I’d like to introduce our next speaker in our practice we have an on-site dramatic pathologist so very lucky that when we take samples we can go upstairs and look through the microscope and talk with her directly about it so dr. Michelle Harry from California skin Institute is here to go over some pearls of dramatic pathology specifically in this lecture she’s going to talk about helping us with inflammatory disorders and piecing together what we see in the patient from when we take the biopsy on our end and what she sees on her end through the microscope thank you you got a point what a great room I feel like I’m getting an award like to pick my parents okay so today we’re going to talk about inflammatory derma toasties I know a lot of people kind of roll their eyes sometimes especially for a derm path but keep with me I’m not going to try and teach you duromatic pathology I’m just going to give you some key points and what to provide your pathologist so we’re gonna talk about biopsy technique very briefly spongy otic dermatitis psoriasis like annoyed or interface tissue reactions and blistering diseases so among quite a bit of time ago we get there was a little study in skin and allergy news basically showing the top 10 diagnoses and dermatology offices I think they did about 85 different dermatology offices and looked the most common diagnosis and you know for inflammatory derm toasties you need to keep them in mind because they’re about a third of the cases that were presented to the offices no one really has a problem especially after dr.

Cohen’s talk looking at these easy you know this was actually happened to be a nickel allergy and this is linear vesicles of poison oak but then you start getting into things that a little bit may be more challenging this happened to be more of a this hydraulic eczema this could be fungal infection or contact this ended up being a topic dermatitis a popular form but then you also get the more generic spongy otic derm what do you do do you treat you biopsy what to do to drug contact you’re not really sure a lot of the times clinicians turn to biopsy to tell them what it is if they can’t figure it out based on clinical or history so here’s a quick case just to start us off 52 year old female with recent onset of an itchy rash now coming in with Bowlin there’s no new medications and no new topical exposure not to say that they’re not on some medications just nothing new so what would you do first one culture or biopsy a shade biopsy how about just treat them and then come back if they’re not improved and then do a biopsy or start off with the punch biopsy so if you chose a biopsy what would you do to shave or punch I know I get a lot of either shave or punches for inflammatory Dermer Tosi’s the ideal biopsy is a punch biopsy you need to get the full dermis and sometimes even go into the subcutaneous tissue if you’re looking for something like funiculi tiss obviously your dramatic pathologist needs to see the fat but you need to see the entire dermis you need to see the vascular plexus you need to see the iDEN axial structures soshe biopsy isn’t not usually appropriate for any sort of inflammatory derma ptosis where to biopsy this is important usually for these these spongy otic dermatitis cases you want to be intralesional but say you have a scarring alopecia don’t take it in to lesion all you’re just gonna see a scar you go peri lesion all so at the advancing border something that’s a little bit more effeminate and not quite scarred and then if you’re taking a biopsy for di f direct immunofluorescence if you have a blistering disorder don’t take intralesional you take peri lesion all I’m sure that’s probably something that was ingrained in you in schooling but a lot of times people forget and that’s because you can have a false negative if you take it intralesional so especially for alopecia this is important if you how many biopsies to take so if you’re doing work up for alopecia a lot of the times I get to millimeter punch biopsies you need to have at least two four millimeter punch biopsies to evaluate for alopecia and why is this important because you actually look at two planes of section you look at the vertical and you look at horizontal cross section to look at the hairs that can give you the best diagnosis for alopecia and then especially for a genetic causes you want to take a biopsy in the involved area of the scalp and the uninvolved area just so you can compare the two areas that’s one of the major diagnostic features that androgenetic is the comparison between normal and involved so don’t forget if you’re taking your biopsies think about taking additional biopsies it’s for alopecia and for direct immunofluorescence so having said all this about biopsies it’s not a routine blood test it’s not going to tell you your answer 100% of the time a biopsy alone is not definitive it can lend support to what you think clinically but a lot of the times it’s not going to be your slam-dunk I don’t have to you know take a history or give a differential I’ll just take a biopsy and give me the answer why because it’s a reaction pattern it’s a generic reaction pattern of the skin a lot of these things will look the same unfortunately and a lot of the times I just give differential diagnoses so I’ll say the spongy otic dermatitis this differential usually it’s key to remember if your pathologist gives you differential the first thing that they list is the most likely thing that it is and then it kind of goes down in descending order okay so if you are not getting differential diagnoses from your pathologist you may have a problem be aware of the dogmatic pathologist that says it’s this because some of the times they can be really really riped and some of the times they’re really really wrong so they will always give you a differential and then you know a lot of times I get rule out drug reaction a biopsy it’s really not going to prove it’s the rashes due to a drug or not it can give you clues it might be sometimes you see you just to eosinophils maybe that’ll give you you know point you in the right direction but you don’t have to see them so even if ills are not really you know since the case going sick so for clues so when I look at the biopsies there are certain clues that maybe point me in a certain direction not necessarily nailing the diagnosis but kind of pointing me in the right direction and that’s mostly based on a few things here so give me the anatomic site so if I see spongy OSIS with some micro vesicles in the epidermis and it’s on a lateral aspect of the finger it’s more likely to be a decider OSIS or just hydraulic eczema or if there’s some River Site extravasation in the dermis and it’s on the legs more likely to be a stasis storm and then this is very important to have the punch biopsy iLook need to look at the deeper vascular network if there’s a lot of inflammation around the vessels down there it could be an arthropod bite or a drug reaction if I’m only seeing a lot of spongy OSIS right around the hair follicles atopic Durham or sub term and then if I’m seeing dying keratinocytes in the epidermis sometimes not always it’s due to a drug reaction so these things sort of point you in the right direction so what do you want to give your pathologist you need to give a good history so is there a new drug or topical agent and not just new drug a drug that could be causing so not a drug drugs are you dissing Craddock in their side effects so yeah the patient has been on hydrochlorothiazide for ten years I don’t need to worry about that well it can still cause a reaction ten years later so even though it’s not new let the let the pathologists know and then tell me what it looks like is it a large plaque is their small papules is their scale and where is it on the body is its unexposed only you know these things are very helpful in diagnosis so really when you have this clinic good clinical history and a good biopsy together most of the time a diagnosis can be made or at least point you in the right direction so just you know this is what we have on our this is what I would give for a report so I give the a reaction pattern this happened to be sorry asta form spongy otic dermatitis and I’ll get into what these things mean a little bit later and I give a differential and then usually you do staining for Tamiya just to rule that out so what are some of the histologic features so we have what may be an acute spongy Adak dermatitis would look like clinically and I know I don’t know that these terms actually mean anything to you right now but they will in a minute so you have something called basket-weave orthocare Tosa so this is what we’re talking about the stratum corneum so the top layer of skin it’s basically normal it’s what all that means it’s a normal stratum corneum it’s a very acute process it just came on and then you have this spongy osis with a micro vez circulation which means there are just some small vessels within the epidermis maybe you can’t even see them clinically it doesn’t look like a blister now the sub acute pattern here is defined by para keratosis so that just means in the stratum corneum the top layer skin you still have retention of the nuclei that means it’s kind of like a more immature stratum corneum it’s more of a turnover and chronic lesions like this one are most likely due to Sri Asif or hyperplasia so this is what I’m talking about this is a nice picture showing spongy osis so all spongy OSIS is is edema it’s edema between the keratinocytes so you have these nice little squamous cells keratinocytes and they’re held to the next one the next character in sight next to it with Demi desmosomes so usually they’re nice and tight you can’t see any sort of white lying around that and that white line is basically just an artifact of processing but when they pull apart you actually that’s where you see these these little lines here those are the Hemi desmosomes in between them so that is spongy osseous is just a demon and sometimes you get a lot of edema pushing the character insides apart and you get little vesicles that’s all it is and this one happens to be in acute form because this is the stratum corneum and it’s totally normal this is a subacute so you still have your spongy osis down here so that you see the spaces in between the keratinocytes this is your stratum corneum and you can actually see little nuclei here in there so that just makes it a subacute pattern and that’s the sori Asif form so sorry asta form just means looks like psoriasis because histologically psoriasis has these down growths of the epidermis into the dermis like that there are subtle differences which again I’m not really gonna go into in detail the difference between psoriasis and psoriatic form and spongy dermatitis but needs to say sometimes you can’t always tell them apart especially if you take a biopsy on the April area looking for spongy us spent sorry-ass from Sponge osis versus psoriasis they can look very similar so there are many different differential diagnosis for sponge derm these are the most common ones that I come up with in my in my practice you know on a daily basis okay when you specifically see a lot of eosinophils sometimes they can put you in a certain direction and these are the most common ones that I see a lot of us in a filled-in now if you clinically are worried about a blistering disorder like one of these first three remember to take another biopsy a second biopsy for direct I mean fluorescence and always always always look in the report and make sure the pathologist has ruled out tinea your Koh may be negative but that’s not always you know gonna help you you need to look for a pas stain did they look for fungus sometimes in acute lesions you don’t really need to do a pas stain look for fungus I haven’t really seen two to many cases where it’s positive but once you start getting subacute to sur easa form you still need to test for it so psoriasis briefly the beautiful pictures of Erath ominous plaques with the silvery scale and that’s more of a pattern but what does it look like to me well kind of looks like that sorry I asked to form spongy of this picture you have those down growth again the story acid form growth of the epidermis but here there’s actually not any spaces you can’t see any spaces here there’s really not much in the way of spongy OSIS so unless you take an April biopsy you’re not really really see any spongy roses and of course there are other characteristics for psoriasis you have neutrophils in the stratum corneum but just suffice it to say they can appear similar on April services but usually a Soria psoriasis on a biopsy is pretty definitive what about like annoyed or interphase dermatitis well the stereotypical of like annoyed dermatitis is lichen planus don’t forget you can have like a – of the fall of hair follicles it’s like implanted pilaris so that can cause alopecia like andwe drug reaction and lichen planus like keratoses so you may get a diagnosis from your pathologist basically saying like annoyed tissue reaction and give you a differential of lichen planus or like annoyed a drug reaction especially as they see a couple of aoc and here and there so you may again even for these entities you may not get a definitive diagnosis if you’re getting something if I have some biopsy that comes in rule out basal cell carcinoma more likely it’s a solitary lesion that’s going to be like a plant of lichen planus like keratosis don’t forget all of these entities as well have a like annoyed or interphase dermatitis that you need to have on your differential if that’s is that is what you’re seeing clinically and lupus can cause alopecia I know I’m kind of really big on alopecia sand but that’s it’s really important that’s especially for biopsies because that is the one place I noticed that it’s it’s not biopsied correctly and you can’t make a diagnosis then or at least the pathologist can’t so this is a clinical picture of lichen planus and this is what I see under the microscope so this is what I’m talking about when I say like annoyed or interface dermatitis so all of the lymphocytes kind of line up along the border of the dermis and the epidermis okay and sometimes you can’t even tell where the epidermis stops and where the dermis begins and that is an interface dermatitis when you can’t tell the difference between the two areas and when the inflammation is a budding right up to the epidermis from the dermis you can actually get some of the the squamous cells dying and that is a necrotic keratinocyte so that is very characteristic for lichen planus but like I mentioned before you can see that in drug reactions usually the dying keratinocytes are a little bit higher up and not right at the at the end the junction of the dermis and the epidermis this is LPP like in pineapple era so again if you took a Babs the intralesional all you see a scar it’s not helpful okay so briefly we can talk about blistering diseases and usually we classify blistering diseases based on where the split is you can have just below the stratum corneum so sub corneal of intra epidermal and sub-epidermal and for today’s cases I’m just going to briefly touch on the sub-epidermal cases so for our case that came into the clinic this patient was biopsied and we’ll go into what the biopsy showed in a minute just to keep in mind in adults if you have a blistering just disease it’s most likely due to auto antibody formation which is different than Pediatrics I don’t know if anyone sees Pediatrics here so this is what it looked like you have this is the epidermis stratum corneum is around top this is epidermis and here’s this big blister and they’re all these cells in here and those that’s what it looks like higher magnet magnification they’re all little red cells those are yeast in the fills so this is a sub epidermal blister with abundant eosinophils and that’s how I would basically sign that’s my top-line diagnosis and then I give the differential because without directive from immunofluorescence that is not even though it’s beautiful for a bullous pemphigoid histologically you can be thrown off by many different things so bolus tinea can appear the same way histologically a bolus Arthur pod bite will look exactly the same again it’s a reaction pattern of the skin you need a directive immunofluorescence if you want a definitive diagnosis of immuno Bullis disease and they have different staining patterns so a pemphigus will have this sort of inter woven in between the keratinocytes staining and well it’s pemphigoid will have this beautiful linear staining of IgG and dermatitis herpetiformis will have more of it in the dermal papilla be little globules in the dermal papilla of iga deposition these are just a couple there are other entities but these are the most common that I see so don’t forget your Grif now I have a lot of clinicians that say I don’t want you to test for that because it’s expensive maybe it’s out of product out of pocket patient no problem let your pathologists know that if you need to use the biopsy go for it otherwise hold it because it can stay in this media and this is a special media so it cannot go and formaldehyde okay we’re formalin so special media hold it if it looks like it could be BP or some bullets disorder then use it no problem we’ll keep it and if we don’t need it we won’t use it okay that’s all thank you so much you

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