chronic plaque psoriasis, guttate psoriasis and pustular psoriasis, with two cases of each and thus forming 5.26% of the total of the psoriasiform lesions.
Lichen planus presented as flat topped, violaceous to erythematous lesions over the extremities and trunk which is classically described by authors.[1,10,11] A case of oral lichen planus was also included in our study [Figure 1]. Cases of hypertrophic lichen planus presented as thickened, verrucous plaques over the knees and legs predominantly like those described by Boyd et al. Patients of lichen planus pigmentosus presented with multiple, hyperpigmented patches over the face and extremities but also on the trunk. Lichen planus pigmentosus is described mainly on the sun exposed areas in the literature.[12,13] Psoriasis vulgaris presented as erythematous sharply demarcated plaques covered with silvery scales [Figure 2]. Plaque psoriasis was seen in our patients who presented with thick, itchy, round to oval, scaly lesions over the buttocks, ankles, soles and shin, like other authors have described. Two cases of guttate psoriasis were seen. Griffith et al. described similar lesions in guttate psoriasis; however, etiology was not known. Pustular psoriasis patients presented as tiny, erythematous, itchy papules gradually increasing to involve various parts of the body. Similar reports were seen in the literature.[6,7,14]
As far as histology is concerned, all our cases of lichen planus showed hyperkeratosis, hypergranulosis, sometimes focally, irregular acanthosis, vacuolar degeneration of the basal layer and a band-like infiltrate in the papillary dermis [Figure 3]. Boyd et al. described similar histopathological findings with addition of Max Joseph spaces and civatte bodies. Shai et al. also described similar findings. Malignant degeneration was, however, not seen in our cases, which are described in the literature.[10,15–17] The histology of lichen planus pigmentosus in our nine cases showed basal layer degeneration with pigment incontinence in the upper dermis along with mononuclear cell infiltrate. Histology of our cases matched with those of Bhutani et al. We had 38 cases of psoriasis in which histology revealed hyperkeratosis, parakeratosis, irregular thinning and focal elongation of the rete ridges in plaque psoriasis. The dermis showed a dense chronic perivascular and periadnexal infiltrate [Figure 4]. Psoriasis vulgaris showed Munro’s micro abscesses. Similar findings have been described by various authors.[3–6,14]
An analysis of the clinical diagnosis with the histopathological diagnosis revealed a positive correlation in 97.52% of cases and a negative correlation in 2.48 % of cases [Table 1]. As far as contribution of histopathology to the diagnosis was concerned, histopathology confirmed the diagnosis in 92.55% of cases gave the diagnosis in 4.97% of cases and was non contributory in only 2.48% of cases [Table 2] thus emphasizing the importance and utility of histopathology in arriving at a conclusive diagnosis.
Non-infectious erythematous papulosquamous lesions biopsies constituted 15.80% of the total load of surgical pathology biopsies and 30.99% of the total number of skin biopsies at our institute. The age distribution pattern indicated a high percentage in the 30-40 year age group range of 28.6% compared to the 5.6% in the age range of 0-10 years. The youngest patient was three and oldest was 80 years old. The mean age was 36 years. The sex distribution pattern revealed a male preponderance of 60.25% compared to 39.75% females. The anatomic distribution of the lesions revealed that the highest number of cases occurred in the extremities 67.79%. Classification of the histopathological skin lesions into broad categories [Figure 5] revealed that the lichenoid lesions were most frequently encountered 48.58% followed by the psoriasiform lesions 23.60%. A further split up of the broad categories reveal lichen planus (26.7%) and psoriasis vulgaris (19.88%) to be most frequently individual encountered lesions. Correlation of clinical diagnosis with the histopathological diagnosis was positive in 97.52% cases and negative in 2.48% cases [Table 1]. It confirmed the diagnosis in 92.55% cases and gave the diagnosis in only 4.97%. It was not contributory in 2.48% cases [Table 2].
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