Dermatopathology

Figure 7-1 Electrocautery. (From Elston D, et al. Dermatopathology, 2nd Ed. Elsevier. 2013)

Figure 7-2 Gelfoam, purple, angled deposits. (From Weedon D. Weedon’s Skin Pathology, 3rd ed. Elsevier. 2009)

Figure 7-3 Histopathologic features of a granulomatous reaction to hyaluronic acid. Low power view showing basophilic material at different levels of the dermis. (From Requena et al. Adverse reactions to injectable soft tissue fillers. J Amer Acad Dermatol 2010;64:6:1178)

Figure 7-4 Histopathologic features of a granulomatous reaction to hyaluronic acid. Basophilic material is surrounded by histiocytes and multinucleated giant cells. (From Requena et al. Adverse reactions to injectable soft tissue fillers. J Amer Acad Dermatol 2011;64:6:1178)

Figure 7-5 Histopathologic features of granulomatous reaction to New-Fill (Dermik Laboratories, Berwyn, PA). Most of the particles show fusiform or oval shape. (From Requena et al. Adverse reactions to injectable soft tissue fillers. J Amer Acad Dermatol 2011;64:6:1178)

Figure 7-6 Histopathologic features of granuloma secondary to injections of calcium hydroxylapatite microspheres. Scanning power showing a diffuse involvement of the corium of the oral mucosa. (From Requena et al. Adverse reactions to injectable soft tissue fillers. J Amer Acad Dermatol 2010;64:6:1178)

Figure 7-7 Histopathologic features of granuloma secondary to injections of calcium hydroxylapatite microspheres. Granulomas surrounding the calcium hydroxylapatite microspheres. (From Requena et al. Adverse reactions to injectable soft tissue fillers. J Amer Acad Dermatol 2011;64:6:1178)

Immunofluorescence and related studies (Summarized in Table 7-10, Staining Characteristics of Subepidermal Blistering Diseases)

• Collagen IV immunostaining (stains the BMZ)

■ Performed on paraffin embedded sections to determine level of epidermal separation by comparing to stained BMZ

■ Is an alternative to salt-split skin immunofluorescence

■ Staining along floor of a blister: BP

■ Staining along roof of a blister: diseases targeting collagen VII (EBA and bullous SLE)

■ BE CAREFUL! Collagen IV immunostaining patterns are OPPOSITE of salt-split skin DIF (and IIF) patterns!

• DIF

■ Performed on fresh frozen sections obtained from a biopsy of the patient’s affected/perilesional skin

■ DIF patterns:

○ Linear (Fig. 7-8)

♦ C3: pemphigoid gestationis

♦ IgG and C3: bullous pemphigoid, lichen planus pemphigoides, EBA, cicatricial pemphigoid, anti-p200, anti-p105, and bullous SLE

➔ NEED further studies to distinguish!!!

♦ IgA: LABD

○ Granular

♦ IgG, IgM, IgA, and/or C3 along BMZ = lupus band (Fig. 7-9)

♦ IgA in dermal papillae: DH (Fig. 7-10)

○ Intercellular

♦ IgG and C3 (“pemphigus pattern”): P. vulgaris, P. foliaceus, and paraneoplastic pemphigus

➔ Need further studies and clinical to differentiate

♦ IgA: IgA pemphigus

○ Linear to granular BMZ and intercellular: pemphigus erythematosus (Senear-Usher)

○ Linear BMZ and intercellular: paraneoplastic pemphigus

○ Vessel wall staining

♦ Stippled, not thickened: LCV including IgA vasculitis and HSP

♦ Thickened and smooth: porphyrias with cutaneous involvement and pseudoporphyria; may also see linear BMZ staining in these entities!

• Salt-split skin studies (DIF/IIF): leads to a separation of the skin at the DEJ, and allows you to see where the immunoreactants are depositing; allows for distinction between various subepidermal blistering diseases (Table 7-10, Fig. 7-12)

■ n-serrated/u-serrated pattern evaluated on DIF and may be used as a substitute for salt-split skin analysis (Fig. 7-11)

• Indirect immunofluorescence (IIF): serologic study where blood is obtained from the patient and then tested for antibodies against skin antigens, using a normal/control sample of skin; staining patterns same as for DIF; generally less sensitive than DIF (Table 7-10)

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