Dermatopathology

Kuliah-1 / Blok DMS

Dr. H
Dr H. Soekimin
Soekimin, SpPA
Dr. T. Ibnu Alferraly, SpPA
Departemen
p Patologig Anatomi
FK USU
Makroskopis Jaringan Kulit
Makula ( Macule ) : ruam bulat pada kulit, ukuran bervariasi, datar, perbedaan warna dgn
kulit sekitar

Papula ( Papule ) : daerah kulit dgn elevasi solid 5 mm

Nodul ( Nodule ) : daerah kulit dgn elevasi solid 5 mm

Plak ( Plaque ) : daerah kulit dgn elevasi

elevasi, permukaan datar
datar, 5 mm

Vesikel ( Vesicle ) : daerah kulit yang berisi cairan, 5 mm

Bula ( Bulla ) : vesikel besar

besar, 5 mm

Blister : istilah untuk vesikel atau bula

Likenifikasi
f ( Lichenification
f ) : penipisan daerah kulit, batas jelas, akbt
pengikisan yg ber-ulang

Ekskoriasi ( Excoriation ) : - lesi akibat trauma

- kerusakan
k k epidermis
id i (ddeep scratch
h)
- sering ok self-induced
 Papule: Raised dome shaped lesion less than 0.5 cm. (Common Nevi,
Moles, Cherryy angioma,
g Sarcoidosis

Plaque: A slightly raised area which is not very deep with a flat top and >0.5
cm . (Psoriasis)
( )

Xanthelasma: Lipid deposits around the eyes.

Wheal: Firm, edematous (peau de orange) plaque. Evanescent and pruritic.

(Hives)

Macule: A flat area of discoloration

discoloration, between 0
0.5-1
5 1 cm in size
size. (freckles) bluish
(freckles),
macule (Mongolian spots).

Patch:
atc Macule larger
g than 1 cm in size. Monocytic
y Leukemia

Maculo-papular lesion: Characetristics of macule and papule. (

Sarcoidosis Malignant Melanoma
Hypereosinophilic syndrome
syndrome, Lymphoma )
Rash
Desquamation
 Striae: Prior stretch (pregnancy, loss of obesity, Gardner Diamond syndrome)

Excoriation: Infection (Scabies), primary skin disease (Eczema), Systemic

disease (Hodgkin's disease, Liver disease)

Scale: Flake of flat horny cells which is loosened from the cells below
(Psoriasis)

Crust: Dried serum, blood or superficial skin cells or a mixture of (Squamous

cell cancer)

Scar: Reflects healing

Atrophy:
p y Loss of substance of Skin. Thinningg of epidermis,
p , dermis or
subcutaneous tissue. Ehler's Danlos syndrome

Lichenification: Thickened skin with increased skin markings (Lichen

simplex chronicus)

Keloid: Exuberant scar formation

 Vescicle: Dome shaped, thin wall, less than 05.cm in diameter, filled with fluid
(Leukemia cutis)

Pustule: Vescicle filled with pus. Less than 0.5 cm in size. (Acne pustule)

Blister: Vesicle larger than 0.5 cm

Bullae: Gas gangrene.

Cyst: Deeply seated fluid (pus

(pus, blood or fluid) filled cavity.
cavity < 0.5
0 5 cm in size.
size
Fluctuation present.

Fissure: Leniar cleavage in skin. Dermis exposed, hence painful.

Ulcer: Hole in skin. Heals with scar when it is not malignant. (Squamous cell
cancer)

E ti
Erotion: L
Less d
deeper than
h ulcer
l

Telangiectasia: a small spidery superficial vascular lesions. Blanches with pressure.

(normal in children and women. Liver disease)

Petechiae: Extravasation of blood. Does not blanch with pressure. <0.5 mm

Vesicle/ Bullae
Clinical findings of the proband. (a) Confluent vesicles and bullae on the palms
and
d llateral
t l aspects
t on ththe fifingers. (b) D
Desquamation
ti on th
the palms.
l ((c)) Confluent
C fl t
vesicles on the sole. (d) Histological results showing spongiosis and spongiotic
vesicles (hematoxylin and eosin staining).
Purpura

Fisure
Fi
 Fissure (fish Your), Erosion, And Ulcer

A fissure is a thin but

deep linear split in the
epidermis that e extends
tends
into the dermis. Severe
dry skin can have
fissures. An erosion is a
depressed lesion that is
wider than a fissure but
not as deep. An erosion,
which is usually moist,
may result from a
ruptured vesicle or bulla.
An ulcer is a deep
erosion in which all of the
epidermis and part of the
dermis are eaten away
(eroded). A bed sore is
an ulcer. Ulcers often
leave scars.
scars
Macula
Telengiectasi
g
Ulcer
Mikroskopis Jaringan Kulit
AKANTOLISIS :
The loss of cohesion between epidermal or adnexal keratinocytes

Example of acantholysis in Pemphigus Foliaceus

AKANTOSIS

The increase in the thickness of the stratum malpighii

Examples of acanthosis in
Psoriasis

Lichen Simplex
Chronicus
Acanthosis Nigricans: Velvety appearing,
appearing hyperpigmented skin skin.
Associated with diabetes and a number of other disorders.
Multiple skin tags also seen in this picture of the axillary region.
ANAPLASIA

The atypical appearance of nuclei as is found in malignant neoplasia.

Anaplastic nuclei are usually large, irregular and hyperchromatic, and may
produce bizarre or atypical mitotic figures.
APOPTOSIS

The dropping off of colloid bodies from the epidermis into the dermis.
Apoptosis typically occurs in disorders in which basal cell damage occurs, such as
lichenoid tissue reactions

Lichen Plannus

Benign Lichenoid Keratosis

BULLA

A cavity of at least 5 mm in diameter forming within or below the epidermis

Example is a sub-epidermal bulla in Epidermolysis Bullosa

 EPIDERMOLITIK HIPERKERATOSIS
Also called granular degeneration. It is characterized by:

1. Peri-nuclear clear spaces

p in the upper
pp stratum malpighii
pg
2. Indistinct cellular boundaries
3. A markedly thickened granular layer with increased numbers of keratohyalin
4. Granules and hyperkeratosis
Actinic Keratoses
1.Acantholysis, 2. Hyperkeratosis, 3. Parakeratosis
Hypergranulosis is the most prominent feature in this
case.
EPITHELOID

Cells derived from macrophages, seen in granulomas and characterized by a large,

usually oval, pale, vesicular nucleus with a clearly visible nuclear membrane.
The cytoplasm is abundant,
abundant ill
ill-defined
defined and slightly eosinophilic.
eosinophilic
Multinucleated epithelioid or giant cells arise from mature macrophages
that fuse rather than divide.
Langhans giant cells have nuclei in a semicircle at the cell periphery.
Foreign body giant cells have nuclei distributed randomly.
GIANT CELL

Large multinucleated cells.

Epidermal multinucleated giant cells are characteristic of herpes virus infections.
Histiocytic giant cells whose nuclei form a horseshoe arrangement are called
Langhans type giant cells.
Touton type giant cells have a ring of nuclei surrounding foamy cytoplasm with
cytoplasm usually also visible around the nuclei.
Foreign-body giant cells have a haphazard nuclear arrangement
PARAKERATOSIS

Retention of nuclei in the stratum corneum.

This is a normal finding on mucous membranes
PLEOMORFIK

The variation in the appearance of the nuclei of the same cell type. If pronounced
and associated with large, irregular, hyperchromatic nuclei it is termed anaplasia
and is often an indication of malignancy.
VILLUS

A dermal papilla extending into a bulla, vesicle, or lacuna which is covered with a
single layer of epidermal cells resulting from suprabasalar acantholysis .
Example of Villus in Pemphigus vulgaris
REAKSI UMUM KULIT TERHADAP JEJAS (injury)
(i j )

Inflamasi Akut : dermis + epidermis

p ; kemerahan,, panas,
p , bengkak,
g , sakit

Penumpukan cairan antara keratinosit : Spongiosis

Spongiosis yg hebat : Vesikel ( penumpukan cairan terlokalisir )

Pembengkakan dermis : elevasi epidermis ( wheal formation )

Jejas berat : kulit Nekrosis

Epdermis Nekrosis : Ulcerasi
Dermis Nekrosis : gmbrn klinis beragam, tgtng struktur yg terlibat

Inflamasi Kronis :
- Penebalan epidermis : ACANTHOSIS
- penebalan Staratum Corneum : HYPERKERATOSIS
- Fibrosis dermis
Inflamasi Kulit Akut

- Terjadi dalam hitungan hari minggu

- Mikroskopis : sel2 mononuklear ( PMN ), neutrofil ( jarang ), oedem,

jejas pada : epidermis, pembuluh darah, sub-kutan

- Dapat berlanjut : kronis

Inflamasi Kulit Kronis

Inflamasi Kulit Akut
Urticaria
Skin lesions and pruritus occur, caused by an allergic or nonallergic mechanism.

Histamine is thought to be the most important biochemical mediator in urticaria.

Mast cells are the majorj histamine-releasingg cells of the skin.

The mast cell possesses high-affinity receptors for immunoglobulin E (IgE).
In allergic reactions, adjacent IgE molecules, which are bound to the surface of
mast cells by the high-affinity IgE receptors, are cross-linked by allergens, leading
to the release of histamine and other mediators
mediators.

Basophils also possess the high-affinity IgE receptor and may be involved in
urticaria.

Other inflammatory cells (ie, vide infra) are recruited into the lesional area in
urticaria, particularly in chronic urticaria. These cells can release cytokines and
chemokines that can cause histamine release or otherwise contribute to the
pathology.
 A lymphocytic infiltrate is commonly found in the lesions of both acute and
chronic types of urticaria.

Some urticarial lesions have a mixed cellular infiltrate, ie, a mixture of lymphocytes,
polymorphonuclear leukocytes (PMNs), and other inflammatory cells.

This mixed type of infiltrate seems to be particularly characteristic of certain

refractory forms of chronic urticaria, such as autoimmune-mediated urticaria.

The mixed infiltrate is similar to the histopathology of the allergic late-phase

late phase
response.

Some patients with particularly severe or atypical urticaria are found to

h
have vasculitis
li i on skin
ki bi
biopsy.
Indeed, a spectrum in histopathology seems to exist, ranging from lymphocytic to
vasculitic, that correlates approximately with disease severity, from mild to severe.
Eczematous Dermatitis Acute

Eczema : clinical term, embrace many conditions, many underlying causes

Early stage : red, papulovesiculer, oozing, crusted lesions

If persistence : Scaling Plaques (+)

Classification : - Allergic contact

- Atopic
- Drug Related Eczematous
- Photoeczematous
- Primary irritant forms
 Eczema Dermatitis

Histologic sections of skin show epidermal acanthosis with marked spongiosis,

spongiosis
leading to intraepidermal vesicle formation. The vesicles are filled with serum and
inflammatory cells.
 Eczema
Dermatitis

A higher power view reveals the nature of the infiltrate.

Associated with the spongiosis and vesicle formation are numerous eosinophils and
scattered neutrophils
Erythema Multiformis

Erythema multiforme (EM) is an acute self-limited eruption characterized by

a distinctive clinical eruption, the hallmark of which is the iris or target lesion.

EM may present within a wide spectrum of severity

severity.

EM minor represents a localized eruption of the skin with mild or no mucosal

involvement, corresponding to the initial description of von Hebra.

EM major and Stevens-Johnson syndrome (SJS) are more severe mucosal and
skin diseases and are potentially life-threatening disorders.
Erythema Multiformis

The early lesion of EM is characterized

by infiltration of lymphocytes at the
dermal-epidermal interface with
accompanying exocytosis and
spongiosis in the epidermis.

Individual eosinophilic necrotic

keratinocytes may be scattered and
surrounded by lymphocytes (satellite
cell necrosis).

The dermal changes

include edematous papillary dermis,
ectatic and swollen endothelial cells of
the vessels, and extravasation of the
red blood cells.
 Inflamasi Kulit Kronis
Psoriasis
Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin
with silvery scales.

Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong

genetic basis

Usually lesions on elbows, knees, scalp, back, face, palms and feet, but they can
show up on other parts of body.

A problem with immune system causes psoriasis. In a process called cell turnover,
skin cells that grow deep in the skin rise to the surface.
Normally,y this takes a month. In p
psoriasis, it happens
pp in jjust days
y because yyour cells
rise too fast.

Psoriasis can last a long time, even a lifetime. Symptoms come and go.
Psoriasis
Psoriasis

Epidermis
Mitotic activity of basal keratinocytes is increased almost 50-fold, with
keratinocytes migrating from the basal to the cornified layers in only 33-5
5 days
compared to the normal 28-30 days.

With hyperproliferation of skin cells, the epidermis becomes thickened or

acanthotic in appearance and an increase in size of the rete ridges is observed.

Abnormal keratinocyte differentiation is noted throughout the psoriatic plaques,

as manifested by the loss of the granular layer
layer.

The stratum corneum is also thickened, and the retention of cell nuclei in this
layer is referred to as parakeratosis.

Neutrophils and lymphocytes can be observed migrating upwards from the

dermis into the acanthotic epidermis. Neutrophils may form localized collections
known as Munro microabscesses
microabscesses. The presence of alternating collections of
neutrophils sandwiched between layers of parakeratotic stratum corneum is
virtually pathognomonic for psoriasis.
Munro microabscesses are composed of degenerated polymorphonuclear
leukocytes (PMN's) in the horny layer (stratum corneum) and are seen in
psoriasis and seborrheic dermatitis
Psoriasis
Dermis

Marked hypervascularity and an increase in the size of the dermal

papillae occur
occur.

An activated CD3+ lymphocytic infiltrate is noted around blood vessels, with

T cells expressing cutaneous lymphocyteassociated antigen, co-stimulatory
molecules such as CD2, and LFA-1 adhesion molecules.

An aggregation of neutrophils in the dermis occurs that extends up into the

epidermis.
 Lichen Planus

LP is a cell-mediated immune response of unknown origin

origin.

LP may be found with other diseases of altered immunity; these conditions

include ulcerative colitis, alopecia areata, vitiligo, dermatomyositis,
morphea, lichen sclerosis, and myasthenia gravis.

An association is noted between LP and hepatitis C virus infection, chronic active

hepatitis and primary biliary cirrhosis
hepatitis,

The histopathologic features distinguish LP based on the presence of irregular

acanthosis and colloid bodies in the epidermis with liquefactive degeneration
and linear fibrin deposition in the basal layer. The upper dermis has a bandlike
infiltrate of lymphocytes and histiocytes.
Lichen Planus

The inflammatory reaction pattern is characteristic.

The epidermis is hyperkeratotic with irregular acanthosis and focal thickening in
the granular layer
layer.

Degenerative keratinocytes, known as colloid or Civatte bodies, are found in

the lower epidermis.
In addition to apoptotic keratinocytes, colloid bodies are composed of globular
deposits of IgM (occasionally immunoglobulin G [IgG] or immunoglobulin A [IgA])
and complement.

Linear or shaggy deposits of fibrin and fibrinogen and liquefaction are in the
basement membrane zone.
Lichen Planus
 Lichen Simplex Chronicus
LSC is found on the skin in regions accessible to scratching.
Pruritus provokes rubbing that produces clinical lesions, but the underlying
pathophysiology is unknown.

Some skin types are more prone to lichenification, such as skin that tends toward
eczematous conditions (ie, atopic dermatitis, atopic diathesis).

A relationship likely exists between central and peripheral neural tissue and
inflammatory cell products in the perception of itch and ensuing changes in LSC.

The possible interplay among primary lesions

lesions, psychic factors
factors, and the intensity of
pruritus additively influence the extent and severity of LSC.

Histologic examination demonstrates hyperkeratosis, acanthosis, spongiosis, and patches

of parakeratosis in the epidermis.

Epidermal thickening of all layers is noted, with elongation of rete ridges and with
pseudoepitheliomatous hyperplasia. Papillary dermal fibrosis with vertical streaking of
collagen bundles is characteristic.

A characteristic finding of LSC that is noted on electron microscopy is frequent

collagen fibers attached to and just above the lamina basalis