Nonneoplastic Dermatopathology -

eBook PDF
Visit to download the full and correct content document:
https://ebooksecure.com/download/nonneoplastic-dermatopathology-ebook-pdf/
 SECOND EDITION

HALL | COCKERELL
CHISHOLM • JESSUP • VANDERGRIFF • MOTAPARTHI • ELSTON
ii
 SECOND EDITION

Brian J. Hall, MD
Dermatopathologist
Utah Pathology Services, Inc.
Adjunct Assistant Professor, Department of Pathology
University of Utah School of Medicine
Salt Lake City, Utah

Clay J. Cockerell, MD
Clinical Professor of Dermatology and Pathology
Director, Division of Dermatopathology
University of Texas Southwestern Medical Center
Dallas, Texas

Cary Chisholm, MD Kiran Motaparthi, MD

Dermatopathologist
Central Texas Pathology Laboratory
Waco, Texas
Chad Jessup, MD, MS
Instructor
Department of Dermatology
Massachusetts General Hospital
Boston, Massachusetts
Travis Vandergriff, MD
Assistant Professor of Dermatology and Pathology
University of Texas Southwestern Medical Center
Dallas, Texas
Assistant Professor
Department of Dermatology
University of Florida College of Medicine
Gainesville, Florida
Dirk M. Elston, MD
Professor and Chairman
Department of Dermatology and Dermatologic Surgery
Medical University of South Carolina
Charleston, South Carolina

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC PATHOLOGY: NONNEOPLASTIC DERMATOPATHOLOGY, SECOND EDITION ISBN: 978-0-323-37713-3

Copyright © 2017 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

Publisher Cataloging-in-Publication Data

Names: Hall, Brian J. (Brian John), 1981-

Title: Diagnostic pathology. Nonneoplastic dermatopathology / [edited by] Brian J. Hall
Other titles: Nonneoplastic dermatopathology.
Description: Second edition. | Salt Lake City, UT : Elsevier, Inc., [2016] | Includes
bibliographical references and index.
Identifiers: ISBN 978-0-323-37713-3
Subjects: LCSH: Skin--Diseases--Diagnosis--Handbooks, manuals, etc. |
MESH: Skin Diseases--pathology--Atlases. | Skin Diseases--diagnosis--Atlases.
Classification: LCC RL105.D53 2016 | NLM WR 17 | DDC 616.5’075--dc23

International Standard Book Number: 978-0-323-37713-3

Cover Designer: Tom M. Olson, BA
Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To my wife, Jamie, our Great Dane, Sadie, and all the wonderful, bright, hard-working,
and dedicated authors who I have gotten to know over the years and have the pleasure of
considering my close friends. I also want to thank all the contributors as well as authors for
their selfless giving of images for chapters that were not their own. This book would not be
possible without everyone listed in the table of contents as well as on the contributors page.

BJH

To my wife, Brenda, and children, Charlie and Lily, who have supported me so much
in my life and in my career.

CJC

To my wife and kids, thank you for your unwavering love and support. For all the other
contributors, thank you for your hard work and dedication to produce such a high-quality
dermatopathology text. To me, Brian, and Travis: Strong work you rugged, chiseled gentlemen.

CC

I would like to thank my incredibly loving and supportive wife, Clarissa, whose sacrifices have
allowed me to work on this book. Equally as important, I would like to dedicate this endeavor to
her, my sons, Carter and Clark, as well as the memory of my late parents, Don and Joyce.

CJ

To my mentors and colleagues, who teach me, and to my patients,

who inspire me to keep learning.

TV

v
 Contributing Authors
Patricia J. Alvarez, MD John C. Hall, MD
Dermatologist and Dermatopathologist Dermatologist
Centro Medico Naval St. Luke’s Hospital
Lima, Peru Associate Staff
University of Missouri Kansas City Medical School
Kansas City Free Health Clinic
Francisco Bravo, MD Kansas City, Missouri
Associate Professor of Pathology and Dermatology
Facultad de Medicina Alberto Hurtado
Universidad Peruana Cayetano Heredia Fatima A. Khan, MD
Lima, Peru Medical Resident
Department of Internal Medicine
Texas Health Resources
Tiffany Chen, MD Dallas Presbyterian Hospital
Research Associate
Dallas, Texas
Department of Dermatology
University of Texas Southwestern Medical Center
Dallas, Texas Christine J. Ko, MD
Professor of Dermatology and Pathology
Yale University
Wang L. Cheung, MD, PhD New Haven, Connecticut
Attending Pathologist
Department of Pathology
Orlando Health Martin C. Mihm, Jr., MD
Orlando, Florida Professor of Pathology and Dermatology
Harvard Medical School
Director of Melanoma Program, Dermatology
George R. Collins, DO Brigham and Women’s Hospital
Dermatopathologist and Cytopathologist
Co-Director of Melanoma Program
Dominion Pathology Associates
Dana-Farber and Brigham and Women’s Cancer Center
Roanoke, Virginia
Boston, Massachusetts

David J. DiCaudo, MD Annie O. Morrison, MD

Associate Professor
Dermatopathology Fellow
Departments of Dermatology and
Department of Dermatology
Laboratory Medicine & Pathology
University of Texas Southwestern Medical Center
Mayo Clinic College of Medicine
Cockerell Dermatopathology
Scottsdale, Arizona
Dallas, Texas

Garth Fraga, MD Christie Riemer, BS

Associate Professor of Pathology and Dermatology
MS4 (4th Year Medical Student)
University of Kansas School of Medicine
Michigan State University College of Human Medicine
Kansas City, Kansas
Grand Rapids, Michigan

Gretchen W. Frieling, MD Bruce R. Smoller, MD

Dermatopathologist
Professor and Chair, Department of Pathology
Miraca Life Sciences
Professor, Department of Dermatology
Newton, Massachusetts
University of Rochester School of
Medicine and Dentistry
Rochester, New York

vi
 Joseph Susa, DO Andrew Walls, MD
Fellowship Program Director Dermatology Resident
Department of Dermatology Harvard Combined Dermatology Residency
University of Texas Southwestern Medical Center Boston, Massachusetts
Dallas, Texas
Talley Whang, MD
Connie V. Tran, BA Dermatologist and Dermatopathologist
Medical Student Dermatology Center of Southern Indiana
Texas A&M University, College of Medicine Bloomington, Indiana
Bryan, Texas Volunteer Faculty
Indiana University School of Medicine
Indianapolis, Indiana

Additional Contributors
Malak Abedalthagafi, MD Susan Müller, DMD, MS
Kajsa Affolter, MD Khang Nguyen, MS
David S. Cassarino, MD, PhD Michael W. Peterson, DO
Jessica M. Comstock, MD Eleanor Russell-Goldman, MD, PhD
Gonzalo De Toro, MD Chandra N. Smart, MD
Senait Dyson, MD Emma Taylor, MD
Carly A. Elston, MD Viseslav Tonkovic-Capin, MD
Tammie Ferringer, MD Diane L. Wang, BSc
Larissa V. Furtado, MD Noelle Williams, MD
Sudeep Gaudi, MD Aparche Yang, MD
L. David Hall, MD
Julie E. Jackson, MD
Michelle Lucero Jackson, MD
Sharon Jacob, MD
Dražen M. Jukić, MD, PhD
Atsuko Kodama, MD
Irina Margaritescu, MD, DipRCPath
Danny A. Milner, Jr., MD, MSc
Elizabeth A. Montgomery, MD
Cornelia S. L. Müller, MD

vii
viii
Image Contributors
Nnenna Agim, MD Bhushan Madke, MBBS, MD
Richard J. Antaya, MD Mac Mahan, MD
Steven Billings, MD Brian M. Matthys, DO
Jyotirmay Biswas, MD Timothy H. McCalmont, MD
Anneli R. Bowen, MD Amy McClung, MD
Lisa Mask Bull, MD Martha McCollough, MD
Romana Ceovic, MD, PhD Samuel L. Moschella, MD
Marsha L. Chaffins, MD Thaddeus W. Mully, MD
Joanna Chan, MD Rosalynn M. Nazarian, MD
Stephanie Chan, MD Elan M. Newman, MD
Melvin Chiu, MD, MPH Amy Jo Nopper, MD
Cheryl Coffin, MD Amit Pandya, MD
Lisa M. Cohen, MD Karen Paucar, MD
Jaime Cok, MD Howard Pride, MD
Landon W. Coleman, MD Bobbi Pritt, MD, MSc, DTMH
Joseph D. Conlon, MD Yousuf Qureshi, MD
Mariana C. Costa, MD Cesar Ramos, MD
Abdul Hafeez Diwan, MD, PhD Marcia Ramos-e-Silva, MD, PhD
Sunil Dogra, MD Scott M. Ravis, MD
Arturo Dominguez, MD Charles Rhoades, MD
Keith L. Duffy, MD Deanne Mraz Robinson, MD
Senait W. Dyson, MD Cecilia M. Rosales, MD
Aleksander Dzamic, MD Ilana Rosman, MD
Gary L. Ellis, DDS Beth S. Ruben, MD
Jürgen Ervens, MD, DMD Cesar Salinas, MD
Sebastien de Feraudy, MD Peter Sarantopoulos, MD
Scott R. Florell, MD David M. Scollard, MD, PhD
Nima Gharavi, MD, PhD Harleen K. Sidhu, MD
Analisa V. Halpern, MD Theresa Sofarelli, PA-C
Ronald M. Harris, MD, MPH Paul M. Southern, Jr., MD, DTMH
Paul B. Hillesheim, DO Carole Stanford, MD
Sylvia Hsu, MD James W. Steger, MD
Kathie Huang, MD Gabriela Strauch, MD
H. Ray Jalian, MD Ki-Young Suh, MD
Richard Allen Johnson, MD Amanda Tauscher, MD
David Kaplan, MD Lester D. R. Thompson, MD
Thelda Kestenbaum, MD Michele Thompson, MD
Kevin Kia, MD Sheryll L. Vanderhooft, MD
Erik W. Kraus, MD Richard Wang, MD, PhD
Zelika Kumakawa, MD Kalman Watsky, MD
Lester J. Layfield, MD Lindsay Wilson, MD
Philip E. LeBoit, MD Sook-Bin Woo, DMD, MMSc
Kristin M. Leiferman, MD Scott Worswick, MD
Evelyn Lilly, MD John M. Wright, DDS, MS
Peter A. Lio, MD Jashin Wu, MD
Adam D. Lipworth, MD Clarissa Yang, MD
Daniel S. Loo, MD Holly Zhou, MD

ix
x
 Preface
Nonneoplastic dermatopathology is sometimes seen as one of the most difficult parts of pathology
residency training, and it can represent a very confusing subject for the general pathologist who
does not see these types of cases on a regular basis. Part of the difficulty is due to the importance
of clinical correlation. Although important in all of medicine, clinicopathologic correlation may
be most important in nonneoplastic dermatopathology, as clinically striking lesions can have near
normal histologic findings, and prominent histologic changes may lead to less than impressive clinical
manifestations. Moreover, many clinical entities are not often seen or taught outside of a specific
rotation in dermatology or dermatopathology.

Diagnostic Pathology: Nonneoplastic Dermatopathology, Second Edition therefore includes clinical images
of nearly all the entities discussed, 250 in all (with approximately 90 new entities in this second edition).
We hope that in-training and practicing pathologists will gain a better understanding of the clinical and
histopathologic appearance of these lesions and, more importantly, their major histologic and clinical
differential diagnoses.

We also anticipate that dermatologists and dermatopathologists can benefit from this book. Classic
histologic images highlight the most important findings, allowing more confident diagnoses and
histologic differential diagnoses. This book can also be used as a great study aid for fellows studying
for their dermatopathology boards. The quality of the more than 1,500 clinical and histologic images
in this book is not easily matched, thanks to the many contributing authors and the work of the
image editors at Elsevier.

The book is organized into major histologic reaction patterns &/or disease categories. Within
each section, we have attempted to organize entities in order of decreasing frequency usually
encountered in general practice. We have also added numerous entities in this second edition in the
hopes of producing a more consummate tome.

Our hope is to make the confusing subject of inflammatory dermatopathology much easier to
comprehend and master, such that no important diagnoses will be easily overlooked or missed,
therefore, improving patient care whether offered by pathologists or dermatologists. The eBook
version of this book, Expert Consult, makes Diagnostic Pathology: Nonneoplastic Dermatopathology a
comprehensive and easily searchable reference.

Brian J. Hall, MD
Dermatopathologist
Utah Pathology Services, Inc.
Adjunct Assistant Professor, Department of Pathology
University of Utah School of Medicine
Salt Lake City, Utah

xi
xii
Acknowledgments
Text Editors
Arthur G. Gelsinger, MA
Nina I. Bennett, BA
Terry W. Ferrell, MS
Karen E. Concannon, MA, PhD
Matt W. Hoecherl, BS
Tricia L. Cannon, BA

Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

Illustrations
Laura C. Sesto, MA
Lane R. Bennion, MS
Richard Coombs, MS

Art Direction and Design

Tom M. Olson, BA
Laura C. Sesto, MA

Lead Editor
Lisa A. Gervais, BS

Production Coordinators
Angela M. G. Terry, BA
Rebecca L. Hutchinson, BA
Emily Fassett, BA

xiii
 Sections
SECTION 1: Spongiotic and Psoriasiform Dermatoses

SECTION 2: Lichenoid and Vacuolar Interface Dermatoses

SECTION 3: Vesiculobullous Dermatoses

SECTION 4: Vasculitis, Vasculopathy, and

Perivascular Dermatoses

SECTION 5: Panniculitides

SECTION 6: Connective Tissue/Soft Tissue Diseases

SECTION 7: Degenerative and Perforating Diseases

SECTION 8: Metabolic/Deposition Diseases

SECTION 9: Mucinoses

SECTION 10: Granulomatous Diseases

SECTION 11: Pilosebaceous Diseases

SECTION 12: Alopecias

SECTION 13: Reactions to Drugs

SECTION 14: Disorders of Epidermal
Maturation and Keratinization

SECTION 15: Disorders of Pigmentation

xiv
 SECTION 16: Neutrophilic Dermatoses

SECTION 17: Nutritional Deficiencies

SECTION 18: Photosensitivity Dermatoses

SECTION 19: Bacterial Infections

SECTION 20: Spirochetal Diseases

SECTION 21: Viral Infections

SECTION 22: Fungal Infections

SECTION 23: Arthropods/Parasites

SECTION 24: Other

xv
 TABLE OF CONTENTS

58 Lichen Sclerosus et Atrophicus

SECTION 1: SPONGIOTIC AND Christine J. Ko, MD
PSORIASIFORM DERMATOSES 60 Graft-vs.-Host Disease
4 Atopic Dermatitis Julie E. Jackson, MD and Chandra N. Smart, MD
Wang L. Cheung, MD, PhD 64 Pityriasis Lichenoides
6 Contact Dermatitis Julie E. Jackson, MD and Chandra N. Smart, MD
George R. Collins, DO, Joseph Susa, DO, and Clay J. 68 Pityriasis Rubra Pilaris
Cockerell, MD Christine J. Ko, MD
10 Nummular Eczema 70 Erythema Dyschromicum Perstans
Brian J. Hall, MD Chad Jessup, MD, MS and Martin C. Mihm, Jr., MD
14 Asteatotic Eczema 72 Lichen Striatus
Chad Jessup, MD, MS Chad Jessup, MD, MS and Martin C. Mihm, Jr., MD
16 Dyshidrotic Eczema 74 Lichen Nitidus
Brian J. Hall, MD Chad Jessup, MD, MS and Martin C. Mihm, Jr., MD
18 Id Reaction 76 Phytophotodermatitis
Brian J. Hall, MD Kiran Motaparthi, MD
20 Seborrheic Dermatitis
Wang L. Cheung, MD, PhD SECTION 3: VESICULOBULLOUS
22 Pityriasis Rosea DERMATOSES
L. David Hall, MD and Tammie Ferringer, MD 80 Bullous Pemphigoid
24 Stasis Dermatitis Emma Taylor, MD
Cary Chisholm, MD 82 Pemphigus and Variants
26 Lichen Simplex Chronicus Emma Taylor, MD
Khang Nguyen, MS, Chad Jessup, MD, MS, and Martin C. 86 Dermatitis Herpetiformis
Mihm, Jr., MD Christine J. Ko, MD
28 Prurigo Nodularis 88 Cicatricial Pemphigoid
Khang Nguyen, MS, Chad Jessup, MD, MS, and Martin C. Emma Taylor, MD
Mihm, Jr., MD 92 Hailey-Hailey Disease
30 Frictional Keratosis Christine J. Ko, MD
Travis Vandergriff, MD 94 Epidermolysis Bullosa Acquisita
32 Psoriasis Emma Taylor, MD
Cary Chisholm, MD 96 Epidermolysis Bullosa (Inherited)
36 Zoon Balanitis Jessica M. Comstock, MD
Gonzalo De Toro, MD 98 Linear IgA Bullous Dermatosis
38 Reactive Arthritis Brian J. Hall, MD
Christie Riemer, BS, Annie O. Morrison, MD, and Clay J. 100 Erythema Toxicum Neonatorum
Cockerell, MD Jessica M. Comstock, MD
42 Parapsoriasis 102 Transient Neonatal Pustular Melanosis
Andrew Walls, MD Larissa V. Furtado, MD
104 Acropustulosis of Infancy
SECTION 2: LICHENOID AND VACUOLAR Larissa V. Furtado, MD
INTERFACE DERMATOSES 106 Pemphigoid Gestationis
46 Lichen Planus Emma Taylor, MD
Chad Jessup, MD, MS and Martin C. Mihm, Jr., MD 108 Bullous Diabeticorum
50 Lichenoid Keratosis Chad Jessup, MD, MS
Cary Chisholm, MD 110 Palmoplantar Pustulosis
52 Erythema Multiforme and Related Disorders Andrew Walls, MD
Julie E. Jackson, MD and Chandra N. Smart, MD 112 Erosive Pustular Dermatosis
56 Pigmented Purpuric Dermatoses Cary Chisholm, MD
Gonzalo De Toro, MD

xvi
 TABLE OF CONTENTS
114 Porphyria Cutanea Tarda 172 Erythema Induratum
Michael W. Peterson, DO, Cary Chisholm, MD, and Clay J. Cary Chisholm, MD
Cockerell, MD 176 Sclerema Neonatorum
George R. Collins, DO, Joseph Susa, DO, and Clay J.
SECTION 4: VASCULITIS, Cockerell, MD
VASCULOPATHY, AND PERIVASCULAR 178 Subcutaneous Fat Necrosis of the Newborn
DERMATOSES Jessica M. Comstock, MD
118 Leukocytoclastic Vasculitis 180 Post-Steroid Panniculitis
Brian J. Hall, MD Travis Vandergriff, MD
122 Granuloma Faciale 182 Cold Panniculitis
Brian J. Hall, MD Kiran Motaparthi, MD
124 Erythema Elevatum Diutinum 184 Pancreatic Panniculitis
Brian J. Hall, MD and Garth Fraga, MD Gretchen W. Frieling, MD
126 Urticaria and Variants
Brian J. Hall, MD, John C. Hall, MD, and Garth Fraga, MD
SECTION 6: CONNECTIVE TISSUE/SOFT
130 Thrombotic Vasculopathy
TISSUE DISEASES
Brian J. Hall, MD and David J. DiCaudo, MD 188 Scar
134 Livedoid Vasculopathy Talley Whang, MD
Brian J. Hall, MD and Bruce R. Smoller, MD 190 Keloid
136 Polyarteritis Nodosa Chad Jessup, MD, MS
Wang L. Cheung, MD, PhD 192 Lupus Erythematosus and Variants
138 Annular Erythemas Julie E. Jackson, MD and Chandra N. Smart, MD
Brian J. Hall, MD, David J. DiCaudo, MD, and Dirk Elston, 200 Morphea/Scleroderma
MD Sudeep Gaudi, MD and Dražen M. Jukić, MD, PhD
142 Giant Cell Arteritis 204 Dermatomyositis
Michelle Lucero Jackson, MD, Cary Chisholm, MD, and Sudeep Gaudi, MD and Dražen M. Jukić, MD, PhD
Clay J. Cockerell, MD 208 Radiodermatitis
144 Pruritic Urticarial Papules and Plaques of Pregnancy Talley Whang, MD
Brian J. Hall, MD and Bruce R. Smoller, MD 210 Eosinophilic Fasciitis
146 Granulomatosis With Polyangiitis Cary Chisholm, MD
Brian J. Hall, MD 212 Nodular Fasciitis
148 Churg-Strauss Syndrome Cary Chisholm, MD and Elizabeth A. Montgomery, MD
Brian J. Hall, MD and Dirk Elston, MD 216 Pseudoxanthoma Elasticum
150 Behçet Disease Irina Margaritescu, MD, PhD
Brian J. Hall, MD, Bruce R. Smoller, MD, and David J. 218 Relapsing Polychondritis
DiCaudo, MD Aparche Yang, MD and Sharon Jacob, MD
152 Malignant Atrophic Papulosis 220 Nephrogenic Fibrosing Dermopathy (Nephrogenic
Brian J. Hall, MD and Bruce R. Smoller, MD Systemic Fibrosis)
154 Livedo Reticularis Cary Chisholm, MD
Brian J. Hall, MD and Garth Fraga, MD 222 Atrophoderma
156 Thrombophlebitis Gretchen W. Frieling, MD
Michelle Lucero Jackson, MD, Cary Chisholm, MD, and 224 Favre-Racouchot Syndrome
Clay J. Cockerell, MD Talley Whang, MD
158 Pernio 226 Collagenous and Elastotic Marginal Plaques of the
Travis Vandergriff, MD Hands
Travis Vandergriff, MD
SECTION 5: PANNICULITIDES 228 Erythema Ab Igne
162 Erythema Nodosum Kiran Motaparthi, MD
Gretchen W. Frieling, MD, Chad Jessup, MD, MS, and 232 Anetoderma
Cary Chisholm, MD
Martin C. Mihm, Jr., MD
234 Cutis Laxa
166 Lipodermatosclerosis
Kiran Motaparthi, MD
Wang L. Cheung, MD, PhD
236 Acrokeratoelastoidosis
168 Traumatic Panniculitis
Brian J. Hall, MD and Dirk Elston, MD
Gretchen W. Frieling, MD
170 Eosinophilic Panniculitis
George R. Collins, DO, Joseph Susa, DO, and Clay J.
Cockerell, MD

xvii
 TABLE OF CONTENTS
304 Scleredema
SECTION 7: DEGENERATIVE AND Brian J. Hall, MD and Dirk Elston, MD
PERFORATING DISEASES 306 Reticular Erythematous Mucinosis
240 Chondrodermatitis Nodularis Helicis Brian J. Hall, MD and David J. DiCaudo, MD
Brian J. Hall, MD and John C. Hall, MD 308 Digital Mucous Cyst
242 Perforating Dermatoses David S. Cassarino, MD, PhD and Senait Dyson, MD
Brian J. Hall, MD, John C. Hall, MD, and Dirk Elston, MD 310 Mucocele
246 Elephantiasis Nostras Verrucosa Chad Jessup, MD, MS
Travis Vandergriff, MD 312 Cutaneous Myxoma
Annie O. Morrison, MD and Clay J. Cockerell, MD
SECTION 8: METABOLIC/DEPOSITION 314 Follicular Mucinosis
DISEASES Kiran Motaparthi, MD
250 Acanthosis Nigricans
Cary Chisholm, MD SECTION 10: GRANULOMATOUS
252 Confluent and Reticulated Papillomatosis DISEASES
Chad Jessup, MD, MS 320 Sarcoidosis
254 Amyloidosis Brian J. Hall, MD and John C. Hall, MD
Kajsa Affolter, MD 324 Granuloma Annulare
258 Colloid Milium Christine J. Ko, MD
Chad Jessup, MD, MS 326 Necrobiosis Lipoidica
260 Calcinosis Cutis Christine J. Ko, MD
Dirk Elston, MD and Carly A. Elston, MD 328 Foreign Body Granuloma
264 Osteoma Cutis Brian J. Hall, MD and John C. Hall, MD
Andrew Walls, MD 330 Rheumatoid Nodule
266 Gout Brian J. Hall, MD and John C. Hall, MD
Cary Chisholm, MD 332 Actinic Granuloma
268 Tattoo Ink Kiran Motaparthi, MD
Kiran Motaparthi, MD 336 Annular Elastolytic Giant Cell Granuloma
272 Reaction to Cosmetic Fillers Cary Chisholm, MD
Travis Vandergriff, MD 338 Melkersson-Rosenthal Syndrome
276 Silicone Reaction Brian J. Hall, MD and John C. Hall, MD
Cary Chisholm, MD 340 Multicentric Reticulohistiocytosis
278 Amalgam Tattoo Christine J. Ko, MD
Susan Müller, DMD, MS 342 Necrobiotic Xanthogranuloma
280 Argyria Christine J. Ko, MD
Talley Whang, MD 344 Perioral Dermatitis
282 Minocycline Deposition Kiran Motaparthi, MD
Chad Jessup, MD, MS 348 Lupus Miliaris Disseminatus Faciei
284 Monsel Reaction Talley Whang, MD
Brian J. Hall, MD 350 Cutaneous Crohn Disease
286 Calciphylaxis Brian J. Hall, MD
Wang L. Cheung, MD, PhD 354 Interstitial Granulomatous Dermatitis
288 Ochronosis Andrew Walls, MD
Diane L. Wang, MD, George R. Collins, DO, and Clay J. 356 Palisaded Neutrophilic Granulomatous Dermatitis
Cockerell, MD Andrew Walls, MD
292 Lipoid Proteinosis
Atsuko Kodama, MD, Joseph Susa, DO, and Clay J. SECTION 11: PILOSEBACEOUS DISEASES
Cockerell, MD 360 Folliculitis
294 Necrolytic Migratory Erythema Kiran Motaparthi, MD, Carly A. Elston, MD, and Cary
Cary Chisholm, MD Chisholm, MD
366 Acne
SECTION 9: MUCINOSES Viseslav Tonkovic-Capin, MD, Cary Chisholm, MD, and
298 Focal Cutaneous Mucinosis Clay J. Cockerell, MD
Cary Chisholm, MD 370 Rosacea
300 Myxedema Diane L. Wang, MD, George R. Collins, DO, and Clay J.
Brian J. Hall, MD and John C. Hall, MD Cockerell, MD
302 Papular Mucinosis
Brian J. Hall, MD and Bruce R. Smoller, MD

xviii
 TABLE OF CONTENTS
374 Hidradenitis Suppurativa
Michelle Lucero Jackson, MD, Cary Chisholm, MD, and
SECTION 14: DISORDERS OF EPIDERMAL
Clay J. Cockerell, MD
MATURATION AND KERATINIZATION
376 Furuncle 442 Grover Disease
Connie V. Tran, BA, Annie O. Morrison, MD, and Clay J. Atsuko Kodama, MD, Joseph Susa, DO, and Clay J.
Cockerell, MD Cockerell, MD
378 Eosinophilic Pustular Folliculitis 446 Darier Disease
Christine J. Ko, MD Irina Margaritescu, MD, PhD
380 Fox-Fordyce Disease 450 Porokeratosis
Michael W. Peterson, DO, Cary Chisholm, MD, and Clay J. George R. Collins, DO, Joseph Susa, DO, and Clay J.
Cockerell, MD Cockerell, MD
382 Chloracne 454 Ichthyosis
Travis Vandergriff, MD Michael W. Peterson, DO, Cary Chisholm, MD, and Clay J.
Cockerell, MD
SECTION 12: ALOPECIAS 456 Epidermolytic Hyperkeratosis
386 Androgenetic Alopecia Viseslav Tonkovic-Capin, MD, Joseph Susa, DO, and Clay J.
Garth Fraga, MD Cockerell, MD
390 Telogen Effluvium 458 Granular Parakeratosis
Garth Fraga, MD Christine J. Ko, MD
392 Trichotillomania 460 Incontinentia Pigmenti
Garth Fraga, MD Christine J. Ko, MD
396 Alopecia Areata 462 Keratosis Pilaris
Garth Fraga, MD Travis Vandergriff, MD
400 Lichen Planopilaris 464 Circumscribed Acral Hypokeratosis
Chad Jessup, MD, MS Brian J. Hall, MD
404 Discoid Lupus Alopecia 466 ILVEN
Talley Whang, MD Cary Chisholm, MD
406 Central Centrifugal Cicatricial Alopecia
Garth Fraga, MD SECTION 15: DISORDERS OF
410 Folliculitis Decalvans PIGMENTATION
Garth Fraga, MD 470 Vitiligo
414 Acne Keloidalis Nuchae Cary Chisholm, MD
Christie Riemer, BS, Annie O. Morrison, MD, and Clay J. 472 Postinflammatory Pigment Alteration
Cockerell, MD Christie Riemer, BS, Annie O. Morrison, MD, and Clay J.
416 Dissecting Cellulitis Cockerell, MD
Chad Jessup, MD, MS 474 Pityriasis Alba
Brian J. Hall, MD
SECTION 13: REACTIONS TO DRUGS 476 Becker Nevus
420 Morbilliform Drug Reactions Andrew Walls, MD and Annie O. Morrison, MD
Brian J. Hall, MD, Garth Fraga, MD, and David J. DiCaudo, 478 Melasma
MD Brian J. Hall, MD
424 Fixed Drug Eruption 480 Idiopathic Guttate Hypomelanosis
Carly A. Elston, MD and Dirk Elston, MD Kiran Motaparthi, MD
426 Lichenoid Drug Eruptions 482 Dowling-Degos Disease
Kiran Motaparthi, MD Brian J. Hall, MD and Dirk Elston, MD
430 Photodrug Eruptions
Chad Jessup, MD, MS SECTION 16: NEUTROPHILIC
432 Phototoxic Dermatitis DERMATOSES
Travis Vandergriff, MD 488 Sweet Syndrome
434 Acute Generalized Exanthematous Pustulosis Brian J. Hall, MD and Bruce R. Smoller, MD
Gretchen W. Frieling, MD, David J. DiCaudo, MD, and 490 Pyoderma Gangrenosum
Martin C. Mihm, Jr., MD Brian J. Hall, MD and Garth Fraga, MD
436 Drug Rash With Eosinophilia and Systemic 492 Subcorneal Pustular Dermatosis
Symptoms Brian J. Hall, MD and Dirk Elston, MD
Gretchen W. Frieling, MD, Chad Jessup, MD, MS, and 494 Neutrophilic Eccrine Hidradenitis
Martin C. Mihm, Jr., MD Cary Chisholm, MD
438 Toxic Erythema of Chemotherapy
Travis Vandergriff, MD

xix
 TABLE OF CONTENTS
SECTION 17: NUTRITIONAL DEFICIENCIES SECTION 20: SPIROCHETAL DISEASES
498 Necrolytic Acral Erythema 576 Syphilis
Annie O. Morrison, MD Gonzalo De Toro, MD
500 Pellagra
Christie Riemer, BS, Annie O. Morrison, MD, and Clay J. SECTION 21: VIRAL INFECTIONS
Cockerell, MD 580 Viral Exanthem
502 Scurvy Chad Jessup, MD, MS
Annie O. Morrison, MD and Tiffany Chen, MD 584 Herpesvirus
504 Acrodermatitis Enteropathica Wang L. Cheung, MD, PhD
Talley Whang, MD 586 Varicella/Herpes Zoster
Talley Whang, MD, Chad Jessup, MD, MS, and Martin C.
SECTION 18: PHOTOSENSITIVITY Mihm, Jr., MD
DERMATOSES 590 Epstein-Barr Virus Infections
508 Polymorphous Light Eruption Michelle Lucero Jackson, MD, Joseph Susa, DO, and Clay
Brian J. Hall, MD, Dirk Elston, MD, and Bruce R. Smoller, J. Cockerell, MD
MD 594 Cytomegalovirus
510 Chronic Actinic Dermatitis Viseslav Tonkovic-Capin, MD, Cary Chisholm, MD, and
Kiran Motaparthi, MD Clay J. Cockerell, MD
514 Hydroa Vacciniforme 596 Orf and Milker's Nodule
Brian J. Hall, MD Noelle Williams, MD, Chad Jessup, MD, MS, and Martin C.
Mihm, Jr., MD
SECTION 19: BACTERIAL INFECTIONS 598 Hand, Foot, and Mouth Disease
518 Impetigo Cary Chisholm, MD
Irina Margaritescu, MD, PhD
522 Cellulitis SECTION 22: FUNGAL INFECTIONS
Brian J. Hall, MD and John C. Hall, MD 602 Dermatophytosis
524 Necrotizing Fasciitis Christine J. Ko, MD
Brian J. Hall, MD and John C. Hall, MD 604 Majocchi Granuloma
526 Ecthyma Gangrenosum Andrew Walls, MD
Cary Chisholm, MD 606 Onychomycosis
528 Staphylococcal Scalded Skin Syndrome Chad Jessup, MD, MS
Brian J. Hall, MD 608 Pityriasis (Tinea) Versicolor
530 Lyme Disease and Its Manifestations Kiran Motaparthi, MD
Cornelia S. L. Müller, MD and Bruce R. Smoller, MD 610 Tinea Nigra
534 Tuberculosis Travis Vandergriff, MD
Francisco Bravo, MD and Patricia J. Alvarez, MD 612 Candidiasis
542 Atypical Mycobacterial Infections Irina Margaritescu, MD, PhD and Bruce R. Smoller, MD
Cary Chisholm, MD 616 Sporotrichosis
544 Leprosy Gretchen W. Frieling, MD, Chad Jessup, MD, MS, and
Brian J. Hall, MD, Francisco Bravo, MD, and Dirk Elston, Martin C. Mihm, Jr., MD
MD 618 Coccidioidomycosis
552 Cat Scratch Disease/Bacillary Angiomatosis Brian J. Hall, MD and David J. DiCaudo, MD
Irina Margaritescu, MD, PhD and Bruce R. Smoller, MD 620 Cryptococcosis
558 Nocardiosis and Actinomycosis Patricia J. Alvarez, MD and Francisco Bravo, MD
Brian J. Hall, MD and David J. DiCaudo, MD 624 Histoplasmosis
564 Rocky Mountain Spotted Fever Cornelia S. L. Müller, MD and Bruce R. Smoller, MD
Aparche Yang, MD and Sharon Jacob, MD 626 Blastomycosis
566 Rhinoscleroma Brian J. Hall, MD and David J. DiCaudo, MD
Patricia J. Alvarez, MD and Francisco Bravo, MD 628 Chromomycosis
568 Ecthyma Brian J. Hall, MD and David J. DiCaudo, MD
Cary Chisholm, MD 630 Aspergillosis
570 Erythrasma Andrew Walls, MD, Chad Jessup, MD, MS, and Martin C.
Cary Chisholm, MD Mihm, Jr., MD
572 Cutaneous Malakoplakia 634 Zygomycosis
Cary Chisholm, MD Brian J. Hall, MD, John C. Hall, MD, and David J. DiCaudo,
MD

xx
 TABLE OF CONTENTS
636 Mycetoma 700 Supernumerary Nipple
Brian J. Hall, MD and Francisco Bravo, MD Fatima A. Khan, MD, Annie O. Morrison, MD, and Clay J.
640 Paracoccidioidomycosis Cockerell, MD
Francisco Bravo, MD and Patricia J. Alvarez, MD
644 Lobomycosis
Patricia J. Alvarez, MD and Francisco Bravo, MD
646 Rhinosporidiosis
Brian J. Hall, MD and David J. DiCaudo, MD
648 Phaeohyphomycosis
Connie V. Tran, BA, Annie O. Morrison, MD, and Clay J.
Cockerell, MD
650 Penicilliosis
Danny A. Milner, Jr., MD, MSc

SECTION 23: ARTHROPODS/PARASITES

654 Demodex Infestations
Malak Abedalthagafi, MD and Danny A. Milner, Jr., MD,
MSc
656 Bite Reactions
Atsuko Kodama, MD, Joseph Susa, DO, and Clay J.
Cockerell, MD
660 Scabies
Gonzalo De Toro, MD
662 Leishmaniasis
Brian J. Hall, MD and Francisco Bravo, MD
666 Larva Migrans and Currens
Atsuko Kodama, MD, Joseph Susa, DO, and Clay J.
Cockerell, MD
668 Onchocerciasis
George R. Collins, DO, Dirk Elston, MD, and Clay J.
Cockerell, MD
670 Schistosomiasis
Michael W. Peterson, DO, Cary Chisholm, MD, and Clay J.
Cockerell, MD
672 Dirofilariasis
Noelle Williams, MD, Chad Jessup, MD, MS, and Dirk
Elston, MD
674 Myiasis
Travis Vandergriff, MD
676 Tungiasis
Brian J. Hall, MD
678 Pediculosis
Annie O. Morrison, MD
680 Human Filariasis
Eleanor Russell-Goldman, MD, PhD

SECTION 24: OTHER

686 Cutaneous Endometriosis
Brian J. Hall, MD
690 Wells Syndrome
Andrew Walls, MD
692 Thermal Injury
Connie V. Tran, BA, Annie O. Morrison, MD, and Clay J.
Cockerell, MD
696 Black Heel
Kiran Motaparthi, MD
698 Accessory Tragus
Cary Chisholm, MD

xxi
This page intentionally left blank
 SECOND EDITION

HALL | COCKERELL
CHISHOLM • JESSUP • VANDERGRIFF • MOTAPARTHI • ELSTON
This page intentionally left blank
 SECTION 1

Spongiotic and Psoriasiform Dermatoses

Atopic Dermatitis 4
Contact Dermatitis 6
Nummular Eczema 10
Asteatotic Eczema 14
Dyshidrotic Eczema 16
Id Reaction 18
Seborrheic Dermatitis 20
Pityriasis Rosea 22
Stasis Dermatitis 24
Lichen Simplex Chronicus 26
Prurigo Nodularis 28
Frictional Keratosis 30
Psoriasis 32
Zoon Balanitis 36
Reactive Arthritis 38
Parapsoriasis 42
 Atopic Dermatitis

KEY FACTS
Spongiotic and Psoriasiform Dermatoses

TERMINOLOGY MICROSCOPIC
• Chronic dermatitis with itching • Acute: Microvesicles with spongiosis and superficial
perivascular lymphocytes
ETIOLOGY/PATHOGENESIS
• Subacute: Spongiosis with parakeratosis and superficial
• Activated T cells (Th2) dermal lymphocytes
• 73% with positive family history of atopy • Chronic: Epidermal acanthosis with mild spongiosis
• Mutations in filaggrin seen in atopic dermatitis (AD)
• Staphylococcus aureus in 90% of AD TOP DIFFERENTIAL DIAGNOSES
• Predisposed to cutaneous viral and fungal infections • Scabies
• Psoriasis
CLINICAL ISSUES
• Other spongiotic dermatitides
• Acute: Vesicles with serous fluid, intense pruritus, papules • Dermatitis herpetiformis
and plaques with lichenification • Cutaneous T-cell lymphoma
• Subacute: Papules and plaques with excoriation
• Chronic: Thickened plaque with lichenification involving
antecubital fossa, posterior neck, wrists, and ankles

Acute Eczema Over Back Spongiotic Dermatitis With Microvesicles

(Left) Acute eczema over the
back of this patient is
excoriated with oozing from
open wounds. (Right) This
chronic lesion shows mild
spongiosis with irregular
epidermal acanthosis. There is
compact orthokeratosis ﬊
and hypergranulosis st, which
are features of chronic
rubbing.

Spongiotic Microvesicle High Power Intercellular Edema of Spongiosis

(Left) Acute lesion of atopic
dermatitis (AD) shows a
vesicle ﬊ with abundant
epidermal spongiosis ﬈
(intercellular edema). (Right)
High-power view of AD shows
spongiosis ﬈ of the epidermis
(intercellular edema).

4
 Atopic Dermatitis

Spongiotic and Psoriasiform Dermatoses

TERMINOLOGY MICROSCOPIC
Abbreviations Histologic Features
• Atopic dermatitis (AD) • Findings similar to those seen in other spongiotic
dermatitides
Synonyms
○ Acute: Microvesicles with spongiosis and superficial
• Atopic eczema, eczema perivascular lymphocytes
Definitions ○ Subacute: Spongiosis with parakeratosis and superficial
dermal lymphocytes
• Chronic dermatitis with itching and often history of atopy
(asthma, allergic rhinitis, food allergies) ○ Chronic: Epidermal acanthosis with mild spongiosis

ETIOLOGY/PATHOGENESIS ANCILLARY TESTS

Infectious Agents Serologic Testing
• Staphylococcus aureus in 90% of AD • Serum IgE level determined by radioallergosorbent test
(RAST)
Genetic Factors
• 73% with positive family history of atopy DIFFERENTIAL DIAGNOSIS
Immunologic Factors Histological
• Activated T cells (Th2) • Other spongiotic dermatitides
○ Identical histologically in many instances
CLINICAL ISSUES • Dermatophytosis
○ Need PAS or GMS to rule out tinea
Epidemiology
• Psoriasis
• Age
○ Acanthosis, but should be minimal spongiosis
○ 90% with onset before 5 years
○ Loss or decreased granular layer
Presentation ○ Neutrophils in spinous layer of epidermis (Kogoj
• Infancy pustules)
○ Initially involves creases with eventual spread to cheeks, • Cutaneous T-cell lymphoma
scalp, and extensor surfaces ○ More lymphocytes extending into epidermis
○ Ill-defined, erythematous patches and plaques; xerosis ○ Less spongiosis and less parakeratosis
○ Severe pruritus with uncontrollable scratching ○ Lymphocytes lining up at dermoepidermal junction
• Childhood Clinical
○ Involved areas often have prominent lichenification
• Other spongiotic dermatitides
– Most prominent in creases (antecubital fossa,
○ Clinical history may identify triggers of allergic or irritant
popliteal fossa, gluteal-thigh creases)
contact dermatitis
○ Crusting and excoriation common
○ Nummular patches in nummular dermatitis
• Adults
○ Treatment is similar, and distinguishing between
○ Xerosis and erythema are more diffuse; lichenification spongiotic dermatitides may not be reliable
may be present
• Dermatophytosis
○ Macular ring of hyperpigmentation may be seen around
○ Usually localized annular patch or plaque
neck due to amyloid deposition
• Psoriasis
Treatment ○ Well-defined patches and plaques with silver scale
• Drugs ○ Positive Auspitz sign
○ Emollients, topical corticosteroids, topical calcineurin ○ Mediated by Th1 T cells
inhibitors, systemic steroids, antimicrobials, • Cutaneous T-cell lymphoma
antihistamines ○ Poikilodermatous patches and plaques ± scale
○ More systemic immune modulators in severe cases ○ Often annular, serpiginous, or geometric in shape
• Others ○ Pruritus not prominent feature
○ Avoidance of triggers
○ Phototherapy SELECTED REFERENCES
Prognosis 1. Mohan GC et al: Comparison of dermatology and allergy guidelines for
atopic dermatitis management. JAMA Dermatol. 151(9):1009-13, 2015
• Benign disease, but most children have disease persisting 2. Slater NA et al: Systemic therapy of childhood atopic dermatitis. Clin
into adulthood Dermatol. 33(3):289-99, 2015
3. Andreae DA et al: Immunologic effects of omalizumab in children with
severe refractory atopic dermatitis: a randomized, placebo-controlled clinical
trial. Pediatrics. 134 Suppl 3:S160, 2014
4. Aslam I et al: What's new in the topical treatment of allergic skin diseases.
Curr Opin Allergy Clin Immunol. 14(5):436-50, 2014

5
 Contact Dermatitis

KEY FACTS
Spongiotic and Psoriasiform Dermatoses

TERMINOLOGY ○ Both have varying degrees of spongiosis depending on

• Allergic contact dermatitis (ACD): Inflammatory skin
disorder initiated by contact with allergen to which person
has already been sensitized
• Irritant contact dermatitis (ICD): Inflammatory skin
condition produced in response to nonimmune-mediated
direct toxic effect of chemical or physical irritant substance
damaging skin barrier
CLINICAL ISSUES
• Prevalence of contact dermatitis (irritant and allergic) in
USA varies from 1.5-5.4%
• In USA, Rhus dermatitis due to poison ivy/oak/sumac causes
more cases of ACD than all other allergens combined
• ICD is most common job-related skin disease
MICROSCOPIC
• Allergic and irritant contact dermatitis often not reliably
distinguished due to overlap of histologic features
whether it is acute, subacute, or chronic
○ May or may not have eosinophils in dermal infiltrate
○ ICD often has degree of epidermal necrosis (single cell,
patchy, or confluent)
DIAGNOSTIC CHECKLIST
• ACD and ICD may appear histologically similar, which makes
separation difficult
• Acute ACD shows prominent spongiosis with vesicles,
neutrophils, superficial perivascular lymphohistiocytic
dermal infiltrates with eosinophils and no epidermal
necrosis
• Chronic ACD may show parakeratosis, minimal spongiosis,
and epidermal hyperplasia and may even resemble lichen
simplex chronicus
• ICD shows epidermal necrosis, ballooning, dyskeratotic
keratinocytes, and less spongiosis, but features vary and
may simulate ACD

Irritant Contact Dermatitis to Glove Allergic Contact Dermatitis to Adhesive

(Left) Irritant contact
dermatitis of the hand is a
nonimmune-mediated injury
resulting in well-demarcated
erythematous, crusted plaques
at points of contact with the
inciting irritant glove material.
(Right) Allergic contact
dermatitis (ACD) with a well-
demarcated erythematous
plaque in an area of skin
contact with offending
allergen (an adhesive in this
case) shows sparing where
gauze prevented contact ﬉.

Sandal Allergic Contact Dermatitis on

Bilateral Feet Diaper Rash
(Left) The well-demarcated
erythematous plaques of ACD
seen on the dorsal feet
bilaterally ﬈ correspond to
areas of the feet in direct
contact with sandals that
served as the offending
antigen in this case. (Right)
"Diaper rash," depicted here, is
one of many expressions of
irritant contact dermatitis.
The rash st results from
prolonged direct exposure to
feces and urine, leading to
nonimmune-mediated injury.

6
 Contact Dermatitis
TERMINOLOGY
Abbreviations
• Allergic contact dermatitis (ACD)
• Irritant contact dermatitis (ICD)
Synonyms
• Hand dermatitis, diaper rash, and chemical dermatitis refer
to types of ICD
• ACD may be referred to as eczematous dermatitis by some
clinicians
Definitions
• ACD
○ Inflammatory skin disorder initiated by contact with
allergen to which person has already been sensitized
○ Caused by cutaneous type IV cell-mediated delayed
hypersensitivity allergic reaction
• ICD
○ Inflammatory skin condition produced in response to
nonimmune-mediated direct toxic effect of chemical or
physical irritant substance damaging skin barrier
○ Irritants cause damage in many ways such as removal of
surface lipids, damage of cell membranes, denaturation
of epidermal keratins, cytokine release, and direct
cytotoxic effect
ETIOLOGY/PATHOGENESIS
Environmental Exposure
• ACD
○ Depends on sensitization, usually requires at least 2
exposures to exogenous antigen, and occurs only in
sensitized individuals
○ Common allergens include nickel, fragrances, cosmetics,
urushiol found in Rhus and Toxicodendron spp. (poison
ivy/oak/sumac), formaldehyde, topical antibiotics, latex,
rubber, balsam of Peru
• ICD
○ Acute form can occur upon even single exposure to toxic
agent with severe cases resulting in necrosis
○ Commonly due to repeated or continuous exposures to
alkaline soaps/detergents, organic solvents, and excess
moisture (hand, diaper area, colostomy site)
○ Common irritants include acids, alkalis, cement, metal
salts, phenols, kerosene, ethylene glycol, lime acids,
plants, alcohol solvents, acetone, fiberglass
CLINICAL ISSUES
Epidemiology
• Incidence
○ Prevalence of contact dermatitis (ICD and ACD) in USA
varies from 1.5-5.4%
○ ACD
– Affects limited number of sensitized people, yet it is
common and accounts for up to 20% of all cases of
dermatitis in children
– Sensitization to nickel is leading cause of ACD
worldwide
– In USA, Rhus dermatitis due to poison ivy/oak/sumac
causes more cases of ACD than all other allergens
combined
Spongiotic and Psoriasiform Dermatoses
○ ICD
– Increased susceptibility (thin stratum corneum) in 15%
of people, but anyone can be affected
– Most common job-related skin disease (80% of cases)
Site
• ACD
○ Localized to 1 region or generalized in random pattern or
on exposed areas
○ Initially confined to area of allergen contact and may be
linear
• ICD
○ Acute forms may be localized or generalized depending
on nature of contact with toxic agent; chronic form
commonly affects hands
Presentation
• ACD
○ Immune-mediated reaction that may spread to involve
adjacent skin or even beyond affected site with rare
generalized involvement
○ Rapid onset once sensitized usually 12-48 hours after
antigen exposure and persisting up to 3-4 weeks
○ Can occur with as few as 2 exposures (poison ivy) or
require many exposures with weaker allergens
○ Intense pruritus and even pain with fever and acute
illness syndrome in severe cases
○ Appearance of skin lesions depends on severity and
location and evolves over time
– Acute: Well-demarcated erythematous plaques and
edema with superimposed vesicles &/or papules with
bullae and confluent erosions in severe cases
– Subacute: Plaques of mild erythema with small, dry
scales and small firm papules are seen
– Chronic: Lichenified plaques; scaling with small, firm,
round to flat papules; and excoriations with erythema
and pigmentation
○ Special variants include systemic, airborne, urticarial, and
allergic phytodermatitis
• ICD
○ Toxic phenomenon confined to exposed area, so it is
always sharply marginated and never spreads
○ Occurs minutes after exposure or may be delayed over
24 hours; hands most common site affected
○ Skin lesions range from sharply demarcated erythema
with dry, cracked, fissured, crusted skin to vesicles and
caustic burn with necrosis
○ Configuration of lesions is often linear or irregular
suggesting "outside job" effect
○ Requires 1 to many exposures depending on traits of
person's epidermal barrier with typically gradual onset as
barrier becomes compromised
○ Special forms include hand dermatitis, airborne, pustular,
and acneiform variants
Laboratory Tests
• ACD
○ Positive skin patch tests
• ICD
○ Negative skin patch tests
7
 Contact Dermatitis
Spongiotic and Psoriasiform Dermatoses
Treatment
• ACD
○ Identify and avoid stimulating antigen to prevent
occurrence; mild to moderate erythema requires class I-V
topical corticosteroids; severe cases require oral
prednisone or IM triamcinolone
○ Acute blisters and intense erythema effectively treated
with cold, wet compresses and hydroxyzine or
diphenhydramine for itching
• ICD
○ Identify and remove etiologic agent; use lubricating
creams and barrier protection (gloves, creams, etc.); use
potent topical class I corticosteroids in acute cases,
prednisone if severe
○ Wash hands in cool water if exposed to irritant, and use
cool compresses to treat vesicles/inflammation
Prognosis
• ACD
○ Symptomatic episodes will occur with each exposure
after sensitization, so avoidance of allergen is essential to
avoid recurrences
• ICD
○ Usually heals in 2 weeks upon removal of noxious
stimulus, but chronic cases may take 6 weeks to heal
○ Only 1/3 of occupational cases achieve remission, while
2/3 require change of occupation
MACROSCOPIC
General Features
• ACD
○ Well-demarcated erythematous plaques with vesicles
&/or dry scaling; lichenification; small, firm, round to flat
papules; bullae; confluent erosions
• ICD
○ Spectrum of lesions ranges from sharply demarcated
erythema with dry, cracked, fissured, crusted skin to
lesions with vesicles and necrosis
MICROSCOPIC
Histologic Features
• ACD and ICD often not reliably distinguished due to overlap
of histologic features
• ACD
○ Acute phase
– Epidermal spongiosis often with vesicles at different
levels of epidermis, exocytosis of lymphocytes and
eosinophils, and microabscesses
– Dermal edema and superficial perivascular
lymphohistiocytic infiltrates with eosinophils
○ Subacute phase
– Orthohyperkeratosis, focal parakeratosis, less
epidermal spongiosis, mild epidermal hyperplasia,
superficial dermal chronic inflammation
○ Chronic phase
– Parakeratosis, psoriasiform epidermal hyperplasia,
minimal spongiosis, papillary dermal fibrosis
– Can show features similar to lichen simplex chronicus
in most chronic form
8
○ Special variants include pustular, purpuric, photoallergic,
granulomatous, urticarial, and follicular
• ICD
○ Features vary with nature of irritant and duration of
exposure
○ Highly concentrated irritants cause marked keratinocytic
ballooning degeneration with variable necrosis ranging
from single cells to confluent zones within upper
epidermis
– Mild spongiosis in adjacent epidermis and occasional
dyskeratotic keratinocytes may be seen
– Neutrophils are present in areas of epidermal necrosis
and ballooning degeneration, and upper dermal
infiltrates include neutrophils
– Mild epidermal hyperplasia often seen, and
psoriasiform hyperplasia may be present
○ Lower irritant concentrations cause spongiosis,
perivascular infiltrates, and dermal edema similar to ACD
○ Pustular variant shows subcorneal vesicles with fibrinous
exudate, debris, and neutrophils
DIFFERENTIAL DIAGNOSIS
Allergic Contact Dermatitis
• Spongiotic dermatitides appear similar with overlapping
features giving nonspecific histologic differential diagnosis
requiring clinical correlation
• Mycosis fungoides can resemble subacute and chronic
phases of ACD
• Dermatophytosis can cause spongiotic dermatitis, so
judicious use of special stains (PAS, GMS) to exclude fungus
is necessary in some cases
Irritant Contact Dermatitis
• Shares features with some interface dermatitides and
spongiotic dermatitides like ACD, spongiotic drug reaction,
and nummular dermatitis
○ Clinical correlation helpful for diagnosis
DIAGNOSTIC CHECKLIST
Pathologic Interpretation Pearls
• ACD and ICD may appear histologically similar, which makes
separation difficult
• Acute ACD shows prominent spongiosis with vesicles,
neutrophils, and no necrosis, while chronic phase shows
minimal spongiosis and may resemble lichen simplex
chronicus
• ICD shows epidermal necrosis, dyskeratotic keratinocytes,
and less spongiosis
• Clinical correlation is helpful for proper diagnosis
SELECTED REFERENCES
1. Peng W et al: Pathogenesis of atopic dermatitis. Clin Exp Allergy. 45(3):566-
74, 2015
2. Tuchman M et al: Nickel contact dermatitis in children. Clin Dermatol.
33(3):320-6, 2015
3. Ale IS et al: Irritant contact dermatitis. Rev Environ Health. 29(3):195-206,
2014
4. Friis UF et al: Occupational irritant contact dermatitis diagnosed by analysis
of contact irritants and allergens in the work environment. Contact
Dermatitis. 71(6):364-70, 2014
5. Schlapbach C et al: Update on skin allergy. Allergy. 69(12):1571-81, 2014
6. Duarte I et al: Allergic contact dermatitis in private practice: what are the
main sensitizers? Dermatitis. 22(4):225-6, 2011

Acute Spongiotic Dermatitis With
Microvesicles
Superficial Epidermal Necrosis in Irritant
Contact Dermatitis
Subacute Spongiotic Dermatitis With Mild
Spongiosis
Contact Dermatitis
Spongiotic and Psoriasiform Dermatoses
Hallmark of Acute Spongiosis: Spongiotic
Microvesiculation
(Left) Acute ACD
demonstrates prominent
epidermal spongiosis with
vesiculation st, "basket
weave" cornified epidermal
layer showing compact
orthohyperkeratosis ﬊,
lymphocyte exostosis, and
dermal perivascular
lymphohistiocytic
inflammation with eosinophils
﬈. (Right) Prominent
spongiosis ﬉ and resultant
spongiotic microvesiculation
﬊ are characteristic
expressions of intercellular
edema that serve as hallmarks
of acute ACD.
Epidermal Necrosis With Spongiosis in
Irritant Contact Dermatitis
(Left) This example of irritant
contact dermatitis shows
superficial epidermal necrosis
﬉ with ballooning
degeneration, edema, and
vesicle formation ﬊ along
with spongiosis ﬈ and mixed
inflammatory infiltrates with
neutrophils. (Right) Irritant
contact dermatitis due to
chemical irritant exposure can
result in confluent superficial
zones of epidermal necrosis ﬈
with edema and ballooning
degeneration ﬉, epidermal
spongiosis ﬊, and variable
mixed inflammation.
Eosinophils and Edema in Allergic Contact
Dermatitis
(Left) Subacute to chronic ACD
shows compact
orthohyperkeratosis with
parakeratosis ﬉, mild
spongiosis ſt, and
psoriasiform epidermal
hyperplasia ﬊ with a retained
granular layer. At the extreme
chronic end of the spectrum,
there can be absent
spongiosis, prominent
psoriasiform hyperplasia, and
dermal fibrosis mimicking
lichen simplex chronicus.
(Right) Close inspection of the
dermis confirms the presence
of eosinophils ﬉ and edema
﬊.
9
 Nummular Eczema

KEY FACTS
Spongiotic and Psoriasiform Dermatoses

TERMINOLOGY MICROSCOPIC
• Form of eczema that is distinct from other forms of eczema • General spongiotic pattern
because of its sharply defined border and often coin- • Spongiosis ranges from microvesicle formation (acute
like/circular shape lesions) to minimal (chronic lesions)
○ Nummular means coin-like and comes from Latin word ○ Amount of spongiosis depends on clinical duration of
nummulus, which means small coin lesions
CLINICAL ISSUES • Superficial perivascular lymphohistiocytic infiltrate with
eosinophils
• Usually occurs in adults
• Epidermal acanthosis is present in more chronic lesions
• Occurs as sharply demarcated, circular, erythematous patch
or plaque that occurs on any part of body but prefers lower TOP DIFFERENTIAL DIAGNOSES
extremities, upper extremities, and torso • Contact dermatitis
• Dorsal (extensor) surfaces of extremities and back are most • Id reaction
common sites • Dyshidrotic dermatitis
• Plaques may be quite small (quarter sized) or as large as • Atopic dermatitis
palm of hand
• Usually pruritic DIAGNOSTIC CHECKLIST
• Usually chronic disease commonly with relapses and • Can mimic other spongiotic processes histopathologically
remissions • Clinical correlation is necessary for accurate diagnosis

Circular ('Coin-Shaped') Exudative Lesion

Oval exudative crusted dermatitis on the upper outer arm in a case of nummular eczema is seen here. Note the well-demarcated edge
with oozing and crusting but no scaling and no elevated edge with clearing center.

10
 Nummular Eczema

Spongiotic and Psoriasiform Dermatoses

○ Topical corticosteroids, tacrolimus, or pimecrolimus can
TERMINOLOGY also be used
Synonyms ○ In severe or refractory cases, systemic corticosteroids
• Nummular dermatitis may be used
• Discoid eczema ○ Antihistamines can relieve pruritus
• Papulovesicular eczema Prognosis
• Orbicular eczema
• Usually chronic disease commonly with relapses and
Definitions remissions
• Form of eczema that is distinct from other forms of eczema ○ Lesions may also persist for long periods
because of its sharply defined border and often coin-
like/circular shape MICROSCOPIC
○ Most other forms of eczema characteristically have Histologic Features
indistinct outline
• General spongiotic pattern
○ Nummular means coin-like and comes from Latin word
• Acute lesions show
nummulus, which means small coin
○ Superficial perivascular lymphohistiocytic infiltrate with
eosinophils
ETIOLOGY/PATHOGENESIS
○ Abundant spongiosis with microvesicle formation
Unknown ○ Difficult to differentiate from other acute
• Several factors have been proposed in pathogenesis spongiotic/eczematous processes
○ Dry skin • Subacute lesions show
○ Emotional stress ○ Superficial perivascular lymphohistiocytic infiltrate +
○ Stasis eosinophils
○ Atopic dermatitis in childhood ○ Acanthosis with slight psoriasiform epithelial hyperplasia
○ Mild spongiosis ± parakeratosis
CLINICAL ISSUES • Chronic lesions
○ Hyperkeratosis, parakeratosis, and acanthosis
Epidemiology
○ Mild spongiosis with lymphocyte exocytosis
• Incidence ○ Superficial perivascular lymphohistiocytic + eosinophils
○ ~ 2 in 1,000 ○ Difficult to distinguish from other
• Age spongiotic/eczematous processes
○ Usually occurs in adults
– Bimodal peaks in 6-7th decade of life (most common) ANCILLARY TESTS
and 2nd-3rd decade of life
○ Rare in children Histochemistry
• Sex • PAS should always be considered on any spongiotic process
○ Most studies report slight male predominance to rule out dermatophyte infection
• Ethnicity ○ Careful scrutinization of stratum corneum for organisms
○ No racial predilection has been reported can also suffice
• Seasonal variation Patch testing
○ Lesions often have peak frequency in winter • Should be considered in severe or persistent disease to
○ Summer may also worsen lesions especially in men exclude contact allergens
Presentation
DIFFERENTIAL DIAGNOSIS
• Occurs as sharply demarcated, circular, erythematous patch
or plaque that occurs on any part of body but prefers lower Histopathologic
extremities, upper extremities, and torso • Other spongiotic/eczematous processes
○ Dorsal (extensor) surfaces of extremities and back are ○ Contact dermatitis
most common sites – Can be indistinguishable histopathologically
○ Dorsal (extensor) surfaces of hands are also commonly – Lacks sharply defined, circular border
involved – Often asymmetric and typically forms streaks or
• Plaques may be quite small (quarter-sized) or as large as geometric shapes
palm of hand ○ Id reaction
○ Average size is around size of silver dollar – Tends to be drier and very diffuse
• Usually pruritic – No distinct circles clinically
• May be solitary or multiple, can be widespread – Very symmetric (nummular may or may not be)
Treatment – Histopathologically can be indistinguishable
• Drugs ○ Dyshidrotic dermatitis
○ Emollients are first line – Can ooze and crust, but primary lesion is vesicle

11
 Nummular Eczema
Spongiotic and Psoriasiform Dermatoses
– Typically palms, soles, sides of fingers, and sides of
toes
– Histopathologically can be indistinguishable, but
typically dyshidrosis shows spongiotic pattern limited
to acral skin
○ Atopic dermatitis
– Can be indistinguishable histopathologically
– Often affects younger patients
– Typically lichenified clinically
○ Dermatophytosis
– Fungal hyphae present in stratum corneum
□ Can be highlighted with PAS or other fungal stain
– Careful search for fungal hyphae within stratum
corneum or PAS stain is warranted on all cases with
spongiotic pattern
□ Treatment differs widely, and steroids will worsen
disease
○ Pityriasis rosea
– Clinically doesn't itch
– Clinically diffuse hypopigmentation often involving
upper trunk with very fine adherent scale
– Histopathologically shows gently undulating
epidermis with parakeratotic mounds and spongiosis
○ Seborrheic dermatitis
– Usually in seborrheic areas
□ Intertriginous areas and folds, scalp, and forehead
– Fine nonadherent scale that is greasy rather than dry
– Typically shows parakeratosis at lips of follicular ostia
□ Spongiosis typically involves hair follicle epithelium
○ Stasis dermatitis
– Clinically localized below knee on lower legs and
ankles (typically medial malleolus)
□ Lower legs and ankles (typically medial malleolus)
– Tends to be symmetric (both legs) and on large area
□ Nummular eczema is asymmetric, typically circular
with multiple spots
– Reddish-brown pigmentation is characteristic
□ Not seen in nummular eczema
• Spongiotic drug eruption
○ Very uncommon type of drug eruption
○ Symmetric clinically
○ Typically occurs between 2-14 days after drug initiation
○ Large confluent areas, typically symmetric, no discrete
circles (typically diffuse)
Clinical
• Dermatophytosis
○ Clear in center (vs. nummular dermatitis)
○ Lesions spread concentrically
– Nummular lesions attain full size immediately
○ Rarely oozes and crusts (vs. most cases of nummular
eczema that ooze and crust)
○ Both pruritic
○ Commonly intertriginous
– Nummular eczema is extensor disease
• Psoriasis (especially guttate)
○ Almost never itches
○ Lesions are papulosquamous (elevated and with scale)
○ Typically no atopic history (vs. nummular eczema)
– Not uncommon to have family history of psoriasis
12
○ More numerous lesions that are typically smaller
• Allergic contact dermatitis
○ Oozing and crusting can be similar
○ Streaks and can have large blisters
○ Geometric shapes and asymmetry typically
• Atopic dermatitis
○ Lichenified clinically
○ Dry dermatitis (typically no oozing or crusting)
○ More chronic (not sudden as in nummular eczema)
• Stasis dermatitis
○ Localized below knee
○ Reddish-brown hyperpigmentation is characteristic
○ Associated with edema or venous disease (varicosities)
○ Typically affects older age group
• Neurodermatitis (lichen simplex chronicus)
○ Not usually symmetric
○ Often just a few areas involved (areas within reach of
patient)
– Often in butterfly distribution with central areas
where they can't reach
○ Linear scratches and excoriations typically present
○ Around edge are papules that coalesce into large
plaques
○ Oozing and crusting typically not present
○ Itching is typically paroxysmal
○ Characteristically heals with hypopigmented scars
– Eczema typically does not scar
DIAGNOSTIC CHECKLIST
Clinically Relevant Pathologic Features
• General spongiotic pattern
○ Can mimic other spongiotic processes
○ Clinical correlation is necessary for accurate diagnosis
SELECTED REFERENCES
1. Jiamton S et al: Clinical features and aggravating factors in nummular
eczema in Thais. Asian Pac J Allergy Immunol. 31(1):36-42, 2013
2. Bonamonte D et al: Nummular eczema and contact allergy: a retrospective
study. Dermatitis. 23(4):153-7, 2012
3. Bettoli V et al: Nummular eczema during isotretinoin treatment. J Am Acad
Dermatol. 16(3 Pt 1):617, 1987
4. Bendl BJ: Nummular eczema of statis origin. The backbone of a morphologic
pattern of diverse etiology. Int J Dermatol. 18(2):129-35, 1979
5. Hellgren L et al: Nummular eczema--clinical and statistical data. Acta Derm
Venereol. 49(2):189-96, 1969
6. Sachs W et al: Nummular eczema. Skin (Los Angeles). 3:103-8, 1964
7. Krogh HK: Nummular eczema. Its relationship to internal foci of infection. A
survey of 84 case records. Acta Derm Venereol. 40:114-26, 1960
8. Gross P: Nummular eczema with special reference to dermatitis of the hands
in housewives. Ann Allergy. 17:745-54, 1959
9. Weidman AI et al: Nummular eczema; review of the literature: survey of 516
case records and follow-up of 125 patients. AMA Arch Derm. 73(1):58-65,
1956
10. Baer TW: Nummular eczema; its diagnosis and treatment. Pa Med J.
57(3):230-3, 1954
11. Fowle LP et al: Etiology of nummular eczema. AMA Arch Derm Syphilol.
68(1):69-79, 1953
 Nummular Eczema
Slight Psoriasiform Epithelial Hyperplasia
Mild Spongiosis, Parakeratosis and Serum
Lymphohistiocytic Infiltrate With Rare
Acute Spongiotic Dermatitis
Spongiotic and Psoriasiform Dermatoses
Subacute Spongiotic Dermatitis
(Left) A low-power view of a
case of nummular eczema
demonstrates an acanthotic
epidermis with slight
psoriasiform epithelial
hyperplasia with a superficial
lymphohistiocytic infiltrate ﬉.
(Right) This example of a
subacute lesion of nummular
eczema demonstrates a slight
spongiotic dermatitis with
psoriasiform hyperplasia ﬈
and some serum ﬉ within the
stratum corneum. The serum
represents prior edema that
has been extruded out
through the epidermis.
Langerhans Cell Microgranuloma
(Left) In subacute lesions of
nummular dermatitis,
spongiosis ﬈ (seen here as
white spaces between
keratinocytes) is mild, and
overlying parakeratosis and
serum crust are often present.
(Right) A Langerhans cell
microgranuloma ﬈ is seen
here in a case of nummular
eczema. Langerhans cell
microgranulomas can be seen
in all types of spongiotic
processes and are not specific
for any one process. Note the
acuteness of this nummular
lesion with the "basket
weave" stratum corneum.
Eosinophils
(Left) This case of acute
nummular dermatitis
demonstrates another
Langerhans cell
microgranuloma ﬊ with
significant spongiosis
surrounding and a "basket
weave" stratum corneum ﬉.
(Right) The superficial
lymphohistiocytic infiltrate
often has occasional
eosinophils ﬉. Eosinophils are
not a prerequisite for the
diagnosis, but most spongiotic
processes should have
occasional eosinophils if
biopsies are scrutinized
enough.
13
 Asteatotic Eczema

KEY FACTS
Spongiotic and Psoriasiform Dermatoses

TERMINOLOGY TOP DIFFERENTIAL DIAGNOSES

• Eczema craquelé • Atopic dermatitis
• Winter itch ○ Clinically follows specific patterns of involvement from
• Xerosis extensor to flexural over time in childhood to more focal
locations in adults
CLINICAL ISSUES
○ Histopathology can be indistinguishable
• Preferentially affects shins of elderly patients during winter • Stasis dermatitis
months ○ Clinically preferentially affects lower extremities of
• Presents as dry skin with fine scale and cracks, which elderly or those with poor circulation
resemble dry riverbed ○ Histopathology shows prominent vascular components
MICROSCOPIC with adjacent hemosiderin deposition
• Spongiosis of varying degrees • Allergic contact dermatitis
○ Acute lesions have more spongiosis ○ Clinically shows geographic lesions where contactant
was in touch with skin
○ Chronic lesions have less spongiosis
○ Histopathology can be indistinguishable, but Langerhans
• Exocytosis of varying degrees
cell microgranulomas can be clue
• Acanthosis of varying degrees
○ Acute lesions have less acanthosis
○ Chronic lesions have more spongiosis

PseudoIchthyosis of Asteatotic Eczema Dried Riverbed Clinical Appearance

(Left) Shins of a middle-aged
man during the winter season
exhibit pseudoichthyosis-like
scale ﬊ and on a background
of xerotic skin. Focal patches
of erythema ﬈ are from
excoriations. (Courtesy E. Lilly,
MD.) (Right) Close-up of the
shin exhibits what looks like a
dry riverbed type of xerotic
scale with interlocking
superficial cracks in the
epidermis. (Courtesy E. Lilly,
MD.)

Spongiosis and Superficial Perivascular

Subacute Spongiotic Dermatitis Infiltrate
(Left) Low-power image shows
the subacute stage of a
spongiotic dermatitis with
hyperkeratosis ﬉, epidermal
hyperplasia ﬊, and focal
spongiosis ﬈ of the
keratinocytes. (Courtesy S.
Wenson, MD.) (Right) High-
power image shows the
subacute stage of a spongiotic
dermatitis with hyperkeratosis
﬉, epidermal hyperplasia ﬊,
and focal spongiosis ﬈ of the
keratinocytes. A nonspecific
superficial perivascular
lymphocytic infiltrate ſt is
also seen. (Courtesy S.
Wenson, MD.)

14
 Asteatotic Eczema
TERMINOLOGY
Synonyms
• Eczema craquelé
• Winter itch
• Dry skin
• Xerosis
Definitions
• Pruritic type of eczema that preferentially affects lower
extremities of elderly patients, especially in cold climates
CLINICAL ISSUES
Presentation
• Presents as dry skin with fine scale and cracks, which
resemble dry riverbed
• Preferentially affects shins but can occur anywhere
• Elderly tend to be affected more, especially in winter
months when humidity is low, people take hot showers (±
use of soaps), when they are exposed to dry winter air and
dry indoor heat
Treatment
• Options, risks, complications
○ Decreased duration and temperature of showers
○ Limit use of gentle soaps to intertriginous areas and
hands only
○ Pat skin dry after showering, then apply cream or
ointment moisturizer
○ For recalcitrant cases not responding to emollients,
topical steroids are great options
Prognosis
• Generally most people improve with decreased drying
habits, increased emollient use ± use of topical steroids
MICROSCOPIC
Histologic Features
• Spongiosis is key feature along with varying degrees of
parakeratosis, acanthosis, and lymphocytic exocytosis ±
superficial perivascular lymphocytic infiltrate
• Historically considered 1 of 3 possible states of activity
depending on duration
○ Acute
– Tends to have more prominent spongiosis
(intercellular edema), which can produce
intraepidermal spongiotic vesicles
– Exocytosis present in variable amounts
– Little to no acanthosis or parakeratosis
○ Subacute
– Varying amounts of spongiosis, acanthosis,
parakeratosis, and exocytosis somewhere between
acute and chronic
○ Chronic
– Tends to be more acanthotic with compact
hyperkeratosis
– Less spongiosis compared with acute and subacute
cases
Spongiotic and Psoriasiform Dermatoses
DIFFERENTIAL DIAGNOSIS
Histopathologic
• Atopic dermatitis
○ Part of eczematous dermatitis spectrum with variable
amounts of hyperkeratosis, acanthosis, spongiosis, and
superficial perivascular lymphocytic infiltrate
○ Eosinophils can be present but tend not to be prominent
• Stasis dermatitis
○ More prominent vascular proliferations, sometimes
glomeruloid in appearance in superficial to mid dermis
○ More hemosiderin deposition
• Allergic contact dermatitis
○ Features similar to eczema, but eosinophils tend to be
more prominent in number
Clinical
• Atopic dermatitis
○ Depending upon patient's age, distribution pattern is
helpful
○ Infants: Scalp, cheeks, extensor surfaces, sparing diaper
area
○ Children: Tends to involve surfaces of neck, wrists,
elbows, knees, ankles
○ Adults: Tends to be more localized in distribution like
flexural surfaces, hands, eyelids, nipples
• Stasis dermatitis
○ Preferentially affects lower extremities of elderly who
have poor circulation
○ Can appear bronze or pigmented over shins; ulceration
can happen in more severe cases
• Allergic contact dermatitis
○ Often occurs after exposure to specific culprit allergen,
so thorough history of potential new exposures, changes
in environment, or medications is imperative
○ Can occur in specific pattern like photodistribution,
asymmetric, phytophoto, etc.
DIAGNOSTIC CHECKLIST
Clinically Relevant Pathologic Features
• Presents as dry skin with fine scale and cracks, which
resemble dry riverbed
Pathologic Interpretation Pearls
• Spongiosis and exocytosis
SELECTED REFERENCES
1. Yamada S et al: Acute edema/cutaneous distension syndrome representing
as eczéma craquelé-like change: a case and published work review. J
Dermatol. ePub, 2016
2. Chu CH et al: Generalized eczema craquelé (asteatotic dermatitis) associated
with pemetrexed treatment. J Eur Acad Dermatol Venereol. ePub, 2015
3. Cassler NM et al: Asteatotic eczema in hypoesthetic skin: a case series. JAMA
Dermatol. 150(10):1088-90, 2014
4. Yuan C et al: N-palmitoylethanolamine and N-acetylethanolamine are
effective in asteatotic eczema: results of a randomized, double-blind,
controlled study in 60 patients. Clin Interv Aging. 9:1163-9, 2014
5. Kimura N et al: Prevalence of asteatosis and asteatotic eczema among
elderly residents in facilities covered by long-term care insurance. J
Dermatol. 40(9):770-1, 2013
6. Li LF et al: Bathing and generalized asteatotic eczema: a case-control study.
Br J Dermatol. 159(1):243-5, 2008
15
 Dyshidrotic Eczema

KEY FACTS
Spongiotic and Psoriasiform Dermatoses

TERMINOLOGY ○ Spongiosis with exocytosis of lymphocytes

• Subtype of eczema that occurs as vesiculopustules on
hands, feet, fingers, &/or toes
• Synonyms include dyshidrosis, pompholyx, palmoplantar
eczema
CLINICAL ISSUES
• Occurs more commonly in warmer weather and often at
intervals
○ Intervals can be regular or irregular and can be separated
by several weeks, months, or even years
• Presents as sudden onset of numerous deep-seated pruritic
crops of clear, sago grain-like vesicles on palms &/or soles
○ Often symmetric
• Mild cases often involve lateral fingers
• Scaling, fissures, and lichenification can ensue later
MICROSCOPIC
• Acute lesions
○ Intraepidermal vesiculation
○ Superficial lymphohistiocytic infiltrate ± eosinophils
• Chronic lesions
○ More acanthosis and parakeratosis
○ Spongiosis diminished and vesiculation absent
○ Superficial lymphohistiocytic infiltrate ± eosinophils
TOP DIFFERENTIAL DIAGNOSES
• Other spongiotic dermatitides
○ Include allergic contact dermatitis, nummular dermatitis,
id reaction, and atopic dermatitis
– More easily distinguished clinically
• Bullous arthropod bite reaction
• Bullous dermatophytosis
• Photoallergic contact dermatitis

Deep-Seated Vesicles Over Fingertips Spongiotic Dermatitis on Acral Skin

(Left) Deep-seated vesicles ﬈
over the fingertips, some of
which have become
hemorrhagic crusts, are seen
in a patient with dyshidrosis.
(Right) Low-power view of a
case of dyshidrosis
demonstrates a nonspecific
spongiotic pattern with
microvesicle formation ﬉ as
well as a superficial
perivascular infiltrate. A thick,
compact stratum corneum
indicates that this is from
acral skin.

Superficial Perivascular Lymphohistiocytic

Microvesicle Present on Acral Skin Infiltrate
(Left) A small microvesicle ﬈
is seen with exocytosis of
lymphocytes, surrounding
spongiosis, and a superficial
perivascular lymphohistiocytic
infiltrate. Note the thickened,
compact stratum corneum of
acral skin ﬉. (Right) A high-
power view of dyshidrosis
demonstrates a nonspecific
superficial perivascular
lymphohistiocytic infiltrate.
Eosinophils may or may not be
present.

16
 t t p
t ss:
p t t p
t ss:
p
hht Dyshidrotic Eczema
hht
rrss rrss

Spongiotic and Psoriasiform Dermatoses

o k e
k e
TERMINOLOGY
o ke
ke ○ Spongiosis with exocytosis of lymphocytes

o
eebb o o
Abbreviations
e bboo o e b o
○ Intraepidermal vesiculation

b o
○ Superficial perivascular lymphohistiocytic infiltrate ±
• Dyshidrotic eczema (DE)

m ee/ /e eosinophils

m ee/ / e
Synonyms
: / /
/ t
/ .t.m • Chronic lesions

: / /
/ t
/ .t.m
○ More acanthosis and parakeratosis
• Dyshidrosis

t t p
t ss:
p t t p
t ss:
○ Spongiosis is diminished
p
hht hht
• Pompholyx ○ Vesiculation typically absent
• Palmoplantar eczema ○ Superficial perivascular lymphohistiocytic infiltrate ±
Definitions eosinophils
• Subtype of eczema that occurs as vesiculopustules on
hands, feet, fingers, &/or toes DIFFERENTIAL DIAGNOSIS

k eers
rs k e r
erss Histopathologic

o o
o ok
ETIOLOGY/PATHOGENESIS
oooo k • Other spongiotic dermatitides
oo
eebb b b
Unknown ○ Allergic contact dermatitis

e/ e
/ e b
• However numerous things have been reported to worsen
e e / e
/ eb
– Can be indistinguishable histopathologically

e
or induce lesions

: // t
/ .
t m
. m // t/ tm
– Distinguished clinically
. . m
□ Lesions are sharply confined within areas where
:
○ Palmoplantar hyperhidrosis
○ Hot climate
t p ss
p : / tp pss : /
causative agent was in contact with skin

t
hht
○ Psychological stress
t
• Allergies to the following have also been reported to
t
hht t
○ Nummular dermatitis
– Can be indistinguishable histopathologically
– Clinically, shows tense vesicles in coin-like clusters
induce or exacerbate lesions
○ Nickel ○ Id reaction
○ Drugs – Can be indistinguishable histopathologically

keerrss
CLINICAL ISSUES
k eerrss – Clinically, widespread symmetric eruption of tense
vesicles that can be pompholyx-like

b ooook
Epidemiology
b o ook
o b o
□ Lesions tend to be transient

o
eeb • Incidence
ee/ e
/ e b e /e/e b
□ Usually associated with tinea pedis in this instance
□ Clinically, can also be more generalized intensely
e
intervals
: / //t/t.m
○ Occurs more commonly in warmer weather and often at
. m : / .
//t/t.mm
pruritic papulovesicular eruption that can involve
multiple sites

t t t s
p s :
– Intervals can be regular or irregular and can be
p
separated by several weeks, months, or even years
p s s :
○ Atopic dermatitis

t t t p
Presentation hh t hh t
– Can be indistinguishable histopathologically
– Lesions typically develop in infancy and are more
widespread (not limited to palms and soles)
• Sudden onset of numerous deep-seated pruritic crops of
clear, sago grain-like vesicles on palms &/or soles • Bullous bite reaction
○ Often symmetric ○ Infiltrate is typically deeper and wedge-shaped and often

k e rs
rs
• Mild cases often involve lateral fingers

e k eerrss has more eosinophils

– Deep, interstitial eosinophils are highly suggestive

b ooook
• Severe cases can form large coalescing bullae

b o ook
o
• Scaling, fissures, and lichenification can ensue later
• Bullous dermatophytosis

b oo
eeb Treatment
ee/ e
/ e b e / e
/ e b
○ Hyphae present within stratum corneum
– Can be highlighted with PAS stain
e
• Drugs

: / / t
/ m
.t.m : / / t
/ m
.t.m
• Photoallergic contact dermatitis
○ Topical calcineurin inhibitors

t p ss:
○ Steroid or tacrolimus creams
p / t p ss: /
○ Typically deeper lymphohistiocytic infiltrate around
superficial and deep vessels
p
t
hht t
• In severe or recalcitrant cases, other treatments can be
tried, such as
t
hht t
○ Occasionally necrotic keratinocytes may be present

○ Systemic steroids SELECTED REFERENCES

• Narrow-band UVB can also be used for recalcitrant cases 1. Pai VV et al: Unusual presentation of severe pompholyx. Indian Dermatol
Online J. 5(Suppl 1):S48-9, 2014

rrss rrss
Prognosis 2. Sehgal VN et al: Hand dermatitis/eczema: current management strategy. J

o k e e
• Generally good
k o kkee 3.
Dermatol. 37(7):593-610, 2010
Wollina U: Pompholyx: a review of clinical features, differential diagnosis,

o
eebb o o b o
○ Although disease is benign, severe cases can be

b oo
debilitating to some patients and significantly affect
e 4.
e bboo
and management. Am J Clin Dermatol. 11(5):305-14, 2010
Wollina U: Pompholyx: what's new? Expert Opin Investig Drugs. 17(6):897-
quality of life

m ee/ / e 5.
904, 2008

m ee/ /e
Jain VK et al: Role of contact allergens in pompholyx. J Dermatol. 31(3):188-
MICROSCOPIC
: / /
/ t
/ .t.m 93, 2004

: / /
/ t
/.t.m
ss: ss:
6. Thin G: Remarks on a skin-affection lately observed and described as
Histologic Features
• Acute lesions t
hhtt p
t p t
hhtt p
dysidrosis, cheiro-pompholyx, and pompholyx. Br Med J. 2(883):760-2, 1877

t p
17
 t t ppss: t t ps
ps :
hhtt Id Reaction
hhtt
rrss rrss KEY FACTS
Spongiotic and Psoriasiform Dermatoses

o k e
k e o ke
ke
o
eebb o o TERMINOLOGY

e bboo o eosinophils
e b o
○ Superficial perivascular lymphohistiocytic infiltrate +

b o
e/ e
• Generalized, eczematous, type IV delayed hypersensitivity

e /
skin reaction that occurs at sites distant to previously
m
•

m e
Late lesions
e/ / e
localized dermatitis

: / /
/ t
/ .t.m •
•
: / /
/ t
/ .t.m
Regularly elongated rete ridges
Less spongiosis, less lymphocyte exocytosis
CLINICAL ISSUES

t t p
t ss:
p t t p
t ss:
•
p
Hyperkeratosis, with wedge-shaped hypergranulosis +

hht
• Most commonly involves forearms, legs, and trunk
• Clinical appearance is typically symmetric widespread
papules that are extremely itchy
hht parakeratosis
TOP DIFFERENTIAL DIAGNOSES
• Occurs 1-2 weeks after primary infection/dermatitis occurs • Contact dermatitis
or worsens • Nummular eczema

k eers
rs treatment
k e r
erss
• Vigorous treatment of primary lesions/dermatitis is key for •
•
Dyshidrotic dermatitis (pompholyx)
Viral exanthem

o o
o ok MICROSCOPIC
oooo k • Spongiotic drug eruption
oo
eebb • Early lesions
e/
e e
/ b
e b ee/ e
/ b
eb
// t t
○ Prominent lymphocyte exocytosis
: / m
○ Prominent spongiosis ± microvesicle formation
. . m : // t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
Acute Spongiosis With Microvesicle
Desquamative Id Reaction Formation
(Left) Patient with vesicular

keerrss tinea pedis and a

desquamative st nonspecific
k eerrss
b ooook id reaction on the flexor
fingers and palm. (Right) This
b o ook
o b oo
eeb example of an id reaction
shows a nonspecific acute
ee/ e
/ e b ee/e/e b
spongiotic pattern with

: / / t
/ .
t m
. m : / / t
/ .
t m
. m
microvesicle formation ﬉ as
well as a superficial

t p ss
p : / t p ss
p : /
t
hht t
lymphohistiocytic infiltrate ﬈.
Occasional eosinophils were
present on higher power.
t
hht t

k eers
rs k eerrss
b ooook b o ook
o b oo
eeb / e e b
Spongiosis With Superficial Perivascular

ee / Infiltrate
ee/ e
/ e b
Spongiotic Dermatitis With Occasional
Eosinophils

/
(Left) Low-power view of an id

: / t
/ m
.t.m : / / t
/ m
.t.m
reaction demonstrates a

t p ss : /
nonspecific spongiotic pattern
p t ppss : /
t
hhtt
without microvesicle
formation and a superficial
perivascular infiltrate ﬈.
t
hhtt
There is also focal
parakeratosis ﬉. (Right) This
example of an id reaction

k e rrss
e
demonstrates mild to
moderate spongiosis with a
k eerrss
o o
o o k superficial perivascular

o o
oo k oo
eebb b b
lymphohistiocytic infiltrate
and an occasional eosinophil
﬉.
ee/ e
/ e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
18
 t t p
t ss:
p t t p
t ss:
p
hht Id Reaction
hht
rrss rrss

Spongiotic and Psoriasiform Dermatoses

o k e
k e
TERMINOLOGY
o ke
ke ○ Wound care may be needed for weeping eczematous

o
eebb o o
Synonyms
e bboo o lesions
• Drugs
e b o
b o
• Hypersensitivity reaction

m ee/ /e m e / / e
○ Antihistamines may help with itch &/or for sedative
e
•
•
Eczematid or autoeczematization

:
Autosensitization dermatitis
/ /
/ t
/ .t.m : / /
/ / .t.m
purposes at night
t
○ Topical or systemic steroids may be needed to quell
•
t p ss:
Disseminated secondary eczema
t t p t t p
t ss:
dermatitis
p
•
• hht
Isomorphic response
Dermatophytid, pediculid, scabid, virusid, and bacterid
when associated with corresponding etiologic
hht
○ Potassium permanganate may be given for weeping
lesions to prevent infection
• Vigorous treatment of primary lesions/dermatitis is
factor/infectious agent tantamount
○ May require systemic therapy depending on etiology or

ee s
Definitions
rrs e r
er
• Generalized, eczematous, type IV delayed hypersensitivity
k k ss severity of disease

o o
o ok oo k
skin reaction that occurs at sites distant to previously
oo
Prognosis

oo
eebb b b
localized dermatitis • Usually good with appropriate recognition and treatment

e/
e e
/ e b MICROSCOPIC
ee/ e
/ eb
ETIOLOGY/PATHOGENESIS

: // t
/ .
t m
. m : // t/.tm.
Histologic Featuresm
Exact Cause Unknown
• Several theories
t p ss
p : / tp ss : /
• General spongiotic pattern
p
t
hht t
○ Immune response to circulating cytokines or infectious
organisms
t
hht t
○ Spongiosis ± microvesicle formation (typically in early
lesions only)
– Dissemination of infectious antigens with secondary ○ Lymphocyte exocytosis
response ○ Superficial perivascular lymphohistiocytic infiltrate ±
– Hematogeneous dissemination of inflammatory eosinophils

keerrss cytokines from primary site

k eerrss – Eosinophils may be less conspicuous than in other

spongiotic dermatitides
ook ook
○ Abnormal immune recognition of autologous skin

b
eeboo antigens

/ e b o
b o
○ Increased stimulation of normal T cells by altered skin
• Early lesions

/e bboo
○ Spongiosis more prominent, and microvesicles may be
constituents
m ee / e present

m ee /e
○ Lowering of "irritation threshold"

: / .
//t/t. m .
//t/t. m
○ Lymphocyte exocytosis is more prominent

: /
CLINICAL ISSUES
t t p
t s
p s : t p s
p s :
• Late lesions
○ Regularly elongated rete ridges
t t
Epidemiology
• Age
hh t hh t
○ Less spongiosis and less lymphocyte exocytosis
• Later lesions can be indistinguishable from lichen simplex
chronicus
○ Can occur at any age
• Sex DIFFERENTIAL DIAGNOSIS

k eerss
○ No predilection
r
• Ethnicity
k eerrssHistopathologic

b ooook ○ No predilection

b o ook
o
• Contact dermatitis

b oo
eeb b b
○ More eosinophils and Langerhans cell microgranulomas
Site
ee/ e
/ e e / e
/ e
○ Clinically limited to areas where contactant touched skin
e
: / / t
/ m
• Most commonly involves forearms, legs, and trunk
.t.m • Nummular eczema

: / / t
/ m
.t.m
Presentation

t p ss:
p /
• Clinical appearance is typically symmetric widespread
t p ss: /
○ Clinically circular lesion without clearing in center
• Dyshidrotic dermatitis (pompholyx)
p
t
hht t
papules that are extremely itchy
○ Occurs 1-2 weeks after primary infection/dermatitis
t
hht t
○ Dyshidrotic dermatitis is limited to hands and feet (no
widespread eruption as in id reaction)
occurs or worsens • Viral exanthem
○ Lesion can also occasionally be papulovesicular or ○ Clinically symmetric, diffuse redness
eczematous • Spongiotic drug eruption

k e rrss
e
– Exception rather than rule

k eerrss ○ Clinical history of drug exposure

○ No history of localized, preceding inflammation (as

o o
o o k
○ Vesicles on hands &/or feet may appear mimicking
pompholyx
o o
oo k o
would be seen in id reaction)
o
eebb ○ Very nonspecific clinically

ee/
• Occasionally patient may feel general malaisee
/ b
e b SELECTED REFERENCES
ee/e/ebb
○ Loss of appetite, fever

: / / t
/ m
.t.m 1.

/ t m
.t.m
Medscape: Id Reaction (Autoeczematization).

: / /
Treatment
t p ss:
p / t p ss: /
http://emedicine.medscape.com/article/1049760-overview. Published
October 14, 2015. Accessed January 20th, 2016

p
t
hht t
• Options, risks, complications
2.
t
hht t
Winfield H et al: Non infectious vesiculobullous and vesiculopustular
diseases. In Elder DE et al: Lever's Histopathology of Skin 11th ed.
Philadelphia: LWW. 282. 2015

19
 t t p
t ss:
p t t p
t ss:
p
hht Seborrheic Dermatitis
hht
rrss rrss KEY FACTS
Spongiotic and Psoriasiform Dermatoses

o k e
k e o ke
ke
o
eebb o o TERMINOLOGY

e bboo o pustules)
e b o
○ Neutrophils in spinous layer of epidermis (Kogoj

b o
ee/ e
• Erythema and scale on seborrheic distribution (malar
/
region, scalp, external ear canal, nasolabial folds, eyebrow,
m m e / / e
• Contact dermatitis
e
ears, and chest)

: / /
/ t
/ .t.m : / /
/ t
/ .t.m
○ More diffuse spongiosis
○ Clinically, not in seborrheic areas and more focal to the
CLINICAL ISSUES

t t p
t ss:
p t t p
t ss:
p
irritant

distribution hht
• Scaly and greasy papules and plaques in seborrheic

• Infancy, puberty, and peak at middle age

hht • Dermatophytosis
○ Hyphae seen in special stain such as PAS-D
• Discoid lupus
MICROSCOPIC ○ Superficial and deep perivascular and periadnexal
inflammatory infiltrate

k eers
rs epithelium
k e r
ers
• Spongiosis (acute or chronic) in epidermis and follicular
s ○ Interface changes (basal vacuolar alteration and necrotic
keratinocytes) of epidermis

o o
o ok • Mounds of scale crust at follicular ostia

oooo k o
○ Increased dermal mucin
o
eebb b b
• Neutrophils located at scale crust

e/
e e
/ e b
• For chronic lesions, more psoriasiform epidermis
ee e
/ eb
○ Thickened basement membrane
/
TOP DIFFERENTIAL DIAGNOSES

: // t
/ .
t m
. m : // t/.tm. m
• Psoriasis

t p ss
p : /
○ More regular psoriasiform hyperplasia
tp pss : /
t
hht t t
hht t
Follicular Spongiosis of Seborrheic
Greasy Fine Scale of Seborrheic Dermatitis Dermatitis
(Left) Seborrheic dermatitis

keerrss presents in this patient as a

papulosquamous dermatitis
k eerrss
b ooook preferring the creases of the
skin with greasy, fine,
b o ook
o b oo
eeb nonadherent scale ﬈ on a
pink base. (Right) Low-power
ee/ e
/ e b ee/e/e b
view of seborrheic dermatitis
shows spongiosis of the
: / .
//t/t.mm : / .
//t/t.mm
p s
epidermis ﬈ and follicular

t t t p s : t t p
t s
p s :
epithelium ﬊.

hh t hh t

k eers
rs k eerrss
b ooook b o ook
o b oo
eeb ee/ e
/ e b
Parakeratosis and Follicular Spongiosis
ee/ e
/ e b
Parakeratosis at "Lips" of Follicular Ostia
(Left) Higher power view of

: / / t
/ m
.t.m : / / t
/ m
.t.m
t ss:
seborrheic dermatitis shows

p /
parakeratosis in the follicular
p t p ss:
p /
t
hht t
ostia ﬊ and spongiosis of the
follicular epithelium ﬈.
(Right) A later lesion of
t
hht t
seborrheic dermatitis
demonstrates psoriasiform
epidermal hyperplasia ﬈ with

k e rrss
e
parakeratosis in the follicular
ostia ﬊. Often it occurs at the
k eerrss
o o
o o k "lips" or at the edges of

o o
oo k oo
eebb b b
follicular ostia, as seen here
﬉.

ee/ e
/ e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
20
 t t p
t ss:
p t t p
t ss:
p
hht Seborrheic Dermatitis
hht
rrss rrss

Spongiotic and Psoriasiform Dermatoses

o k e
k e
TERMINOLOGY
o ke
ke MICROSCOPIC
o
eebb o o
Abbreviations
e bboo o Histologic Features
e b o
b o
• Seborrheic dermatitis (SD)

m ee/ /e m e / / e
• Spongiosis (acute or chronic) in epidermis and follicular
e
Synonyms
: / /
/ t
/ .t.m epithelium

: / /
/ t
/ .t.m
• Mounds of scale crust at follicular ostia
• Seb derm

t t p
t ss:
p t t p
t ss:
• Neutrophils located at scale crust
p
hht hht
• Cradle cap in infants; dandruff (mild form of SD) • For chronic lesions, more psoriasiform epidermis
Definitions
• Erythema and scale on seborrheic distribution (malar DIFFERENTIAL DIAGNOSIS
region, scalp, external ear canal, nasolabial folds, eyebrow, Histologic Differential Diagnosis
ears, and chest)

k eers
rs k e r
erss
• Psoriasis
○ More regular psoriasiform hyperplasia

o o
o ok
ETIOLOGY/PATHOGENESIS
oooo k ○ Less spongiosis
oo
eebb b b
Infectious Agents

e/ e
/ e b
• Possible link to Malassezia furfur or other Malassezia species
e
pustules)
ee/ e
/ eb
○ Neutrophils in spinous layer of epidermis (Kogoj

such as M. globosa and M. restricta

: // t
/ .
t m
. m // t
ostia)
: / tm
○ More confluent parakeratosis (not restricted to follicular
. . m
Unknown

t p ss
p : / tp ss : /
○ Loss or decrease of granular layer

p
t t
• Thought to be dysfunction of sebaceous gland

hht
• Possibly linked to Malassezia (Pityrosporum) species
• Possible link to UV exposure
t
hht t○ Dilated vessels in dermal papillae
• Contact dermatitis
○ More diffuse spongiosis
Disease Association ○ More dermal eosinophils
○ More confluent parakeratosis
• Worse in HIV patients

keerrss k e r
• Can be seen in Parkinson disease, obesity, zinc deficiency,

e rss ○ No increase of Langerhans cells

○ Clinically, not in seborrheic areas and more focal to

ook ook
and chronic alcoholism

b
eeboo • Can be precipitated by lithium

/ e b o
b o
irritant
• Dermatophytosis
/e bboo
CLINICAL ISSUES
m ee / e e /e
○ Hyphae seen in special stain such as PAS-D

m e
Epidemiology
: / .
//t/t. m : / .
//t/t. m
○ Usually mounds of parakeratosis more diffuse and not
localized to follicular ostia
• Incidence

t t p
t s
p s : t p s s :
• Discoid lupus
t t p
hh
○ Up to 20% for dandruff
• Age
t
○ High: 3-5% of general population
hh t○ Superficial and deep perivascular and periadnexal
inflammatory infiltrate
○ Interface changes (basal vacuolar alteration and necrotic
○ Infancy, puberty, and peak at middle age keratinocytes) of epidermis
• Sex ○ Thickened basement membrane

k eers
rs
○ No predilection

k eerrss ○ Hyperkeratosis and follicular plugging

○ Increased dermal mucin

b ooook
Site

b o ook
o oo
○ In tumid lesions, there is epidermal atrophy

b
eeb b b
• Malar region, scalp, external ear canal, nasolabial folds,

e / e
/ e
eyebrow, ears, and chest ("seborrheic distribution")

e e
SELECTED REFERENCES
e/ e
/ e
Presentation

: / / t
/ m
.t.m 1.

: / / t m
.t.m
Dessinioti C et al: Seborrheic dermatitis: etiology, risk factors, and

/
distribution
t ss:
p /
• Scaly and greasy papules and plaques in seborrheic

p 2.

t p ss: /
treatments: facts and controversies. Clin Dermatol. 31(4):343-51, 2013
Shin H et al: Clinical efficacies of topical agents for the treatment of

p
Treatment t
hht t t
hht
3.
t seborrheic dermatitis of the scalp: a comparative study. J Dermatol.
36(3):131-7, 2009
Gupta AK et al: Seborrheic dermatitis. J Eur Acad Dermatol Venereol.
18(1):13-26; quiz 19-20, 2004
• Drugs
4. Faergemann J et al: Seborrhoeic dermatitis and Pityrosporum (Malassezia)
○ Shampoo folliculitis: characterization of inflammatory cells and mediators in the skin by
– Salicylic acid immunohistochemistry. Br J Dermatol. 144(3):549-56, 2001

k e rrss
– Tar

e
– Selenium
k eerrss 5. Ford GP et al: The response of seborrhoeic dermatitis to ketoconazole. Br J
Dermatol. 111(5):603-7, 1984

o o
o o k
○ Ketoconazole
o o
oo k oo
eebb ○ Corticosteroids

ee/ e
/ b
e b ee/e/ebb
Prognosis
• Excellent
: / / t
/ m
.t.m : / / t
/ m
.t.m
○ Benign condition
t p ss:
p / t p ss:
p /
t
hht t t
hht t
21
 t t p
t ss:
p t t p
t ss:
p
hht Pityriasis Rosea
hht
rrss rrss
KEY FACTS
Spongiotic and Psoriasiform Dermatoses

o k e
k e o ke
ke
o
eebb o o TERMINOLOGY

e bboo o MICROSCOPIC

e b o
b o
ee/ e
• Common, self-limited, acute papulosquamous eruption of
/
salmon-pink, oval lesions on trunk, neck, and proximal
m ee/ e
• Histopathological features are nonspecific
/
• Focal spongiosis, patchy or diffuse parakeratosis, often
m
extremities

: / /
/ t
/ .t.m : / / t
/ .t.m
forming angulated mounds
/
CLINICAL ISSUES

t t p
t ss:
p t t p
t ss:
• Mild lymphohistiocytic perivascular and interstitial infiltrate

p
in superficial dermis

hht
• Flu-like prodrome may be reported 2-3 weeks before
cutaneous findings
• "Herald patch" may appear days to weeks before other
hht • Red blood cell extravasation in upper dermis and often
epidermis
pityriasis rosea lesions TOP DIFFERENTIAL DIAGNOSES
○ Pink to salmon-colored oval plaque with central fine • Histologic differential diagnosis

k eers
rs scale and peripheral trailing collarette
• Generalized eruption
k e r
erss ○ Erythema annulare centrifugum
○ Pigmented purpuric dermatosis

o o
o ok o oo k
○ Numerous smaller (1-2 cm) pink or salmon-colored round

o
○ Guttate psoriasis
oo
eebb b b bb
to oval papules with characteristic collarette of scale

e/ e
/ e
○ Trunk and proximal extremities most affected
e ee/ e
• Clinical differential diagnosis

/ e
○ Pityriasis rosea-like drug eruption

: // / .
t m m
○ Fir or Christmas tree pattern on posterior trunk
t . : // t/.tm. m
○ Secondary syphilis

t p ss
p : / tp pss : /
○ Guttate psoriasis

t
hht t t
hht t
Papulosquamous Eruption of Pityriasis
Rosea Spongiosis With Parakeratosis
(Left) Classic distribution of

keerrss pityriasis rosea (PR) shows

small, pink or salmon-colored
k eerrss
b ooook oval papules on the posterior
trunk and proximal arms. The
b o ook
o b oo
eeb long axes of the oval papules
follow skin tension lines,
ee/ e
/ e b ee/e/e b
forming a Christmas tree

: /
pattern. (Right) This case of PR .
//t/t.mm : / .
//t/t.mm
displays more prominent

t t p
t s
p s : t t p
t s
p s :
t
spongiosis ﬊ underlying a

hh
focus of parakeratosis ﬉. The
dermal lymphocytic infiltrate
is sparse and interstitial, and
hh t
red blood cell extravasation is
present.

k eers
rs k eerrss
b ooook b o ook
o b oo
eeb ee/ e
/ e b
Extravasated Erythrocytes
ee/ e
/ e bMounded Parakeratosis
(Left) Extravasation and

: / / t
/ m
.t.m : / / t
/ m
.t.m
t
red blood cells ﬊ are not
ss:
transepidermal elimination of

p p / t p ss:
p /
t
hht t
infrequent findings in PR.
(Right) PR often shows a
mound of parakeratosis ﬈
t
hht t
with adjacent spongiosis ﬇
within a slightly acanthotic
epidermis. A perivascular

k e rrss
e
lymphocytic infiltrate is
present in the superficial
k eerrss
o o
o o k dermis.

o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
22
Another random document with
no related content on Scribd:
and on the shoulders of Lynn Prentiss and Macklin and Ellers—who
would probably be too tight to give a damn. With Lathrup gone he
probably wouldn't be fired, although he deserved to be, with his
inability to remain sober two days in a row. The whole staff had been
under quite a strain.
It helped her to swear inwardly, to be as cynical and hard-boiled as
she could in a moment of torment and uncertainty such as this. Her
father's face in the locket flashed once more across her mind and
she thought: "Poor dad! Poor gentle, kind, moralistic, unworldly dad,
who never quite knew what it was all about and whom I loved so
very much. Do you know what your darling daughter has become?
She has not only slept with a man out of wedlock, she's about to
become an accessory to murder after the event. Or she may decide
not to. It would make her much more of a hypocrite and less
honorable and decent, actually, because she wanted to kill Lathrup
herself. But maybe you'd prefer her to stay on the right side of the
law."
Climbing up out of the excavation took her less than three minutes
but she was conscious every moment of the bulge which the big
pistol made in her hand-bag—it was a miracle she'd been able to fit
it in—and she hoped no one would notice how lopsided and
distended the bag looked when she arrived at street level.
It was only when she reached the pavement above the pit again that
she realized that the worst possible calamity had taken place. Not
one member of the office staff but three saw her climb out of the
excavation, for it was now five minutes to nine and a rush to reach
the office on time was in progress.
Lynn Prentiss passed and stopped to stare, raising her eyebrows
slightly and then continuing on, as if she did not wish to embarrass a
fellow editor in any way. But there had been more than a glimmer of
bewilderment in her eyes, as if she found it difficult to picture Ruth
Porges scrambling out of an excavation in such haste and in so
undignified a manner. What could have prompted her to climb down
in the first place? A rendezvous with the foreman of the construction
gang? Unthinkable ... if you knew what kind of a girl Ruth Porges
was—
Then Tommy Anders, the oldest of the two office boys passed,
turning what was probably the sports pages of a morning newspaper,
and probably not even seeing her, although he was looking straight
in her direction. Then Susan, who had the courtesy not to stare at all,
but must have been as startled as Lynn, and just as bewildered.
All she had to do was stand very still with the bag in plain view and
everyone who hadn't reached the office a little earlier would know
that she'd been behaving in a very strange manner, because there
was dust all over her skirt and she was still breathless from her
exertions. A half-dozen more Eaton-Lathrup employees would see
her and perhaps even Eaton himself. And they'd be sure to notice
the bulge in her hand-bag. The awful thought flashed across her
mind that the very outlines of the gun might be visible.
And of course it would be all over the office in another half hour, and
—he would know. That was the really terrible, frightening thing. Even
if he didn't pass and see her, along with the others, he'd be sure to
know. At least twenty people would know and he'd be among them.
Lathrup's slayer, shaken as he'd failed to be by all the police
questioning, although she remembered—now that she thought about
it and knew the truth about him—he had paled visibly once and
almost betrayed himself. He'd said the wrong thing and had been
forced to cover up quickly.
The man who had entered Lathrup's office six days before and shot
her dead would know that a girl he couldn't possibly have imagined
he'd have any reason to fear had gone down into the excavation
where he'd hidden the murder weapon and had found it, and he'd
remember that he had once showed it to her, and if she went to the
police with it—
Or was she taking too much for granted again, letting her fear
completely distort her thinking? He'd have no way of knowing she'd
climbed all the way down to the bottom of the excavation. He wasn't
stupid, he'd consider the possibility that she'd simply dropped
something—as she had—and climbed down a few feet to recover it.
A book perhaps, or her lipstick. He might not even give the matter a
second thought, even though he knew where he'd hidden the gun,
and how dangerous it would be if someone stumbled on it ahead of
the steam shovel.
It was all very strange anyway. Why hadn't he gotten rid of the gun in
a simpler, safer way—simply tossed it into the river, as she had
thought of doing? Or driven out into the country somewhere and
tossed it into a lake or buried it? It wasn't as easy to get rid of small
objects of a dangerous nature as some people thought—even small
phials of poison had a way of turning up again and sending
murderers to the gallows. She'd read about such cases often
enough. But still—
She suddenly thought she knew why he'd hidden the gun under a
stone in the excavation, probably taking care to see that it was
buried first pretty deeply. The gun had probably been down there
since the day of the murder. He'd had to get rid of it quickly, had to
make sure the police wouldn't find it anywhere about the office and
trace it to him fast. And as the excavation was only a short distance
from the office his hiding it there made sense, was logical enough.
He'd probably climbed down during a lull in the construction work,
when the pit was deserted, and gambled on the steam shovel
scooping the gun up and carrying it off within a fairly short time.
Possibly it hadn't even occurred to him it would still be there after six
days. Quite possibly it had almost gone into the shovel. Been lifted
up, tossed about and reburied. A steam shovel functioned erratically
at times and the tumbled, heaved-up look of the earth all around the
stone made that guess—of course it was only a guess—seem quite
plausible to her.
It had probably continued to worry him, kept him anxious, robbed
him of sleep—if a man with blood on his hands could ever not be
robbed at times of sleep. But even a nightmare kind of anxiety was
better than immediate apprehension by the police. If he'd climbed
down into the excavation again later, to make sure that the gun had
gone into the scoop and been caught with the weapon in his hands
or even just searching for a weapon that had vanished he'd be taking
the same kind of risk a murderer with a psychopathic streak does
when he returns to the scene of his crime in the grip of a morbid
compulsion.
She'd just taken, all unwittingly, the same kind of risk herself but she
was quite sure the police wouldn't suspect her, and if they did she'd
have no trouble in clearing herself. Only the killer would suspect her
—of knowing precisely who he was.
She felt suddenly that she'd been wrong about his not suspecting
she'd gone all the way to the bottom. He'd be sure to suspect a little,
when it went flying about the office that she'd been seen emerging
from the pit. He'd hardly dismiss it with a shrug, even though he'd
have no way of knowing for sure she'd succumbed to an irresistible
impulse ... to overturn a big, flat stone.
She came to a sudden, perhaps not completely wise decision. She
wouldn't go to the office at all this morning. She'd go straight back
home and decide what to do about the gun in the privacy of her own
apartment.
Let Eaton think what he wished, let all the others gossip about her.
Compared to what she'd just discovered it had about as much
importance as a microscopic hair on the leg of a gnat. She could
plead illness, a sudden attack of migraine. It was a good enough
excuse.
Better to return home at once with the gun and come to as
completely wise a decision as she was capable of. If she decided to
go to the police, there was nothing to be lost by waiting until noon.

It was strange, it never ceased to amaze Ruth Porges, how much

familiar surroundings, a chair you sat in daily, a painting on the wall
that had become as well-known to you as the face and even the
shared thoughts of an old friend, a potted palm you'd watch grow
and watered dutifully for years—just how much such objects helped
you to think clearly when you were in a tormented frame of mind.
She'd made her decision now and she felt no remorse, no sense of
guilt at all. She was probably a very unusual person in some
respects, but she had long since ceased to reproach herself because
she felt compelled at times to behave in an unusual way.
She'd hid the gun where she didn't think it would be found easily, if
the police should suspect anything—they still kept dropping in at the
office—and called unexpectedly within the next few hours to
question her about her descent into the excavation and her sudden
decision to take the day off. As soon as it became dark she'd take a
taxi to the East River on the upper East Side, get out a few blocks
from the esplanade that overlooked the most turbulent part of the
river, walk calmly through the beautiful park that ended in an
ascending terrace, and make sure that all of the nearby benches
were unoccupied. Then she'd move quickly to the iron railing and
toss the gun as far out into the river as she could.
Did they ever drag the East River for a murder weapon? Could they,
with any real hope of finding it? She didn't know for sure, but she
rather suspected they couldn't.
And how would anyone ever know, or even remotely suspect, where
she'd tossed the gun? They'd have to drag the Hudson also and the
bay all the way to Staten Island, because you could drop a gun from
a ferry too.
She knew she couldn't morally justify what she was planning to do. It
would have been useless to try. But if she had hated Lathrup herself
enough to want to kill her, she couldn't see herself in the role of a
hypocritical betrayer, sending to his death a man who had lost
control completely and gone all the way. If the police had stumbled
on the gun themselves, without her help, it would have been quite
different. But having opened a Pandora's box, the horror that had
come out had to be destroyed. It was her responsibility—hers alone.
That the box had been a big flat stone that she had overturned
impulsively, with no knowledge of what lay concealed underneath,
changed nothing. The same woman's curiosity which had betrayed
Pandora had been at work in her. It was the most destructive kind of
curiosity in the world, but she had succumbed to it and must pay the
price, even if it would mean that she would have to wear a gray
prison uniform for four or five years.
Probably the killer should be caught and compelled to defend himself
before the law, bolstering his defense with whatever justification he
could offer. But she couldn't—she refused pointblank—to become
the instrument of his destruction. It was a twisted way of thinking,
perhaps, but it was her way and she would have to act upon it.
She had gone into the kitchen and was percolating some coffee
when the doorbell rang. It didn't alarm her particularly or even bring
the image of a policeman with one finger firmly pressed to the bell
into her mind.
The doorbell usually rang eight or ten times a day when she was at
home. Tradesmen mostly, with groceries she'd ordered by telephone
the day before or a special delivery letter from the office with proofs
that required a quick checking-over, or just a neighborly visit from the
over-talkative girl who lived in the apartment across the hall. Sally
Draper could be an awful pest at times—
Then she remembered that no one would expect her to be home on
a week-day morning and did become a trifle uneasy. But salesmen
and peddlers were always calling, weren't they, defiantly ignoring the
big warning sign posted in the hall?
She turned off the gas under the percolator, removed the slightly
soiled apron she'd put on to protect the severe, freshly-laundered
office dress she'd been too emotionally upset to take off on arriving
home and went to answer the bell, crossing the living room with a
slight quickening of her pulse.
She paused for the barest instant with her hand on the knob of the
front door, trying quickly to decide just what she had better say if it
actually was a policeman.
Then she opened the door wide.
Her first impulse, prompted by sheer terror, was to close it again
instantly, slam it in his face with all her strength. But he just stood
there, staring at her so quietly, with not the slightest trace of hostility
in his eyes, that she forced herself to remain calm. And when his
expression changed, and his eyes narrowed to gleaming slits and his
jaw hardened, he was too quick for her.
He brushed past her into the apartment and swung about to face her,
nodding toward the door.
"Better put the chain on," he said. "I imagine the super has a key,
and this is one time when we can't afford to chance any kind of
interruption."
There was something about the way he was looking at her that
compelled instant compliance. She closed the door, clicked the lock
on, and inserted the head of the chain into the metal groove on the
right side of the door. Her fingers shook as she ran it the full length of
the groove.
He was staring at her very steadily now, his eyes still slitted. "You
found it, didn't you?" he asked.
"Found what? I just don't understand. I didn't go to the office this
morning because—"
"Because you found it," he said, not giving her time to finish, and
taking a slow step toward her.
"No, you must listen. Please ... I...."
"Where is it? What have you done with it?" he demanded.
She shook her head, her lips deathly pale now. She was trembling
so violently that it was like ... a confession. How could she hope to
deceive him when he already knew, when the truth was written in her
eyes?
"I showed it to you once," he said. "That's the bad part ... the really
bad part. Just one word from you could send me to the chair. You
wouldn't even have to turn it over to the police."
He took another slow step toward her and quite suddenly ... she
knew. He'd come here to kill her. Even if she told him where the gun
was hidden, even if she put it into his hands and swore that she'd
keep silent, that not even police brutality could force the truth out of
her, he'd never feel secure while she remained alive.
He'd never trust her completely ... because he didn't know her that
well. She'd never really been close to him. Oh, if only she had. If only
they'd been lovers, and she'd gone to bed with him ... anything. The
thought revolted her even now, but it was better than dying ... and
now she was going to die.
He wasn't the kind of man who propositioned every pretty woman he
met. She would have had to let him know unmistakably that she was
... that kind. He'd respected her too much to make even a pass the
few times she'd gone out with him. There had been something
terribly decent about him ... and she'd admired him for it, respected
him in return.
But it would have been better, far better, if she'd let him think her a
whore. A killer could trust a slum prostitute because that kind of
woman was herself an enemy of the law. Or felt put upon, an
outcast, just as he himself had now become, because when he'd
killed Lathrup he'd put himself beyond the pale.
She'd never been close to him, that was the trouble. He didn't know
that there was a fierce kind of loyalty in her that would never have
permitted her to turn informer, because she herself had been a
criminal in her thoughts and had wanted Lathrup to die.
He could never have thought her a street-walking strumpet, but if
she had slept with him he'd have known just what kind of woman she
was, how fierce and determined her loyalty could be. Now it was too
late ... much too late ... and she was going to die.
It seemed unjust, horribly cruel and unnecessary. But how could she
make him see that?
"You've hidden it somewhere about this apartment," he said. "I'm
sure of that. You'd better tell me—fast."
She shook her head, a faint glimmer of hope arising in her. If she
refused to tell him where she'd concealed the gun he might not kill
her until he knew. He'd have to know, have to find it. Or would he? If
she was dead, unable to testify against him, the gun might have
been so well-hidden it would never turn up again. He might even
jump to the conclusion she'd gotten rid of it already or take a chance
on that and—
No, no, no! Now she was thinking crazily. Getting rid of the gun
would mean she was capable of sympathizing with what he'd done,
understanding it—would mean that she was on his side. And that
was the very thing something deep in her nature, her every
reasoning instinct, told her he'd never believe. The closeness again.
She could plead with him until she was hoarse, but he'd never
believe that. He'd kill her anyway. Kill her first perhaps and search
the apartment for the gun afterwards....
And that seemed to be what he had made up his mind to do. He was
losing patience with her; she could see that plainly enough and the
tight knot of fear which was constricting her heart began to tighten
even more, and she swayed a little and had to bite down hard on her
tongue to keep from screaming.
It wasn't just that he was losing patience with her. There was a
heightened tenseness in him, a kind of muscular rigidity that was
making his neckcords bulge, his shoulders stiffen. She could sense
it, feel it—that dangerous tension mounting in him.
He might want to search for the gun first, but there were times when
the human mind went out of control, lost all of its capacity to reason
intelligently.
His face was twisting terribly. She tried not to look at him, tried to
avoid his eyes, and managed to do so for an instant. But she knew
he was still looking at her, that his eyes were burning with a slow,
merciless kind of rage simply because she had discovered the truth
about him.
He was drawing closer to her suddenly. His feet made a scuffling
sound as he advanced upon her and he was breathing in a strange
way, hoarsely, almost raspingly.
Closer he came and closer, but still she dared not look at him. And
then she did look and saw the glaze of fury in his eyes and she
screamed in wild terror, knowing even as she screamed that no help
could come to her.
She fought him desperately, trying to push his arms away, trying to
get free of his arms that were beginning to tighten about her. It
wasn't a lust-crazed lover's embrace. If only it had been there might
have been some hope for her. But how could she hope to escape
from the embrace of a man so goaded, the embrace of a man who
thought that his own life would be forfeited if he did not silence her
quickly and forever.
The harder she struggled the closer his arms came and then it
wasn't his arms but his hands she had most to fear. They were
reaching for her throat and there was no way she could keep them
from encircling her throat and tightening cruelly, no way of avoiding
the strangling grip of his strong, muscular fingers.
His thumbs sank into the soft flesh just above her wind-pipe, and
began to press ... and to press....
She could only shake her head, frantically back and forth, and plead
dumbly. "No. Please don't. There's no need. I'd have thrown the gun
—"
When he finally arose and left her she was lying stretched out full
length on the floor, her sightless eyes staring straight up at the
ceiling, as if it were a great, rushing river sweeping above her and
carrying with it a gun which he spent thirty-five minutes trying to find,
ransacking the apartment and cursing softly from time to time, and
even crying out once in savage rage and frustration.
He did not find it, and left the apartment without even stopping to
look once more at the swollen, purplish face and protruding tongue
of a woman who would have gone to prison to protect him.

Chapter VII
In newspaper jargonese it was what is known as "crowding." It drove
copy-desk men half out of their minds and made reporters more than
unusually bar-conscious. The overtime chalked up by the police
department in the July heat was no more staggering than the extra
hours that had to be divided up between newspapermen covering
the Lathrup slaying.
Another slaying a few days after the first would have been
sensational enough in itself. But two days after the lifeless body of a
second Eaton-Lathrup editor had been found in that editor's own
apartment, the victim of a brutal strangler, a third Eaton-Lathrup
editor vanished.
Allen Gerstle, the magazine group's bespectacled, white-haired cafe
society exposé editor failed to appear at his desk at his usual hour
on a rainy Tuesday morning and in forty-eight hours, goaded into an
extraordinary burst of check-up activity by frantic telephone calls
from his wife and the implications involved in such a disappearance
when the Lathrup slaying was being referred to, by a few papers at
least, as the crime of the century—goaded, indeed, beyond the call
of duty, the police had made certain that it really was a bona fide
missing persons development.
Gerstle hadn't simply gone off somewhere and gotten drunk. He
wasn't given to that and with every policeman in the city on the
lookout for him it is doubtful if he could have carried it off if he had
been. A five-state alert had failed to turn up any trace of him. He had
apparently disappeared into thin air, and while it wasn't quite as
sensational a development as the Ruth Porges slaying, it added
variety and spice to the headlines, and greatly increased the number
of aspirin tablets—and in a few instances, tranquilizers—gulped
down in haste by cops on double-duty and around-the-clock news
commentators on all the major networks.
A "mysterious disappearance" following so close on the original
slaying was just what the case needed—or didn't need, if the
harassed brigade could have made their protests heard—to round
out the pattern of violence.
To complicate everything, and give the Homicide Squad an
additional headache and a feeling of bitter frustration, all this had
taken place when they had been quite sure that the killer had been
apprehended, and was safely in custody.
A young writer who had wanted to kill Helen Lathrup badly enough to
have gone out and purchased a gun and visited the office on the
very morning of the slaying! Now he would have to be released, in all
probability. There was actually nothing to hold him on that would
stand up in court, because Ballistics had confirmed that the gun he'd
purchased had not been the murder weapon. He'd violated the
Sullivan Law, of course—
The comments of Lieutenant of Detective Joseph Fenton on that
particular aspect of the case would not have been printable.
But there was nothing unprintable about the conversation of the four
men who sat now in the Eaton-Lathrup offices discussing the case.
In Macklin's office, to be precise, because Macklin was the calmest,
most unbiased and level-headed of the four and seemed to know
just how comforting a cushion a little sensible talk could provide for
pent-up or over-charged emotions.
"I still think we'll have to look for a pathological killer and will get
nowhere if we write off that probability," Eaton was saying. He sat in
a chair by the window, the sunlight bright on his wide bald patch, the
lenses of his frameless glasses and the dial of his costly wrist-watch.
He was of medium-height, medium-build and had a gray executive
look—a top-echelon executive look—although he was sincerely
trying to relax and fraternize.
"I think so too," Ellers said. "I've thought so from the first. I was pretty
sure, when they arrested Gilmore and Lieutenant Fenton told me
they'd traced the purchase of a gun to him, that they had the right
man. That's doubtful now, but I agree with you about the psycho
likelihood."
"It's very curious," Eaton said. "This whole pathological killer
possibility ... stranger and more chilling that you might suspect. You'd
understand better why I'm saying that if you'd known Helen as well
as I did. There are people insurance companies shy away from or
label very high risks. They're known as the 'accident prone.' It may
be based on nothing but superstition, but you'd have a hard time
convincing an experienced insurance-policy salesman of that.
"Some people seem to have a rare gift for making accidents happen,
of drawing down the lightning upon themselves. They become
seriously injured time and time again. And Helen ... well, you might
almost say she invited a psychopath to kill her ... just because she
dwelt on the horror of that kind of occurrence so often in her mind.
The more gruesome aspects of crime fascinated her, and she liked
to read about 'ripper cases' and brutal slayings in general. A lot of us
do—normal, well-adjusted people in search of exciting reading in the
mystery story field. But I always felt, with her, it went considerably
beyond that. It was a horror which she acutely feared, a horror of the
mind—"
By some kind of near-miracle the veteran ex-newspaperman wasn't
even slightly tight and his voice was steady. He was standing a few
feet from Eaton, leaning lightly against Macklin's desk and puffing on
a light-weight briar.
"I was completely sure," Timothy Hansen said. "Every time Gilmore
came to the office to talk with Miss Lathrup I felt uneasily, just looking
at him. Those burning dark eyes, and that craggy, strange face of
his. Brother! He sure fitted the picture most people probably had of
writers—back in the Victorian Age. You'd think he'd stepped right out
of the pages of Wuthering Heights."
Hansen was not quite an associate but a little more than an assistant
editor. He was still quite young—twenty-seven—and had been on
the staff for three years, working directly under Allen Gerstle's
guidance. Macklin had always translated that as "thumb" in the
preparation of the missing editor's cafe society exposure columns.
Gerstle had a fiery temper and could lose it easily, but Hansen
seemed to have a genuine affection for him and was taking his
vanishment very much to heart.
Macklin sat behind his desk, idly running his forefinger over the
space-bar of his typewriter, back and forth lightly, as if he were
inwardly telling himself that if he should decide to write an account of
the progress which the police had made so far, he would only need
to depress the bar continuously.
"You're all making the same mistake," Macklin said. "It's one of the
oldest mistakes in the world—and the most foolish. You're taking it
for granted that there has to be something unusual, abnormal,
different, about an imaginative young writer, or an old one, for that
matter. Or a creative artist in any field. No, I'm not putting it in just
the right way. There is something different about them, or they
wouldn't be creative artists. But that difference doesn't reside in their
sanity—or lack of it. It is my contention that creative artists are—if
you wish to drag abnormality into it—almost abnormally sane."
"I'm afraid I don't get what you're driving at at all," Ellers said quickly.
"I can quote you a passage in refutation of that from no less an
authority than Aristotle."
He paused, smiling a little and nodding to himself, and Macklin found
himself wondering if he were trying to impress Eaton with his
learning, and was not otherwise interested in scoring a point in an
argument which, with a little effort, might be enlarged to include
alcoholics. It would be a completely false and unjustified
enlargement, but Macklin hadn't said enough so far to give Ellers
any inkling of that.
"Here's the quote," Ellers went on. "'No great genius was ever
without some mixture of madness, nor can anything grand or
superior to the voice of common mortals be spoken except by the
agitated soul.'"
"How can you dispute that?" Hansen said, nodding in instant
agreement. "All geniuses are a little mad. And by the same token,
capable of a sudden, explosive violence when a situation gets out of
hand and becomes unendurable to them."
"I couldn't disagree more violently," Macklin said.
Eaton sighed. "And I couldn't care less," he interposed. "Not right at
the moment, anyway. I wish all three of you would shut up."
"I'd like to thrash it out with Fred right now," Macklin said, staring
steadily at Ellers. "It angers me when someone makes a statement
like that—Plato, Aristotle or whomever. It doesn't matter what
towering minds they were supposed to have. They lived long before
modern science could give us just a little understanding, at least, of
why human beings behave as they do."
"All right," Eaton muttered resignedly. "Speak your piece and get it
out of your system. Otherwise we'll have no peace...."
He smiled thinly. "Sorry. No pun intended."
"I'll try to keep it brief," Macklin said. "To me the one great,
distinguishing quality of creative genius is sanity—a sanity that
illuminates every aspect of human experience. I'll quote you a
passage from Emily Dickinson: 'Pardon me my sanity in an insane
world.'
"Well, that makes sense to me, that sums it up. I'll tell you why. A
creative artist has superior insights into the nature of reality. Reason,
completely rational behavior—common sense on a high level, if you
want to put it in another way—is a must with the creative mind, if it
isn't to be crippled or completely destroyed.
"A man of creative genius wages a terrific struggle for survival every
waking moment and even in his sleep. He is torn by emotions a
hundred times as tumultuous as those of the average person. He
has all the emotional intensity of your so-called 'mad genius',
granted. But it stops there. He's simply incapable of accepting the
lunacies of society at its most neurotic, its most hare-brained. In fact,
he's incapable of accepting or compromising with those lunacies at
any point. His basic sanity is too great."
"Just what are you trying to say, Jim?" Eaton asked.
"Simply this. He has a fifty percent chance of winning that struggle
because a man of creative genius has much more than the average
person's inner strength. Don't kid yourself. He has, or he'd go down
fast. Few people could survive the kind of battle he wages with
himself every waking hour for ten minutes at a stretch.
"Life itself, just the terrible kind of punishment that life inflicts—
illnesses, misfortunes of every kind, tragic accidents, death—can
hurt him much more than you or I can be hurt, simply because he
has the emotional sensitivity which goes with genius.
"All right. He has at least a fighting chance of winning that struggle
and contributing something important, a new insight, a new vision
which will enrich human life. But what intensifies the struggle,
making it so bad at times it's a wonder all creative artists don't go
straight out and jump off the bridge, is the often completely irrational
behavior of the people he meets.
"Don't you see? They fasten themselves on him, make impossible
demands, take advantage of his sensitivity by making him a kind of
target for all of their own frustrations and unrealistic adjustments to
life—"
Macklin paused and spread his hands. "I could go on and on, but I
think I've said enough."
"I think you have," Ellers commented, wryly. "I don't agree at all—
with any part of it."
"There could be considerable truth in what Jim has said," Eaton
conceded. "But I agree with Aristotle too, in a way. You might say
that each opinion is a kind of half-truth. The trouble is, when you try
to fit the two parts together you run into more trouble. I still say—and
this really hasn't too much to do with what we've just been talking
about—that the man who killed Helen Lathrup and Ruth Porges was
probably mentally unbalanced. It has all the earmarks of that kind of
double slaying."
"I'm not convinced of that," Macklin said. "And what makes you so
sure the murderer was a man. It could have been a woman."
"I'm afraid I agree with Mr. Eaton," Hansen said.
Macklin regarded him steadily for a moment. "I don't think you do,"
he said.
"What's that?" Hansen's color rose a little and he returned Macklin's
stare almost angrily.
"You've been agreeing with Mr. Eaton all along," he said. "And so
has Fred. But I've a feeling you're really on my side."
"What makes you say that? Why should I lie about it?"
Macklin turned to Eaton. "If he tells you what he really thinks and
why ... will that be all right? I mean, you won't mind his speaking
frankly?"
Eaton looked puzzled. "Why should I mind?"
"Because I don't think he has too much to go on, and neither have I.
If I told you what I suspect, from the few talks I had with Gerstle and
things he let slip out I'd have to do an awful lot of guessing. And I
think Tim's been hesitating to speak frankly for the same reason."
For the first time Macklin grinned, in his characteristic, almost boyish
way. It was the kind of grin which could have charmed a bird down
out of the trees, and it dispelled both Eaton's puzzlement and
Hansen's anger.
"Go ahead, Tim," Eaton said. "Disagree with me as much as you
want to. And if there are gaps in what you suspect, don't let it trouble
you."
"There are plenty of gaps," Hansen said. "Frankly, I'm a little
ashamed of myself. But I was thinking of Mr. Gerstle, of the great
danger he may be in, and I felt it might be wise for me to pretend to
go along with the psychopathic—Oh, heck, I seem to be making it
worse!"
"Not at all," Eaton said, reassuringly. "Things get around, even when
they're told to me in strict confidence. I'm not speaking sarcastically,
believe me, or actually blaming myself. Only a fool would claim he
can always keep every part of a confidence. A few stray bits of
information often slip out subconsciously."
"Well," Hansen said, a little more at his ease. "Gerstle had dug up
something pretty sensational and was going to run it, but Miss
Lathrup said no. She was really putting her foot down about it."
"I see," Eaton said. "Did Gerstle show you what he was going to
publish?"
Hansen shook his head. "I just know, in a general way, what kind of
hydrogen bomb it was. No names, nothing specific. He wouldn't
show me the signed statements he'd managed to assemble. But I do
know this—it would have made that Jelke, cafe-society, party-girl
scandal of ten or twelve years ago look like a pin-money racket."
"Was it wholly cafe society?" Eaton asked.
"No—it took in TV, and Hollywood. There were big producers
involved."
"But it was a girls-for-sale racket, wasn't it?" Macklin asked, bluntly.
Hansen hesitated for an instant, then nodded.
"And that's all you know about it?" Eaton asked.
"That's all," Hansen said.
"Not much to go on," Eaton said. "But we'll have to tell the police
about it."
"Should we, sir? That's what's been worrying me. If Mr. Gerstle is in
danger, because of it, might it not be well to keep it to ourselves for a
few days longer?"
Eaton shook his head. "I don't think so. When a child's been
kidnapped, wise parents go straight to the police. It's the best, the
safest way, in the long run. And I doubt very much if anyone is going
to phone us, to say they'll release Gerstle if we promise to make him
kill the story. If Gerstle is in danger—he'll need all the police help he
can get."
"I agree with you there," Macklin said quietly.
Eaton got slowly to his feet. There was an utterly weary, half-
despairing look in his eyes. "This is all very bad," he said. "It will do
the magazines no good—although I suppose I shouldn't even be
thinking of that. I haven't the least idea why Helen wanted to keep
that story hushed up. She didn't tell me a thing about it and naturally
Gerstle wouldn't take me into his confidence without her permission.
He could have told me later—I wish to God he had—but I guess he
had his own reasons for preferring to keep silent. It may cost him his
life, if he isn't dead already."
Hansen paled visibly. "Sir, you don't think—"
"We just don't know," Eaton said. "You're pretty young, Tim. When
you're my age, you'll give up trying to soften, or hide from yourself,
just how ugly a turn life can take at times. There's nothing to be
gained by it."

Chapter VIII
The next unexpected development in the Lathrup case took place in
broad daylight, at two o'clock in the afternoon.
What does a police officer do when he has two sensational murders
and a disappearance weighing heavily on his shoulders and he sees
something of a criminal nature taking place right before his eyes?
There are several things he can do. If he happens to be sitting in a
police car he can exercise quick judgment and gain an advantage
right at the start. He can radio a half-dozen other cars to converge
upon the scene or keep at a distance and follow his lead. He can put
a call directly through to headquarters and in a matter of minutes a
third of the police in the city will be alerted and a big dragnet will be
spread fast.
He can even whip out a gun, step right up and do what he can to put
a stop to it then and there.
But if he's on foot and off-duty, and weary as hell from days and
nights of double-duty it isn't always possible for him to do any of
those things, except the last, with its often dangerous and
opportunity-destroying complications.
It was only by a kind of miracle—what else could you call a sudden,
difficult-to-explain restlessness tugging at a cop who should have
been home asleep with the blinds drawn?—that Lieutenant Fenton
was there at all, a half block from the Eaton-Lathrup building at so
early an hour in the afternoon. And the fact that other restless cops,
cops who could never quite believe they'd done enough in the line of
duty, had had similar experiences in the past, did not diminish the
lucky-accident strangeness of it.
It was his sixth visit to the magazine offices in three days, and it
could have been postponed. But there were still a few questions he'd
neglected to ask the staff, and when sleep wouldn't come he'd gotten
up, brewed himself two cups of strong coffee, put on his clothes—
choosing a light gray tropical worsted suit because it was an
unusually hot and muggy day even for New York in July—and taken
the subway to the Eaton-Lathrup building, stopping only briefly at the
drugstore on the corner to buy himself a fresh pack of cigarettes.
He was about fifty or sixty feet from the building's main entrance
when Timothy Hansen, Gerstle's Man Friday on the big magazine
group's two cafe society, exposé magazines, emerged into the clear,
bright sunlight. The young associate editor was not alone. His steps
seemed almost to drag, and two heavyset men wearing light-weight
summer suits just a little darker in color than the one which Fenton
had donned, had fallen into step on opposite sides of him, their
turned-down panamas shading features which Fenton did not like at
all.
There was a suspicious-looking bulge in the coat pocket of one of
Hansen's two escorts, and the slow, reluctant way the man seemed
to be moving left little doubt in Fenton's mind as to what was taking
place.
There was a black coupe parked at the curb, and the young
associate editor was being escorted toward it. He entered the car a
little ahead of the two heavyset men, but they wasted no time in
climbing in after him, and Fenton caught the momentary glitter of
sunlight on what looked like the barrel of a drawn automatic.
All this Lieutenant Fenton saw, and froze to immobility. Only for an
instant, however. A short distance behind him a middle-aged man
with a brief case was just getting into another car, a green Ford
sedan. He'd noticed the car in passing, along with the man's
unhurried stride. He'd even noticed the car keys dangling from the
sedan owner's hand.
Fenton swung about and was grasping the door of the second car
before the startled man could ease himself completely into the
driver's seat.
Fenton whipped out and displayed his badge. "Get out, please, and
give me those keys," he said, his voice so sharp that the man
obeyed almost automatically and without waiting for Fenton to add:
"This is a police emergency. I'm taking your car. Nothing to worry
about. You'll get it back. Just get out and do as I tell you."
He waited until the man reached the sidewalk before he gave him
further, urgent instructions. He was himself in the driver's seat and
using one of the keys when he met the car owner's agitated gaze
and said, still speaking sharply, "Listen carefully, please. Go to the
drugstore on the corner, and ask for the police. Put the call through
as quickly as you can. Say that Lieutenant Fenton of Homicide—get
that, homicide—has started trailing a car from this address. Say the
car is heading north. And tell them ... it's a kidnapping. Be sure to
give them the number of this building: 584—and the street. It's a
black coupe: YG67999. Got that?"
The man nodded, his face very pale now.
"All right. Make it fast. If you should run into a cop, tell him the same
thing. Even after you've phoned."
Fenton barely waited for the man to nod again before he nosed the
sedan out into the traffic flow and followed the black coupe at a
cautious distance, taking care not to give it too much headway and
slowing a little when he seemed in danger of overtaking it.

A half hour later Fenton was still trailing the coupe at a cautious
distance and he was still alone. No wail of a police siren had arisen
behind him and he was now grateful for that.
It had taken him a few minutes to make up his mind and decide that
he was justified in feeling that way, and even now he had misgivings.
He did not regret the instructions he'd given the owner of the sedan.
The phone call had been routine, a necessary safeguard. He owed
Hansen that much, at least.
And if police cars started converging around him he'd accept what
came. But the kind of instructions he'd have liked to give the startled
car owner only a policeman could have sent in to headquarters.
Keep me in view, but don't give the game away. Don't interfere
unless you see I'm in trouble. A chance like this may never come
again. The payoff could be: two murders and a disappearance
solved.
It wasn't what a policeman would ordinarily do. It was against all
precedent and could cost him his badge. In one way he had
increased the risks for Hansen, by not whipping out a gun and
forcing a showdown in front of the building.
It would have been a risky showdown and Hansen might have ended
up dead. Fenton also—but it was to Fenton's credit that he hadn't
given that a thought. His decision—and he'd made up his mind about
it only after a few minutes of driving—had been influenced chiefly by
two considerations. The missing editor was in great danger, if he was
still alive. It could almost be taken for granted that the murderer had
kidnapped Gerstle, precisely as Hansen had been kidnapped. Not to
force an instant showdown might lead to Gerstle's rescue and to
force a showdown to Hansen's death. To forgo that and trail the car
might be increasing the risks for Hansen in one way, but not in the
most dangerous possible way. If given the choice—would Hansen
prefer to be trailed or dropped to the floor of the car with a bullet in
the head?
One other consideration weighed a little. The murderer had slain
twice and might slay again. He was no ordinary murderer, but the
most dangerous kind of killer. This had become one of the big,
nation-arousing series of crimes. To catch that kind of killer justified
unusual measures, the taking of exceptional risks.
Or did it? Even now, he wasn't completely sure. When a policeman
sees a crime taking place in his presence, he's supposed to draw a
gun and start shooting, if the crime can be prevented in no other
way. Immediately, without stopping to speculate as to what some of
the possible repercussions might be.
Still ... still ... a man had to have the courage of his convictions, even
if it meant bending the rules a little more than the Manual told young
rookies they had a right to do. He wasn't a young rookie; and a cop
who had been on the Force thirty years, and worked his way up to a
Detective Lieutenancy the hard, patient way, had a right, surely, to
exercise his own judgment in a situation like this.
He wouldn't be breaking the backbone of the rules, cracking the
spinal column in a completely demoralizing way. The backbone
would snap back, and a vicious killer would be started on his way to
the chair ... and all he really had to do was to make absolutely
certain that the coupe did not get away.
If he should lose it in the traffic....
He relaxed a little, telling himself that there was much less likelihood
of that now, because they had passed over the Triboro Bridge into
Queens and the traffic had thinned considerably.
They were still on the main highway and quite a few cars were
passing in both directions, but there was no heavy congestion or
traffic snarls or many big trucks to block the view. Fenton was just as
well satisfied to see the traffic change a little now and then, growing
slightly heavy at intervals but thinning out again the instant a turnpike
swept past.
Just two cars on a clear road would have been very bad, he told
himself. This way there was at least a fifty percent chance Hansen's
two escorts wouldn't suspect they were being trailed. A car traveling
on a main traffic artery didn't have to be trailing anyone, even if it
kept a variable distance behind another car for a considerable length
of time.
On sober reflection Fenton cut the likelihood that the pair in the car
ahead would suspect anything from fifty to about twenty percent. To
kidnap a man in broad daylight at the point of a gun from a building
that the police had good reason to keep under fairly close
surveillance was taking a big risk, of course. But it wasn't a police
car that was trailing them, and they'd seen nothing on the block to
make them suspicious—just a middle-aged man getting into another
car further down the block, and a pedestrian approaching the
building with nothing about him to suggest that he was a police
officer.
Of course if they had looked back and seen him take over the other
car on pulling out from the curb, the percentage would soar again,
right up to the hundred mark. But would they be keeping on this way
if they had? The car ahead hadn't zigzagged in and out of traffic at
any time or put on an unusual burst of speed, as if in an effort to
elude a pursuing car.
Fifteen minutes later the scenery changed a bit, the traffic thinned
some more, and in the distance there were occasional glimpses of
Flushing Bay.
The car ahead remained on the main highway for another ten
minutes and then made a sharp turn at a circular, three-lane
intersection and started traveling in the direction of the Bay.
Fortunately the traffic became fairly heavy again at that point, and
Fenton was able to continue on a cautious distance behind without
running the risk of losing sight of the coupe. There were two more
turns and the last brought them to a quite narrow road running
almost parallel with the Bay.
The shining bright waters of the Bay were almost constantly visible
now, cut off by long rows of trees at intervals, but close enough to
bring a wide expanse of open water into clear view. But the coupe
didn't slow down to enable its occupants to train an appreciative eye
on white sails glimmering in the sunlight or to inhale with pleasure
the tangy, brine-scented air. Fenton sat very still, with no admiring
eye for the scenery either, his face set in harsh lines.
The black coupe finally turned into a side road that ran directly
downhill to the bay and Fenton drew in quickly to the side of the
highway and waited until the car ahead was out of sight before
making a turn that otherwise would have been a dead giveaway.
Fenton made the turn slowly and for the next few seconds kept his
eyes straight ahead and watched the road for the slightest stir of
movement. But his extreme caution proved unnecessary, for the
coupe had vanished around a corkscrew curve, and it did not come
into view again until a wide stretch of open water burst on Fenton's
vision.
The car ahead was heading straight for what appeared to be a
fisherman's landing at the narrowing tip of a wide inlet. Fenton could
see the wharf and the boathouse clearly, and rowboats bobbing
about in the tide at the end of the wharf. Far out near the middle of
the inlet a large motor cruiser rode at anchor.
Fenton drew in to the side of the road, switched off the ignition and
descended from the car just beyond the corkscrew curve. He
continued on down the slope on foot, taking care to keep in the
shadows cast by overhanging foliage.
He had about a mile and a half of descending road to cover before
he reached the boathouse and the open clearing in front of the
wharf. He had just about reached it, still keeping close to the edge of
the road with its protective foliage screen when the sound of voices
raised to more than conversational pitch came to his ears.
Fenton stood very still, well within the last cluster of sheltering trees,
and strained his ears to catch what was being said.
The voices came to him whipped by the wind, but he heard one,
sharply-spoken order. "Push off! Don't just stand there! Every one of
these goddam boats has taken on water!"
The complaint was followed by the steady click of oar-locks, and a
dwindling murmur of barely distinguishable sound.
He did not emerge from the cluster of trees immediately, but waited
several minutes. Even then he was careful not to step completely
into the open, but crouched down and peered out from behind a
waist-high clump of thinning foliage.
The rowboat was now about two hundred feet from the wharf and
appeared to be moving out into the inlet on a very straight course, a
course which could hardly fail to bring it close to the anchored motor
cruiser.
He had very little doubt that it was heading directly for the cruiser,
and that the three men in the boat would soon be going aboard. One
of the heavyset men was plying the oars and the other sat in the
middle of the boat facing Hansen, who sat in the stern. Whether or
not he was keeping young Hansen covered with a gun Fenton could
not determine. The sunlight was too bright and an automatic pistol
too small an object to be visible from so great a distance.
Fenton stood very still for a moment, debating the wisdom of going
straight to the boathouse and having a showdown with the man—or
men—he might find there.
He was almost sure that whoever owned the wharf and the boats
knew exactly what was going on and had been paid to cooperate. It
seemed to him unlikely that the pair in the rowboat would have
risked bringing Hansen there otherwise.
But he couldn't be completely sure, and getting in touch with Center
Street fast was very urgent. He'd passed two Manhattan-bound
police cars on the Queen's side of the bridge and a cop on a
motorcycle. But his decision not to flash a warning signal to the car
ahead by enlisting police aid had hardened during the drive and he'd
decided not to. Now he regretted having taken so much upon
himself. A police escort would have swiftly overtaken the kidnappers
and rescued Hansen. Any chance of finding out what had happened
to Gerstle or trapping the murderer would have vanished into thin air,
in all likelihood, for the two kidnappers couldn't be depended upon to
name him. And they could still have silenced Hansen with a bullet,
figuring maybe that a good mouthpiece, hired by the killer, might be
able to turn it into an act of self-defense before a rigged jury. There
was no chance too desperate and even suicidal for trapped gunmen
to take, if you hardly gave them time to reason.
He'd done a foolish thing, however, and he realized it now. Only a
quick phone call from the boathouse could set it right again. With
luck, a dozen police cars could close in on the wharf in fifteen or
twenty minutes. And it wouldn't take long for the police to get to the
cruiser. If it started moving, the Coast Guard could be alerted.
Fenton made up his mind quickly. He had a gun, and even if there
were two or three men in the boathouse the odds would be in his
favor. He was reproaching himself so bitterly now that he decided on
the spot he'd turn in his badge and make a full confession if anything
went wrong and Hansen was slugged and dropped over the rail of
the cruiser before he could be rescued.
He emerged from the cluster of trees and walked straight toward the
boathouse, his hand on the butt of his gun, in instant readiness for
any contingency.
He walked to the door, opened it and stepped inside—and stood
blinking in amazement.
The boathouse wasn't deserted. But it had only one occupant—a
frail little old man of about seventy-five, who sat dozing in a chair by
a dust-darkened window.
Fenton cast one quick glance at the old man and then his eyes
swept the interior of the boathouse and came to rest on a phone
booth behind a waist-high coil of rope and six oars stacked
crosswise. He lost no time in encircling the rope and oars and
wedging himself in the phone booth.
He deposited a dime and waited, with sweating palms, for the
humming sound to start before dialing. There was no humming
sound. He jerked the receiver hook up and down, but nothing
happened. In desperation he dialed the operator. Still nothing.
Cursing softly, he emerged from the booth and shook the old man
awake.
He hardly gave him time to wake up completely. "The phone!" he
demanded. "What's wrong with it?"
The old man stirred drowsily, and blinked sleepy eyes. Then, quite
suddenly, he was wide awake and staring.
"What's matter?" he muttered. "Who're you? How did you get here?"
"Never mind who I am," Fenton said. "Just tell me one thing. Did you
give a boat to three men just now? Better not lie about it. I saw them
pushing off."
The old man shook his head. "Been asleep for an hour," he
mumbled. His eyes had darted to the clock on the opposite wall of
the boathouse, as if Fenton's question had filled him with alarm and
an instant need to find out the time.
"But you expected three men to come and take a boat? One of them
would be acting kind of frightened."
The old man nodded again. "Boss told me to be on the lookout for
them. But I must have dozed off."
"You know why they wanted a boat in a hurry?" Fenton asked. "Boss
tell you?"
"No, he just said they were friends of his."
"What kind of man is this boss of yours. Has he a police record?"
"A police ... record?"
"I'd advise you not to go coy on me. Has he ever been in trouble with
the police? You ought to know. You work for him."
The old man was becoming a little angry now. "Why are you asking
me all these questions?" he demanded. "What business is it of
yours?"
Fenton took out his badge and held it before the old man's eyes.
"A cop, eh?" the old man muttered. "I don't want no trouble with the
police, mister. I'll tell you everything I know. It ain't much. I only been
workin' here three weeks. No police ever came here. But the man
who owns the motor yacht out there in the inlet came here and
talked to the boss a couple of times. He didn't look like no crook to
me. Man about forty or forty-five, hair cut short, and wearing a light-
weight suit same color as yours. Figured he must be loaded, to own
a motor yacht like that. Dressed like he was, too."
"Then what put the idea into your head he might have been a
crook?" Fenton asked.
"Well, he acted kind of funny, kept his voice low and once I saw him
slip the boss some money. And he mentioned the police a couple of
times. Boss doesn't know I have sharp ears. I'm seventy-seven but
there's nothing wrong with my hearing."
"All right," Fenton said. "Now suppose you tell me what I asked you
when I shook you awake. What's wrong with that phone over there? I
dropped a dime in, but there was no dialing sound."
"It's been out of order for two days," the old man said. "There was
supposed to be a man come here to fix it yesterday, but he never
showed up."
"Somebody did a little wire-ripping, maybe?"
The old man shook his head. "No, it just went dead on us. Boss
jiggled the receiver for about ten minutes, to make sure. He tried it
again this morning."
"How far is it to the nearest phone?" Fenton asked.
"Hell, you got to go back to the road you turned off from and drive for
about fifteen minutes. There's a gas station—"
"Never mind," Fenton said. "Do you think you could go back to sleep
again, if I asked it as a special favor?"
"I told you ... I don't want no trouble with the police," the old man
said. "I got a grown daughter and two grandsons—"
It was a difficult decision for Fenton to make. If he walked back to
where he'd parked his car and drove to the gas station twenty-five
minutes at least would have to be written off. It might take even
longer. And after that, he couldn't count on police cars arriving at the
wharf within the optimistic time limit that had come into his mind a
short while before. It was nothing that he could be sure of. It would
depend on how many squad cars were in the immediate vicinity, and
how fast the message went out.
It might be an hour before the police could get to the wharf.
Fenton wasted only about a minute making up his mind. He tapped
the old man lightly on the shoulder. "All right. Just close your eyes
again and stay put. One more question, first. When is the boss
expected back?"
"Not for another couple of hours," the old man said. "His sister-in-law
took sick. That's why he ain't here now."
"He has a car?"
"Yeah, that's right."
"Well, just stay put," Fenton said. "You're in no trouble with the police
right now. If you want to go on being lucky, don't move out of that
chair."
"I won't," the old man promised.
When Fenton descended the slope on the east side of the wharf to
the gleaming, bright water just beyond he was careful to remain as
inconspicuous as possible. He kept close to the shadows cast by
tumbled boulders, and the high fringe of shrubbery which ran almost
to the waterline, weaving in and out between the rocks.
When he reached the water he paused for an instant to make sure
that the rowboat was within a short distance of the cruiser and too far
away to take notice of a solitary figure four-fifths concealed by the
shoulder-high marsh grasses at the edge of the inlet.
He undressed quickly, stripping himself to his shorts, and placing his
clothes in a neat pile behind a large boulder.
The water was not as cold as he'd expected it to be. The noonday
sun had warmed it and he could feel the warmth on his scalp as he
swam, using an inconspicuous breast stroke, and not even trying to
get to the cruiser fast.
Several times he paused to tread water and stare out across the
shining surface of the inlet toward the anchored craft. The rowboat
had rounded the stern of the cruiser and was now on the other side,
no longer visible from the shore.
He began to swim more rapidly only when he felt reasonably sure
that Hansen's two escorts had had time to take the young associate
editor aboard.