Dermatopathology

Kuliah-1 / Blok DMS

Dr. H. Soekimin, Dr H Soekimin SpPA Dr. T. Ibnu Alferraly, SpPA Departemen Patologi Anatomi p g FK USU

Makroskopis Jaringan Kulit

Makula ( Macule ) : ruam bulat pada kulit, ukuran bervariasi, datar, perbedaan warna dgn kulit sekitar Papula ( Papule ) : daerah kulit dgn elevasi solid 5 mm Nodul ( Nodule ) Plak ( Plaque ) : daerah kulit dgn elevasi solid 5 mm : daerah kulit dgn elevasi permukaan datar 5 mm elevasi, datar,

Vesikel ( Vesicle ) : daerah kulit yang berisi cairan, 5 mm Bula ( Bulla ) Blister : vesikel besar 5 mm besar, : istilah untuk vesikel atau bula : penipisan daerah kulit, batas jelas, akbt pengikisan yg ber-ulang : - lesi akibat trauma -k kerusakan epidermis ( d k id i deep scratch ) h - sering ok self-induced

Likenifikasi ( Lichenification ) f f

Ekskoriasi ( Excoriation )

Papule: Raised dome shaped lesion less than 0.5 cm. (Common Nevi,
Moles, Cherry angioma, Sarcoidosis y g

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

>0.5

Xanthelasma: Lipid deposits around the eyes. Wheal: Firm, edematous (peau de orange) plaque. Evanescent and pruritic.
(Hives)

Macule: A flat area of discoloration between 0 5 1 cm in size discoloration, 0.5-1 size.

macule (Mongolian spots).

(freckles), (freckles) bluish

Patch: Macule larger than 1 cm in size. Monocytic Leukemia atc g y Maculo-papular lesion: Characetristics of macule and papule. ( Rash Desquamation
Sarcoidosis Malignant Melanoma Hypereosinophilic syndrome Lymphoma ) syndrome,

Striae: Prior stretch (pregnancy, loss of obesity,

Gardner Diamond syndrome)

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

disease (Hodgkin's disease, Liver disease)

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

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

cell cancer)

Scar: Reflects healing Atrophy: Loss of substance of Skin. Thinning of epidermis, dermis or p y g p ,
subcutaneous tissue. Ehler's Danlos syndrome

Lichenification: Thickened skin with increased skin markings (Lichen

simplex chronicus)

Keloid: Exuberant scar formation

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

Pustule: Vescicle filled with pus. Less than 0.5 cm in size. (Acne pustule) Blister: Vesicle larger than 0.5 cm Bullae: Gas gangrene. Cyst: Deeply seated fluid (pus blood or fluid) filled cavity. < 0.5 cm in size. (pus, cavity 0 5 size
Fluctuation present.

Fissure: Leniar cleavage in skin. Dermis exposed, hence painful. Ulcer: Hole in skin. Heals with scar when it is not malignant. (Squamous cell
cancer)

Erotion: L d E ti Less deeper than ulcer h l Telangiectasia: a small spidery superficial vascular lesions. Blanches with pressure.
(normal in children and women. Liver disease)

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

Vesicle/ Bullae

Clinical findings of the proband. (a) Confluent vesicles and bullae on the palms and l t l aspects on th fi d lateral t the fingers. (b) D Desquamation on th palms. ( ) C fl ti the l (c) Confluent t vesicles on the sole. (d) Histological results showing spongiosis and spongiotic vesicles (hematoxylin and eosin staining).

Purpura

Fisure Fi

Fissure (fish Your), Erosion, And Ulcer

A fissure is a thin but deep linear split in the epidermis that e tends extends into the dermis. Severe dry skin can have fissures. An erosion is a depressed lesion that is wider than a fissure but not as deep. An erosion, which is usually moist, may result from a ruptured vesicle or bulla. An ulcer is a deep erosion in which all of the epidermis and part of the dermis are eaten away (eroded). A bed sore is an ulcer. Ulcers often leave scars. scars

Macula

Telengiectasi g

Ulcer

Mikroskopis Jaringan Kulit

AKANTOLISIS :
The loss of cohesion between epidermal or adnexal keratinocytes

Example of acantholysis in Pemphigus Foliaceus

AKANTOSIS
The increase in the thickness of the stratum malpighii

Examples of acanthosis in Psoriasis

Lichen Simplex Chronicus

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

ANAPLASIA
The atypical appearance of nuclei as is found in malignant neoplasia. Anaplastic nuclei are usually large, irregular and hyperchromatic, and may produce bizarre or atypical mitotic figures.

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

Lichen Plannus

Benign Lichenoid Keratosis

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

Example is a sub-epidermal bulla in Epidermolysis Bullosa

EPIDERMOLITIK HIPERKERATOSIS
Also called granular degeneration. It is characterized by: 1. 2. 3. 4. Peri-nuclear clear spaces in the upper stratum malpighii p pp pg Indistinct cellular boundaries A markedly thickened granular layer with increased numbers of keratohyalin Granules and hyperkeratosis

Actinic Keratoses

1.Acantholysis, 2. Hyperkeratosis, 3. Parakeratosis

Hypergranulosis is the most prominent feature in this case.

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

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

PARAKERATOSIS
Retention of nuclei in the stratum corneum. This is a normal finding on mucous membranes

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

VILLUS
A dermal papilla extending into a bulla, vesicle, or lacuna which is covered with a single layer of epidermal cells resulting from suprabasalar acantholysis . Example of Villus in Pemphigus vulgaris

REAKSI UMUM KULIT TERHADAP JEJAS (i j ) (injury)

Inflamasi Akut : dermis + epidermis ; kemerahan, panas, bengkak, sakit p ,p , g , Penumpukan cairan antara keratinosit : Spongiosis Spongiosis yg hebat : Vesikel ( penumpukan cairan terlokalisir ) Pembengkakan dermis : elevasi epidermis ( wheal formation ) Jejas berat : kulit Nekrosis Epdermis Nekrosis : Ulcerasi Dermis Nekrosis : gmbrn klinis beragam, tgtng struktur yg terlibat Inflamasi Kronis : - Penebalan epidermis : ACANTHOSIS - penebalan Staratum Corneum : HYPERKERATOSIS - Fibrosis dermis

Inflamasi Kulit Akut

- Terjadi dalam hitungan hari minggu - Mikroskopis : sel2 mononuklear ( PMN ), neutrofil ( jarang ), oedem, jejas pada : epidermis, pembuluh darah, sub-kutan - Dapat berlanjut : kronis

Inflamasi Kulit Kronis

Inflamasi Kulit Akut

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

Histamine is thought to be the most important biochemical mediator in urticaria. Mast cells are the major histamine-releasing cells of the skin. j g The mast cell possesses high-affinity receptors for immunoglobulin E (IgE). In allergic reactions, adjacent IgE molecules, which are bound to the surface of mast cells by the high-affinity IgE receptors, are cross-linked by allergens, leading to the release of histamine and other mediators mediators. Basophils also possess the high-affinity IgE receptor and may be involved in urticaria. Other inflammatory cells (ie, vide infra) are recruited into the lesional area in urticaria, particularly in chronic urticaria. These cells can release cytokines and chemokines that can cause histamine release or otherwise contribute to the pathology.

 A lymphocytic infiltrate is commonly found in the lesions of both acute and chronic types of urticaria. Some urticarial lesions have a mixed cellular infiltrate, ie, a mixture of lymphocytes, polymorphonuclear leukocytes (PMNs), and other inflammatory cells. This mixed type of infiltrate seems to be particularly characteristic of certain refractory forms of chronic urticaria, such as autoimmune-mediated urticaria. The mixed infiltrate is similar to the histopathology of the allergic late-phase late phase response. Some patients with particularly severe or atypical urticaria are found to have vasculitis on skin bi h li i ki biopsy. Indeed, a spectrum in histopathology seems to exist, ranging from lymphocytic to vasculitic, that correlates approximately with disease severity, from mild to severe.

Eczematous Dermatitis Acute

Eczema : clinical term, embrace many conditions, many underlying causes Early stage : red, papulovesiculer, oozing, crusted lesions If persistence : Scaling Plaques (+) Classification : - Allergic contact - Atopic - Drug Related Eczematous - Photoeczematous - Primary irritant forms

Eczema Dermatitis
Histologic sections of skin show epidermal acanthosis with marked spongiosis spongiosis, leading to intraepidermal vesicle formation. The vesicles are filled with serum and inflammatory cells.

Eczema Dermatitis

A higher power view reveals the nature of the infiltrate. Associated with the spongiosis and vesicle formation are numerous eosinophils and scattered neutrophils

Erythema Multiformis

Erythema multiforme (EM) is an acute self-limited eruption characterized by a distinctive clinical eruption, the hallmark of which is the iris or target lesion. EM may present within a wide spectrum of severity severity. EM minor represents a localized eruption of the skin with mild or no mucosal involvement, corresponding to the initial description of von Hebra. EM major and Stevens-Johnson syndrome (SJS) are more severe mucosal and skin diseases and are potentially life-threatening disorders.

Erythema Multiformis
The early lesion of EM is characterized by infiltration of lymphocytes at the dermal-epidermal interface with accompanying exocytosis and spongiosis in the epidermis. Individual eosinophilic necrotic keratinocytes may be scattered and surrounded by lymphocytes (satellite cell necrosis). The dermal changes include edematous papillary dermis, ectatic and swollen endothelial cells of the vessels, and extravasation of the red blood cells.

Inflamasi Kulit Kronis

Psoriasis
Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin with silvery scales. Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong genetic basis Usually lesions on elbows, knees, scalp, back, face, palms and feet, but they can show up on other parts of body. A problem with immune system causes psoriasis. In a process called cell turnover, skin cells that grow deep in the skin rise to the surface. Normally, this takes a month. In p y psoriasis, it happens in j pp just days because y y your cells rise too fast. Psoriasis can last a long time, even a lifetime. Symptoms come and go.

Psoriasis

Psoriasis
Epidermis Mitotic activity of basal keratinocytes is increased almost 50-fold, with keratinocytes migrating from the basal to the cornified layers in only 3 5 days 3-5 compared to the normal 28-30 days. With hyperproliferation of skin cells, the epidermis becomes thickened or acanthotic in appearance and an increase in size of the rete ridges is observed. Abnormal keratinocyte differentiation is noted throughout the psoriatic plaques, as manifested by the loss of the granular layer layer. The stratum corneum is also thickened, and the retention of cell nuclei in this layer is referred to as parakeratosis. Neutrophils and lymphocytes can be observed migrating upwards from the dermis into the acanthotic epidermis. Neutrophils may form localized collections known as Munro microabscesses The presence of alternating collections of microabscesses. neutrophils sandwiched between layers of parakeratotic stratum corneum is virtually pathognomonic for psoriasis.

Munro microabscesses are composed of degenerated polymorphonuclear leukocytes (PMN's) in the horny layer (stratum corneum) and are seen in psoriasis and seborrheic dermatitis

Psoriasis
Dermis Marked hypervascularity and an increase in the size of the dermal papillae occur occur. An activated CD3+ lymphocytic infiltrate is noted around blood vessels, with T cells expressing cutaneous lymphocyteassociated antigen, co-stimulatory molecules such as CD2, and LFA-1 adhesion molecules. An aggregation of neutrophils in the dermis occurs that extends up into the epidermis.

Lichen Planus

LP is a cell-mediated immune response of unknown origin origin. LP may be found with other diseases of altered immunity; these conditions include ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis, and myasthenia gravis. An association is noted between LP and hepatitis C virus infection, chronic active hepatitis, hepatitis and primary biliary cirrhosis

The histopathologic features distinguish LP based on the presence of irregular acanthosis and colloid bodies in the epidermis with liquefactive degeneration and linear fibrin deposition in the basal layer. The upper dermis has a bandlike infiltrate of lymphocytes and histiocytes.

Lichen Planus
The inflammatory reaction pattern is characteristic. The epidermis is hyperkeratotic with irregular acanthosis and focal thickening in the granular layer layer. Degenerative keratinocytes, known as colloid or Civatte bodies, are found in the lower epidermis. In addition to apoptotic keratinocytes, colloid bodies are composed of globular deposits of IgM (occasionally immunoglobulin G [IgG] or immunoglobulin A [IgA]) and complement. Linear or shaggy deposits of fibrin and fibrinogen and liquefaction are in the basement membrane zone.

Lichen Planus

Lichen Simplex Chronicus

LSC is found on the skin in regions accessible to scratching. Pruritus provokes rubbing that produces clinical lesions, but the underlying pathophysiology is unknown. Some skin types are more prone to lichenification, such as skin that tends toward eczematous conditions (ie, atopic dermatitis, atopic diathesis). A relationship likely exists between central and peripheral neural tissue and inflammatory cell products in the perception of itch and ensuing changes in LSC. The possible interplay among primary lesions psychic factors and the intensity of lesions, factors, pruritus additively influence the extent and severity of LSC.
Histologic examination demonstrates hyperkeratosis, acanthosis, spongiosis, and patches of parakeratosis in the epidermis. Epidermal thickening of all layers is noted, with elongation of rete ridges and with pseudoepitheliomatous hyperplasia. Papillary dermal fibrosis with vertical streaking of collagen bundles is characteristic. A characteristic finding of LSC that is noted on electron microscopy is frequent collagen fibers attached to and just above the lamina basalis