!

ill EPIDERMAL INVOLVEMENT

BALLOONING

SUPERFICIAL PERIVASCULAR DERMATITIS

Tinea versicolor Dermatophytosis

Corynebacteria in cornified layer ---- ---j ErYlhr~sma

- Pitted keratolysis

No rnelanocytes-in basal layer ---------------- Vitiligo

Extravasated erythrocytes and/or siderophages Schamberg's disease

Viral exanthems of some kinds Drug eruption (one type) Urticaria, late

Erythema figuratum, superficial

lvmphocvtes predominate ---c Extravasated. erythrocytes and/or siderophages ---------- Schamberg's disease

. Eosinophils In variable number Pruritic urticarial papules and

plaques of pregnancy

Dermatitis herpetiform is/ Linear IgA dermatosis/

Dermatitis herpetiform is-like drug eruption/ Acute discoid lupus erythematosus/ Systemic lupus erythematosus Leukocytoclastic vasculitis

Erythema marginatum

Bullous pemphigoid/Herpes gestationis, urticarial

Pemphigus vulgaris, urticarial Arthropod assault, superficial Pruritic urticarial papules and plaques of pregnancy

- Neutroph I" and

eosinophil prominent Urticaria

- Melanophages -------------..,.-------------------1-- Postinflammatory pigmentary alteration

Macular amyloidosis

Sideropha: es --. -------------------------------- Stasis changes

- Macrophages with features of ---------------------------- Minocycline-induced eruption melanophages and siderophages

Mast cells ---------------------------------- Urticaria pigmentosa

Hyphae and spores in cornified layer----------------1

Perivascular only-Lymphocytes predominate--

Individual necrotic keratinocytes, ballooning, spongiosis, pallor in ---- Mucha-Habermann disease upper part of epidermis, and parakeratosis

Lymphocytes along adnexal structures in reticular dermis,------- Lichen striatus individual necrotic keratinocytes

Thinned epidermis, prominent granular layer, parakeratosis ------- Graft vs. host reaction

Extravasated erythrocytes and/or siderophages Lichenoid purpura of Gougerot and Blum

Necrotic keratinocytes, focal parakeratosis, Lichen planus-like keratosis

residuum of solar lentigo sometimes

Cornoid lamellae Disseminated superficial actinic porokeratosis

Lymphocytes within epidermis, scant spongiosis---------- Mycosis fungoides, plaque

Histiocyte» predominate ---c Discrete foci in papillary dermis .... . Lichen nitidus

Discrete tocl and, sometimes, confluence of toe: In reticular dermis Sarcoidosis

Langerhans' cells predominate --- Large cells, crenulated outlines of large pale nuclei, Letterer-Siwe disease

abundant amphophilic cytoplasm

Ballooning mostly-Lymphocytes predominate.--------c Steel-qray nuclei and margination of chromatin ... Herpesvirus infection

lnoividual necrotic keralinocytes and multinucleate epithelial giant cells --- Measles

Perivascular and Interstitial

Vacuolar

Lichenoid

No other abnormalities----------------I

Iyrnphocj.es predominate

-[ Normal cornified layer Erythema multiforme

. .. . Parakeratosis -------- Mucha-Habermann disease

Ballooning and ,indiVidUal Prominent granular layer Graft vs. host reaction

necrotic keratinocytes .

Necrotic keratinocytes in Effects of nitrogen mustard on

, papillary dermis also mycosis fungoides, patch/plaque

{Cornified layer normal ------ Drug eruption (one type) Basement membrane sometimes

No ballooning and few, If any, thickened smudged Interface DIscoid lupus erythematosus/

necrotic keratlnocytes thinned epidermiS ' Dermatomyositis

Sclerosis 111 upper part of dermis --- Lichen sclerosus et atrophicus (morphea) Melanophages In papillary dermis -- Postlnflarnrnatory pigmentary alteration

Eosinophils and neutrophils prominent

_____ Ballooning and individual Cornified layer normal Fixed drug eruption, superficial

necrotic keratinocytes

Jagged epidermal hyperplasia, wedged hypergranulosis, Lichen planus

compact orthokeratosis

Eosinophils sometimes focally thinned epidermis focal parakeratosis ___r- Lichen planus-like drug. eruption

. .' '. -----c___ lichenoid photoderrnatitis

Lymphocytes predominate

L h yt dorm t -----r= Individual necrotic keratinocytes, normal cornified layer Erythema multiforme

-{ ymp oc es pre ormna e Individual necrotic keratinocytes, prominent granular layer, parakeratosis -- Graft vs. host reaction

Interface .. Individual necrotic keratinocytes, ballooning, normal cornified layer FIXed drug eruption. superfic1a

Eosinophils and

neutrophils prominent [ Individual necrotic keratinocytes, spongiosis, neutrophils as solitary Toxic shock syndrome

units within epidermis

Orf

Milker's nodule

Psoriasiform -- Lymphocytes predominate ----Intracytoplasmi~ inclusion bodies -------------1

PSORlf\SIFORM

SUPERFICIAL PERIVASCULAR DERMATITIS (Con!.)

Spongiotic only

Lymphocytes predominate

- Eosinophlls prominent

,-

Psoriasiform---- Lymphocytes predominate

Hyphae in cornified layer -------------- Dermatophytosis

Spongiosis .centered in acrosyringia Miliaria rubra

Sponqiotic.sirnulation of Pautrier's collections Gianotti-Crosti syndrome

Mounds of scale-crust Pityriasis roseal

Erythema annular centrifugum

Mounds of-scale-crust at lips of infundibular ostia ------ Seborrheic dermatitis

Individual necrotic keratinocytes, foci of parakeratosis Lichen striatus

Scant spongiosis, slight parakeratosis Pityriasis alba

Few lymphocytes in epidermis, scant spongiosis,---'---- Mycosis fungoides, macule/patch elongated mounds of scale-crust

- Variable numbers of eosinophils in upper half of dermis,---- Pruritic urticarial papules and plaques

slight spongiosis of pregnancy

[Allergic contact dermatitisl

, Nummular dermatitisl

EosinophHs in dermis and sometimes in epidermis -----I Dyshidrotic dermatitisl

Id reaction, early

Eosinophils as solitary units in

diffuse fashion in epidermis -----------1

Bullous pemphigoidl

Herpes gestationisl Pemphigus vulgaris, urticarial

Eosinophils in collections in foci of prominent spongiosis -~-- Incontinentia pigmenti

Eosinophils in collections in foci of scant spongiosis' Toxic erythema of the newborn

Eosinophlls in focus of prominent spongiosis above Arthropod assault, superficial

apex of we,oge-shaped dermal infiltrate

Prominent spongiosis, scale-crust ----------1

Allergic contact derrnatttis/ Nummular dermatitisl Dyshidrotic dermatitisl

Id reaction

Scale-crusts at lips of follicular ostia--~------- Seborrheic dermatitis Scale-crusts not at lips of follicular ostia Nonbullous congenital ichthyosiform erythroderma

Periadnexal infiltrate of lymphocytes, Lichen striatus

necrotic keratlnocytes

P 'd I ' f'l f I h ic keratl -c Lichen strtaius

-[ ena nexa In I trate 0 ymp ocytes, necrotic eratlnocytes, Bullous pemphigoidl

sponcrosrs With numerous eosinophils Herpes gestation is, urticarial

Lichenoid ----- Lymphocytes predominate L h I" t I ' id ' ' ,

ymp ocytes as so itary units, a east, In ept errrus, MYCOSIS fungoides, patch/plaque

spongiOSIS scant, wiry bundles of collagen in upper part

of dermis I

-[ Periadnexal infiltrate of lymphocytes, necrotic keratinocytes --- Lichen striatus

Spongiosis with numerous eosinophils Bullous pemphigoid/Herpes gestationis.

P iasit ---- Lymphocytes predominate, ,- urticaria'

sonasi orm Lymphocytes as solitary units, at least, within epidermis, Mycosis fungoides, patch/plaque

lichenoid spongiosis scant, wiry bundles of collagen in upper part

of dermis

Lymphocytes along adnexal structures In reticular dermis, ---- Lichen stnatus indfvidual necrotic keratinocytes

Wiry bundles of collagen In haphazard array In upper MYCOSIS fungoides, plaque

scant sponqiosis

Stubby zones of parakeratosis and no granular zone ----- Inflammatory linear verrucous

Lichenoid beneath them epidermal nevus

Hlstiocytes and plasma cells ------------------------- Syphrlis, secondary predominate

Psoriasiform ---- Lymphocytes predominate only

Spiraled capillaries in thin dermal papillae, --------- Psoriasis rete ridges of uniform length, some rete ridges thinned

Rete ridges of uneven lengths, parakeratosis, no spiraled __r- Allergic contact dermatitisl

capillaries in dermal papillae - L Nummular dermatitisl

Dyshidrotic dermatitis, late

Checkerboard pattern of orthokeratosis and parakeratosis ---- Pityriasis rubra pilaris Scale-crust at lips of infundibular ostia ' Seborrheic dermatitis

Hyphae in cornified layer -------------- Dermatophytosis

Pseudohyphae in cornified layer Candidiasis

, ~ Lichen simplex chronicusl

Hyperkeratosis, hypergranulosis, Prurigo nodularis/

coarse collagen bundles often perpendicular to Acanthoma tissuraturn/ ,

skin surfa, ce in thickened papillary dermis Pressure papule from prosthesis/

- Surfer's nodules/

- " . ,- Chondrodermatitis nodularis helicis

II!Q EPIDERMAL INVOLVEMENT

W d h d' fit t ----------- ~- Arthropod assault and simulators of it'

- Eosinophils prominent --C e ge-s ape mira e Erythema chronicum migrans

"Flame figures" in variable numbers Wells' syndrome

Eosinophils and neutrophils -- Sparse infiltrate Urticaria

- Plasma cells present ---- Eosinophils sometimes present also -------------- Erythema chronicum migrans

- Neutrophils, eosinophils, --- "Bottom heavy" infiltrate often, hints of crowded, thickened ------ Scleroderma, early

and plasma cells bundles of collagen sometimes '

{Mucin in center of palisades Granuloma annulare

Oegenerated collagen early, thickened collagen late --------- Necrobiosis lipoidica in center of palisades

Histiocytes predominate ':

'''Bottom heavy" infiltrate often, eosinophils and neutrophils in Interstitial granulomatous dermatitis with arthritis

conjunction with degeneration of collagen bundles focally

Few lymphocytes in epidermis, scant spongiosis ---------- Mycosis fungoides, granulomatous

-[ Basement membrane sometimes thickened, Discoid lupus erythematosus

Lymphocytes predominate smudged interface, thinned epidermis

vaCUOlar-{ Individual necrotic keratmocytes, ballooninq, parakeratosis Mucha-Habermann disease

Neutrophils and Individual necrotic keratmocytes, batlooninc ----------- Fixed drug eruption

eosinophlls prominent

Perivascular only

SUPERFICIAL AND DEEP PERIVASCULAR DERMATITIS

Polymorphous light eruption, early/ Erythema figuratum

, { No other change Erythema chronicum migrans Pernir

Erythema nodosum (no subcutaneous fat in

Lymphocytes predominate superficial biopsy specimen)

Marked edema in papillary dermis ---~-~-------- Polymorphous light eruption

Abundant mucin in reticular dermis Discoid lupus erythematosus, tumid

Nuclei of lymphocytes crenulated Chronic lymphocytic leukemia

B-ceillymphoma

Eosinophils prominent ---- Wedge-shaped infiltrate ----------------- Arthropod assault and simulators of it'

Plasma cells prominent' Erythemachronicum migrans

Histiocytes and ' - Scleroderma

lymphocytes prominent Leprosy, indeterminant

Perivascular and interstitial

Lichenoid

{ Neutrophils splayed between collagen bundles in focus in reticular dermis -- Suppurative folliculitis (periphery of lesion)

Neutrophils in and around eccrine glands Neutrophilic eccrine hidradenitis

,', Wedge-shaped infiltrate Fleabite

Neutrophils prominent Sparse infiltrate, neutrophils splayed between collagen bundles in reticular -- Cellulitis

dermis

Rims of homogeneous material around venules in upper Erythropoietic proto porphyria

~~~m~ ,

Lymphocytes predominate

Eosinophils sometimes, focal parakeratosis Lichenoid drug eruption

Individual necrotic keratinocytes sometimes ----------- Lichenoid photodermatitis

Individual necrotic keratlnocytes, ballooning, spongiosis Mucha-Habermann disease

Thickened basement membrane, smudged appearance of interface, Discoid lupus erythematosus

thinned epidermis focally

Thinned epidermis, prominent granular layer, parakeratosis Graft vs. host reaction

Abnormal lymphocytes in wedge-shaped infiltrate, often plasma cells, --- Lymphomatoid papulosis eosinophils, and neutrophils, as well as small lymphocytes

Lymphocytes in epidermis, scant spongiosis ----------- Mycosis fungoides, plaque

Neutrophils, eosinophils, and -- Abnormal lymphocytes in wedge-shaped infiltrate Lymphomatoid papulosis

plasma yells prominent : "

{Ballooning only -- Lymphocytes predominate Hydroa aestivale/Hydroa vacciniforme

BALLOON _ [ Steel-gray nuclei, margination of chromatin Herpesvirus infection

ING Interface:' Lymphocytes predomlnate-e- Individual necrotic keratinocytes, neutrophils,and eosinophils ------ Fixed drug eruption

among predominant lymphocytes

Spongiosis --- Lymphocytes predominate -- Individual necrotic keratinocytes and neutrophils ---------- Toxic shock syndrome as solitary units in epidermis

-[ Lymphocytes predominate -c:: Sparse perivascular infiltrate of lymphocytes ~-- Photoallergic dermatitis, early

Spongiotic only Moderately dense perivascular infiltrate of lymphocytes -- Polymorphous light eruption

Eosinophils prominent Wedge-shaped infiltrate, eosinophils in reticular dermis mostly Arthropod assault and simulators of it'

Eosinophils in papillary dermis mostly Bullous pemphigoid/Herpes gestationis, urticarial

Psoriasiform -' -- Lymphorlytes predominate -'-C Spongiosis prominent Photoallergic dermatitis

" Sponpiosis scant Mycosis fungoides, plaque

{ Neutrophils and eosinophils in addition to lymphocytes, Fixed drug eruption

spongiosis and ballqonlng prominent

Lichenoid ---- Lymphocytes predominate Neutrophils often in addition to lymphocytes, prominent spongiosis --- Dermatophytosis

Plasma cells prominent, scant spongiosis Acrodermatitis chronica atrophicans

Plasma cells not prominent. scant spongiosis Mycosis fungo ides, plaque

:,

Psoriasiform --- Lymphocytes predominate---, Lymphocytes in epidermis, scant spongiosis ---------- Mycosis fungoides, plaque

lichenoid ' [ Hyphae in cornified layer ----------------- Dermatophytosis

Innumerable mites, progeny of mites, and detritus of mites ------ Norwegian scabies

Psoriasiform --- Lymphocytes predominate - Mixed-cell infiltrate with predominance of lymphocytes, Persistent light eruption, persistently rubbed

only signs of lichen simplex chronicus, including multinucleate (actinic reticuloid) and stellate-shaped fibrocytes

Mounds of parakeratosis ----------------- Pityriasis rosea, herald patch

, [ Periadnexal infiltrate,' .lndivicual necrotic keratlnocytes --------- Lichen striatus

-[ Lymphocytes predominate - W' b " ' ,

L' h 'd uy undies of collagen In upper part of dermis, MYCOSIS tunqoldes. plaque

IC enol Histiocytes and, sometimes, lymphocytes in epidermis

plasma cells predominate ' Syphilis, secondary

---------~--

• Arthropod assault and simulators of it include insect bite, scabies, cutaneous larva migrans, cercarlal dermatitis, reactions to caterpillar hairs, and coral dermatitis.

I J

NODULAR DERMATITIS

NODULAR AND DIFFUSE DERMATITIS

---[ Small lymphocytes mostly --- "Top heavy" usually Pseudolymphoma

Lymphocytes

predominate Abnormal lymphocytes mostly, -- "Bottom heavy" often ---------------- Lymphoma, e.g., B-cell and some T-cell types,

at least in foci . e.p, mycosis funqoides, angiocentric

-{ No fibrin In walls of venules -------------- Sweet's syndrome/lnflammatory bowel disease!

Rheumatoid neutrophilic dermatitis

{ Nonsuppurative Leukocytoclastic vasculitis, acute,

e.g., Henoch-Schdnlein purpura,

Fibrin In walls of venules Churg-Strauss allergic granulomatosis

Neutrophils Leukocytoclastic vasculitis, chronic.

predominate e.q., Granuloma facialel

Erythema elevaturn diutinum, early

[Solitary collection Follicular cyst, ruptured

Suppurative --------1. Acne conglobatal

Collections Acne keloidalisl

Dissecting cellulitisl

Neutrophils, Hidradenitis suppurativa

eosinophils, and

plasma -------------- Nuclear "dust" of neutrophils ,-------------- Granuloma faciale/Erythema elevaturn diutinum

cells prominent L Karyophagocytosis Granuloma gluteale infantum

Eosinophils and { Small lymphocytes mostly --'- "Top heavy" usually Pseudolymphoma

plasma cells Abnormal lymphocytes "Bottom heavy" often Lymphoma, e.q., mycosis fungoides

prominent mostly, at least in foci

--f Few foci in dermal papillae Lichen nitidus

,. Periadnexal infiltrate, Lichen striatus

Interface, lichenoid necrotic epidermal keratinocytes

Many foci in papillary ------ Sarcoidosis - dermis, no epidermal change

Histiocytes predominate

L Sarcoidosis

-{ No foreign body - "Naked tubercle" -------1 Crohn's disease

Sarcoidal -------+- Dermal/ Melkersson-Rosenthal syndrome

Subcuta-

neous __r Polarizable Silica granuloma

Foreign body L

Nonpolarizable Tattoo material, e.u., mercury, cobalt

Perifollicular ------------------- Rosacea, granulomatous

Perineural -~~----------------- Leprosy, tuberculoid and dimorphous Tuberculosis:

- Verrucous, hyperkeratotic ---- Primary cutaneous

Necrosis slight to moderate t.upus vul,garis

Necrosis severe - Scrofuloderma

Miliary

Tuberculoid ----------;------__,

. . _ . I Leishmaniasis, chronic cutaneous Plasma cells numerous ~ Syphilis, late secondary Brucellosis

, -{ ~eu~~~:a::::~~:::~:earIY' thickened bundles late ------- ~~~~~~~~~fSal~~~i~i~ea

Degenerated collagen, cholesterol clefts, lipophages Necrobiotic xanthogranuloma

P I, d d Degenerated collagen, fibrin, nuclear "dust" of neutrophils, Systemic lupus erythematosusl

a rsa e ghost of venule in center Rheumatoid disease

Fibrin Rheumatoid nodule

Urn~ G~

Vasculitis, fibrin, necrosis Papulonecrotic tuberculid

Collagen bundles different from normal human ones Zyderm (bovine collagen) reaction

{ Squames Follicular cyst, ruptured

Specific infectious agent _j- Metals .

not identifiable Tattoo materials, e.q., mercury, carbon

Splinters

Oth f . b d' Sutures

er oreiqn 0 ies . Cactus spines

Silica

Starch

Drug injections

-Talwin

Botryomycosis Blastomycosis-like pyoderma Rhinoscleroma

Specific infectious agent identifiable

Bacterial ----------1

- Scrofuloderma

Mycobacterial --------1 Atypical mycobacterial infections

I Actinomycosis

Actinomycotic --------1L Nocardiosis

Streptornycosis

-----1- Cryptococcosis Histoplasmosis Blastomycosis

Fungal, deep . Paracoccidioidomycosis

Chromornycosis Coccidioidomycosis Sporotrichosis

- Rhinosporidiosis

--l-Kerion Eumycetoma

Fungal, other than deep Phycomycosis

Alternariosis

- Dermatophytosis (Majocchi's granuloma)

Yeast ------------ Candida granuloma Parasitic ----------1 Protothecosis

- Amebiasis

(continued)

DIFFUSE DERMATITIS

NODULAR AND DIFFUSE DERMATITIS (Con!.)

["Top heavy" usually, small lymphocytes ---------~---- Pseudolymphoma mostly, mixed-cell infiltrate

Lymphocytes ---------1

predominate "Bottom heavy" often, abnormal lymphocytes --------,----c---- Lymphoma. e.q., B-cell and some T~cell types,

mostly, at least In fOCI, monomorphous infiltrate e.q., mycosis tunuotdes, anqiocentnc

Neutrophils ------------1 predominate

[ Nonsuppurative Sweet's syndrome/Inflammatory bowel disease/

No vasculitis --------1. Rheumatoid neutrophilic dermatitis

Suppurative with remnant of follicle ----c :Pyoderma gangrenosum

, Follicular cyst, ruptured

Vasculitis (leukocytoc'astic) .,_-----c.._- Granuloma faciale/Erythema elevatum diutinum

Neutrophils ----~------ Nuclear "dust" of neutrophils, fibrin in walls of venules ---------- Granuloma faciale/Erythema elevatum diutinum and

eosinophils [ Infectious agent identifiable -----c Macrophages containing Frisch bacilli -- Rhinoscleroma

prominent by hematoxylin and eosin Macrophages containing Leishmania -- Le.ishmaniasis, cutaneous and mucocutaneous

Plasma cells ----------1. Syphilis, primary

prominent Chanoroid

Infectious agent not identifiable Granuioma inguinale

. by hematoxylin and eosin' Lymphogranuloma venereum Pseudolymphoma ("plasmacytoma") Granuloma faciale/Erythema elevatum diutinurn

Mast cells ----------------------,'-------------------- Urticaria pigmentosa, nodular

predominate

Abnormal leukocytes Myelocytes Extramedullary hematopoiesis Lymphocytes -,----------------------- Pseudolymphoma (sometimes)

Hlstiocytes predominate

'--------- Granulomas throughout the dermis --. -. Lymphoma, e.u., mycosis fungoides,

and, sometimes, 'subcutaneous fat granulomatous

Botryomycosis Blastomycosis-like pyoderma Rhinoscleroma

" _-{ ~~~~~da granuloma

Fungal, other than deep Eumycetoma

Phycornycosls Alternariosis

Dermatophytosls (Majocchi's granuloma)

Protcthecosis

Xanthelasma Xanthoma:

Eruptive Tuberous/tendinous Planar/plantar

Xanthoma disseminatum Verruciform xanthoma

Xanthogranuloma (including reticulohistiocytic granuloma and benign cephalic histiocytosis) Generalized eruptive histiocytoma Malacoplakia

Silicone granuloma

Paraffinoma

Virchow cells ----------------------------------1- Leprosy, lepromatous and dimorphous

(abundant gray-blue finely - Atypical mycobacterial infections

granular cytoplasm)

Siderophages ---------------------------------- Dermatofibroma, early Histiocytosis X, e.g., Letterer-Siwe/

Hand-Soh jj lie r -Ch ristian/Eosi nop h i I ic gran u I 0 ma Congenital self-healing reticulohistiocytosis

Gigantic multinucleate cells in large numbers ----------------------- Granulomatous slack skin (mycosis Iunqo.des)

Bacterial -----------1

\

- I nfectious agent identifiable by hematoxylin and eosin

Actinomycotic --------

Neutrophils prominent (suppurative)

Infectious agent not identifiable by hematoxylin and eosin

Parasitic -----------1

Mycobacterial---------1

{No histiocytic giant cells Lipophages prominent (foamy cytoplasm)

Histiocytic giant cells --------------------1

l.anperhans' cells -------

Actinomycosis Nocardiosis Streptomycosis

Cryptococcosis Histoplasmosis Blastomycosis Paracoccidicldornycosis Chromomycosis Coccidioidomycosis Sporotrichosis Rhinosporidiosis

Amebiasis

Acne.conglobataJ

Acne keloidal is/

Hidradenitis suppurativa/ Dissecting cellulitis of the scalp/ Pilonidal sinus

Follicular cyst, ruptured, and other foreign body reactions Halogenoderma

Tuberculosis cutis verrucosa Atypical mycobacterial infections

Neither leukocytoclastic nor septic vasculitis, i.e.,

fibrin in walls of venules and thrombi in lumina of same vessels Livedo vasculitis

Fibrin in walls, nuclear "dust," thrombi in lumina of different vessels --- Behcet's syndrome

-{ Lymphocytes only Systemic lupus erythematosus

Lymphocytes and eosincphlls ---. ------------ Arthropod assault and simulators of it (episodic)

Lymphocytes .

Abnormal lymphocytes, eosinophils, Lymphomatoid papulosis (episodic)

neutrophils, and plasma cells often

In the center of palisades:

Mucin Granulorna annulare

__ Lymphocytes Degenerated collagen .' Necrobiosis lipoidica, early

and histiocytes Crowded thickened bundles of collagen ------------ Necrobiosis lipoidica, late

Extensive degeneration of collagen, necrosis of inflammatory cells Necrobiotic xanthogranuloma

Fibrin --"----------"---------'------- R~eumatoid nodule

[ DiSS. erninatedintravascular coagulation!

{Thrombi' only . Thrombotic thrombocytopenic purpura!

------------------~ Coumarin-inQuced necrosis/

(not true vasculitis) Paroxysmal nocturnal hemoglobinuria/

Antiphospholipin syndrome Intravascular occlusion

with no infiltrate . . Occlusion by globulin Waldenstrom's macroglobulinemia

-- (simulator of vasculitis) (not true vasculitis) M?noclonal (type 1) cryoglobulinemia

Occlusion by cholesterol Cholesterol emboli

(not true vasculitis)

Arteriole -- Neutrophils early, -------------__;_--------------- Dkgos' disease IYIll phocytes later

[Vein --C Leukocytoclastic ----------------------------- Wegener's granulomatosis

Large Nonleukocytoclastic Thrombophlebitis

- vessel

___j Leukocytoclastic ----------------------------- Polyarteritis nodosa Artery~

Nonleukocytoclastic ~odular vasculitis

VASCULITIS

Leukocytoclastic vasculitis, l.e., nuclear "dust" of neutrophils, -----j fibrin often in walls of vessels

Venule

Septic vasculitis, l.e., -----------------1 thrombi in lumina

- Small vessel

VASCULITIS

Acute:

Henoch-Schonlein purpura! Finkelstein's disease/

Churg-Strauss allergic granulomatosis/ Wegener's granulomatosis/

Mixed cryoglobulinemia (types 1, 2) Hypergammaglobulinemic purpura of Waldenstrom Drug induced/

Malignancy induced/

Hypocomplementemia vasculitis/

Systemic lupus erythematosus/

Rheumatoid arthritis/

Serum sickness

Erythema nodosurn leprosum Lucio's phenomenon

Lues maligna

Herpesvirus infection (episodic)

Chronic:

Granuloma faciale/ Erythema elevatum diutinum

I Chronic gonococcemia!

I Chronic meningococcemia Subacute bacterial endocarditis Staphylococcal septicemia Pseudomonas septicemia

Rocky Mountain spotted fever Rickettsial pOX

-{Focal

Suprabasal Pemphigus vulgaris

[Epidermis mostly cohesive Drug-induced pemphigus foliaceus,

_ Diffuse --------1 e.g., penicillamine, rifampin

Epidermis mostly acantholytlc, at least In fOCI ----------- Hailey-Hailey disease

- Friction blisters

--( Upper spinous/ ---------------------------------------1 Epidermolysis bullosa,

Cleaving gr~nular - Weber-Cockayne type

Intrabasalar Epidermolysis bullosa simplex

Hyphae ---------------------- Dermatophytosis

Pseudo hyphae Candidiasis

Histiocytes and plasma cells Syphilis, rupial

No other findings Psoriasis, pustular and variants'

[Bacteria within pustules Impetigo and bullous impetigo

INTRAEPIDERMAL -[ Acantholysis --------1 Pemphigus foliaceus

PUSTULAR -+_ No bacteria within pustules Staphylococcal scalded-skin

Subcorneal syndrome

DERMATITIS

No acantholysis ------ Neutrophils in tense vesicles ---------------- Miliaria crystallina

Hyphae Dermatophytosis

Allergic contact dermatitis/ Nummular dermatitis! Dyshidrotic dermatitis!

Id reaction, impetiginized

- Ballooning

Spongiosis

INTRAEPIDERMAL VESICULAR DERMATITIS

Acantholysis

INTRAEPIDERMAL VESICULAR AND PUSTULAR DERMATITIS

Distinctive ----------------1 cytologic features

Steel-gray nuclei, margination of chromatin ----------- Herpesvirus infections

Basophilic cytoplasmic inclusions Orf!milker's nodule

Eosinophilic cytoplasmic inclusions , Vaccinia!variola

Pellagra!

Necrolytic mioratory erythemal Acroderrnatltls enteropathica! Hartnup's disease!

Deficiency disease (zinc, biotin) Pachyonychia congenita Immersion blister

No distinctive cytologic features

{No Interface changes on volar skin or mucous membrane ------- Hand-foot-and-mouth disease No Interface changes, confluent necrosis of keratinocytes, normal

cornified layer, lymphocytes and neutropnils Irntant contact dermatitis

No Interface changes, indiVidual necrotic keratinoeytes, normal

Ballooning In midepiderm's cornified layer, lymphocytes and neutrophile ----------- Phototoxic dermatitis

Interface changes, lncividua: necrotic keratlnocytes, normal cornified layer -- Erythema multiforme

Interface changes, individual necrotic keratlnncytes, parakeratosis Mucha-Habermann disease

Interface changes, individual necrotic keratlnocytes, normal cornified layer,

lymphocytes, neutropnils, and eosinophils Fixed drug eruption, early

- Allergic contact dermatitis!

Nummular dermatitis!

[Superficial infiltrate Dyshidrotic dermatitis!

Id reaction, early

Lymphocytes --

Hyphae in cornified layer ---------------------------- Dermatophytosis

Vacuolar alteration, ballooning, necrotic keratinocytes Erythema multiforme

Superficial and deep infiitrate Photoallergic dermatitis, early

- Bullous pemphigoid!

_{ Without striking intraepidermal vesiculation usually Herpes gestation is! - Pemphigus vulgaris

Eosinophils Allergic contact dermatitis!

Intraepidermal vesiculation . Nummular dermatitis

Incontinentia pigmenti Dermatophytosis (uncommon) Focus of spongiosis and/or intraepidermal vesicle

above apex of wedge-shaped infiltrate ----------------------- Arthropod assault and simulators

of it

Neutrophils ---- Hyphae --------------------------------- Dermatophytosis

Neutro.phils Interface changes, ballooning, necrotic keratinocytes Fixed drug eruption

- and eosinophils

Bacteria in blister Bullous impetigo

Pemphigus foliaceus

Drug-induced pemphigus foliaceus, e.q., penicillamine, rifampin Stapylococcal scalded-skin

syndrome

Steel-gray nuclei --------------_;_---- Herpesvirus infections

No steel-gray nuclei Blister beetle (cantharidin) dermatitis

- Uppermost spinous! ------------1 granular

No bacteria in blister ------------------1

Midspinous ---------------1

Eosinophils, no spongiosis, no crusts ------------- Darier's disease Eosindphils, spongiosis, often crusts Grover's disease

Intracorneal,

subcorneal, --1

or intraspinous

(or all together)

Spongiotic vesicles -------------1 associated

No hvptae -------------------j

SUBEPIDERMAL l/ESICULAR DERMATITIS

SUBEPIDERMAL VESICULAR DERMATITIS

Little or no infiltrate -------------1

Epidermolysis bullosa, junctional Epidermolysis bullosa, dermolytic

Epidermolysis bullosa, acquired (one manifestation)

Bart's syndrome

Necrosis of adn~xal epithelia Hypoxemia plus pressure

Necrosis of epidermis with no infiltrate ------- Burn, acute

Necrosis of epidermis with scant infiltrate Erythema multiforme, severe

- No other findings --------------1

F t h'l d ' h'l ---------1 Bullous pemphigoid/

ew neu rop I s an eosrnop IS - Herpes gestationis, cell poor

-{ Porphyria cutanea tarda

Dermal papillae preserved, perivenular Variegate porphyria

rims of homogeneous material, extensive Erythropoietic proto porphyria,

solar elastosis - e,g" drug induced and dialysis induced

Hepatoerythropoietic porphyria

Papillae preserved ------------- Suction blister

Globules of amyloid in upper part of dermis Bullous amyloidosis

Subepidermal fibrosis Blister above a scar

Fringe of basal cells, elongated thin nuclei of ----- Blister secondary to electrodesiccation

- spinous cells perpendicular to skin surface

Ballooning and individual necrotic keratinocytes ---- Erythema multiforme

Sclerosis of thickened papillary dermis, Lichen sclerosus et atrophicus (morphea)

thick collagen bundles in upper part of reticular dermis,

many erythrocytes in blister sometimes

Ballooning, individual necrotic keratinocytes ----- Mucha-Habermann disease

;

Wedge-shaped hypergranulosis of epidermis ----- Lichen planus, bullous at sides of blister

I Bullous pemphigoid/

[ Eosinophils in papillary dermis and in blister -----IL Herpes gestationis

Acquired epidermolysis bullosa (one manifestation)

Eosinophils prominent ------------1

Eosinophlls In Interstitium, of reticular dermis In Arthropod assault and simulators of it

company with lymphocytes (usually in

conjunction with intraepiderrnal vesicle)

[Dermatitis herpetiform is/

____ -I Dermatitis herpetiform is-like drug eruption/

Nuclear bands and "dust" of neutrophils, Linear IgA dermatosis

no abundant mucin in reticular dermis Acquired epidermolysis bullosa (one manifestation)

Nuclear bands and "dust" of neutrophils, ------- Systemic lupus erythematosus

abundant mucin in reticular dermis

Nuclear "dust" of neutrophils, ----~----- t.eukocytoclasnc vasculitis fibrin in walls of venules

Thrombi in dermal vessels Septic vasculitis

Dense diffuse infiltrate of neutrophils Pyoderma gangrenosum

Sparse interstitial infiltrate of neutrophils Cellulitis

in reticular dermis

Sparse infiltrate,of neutrophils in upper -------rC ~~~pO~;gP:s~ft~~~d(~ne manifestation) part of dermis, some eosinophils

Blister also along adnexal epithelium Cicatricial pemphigoid

- Dermatitis herpetiform is/

1- Nuclear bands and "dust" of neutrophils, ------I Dermatitis herpetitorrnis-like drug eruption

no abundant mucin in reticular dermis - Linear IgA dermatosis

Eosinophils and ---------------1

neutrophils prominent B II h d/H t t

Eosinophils and neutrophils in papillary dermis -----c u ous pemp Igol erpes ges a 10niS

- and in blister Acquired epidermolysis bullosa (one manifestation)

Eosinophils also if lesion traumatized

Mast cells ----------------- immediately, e.q. rubbed, before biopsy ------ Urticaria piqrnentcsa

___ _____,[ Bacterial

Sign of infectious .

cause identifiable Fungal-----------i

Viral-------------Herpesvirus infection

[Acne conglobatal Acne keloidalis/

[ r~ruunsdlb~~~~ ~fpi -th-e-lil-Im-------I Dissecting cellulitis of the scalp/

Hidradenitis suppurativa

No sign of infectious -------'-------1 No other findings Pyoderma gangrenosum, early

cause cronn's disease, early

Pseudocar clnornatous nyperplasi Halogenodermas

[Infundibulum plugged by corneocytes ---------------------- Fox-Fordyce disease

Spongiotic -1 Infundibulum not plugged by corneocytes Infundibulofolliculitis

Mucin in infundibula -----------1 Lymphocytes normal-------- Alopecia mucinosa

(and sebaceous epithelium sometimes) Lymphocytes abnormal-------- Mycosis fungoides

Infundibulum plugged by corneocytes Keratosis pilaris/Lichen spinulosus Phrynoderma

Lymphocytes Infundibulum plugged by corneocytes, hair spiraled ----------------- Scurvy

I Wedge-shaped hypergranulosis of infundibula Lichen planopilaris

I Basement membrane of epidermis and epithelial Discoid lupus erythematosus

PERIFOLLICULITIS adnexa thickened, epidermis thinned focally

t R=~

Histiocytes .! C No epidermal involvement Perioral dermatitis/Periocular dermatitis

(granulomatous) Epidermal Involvement, plasma cells In Infiltrate ------------------- Syphilis, secondary (acneiform)

Fibrocytes Wedge-shaped hypergranulosis of infundibulum Lichen planopilaris

(fibrosing) No hypergranulosis of infundibulum Keratosis pilaris/Lichen spinulosus

Suppurative

FOLLICULITIS

FOLLICULITIS ANO PERIFOLLICULITIS

Super ficia

Signs of infectious cause identifiable

Hematoxylin and eosin -- Bacterial------------I

Staphylococcal folliculitis Pseudomonas folliculitis

Hematoxylin and eosin -- Fungal------------- Dermatophytosis

Yeast Candidiasis

Hematoxylin and eosin -- Viral (steel-grey nuclei, ------- Herpesvirus infection margination of chromatin)

Silver _::_- ------- Spirochetal --------- Syphilis, secondary

Comedones -----------Acne vulgaris

[Folliculitis of renal dialysis Systemic medications, e.q.,

No comedones -------- corticosteroids, hydantoin, halogens

Exogenous agents, e.u., cutting oils, petrolatum, adhesives

No comedones, ----------Rosaceal

perifollicular infiltrate of Perioral dermatitis/Periocuiar dermatitis

lymphocytes and histiocytes

No comedones, altered elastic ----- Elastosis perforans serpiginosa fibers in intraepidermal channels

-----i[ Collections of eosinophils in epidermis --- Toxic erythema of the newborn Eosinophils

Collections of eosinophils in infundibula -c::: Eosinophilic pustular folliculitiS

". . Ofuiis syndrome

No sign of infectious cause

Furuncle Carbuncle Ecthyma

Folliculitis decalvans

"Hot tub" folliculitis (Pseudomonas)

Majocchi's granuloma

Favus

Oeep-

ALOPECIA (SCALP)

Inflammatory

ALOPECIA

Some follicles thinned and positioned higher in -- Androgenetic alopecia dermis than normal; in time, all follicles vellus

Lymphocytes predominate

{Normal number of follicles Noninflammatory

Decreased number of follicles --------------- Thickened collagen bundles in -------- Traction alopecia widened fibrous tracts

Most follicles normal, few follicles in ------ Telogen effluvium catagen or telogen

Trichomalacia ------------ Trichotillomania

Around base of follicles----------------------- Alopecia areata

Wedge-shaped hypergranulosis of infundibula --- Lichen planopilaris

Around infundibula mostly Smudged appearance of dermoepidermal Discoid lupus erythematosus junction beneath epidermis thinned focally

Nodules of lymphocytes and

plasma cells at junction of dermis Scleroderma

and subcutaneous fat, and at

junction of septa and lobules

-{ Bactenal (Gram +) ----------- Folliculitis decalvans Fungal (hyphae) -----------Tillea capitis

{Sign of infectious cause Majocchi's granuloma

Identifiable

Vlral---~------·-----ZosterNancella/Herpes simplex

Neutrophlls predominate (steel-gray nuclei, rnarqination of chromatin)

--[ SII1US tracts Dissectinp cellulitis

No sign of lntectlous cause Ulcers Burns

Necrosis of epidermal and adnexal epithelium --- Radiodermatitis, acute

Histiocytes and plasma cells --------------------------------- Syphilis, secondary predominate

Little or no infiltrate of inflammatory cells

Discrete whorls of thin collagen bundles in deep reticular dermis -------- Alopecia areata, late

Fibroplasia along thinned follicles, infundibular hypergranulosis ---------- Lichen planopllaris, late

Thickened basement membrane, thinned epidermis Discoid lupus erythematosus, late

l'hickened, crowded bundles of collagen parallel to skin surface in reticular dermis scleroderma, late

Coarse bundles of collagen and prominent venules parallel to skin surface Burn, late

Sclerosis throughout dermis, abnormal fibrocytes, thrombosed vessels often Radiation sclerosis, late

I Antecedents to tibrosts

Hbrocytes

FIBRDSING increased --------j

DERMATITIS in number

Fibrosis

FIBROSING DERMATITIS

Ulcer

Granulation tissue

Long-standing infiltrate of neutrophils in collections (suppuration)

Long-standing infiltrate of lymphocytes

Long-standing infiltrate of histiocytes (granulomatous)

Fibrocytes and fibrillary collagen bundles parallel to skin surface,---- Scar

venules perpendicular to skin surface' , ".

Fibrocytes and coarse collagen bundles parallel to skin surface,---- Lymphedema, chronic thick-walled venules perpendicular to skin surface

Fibrocytes parallel to markedly thickened collagen bundles in ----- Keloid haphazard array in reticular dermis, venules parallel to

collagen bundles

Fibrocytes amid coarse collagen bundles in haphazard array in ---- Dermatofibroma, late

reticular dermis, epidermal hyperplasia and hyperpigmentation often

Fibrocytes and -------- Fibrocytes, histiocytes, and coarse collagen bundles in ------- Dermatofibroma, fully developed

histiocytes haphazard array in reticular dermis, epidermal hyperplasia

increased in and hyperpigmentation often, induction of folliculosebaceous

number units sometimes

{Thin collagen bundles In haphazard arrangement In Anetoderma, e g , macular atrophy, striae dlstensae

circumscribed zone In reticular dermis

No sclerosis Thick collagen bundles In company with lichenoid Acrodermatitis chronica atrophicans

{Infiltrate of plasma cells

Fibrocytes Thick collagen bundles In center of palisaded Necrobiosis lipoidica

decreased granulomas In reticular dermis and septa of fat

In number

-[ Alteration papillary dermis beneath thickened collagen bundles In --- Lichen sclerosus et atrophlcus (morphea)

SclerOSIS upper part of reticular dermis

- Alteration throughout dermis In conjunction with abnormaJ ttbrocytes -- Radiation sclerosts

PANNICULITIS

Mostly septal

PANNICULITIS

-[ Small vessel ---------Venules ------'----------- Leukocytoclastic vasculitis

Vasculitis

Vein --------------- Thrombophlebitis

Large vessel --------' Artery Polyarteritis nodosa

--c= Granulomatous Inflammation In septa ----- Necrobiosis lipoidica*

{Lymphocytes and plasma cells

No granulomatous inflammation In septa Scleroderma

Mucin In center of palisaded granulomas ---- Granuloma annulare, subcutaneous No vasculitis

Fibrin In center of palisaded granulomas Rheumatoid nodule

Extensive degeneration of collagen, ------ Necrobiotic xanthogranuloma

Histlocytes mostly lipophaqes cholesterol clefts necrosis

(granulomatous) of Inflammatory cells In center of palisaded granulomas

Without mucin, fibrin, or degeneration of ---- Erythema nodosum collagen, but with radial granulomas in septa

. I Small vessel--------- Venules, globi numerous

Vasculitis ~

Large vessel--------- Artery --------------1

Erythema nodosum leprosum Lucio's phenomenon

Nodular vasculitis

Crohn's disease

No vasculitis

- Mostly lobular

'Vasculitis only in early lesions.

Few or no inflammatory cells ---- Needle-shaped clefts in adipocytes ------Sclerema neonatorum

Lymphocytes predominant Superficial and deep perivascular ------ Cold panniculitis dermal infiltrate

Lymphocytes abnormal ----------------------~ tvrnphorna, e.g., mycosis fungoides, angiocentric

Lymphocytes, plasma cells, -----------,---_------ Lupus erythematosus profundus

nuclear "dust" of lymphocytes often

. [ Extensive fat necrosis with -------- Pancreatic panniculitis Neutrophils ----------1. signs of saponification

No other findings Factitial panniculitis

Bacterial infections

Causative organisms identifiable ------- Mycobacterial infections by specialized stains

Neutrophils and histiocytes

(suppurative granulomatous Causative organisms identifiable -------4C Deep fungal infections

with hematoxylin and eosin usually Parasitic infections

I' Focal --- Sarcoidosis

[No needle-shaped ----'L Patchy --- Traumatic fat necrosis

Histiocytes _' clefts in adipocytes Diffuse --- Lipodystrophy

(granulomatous) Needle-shaped clefts mostly In histiocytes, --- Subcutaneous fat necrosis/

sometimes in adipocytes Poststeroid panniculitis

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