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W EEDON’S SKIN PATHOLOGY ESSENTIALS ForElsevier CommissioningEditor:MichaelHouston DevelopmentEditor:LouiseCook ProjectManager:ElouiseBall Design:KirsteenWright IllustrationManager:MerlynHarvey MarketingManager(UK/USA):GaynorJones/TraciePasker W EEDON’S SKIN PATHOLOGY ESSENTIALS RONALD B. JOHNSTON MD Colonel, USAF Chief of Dermatology Eglin AFB, Florida, USA and Affiliate Assistant Professor Department of Dermatology and Cutaneous Surgery University of South Florida College of Medicine Tampa, Florida, USA For additionalonlinecontent visit expertconsult.com CHURCHILLLIVINGSTONE animprint of ElsevierLimited #2012,Elsevier Limited.All rights reserved. TherightofRonaldB.Johnstontobeidentifiedasauthorofthisworkhasbeenassertedbyhiminaccordancewith theCopyright, Designs and Patents Act 1988. No part of this publication may be reproducedor transmitted in any form or byany means, electronic or mechanical, including photocopying, recording, orany information storageand 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 asthe Copyright Clearance Center and the Copyright LicensingAgency, can be found atourwebsite: www.elsevier.com/permissions. This book and the individual contributionscontained in itareprotectedundercopyright bythe Publisher (other than asmay benoted herein). Notices Knowledgeand bestpractice in this fieldare constantly changing. Asnew researchand experience broadenour understanding,changesinresearchmethods,professionalpractices,ormedicaltreatmentmaybecomenecessary. Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledgeinevaluatingandusing anyinformation, methods,compounds, orexperiments described herein. In using such information ormethods they should be mindful of their own safety and the safety of others,including partiesfor whom they have a professional responsibility. Withrespecttoanydrugorpharmaceuticalproductsidentified,readersareadvisedtocheckthemostcurrent informationprovided(i)onproceduresfeaturedor(ii)bythemanufacturerofeachproducttobeadministered,to verifytherecommendeddoseorformula,themethodanddurationofadministration,andcontraindications.Itis theresponsibility of practitioners,relyingon their own experience and knowledge of theirpatients, to make diagnoses, todetermine dosages and thebest treatmentfor each individualpatient, and to take all appropriate safety precautions. To the fullest extent of thelaw, neitherthe Publishernor the authors, contributors, oreditors, assume any liability for any injury and/or damage to personsor property asa matter of products liability, negligenceor otherwise,orfromanyuseoroperationofanymethods,products,instructions,orideascontainedinthematerial herein. Churchill Livingstone ISBN: 978-0-7020-3574-6 The Publisher's policy is to use paper manufactured from sustainable forests Printedin Spain Last digit istheprint number: 9 8 7 6 5 4 3 2 1 Preface Duringmycareerasafighterpilotandthenapilot-physician,checklistswereanintegralpartofproceduresandflying.Similarly,thisbookwas createdas a study guide, review book, rapid reference and microscope “wingman”. Weedon’s Skin Pathology Essentialsindicates the classic features,both clinically and histologically, including numerous photographs of each side-by-side.Additionally,genetic defects, classic treatments, commonly associateddisorders and “memory joggers” wereincluded to assistin remembering thevastamount of information. Asa result,this book describes the more common location and appearance,and not every variationor possibility isdescribed. Thus,to complementthisbook, it isdesigned for use in conjunction withthe primary reference Weedon’s Skin Pathology. Enjoy my dermatologist’s “checklist”! Ronald “R.J.” Johnston “Check six” F-15C Pilot-Physician/Dermatologist Photo of theauthor preparingto air-to-airrefueloffatanker. vi Dedication A special thank you to my wife, Christy, and our son, Gage, for all your support and encouragement during this endeavour. Love, R.J. (Dad) vii Acknowledgments Specialthankstothefollowingindividualsandorganizationsfortheirsupportand/oruseofimagesandpathologyslides(alphabeticalorder): (cid:129) BrookeTaylor Baldwin, MD, Dermatologist, Tampa, FL (cid:129) CarlosCanton, DermPath Diagnostics,Miami,FL (cid:129) Ann A. Church, MD,Departments of Dermatopathology and Dermatology, University of Florida, Gainesville, FL (cid:129) Christopher P. Crotty,MD, Orlando,FL (cid:129) Department of Dermatopathology, Universityof Florida, Gainesville, FL (cid:129) Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, FL (cid:129) L. Frank Glass, MD, Universityof SouthFlorida, Tampa, FL (cid:129) Ricardo J. Gonzalez,MD,Sarcomaand Cutaneous Department, H. Lee Moffitt CancerCenter and Research Institute, Tampa, FL (cid:129) John N. Greene,MD, Division of Infectious Diseases and TropicalMedicine, H. Lee Moffitt Cancer Center and ResearchInstitute, Tampa, FL (cid:129) Ronald Johnston, Colonel (Ret.), USAF, Destin, FL (cid:129) Tim McCardle, MD, H. Lee Moffitt Cancer Center and ResearchInstitute, Tampa, FL (cid:129) J.D. Morgan, MD, Capt. (Ret.), USMSN, private practice, Lake Wales, FL (cid:129) MichaelMorgan, MD, ProfessorPathology USFCOM, Clinical Professor Dermatology UFCOM,MSUCOM, Managing Director, Bay Area Dermatology, Tampa, FL (cid:129) Jonathan Newberry, MD, Capt., USAF, Department of Pathology, Eglin AFB, FL (cid:129) CarlosH. Nousari, MD, Institute forImmunofluorescence, PompanoBeach,FL (DIF, salt-split, scalded skin H& Eand clinical PNP images providedcourtesy of DrNousari) (cid:129) David A. Riggs, Col (ret), D.O., AAFP, USAFP, 96thMedical Group,Eglin AFB, FL (cid:129) LubomirSokol, MD,PhD, Departmentof Malignant Hematology, Moffitt Cancer Center and ResearchInstitute, Tampa, FL (cid:129) Donald R. Stranahan, MD, Easton Dermatology Associates, Easton,MB (cid:129) Isabel C. Valencia, MD, Dermpath Diagnostics,Tampa, FL (cid:129) Vladimir Vincek, MD,PhD, Director of Dermatopathology, University of Florida, Gainesville, FL Further reading Weedon, D.Weedon’s Skin Pathology, 3rd edition. 2009. Bolognia, JL, Jorizzo, JL, Rapini,RP. Dermatology, 2ndedition. 2008. McKee, PH, Calonje, E, Granter,SR. Pathology ofthe Skin,3rd edition.2005. Spitz, JL. Genodermatoses: A ClinicalGuide toGenetic Skin Disorders, 2ndedition. 2005. viii 1 The Basics Major tissue reaction patterns 2 Basic epidermal descriptions 5 Multinucleategiantcellsofgranulomas 7 Lichenoid 2 Acanthosis 5 Melanocyte 8 Psoriasiform 2 Parakeratosis 5 Merkelcell 8 Spongiotic 2 Orthokeratosis 5 Glomusbody 8 Vesiculobullous 2 Grenzzone 5 Histiocyte 8 Granulomatous 3 Types of white blood cells and Muscle 9 complement system 6 Vasculopathic 3 Nerve 9 Minor tissue reaction patterns 3 Neutrophils 6 Paciniancorpuscle 9 Eosinophils 6 Epidermolytichyperkeratosis 3 Meissnercorpuscle 9 Basophils 6 Glands 10 Acantholyticdyskeratosis 3 Lymphocytes 6 Cornoidlamellation 4 Sebaceousgland 10 Monocytes 6 Papillomatosis 4 Eccrinesweatgland 10 Other cells 7 Angiofibromas 4 Apocrinesweatgland 10 Eosinophiliccellulitiswithpossible Plasmacell 7 Epidermal Layers 11 “flamefigures” 4 Mastcell 7 Layersofepidermis 11 Transepithelialelimination 4 Langerhanscell 7 Patternsofinflammation 4 Stratum corneum (horny layer) Stratum lucidum (clear layer, palms/soles) Stratum granulosum (granular layer) Stratum spinosum (spiny layer) Stratum basale (basal layer) 1 2 CHAPTER 1 (cid:129) THE BASICS Name Key Features ClinicalExample Histopathology Major tissue reactionpatterns Lichenoid (cid:129) Epidermalbasalcell (cid:129) Lichenplanus damage (“interface (cid:129) Lichennitidus dermatitis”) (cid:129) Vitiligo (cid:129) Band-like infiltrate (cid:129) Erythema multiforme of inflammatory cellsin superficial dermis, pigment incontinence; Civattebodies (shrunken, eosinophilic, degenerating basal cells) Lichen planus Psoriasiform (cid:129) Epidermal (cid:129) Psoriasis hyperplasia, rete (cid:129) Lichensimplex chronicus ridge elongation (cid:129) Mycosisfungoides uniformly, regular (cid:129) Pityriasis rosea acanthosis (“squirting dermal papilla”) Psoriasis Spongiotic (cid:129) Intraepidermal (cid:129) Pityriasis rosea intercellularedema (cid:129) Bullous pemphigus (cid:129) Atopicdermatitis (cid:129) Contactdermatitis (cid:129) Five patterns: 1. Neutrophilic 2. Eosinophilic 3. Miliarial(acrosyringial) 4. Follicular 5. Haphazard Allergic contact dermatitis Vesiculobullous (cid:129) Blistering within or (cid:129) Pemphigus vulgaris beneath epidermis (cid:129) Impetigo or at DE junction (cid:129) Epidermolysisbullosa (cid:129) Assess: 1. Level of split 2. Underlying mechanism 3. Natureof inflammatory cells in dermis Pemphigus vulgaris