Afecciones De La Piel, Parte I

REVIEW ARTICLE

Dermatopathology for the Surgical Pathologist
A Pattern Based Approach to the Diagnosis of Inflammatory Skin Disorders (Part I)
Nooshin K. Brinster, MD

Abstract: The accurate diagnosis of inflammatory conditions in dermatopathology requires integrating the histopathologic findings with the clinical features. This can be difficult when skin biopsies are seen infrequently and theterminology is unfamiliar, as in a general surgical pathology practice. This 2-part review of inflammatory cutaneous conditions presents a pattern-based approach to the diagnosis of dermatologic disorders and reviews the salient clinical and histologic features. Part I will focus on the spongiotic, psoriasiform, interface, and bullous patterns, whereas Part II will review the perivascular,vasculitis, panniculitis, and nodular and diffuse patterns. Key Words: spongiotic, psoriasiform, interface, lichenoid, vacuolar, subcorneal dermatoses, suprabasilar dermatoses, subepidermal dermatoses (Adv Anat Pathol 2008;15:76–96)

editions, each maintaining the same pattern-based algorithm to the diagnosis of inflammatory skin disorders.2,3 This 2-part series of articles reviews the most commoninflammatory patterns encountered in dermatopathology. The prototypical corresponding clinical entities will be presented and histologic features reviewed. An emphasis will be placed on key distinguishing features, pathologic clues, and potential pitfalls. With each biopsy, the clinician asks a question. It is essential for the surgical pathologist to understand the clinician’s question and recognize thesalient pathologic features to arrive at an accurate diagnosis.

INFLAMMATORY PATTERNS
The pattern-based approach to the diagnosis of inflammatory skin disease uses low power assessment of the primary pathologic process, with evaluation at higher power to determine the presence or absence of additional features to allow for a more specific diagnosis. The most common inflammatory patterns are (Fig.1):  Spongiotic  Psoriasiform  Interface  Bullous  Perivascular  Vasculitis  Panniculitis  Nodular and Diffuse Part I of this review will focus on the spongiotic, psoriasiform, interface, and bullous patterns, whereas Part II will review the perivascular, vasculitis, panniculitis, and nodular and diffuse patterns.

T

he pathologic diagnosis of inflammatory skin disease can bechallenging. This is particularly true in a general surgical pathology practice where skin biopsies are seen less frequently. The appropriate clinical terminology and/or dermatologic entities are often unfamiliar to the surgical pathologist, and clinical-pathologic correlation often is an integral component to an accurate diagnosis. The field of dermatopathology has its inception in clinical dermatology. Thefirst dermatopathology textbooks were written by dermatologists, and they incorporated the clinical aspects of skin disease into the pathologic features and diagnoses. One of the most significant contributions to the field of dermatopathology came in 1978, with A. Bernard Ackerman’s publication of Histologic Diagnosis of Inflammatory Skin Disease.1 This seminal work presented a novel approach todermatopathology, namely the use of low power, pattern-based analysis. Since his first text, there have been 2 more

DEFINITIONS/TERMINOLOGY
Fundamental to the pattern-based classification of inflammatory skin conditions is an understanding of the terminology employed (Table 1).

From the Departments of Pathology and Dermatology, Virginia Commonwealth University School of Medicine, Richmond, VA.Reprints: Nooshin K. Brinster, MD, Departments of Pathology and Dermatology, Virginia Commonwealth University School of Medicine, PO Box 980662, Richmond, VA 23298-0662 (e-mail: nbrinster@ mcvh-vcu.edu). Copyright r 2008 by Lippincott Williams & Wilkins

SPONGIOTIC DERMATITIS
The spongiotic dermatitides include clinical conditions grouped under the term ‘‘eczema’’ (Table 2). Histologically,...