236ConditionSituationofLesionChangeswithintheLesion4djacentEpidermalChangesSubSupraIntraSubAcanthInflammatoryBallooningVilliHyperSpongiosisAcanthosisepidermalbasalepidermalcornealolysisCellsPap ID: 938482
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J.clin.Path.,1973,26,235-237AguidetobullouslesionsoftheskinN.F.C.GANEFromtheDepartmentofPathology,GodfreyHugginsSchoolofMedicine,UniversityofRhodesia,Salisbury,RhodesiaSYNOPSISAsimplesequentialchartforidentifyingbullousskinlesionsispresentedbasedonthesiteandsizeofthebullaandhelpfulchangesinthebulla,epidermis,anddermis.Bullousskinlesionsarefrequentlyasourceofdismaytothebeginnerinhistopathologysincedescriptionsofthedifferentlesionsarescatteredintextbooksamongthevariouschaptersoncongenital,inflam-matory,andtoxicconditions.Sleuthingthroughthesechaptersdoeshelptofamiliarizethebeginnerwiththesetextsbuttheexerciseistime-consumingandoftendiscourageshimfromanintriguingsubject.Thischartseeksnottoreplacetheperusaloftextbooksbuttosimplifyandevenencouragethis.Thechart(pp.236-237)shouldbeworkedthroughfromlefttoright,theinitialbasisofidentificationbeingthesituationofthelesionintheskin.TheSituationoftheLesionOnlyfoursituationsareused:suprabasal,intra-epidermal,subcomeal,andsubepidermal.Themainsnarelieswiththesubepidermalgroupsincethefloorofthebullamayre-epithelializerapidlyandcausetheapparent'migration'ofthebullatoahigherposition.Thepathologistmustrelyonthecliniciantobiopsyanearlylesioninallbullousconditions.Fourdescriptivetermsareusedforthesizeofalesion.Alacuna(L)isasmallgapbetweennormallyadjacentstructures.Thismayexpandlaterallytoformacleft(c)orcircumferentiallytoformaroughlyroundedbleborvesicle(v).Thedifferencebetweenavesicleanditslargerrelative,thebulla(B),isoneofsizeandisinterpretedsubjectivelybydifferentpathologists.Theauthorregardsbullaeasunsightlybutvesiclesofasociallypolitesize.Lymphangiomacircumscriptumisappendedtothesubepidermalgroupsinceitisoccasionallymistakenasabullouslesion.ChangeswithintheLesionAcantholyticcellsandinflammatorycellsinthefluidofabullahelptonarrowthediagnosticReceivedforpublication10January1973.spectrum.Acantholysisisgradedfrom+to++±dependingonitsprom-inence.AdjacentEpidermalChangesThoselistedarethepresenceofvi
lli(hyperplasticaccentuationsofthenormaldermalpapillae),hyperkeratosisplustheoccasionalmentionofparakeratosis('para'),spongiosis,andacanthosis.OtherUsefulFeaturesOnlythemoreimportantfeatureswhichhelptoclarifythediagnosishavebeenincluded.Itisoftenimpossibletodistinguishincontinentiapigmentiandsubcornealpustulardermatosisfrominfections,andawarningofthisisinsertedherewithinbrackets.ChangesintheDermisThesemaybeextremelyusefulbutinmanyconditionstheonlyabnormalityisachronicinflammatorycellinfiltrate(CICI).AffectedSitesoftheBodyThedistributionoflesionsmaydifferentiatecon-ditionswithsimilarhistologicalappearances.Theclinicianoftenbaseshisdiagnosisonthisdistributionbutomitstomentionitontherequestform.AgeOnlythoseconditionswithadefinitepredilectionforcertainperiodsoflifeareindicated.ReferencesLever,W.F.(1967).HistopathologyoftheSkin,4thed.Lippincott,Philadelphia,Pitman,London.Rook,A.,Wilkinson,D.S.,andEbling,F.J.G.(1968).TextbookofDermatology.Blackwell,Oxford.235 236ConditionSituationofLesionChangeswithintheLesion4djacentEpidermalChangesSub-Supra-Intra-Sub-Acanth-InflammatoryBallooningVilliHyper-SpongiosisAcanthosisepidermalbasalepidermalcornealolysisCells(Papillae)keratosisDarrier'sdiseaseL-C+Pemphigus:Familial,benignVulgarisVegetansPyodermitedeHallopeauKeratosissenilis(atrophictype)WartydyskeratomaBullousichthyosiscongenitaContactdermatitisAcute/subacuteHerpes,variola,varicellaMiliariarubraPompholyxIncontinentiapigmenti(early)Pemphigusfoliacus/erythematosisSubcornealpustulardermatosisMiliariacrystallinaPemphigoidBullousV-BBenignmucosalBJuvenileBullouserythemamultiformeBV-BToxicepidermalnecrolysisBDermatitisherpetiformisV-BEpidermolysisbullosaBLupuserythematosus(subacute)L-VBullouslichenplanusV-B+NumerouseosinophilsPara+Manyneutro-philsFibrinnet-work,somepolymorphs,±eosinophils(4)Manyeosinophils+PorphyriaB(lymphangiomacircumscription)(B)ChartAidtoidentifyingbullouslesionsoftheskinN.F.C.GaneL-BC-BBLEosinophilsL-VL-CNumerouseosinophils
Late-+LateV-BV-BV-BVVV-BVariablelymphocytes&polymorphsPara++B+BVScantyeosino-philsandneutrophilsVariableeosinophils+++-4_I-r AguidetobullouslesionsoftheskinOtherUsefulFeaturesChangesintheDermisAffectedSitesoftheBodyAgeCorpsrondsandgrains,papillomatosisScantycorpsandgrainsAcantholyticcellsdegenerateLateintraepithelialabscessesofeosinophilsResemblepustulesBasallayeratypiaCentralkeratinplugPyknoticnucleitocellsReticulardegenerationInclusionbodies,reticulardegenerationInflammationinepidermisaroundvesiclesVesiclesmultipleandclosetogether(Confusedwitherythematoxicumneonatorum)CICICICIMildinflammationEosinophilsCICI(maybeprominent)PerivascularCICIOedemaandperivascularCICIVaryingCICIvasculitisCICIMildCICIEosinophilsSeborrhoeicareas,mucosaeoccasionallyNeck,axillae,groinsSkinandmouthFlexuresmainlyExposedareasFace,scalp,neckFlexuralsurfacesInfancyDependentonvirusFlexures,sweatyareasPalmsandsolesLimbsandflanksBabygirlsBullaeruptureearls,occasionalgrainsCICIandeosinophilsScalp,face,upperbody(Confusedwithimpetigo)PAS-positivematerialinmouthsofsweatglandsInitiallymultiplesmallvesiclesScantypolymorphsaroundvesselsAbdomen,axillae,groinsTrunkMildoedematoseverevasculitisLimbs,groins,axillaeNiltomarkedinflammation,latefibrosisVariableepidermalnecrosisCICIvasculitisMucosae,conjunctivae,genitalia,skinLowertrunk,buttocks,faceExtensorsurfacesandmucosaeDegenerationofepidermisMicroabscessesinpapillaeNiltomildinflammationCICIwitheosinophilsMayinvolvewholebodyExtensorsurfacesandbuttocks20-50yrOccasionallychildrenBasalcellvacuolationNilBasalcellliquefactionCICIroundappendage;,collagendegenerationandoedemaSaw-toothepithelialdowngrowths,Band-LikeCICI,huggingepidermisbasalcelldegenerationPAS-positivematerialandoedemaofcapillarywalls(dilatedsuperficiallymphatics)ChartAidtoidentifyingbullouslesionsoftheskin-continued'Dyskaryoticornecroticdegenerationofacantholyticcellsnoted237ElderlyUnder5yrSkinormucosaeFace,chest,limbsSkinandmucosaeExposedareasInfantsMax30-