INFLAMMATORY DISORDERS OF THE SKIN AND SUBCUTIS:
A PRACTICAL AND ANALYTICAL APPROACH

Course Directors: Cynthia M. Magro, M.D. Ohio State University Columbus, Ohio A.Neil Crowson, M.D. Regional Medical Center and University of Oklahoma Tulsa, Oklahoma Martin C. Mihm Jr., M.D. Massachusetts General Hospital Harvard Medical School Boston, Massachusetts INTRODUCTION The topic of inflammatory skin disease is a challenging and diverse one. We will attempt to review the fundamentals of inflammatory skin diseases. We will consider reactions of the epidermis, dermal based infiltrates and panniculitis. Classification of Inflammatory Disorders of the Skin and Subcutis Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on the slide images for a larger view of each slide. SPONGIOTIC AND ECZEMATOUS DERMATITIS The topic of spongiotic and eczematous dermatitis will be illustrated by 2 cases: allergic contact dermatitis and pityriasis rosea. A discussion aregarding other forms of spongiotic dermatitis will follow. Case 1 - A forty-eight year-old woman purchased a new "anti-wrinkle" eye cream. Within forty-eight hours of applying the cream to her eyelids, she developed redness and swelling of the skin of the eyelids. A skin biopsy was performed. Allergic Contact Dermatitis Allergic Contact Dermatitis Case 2 - A fifteen year-old girl developed a symmetrical macular salmon-colored eruption of papules along the cleavage lines of the trunk and proximal extremities. Clinical examination showed several of these lesions to have a cigarette paper-like scale. A skin biopsy was performed. Pityriasis Rosea Pityriasis Rosea PSORIASIFORM DERMATITIS The topic of psoriasiform dermatitis will be illustrated by 2 cases: psoriasis and pityriasis rubra pilaris. The definition of psoriasiform dermatitis is one of epidermal hyperplasia characterized by excessive elongation and expansion of rete ridges. The pattern of rete ridge elongation may be uniform (i.e. regular psoriasiform hyperplasia) or variable (i.e irregular psoriasiform hyperplasia). The causes include hyperproliferative states of the epidermis such as psoriasis and pityriasis rubra pilaris, chronic reactive eczematous reactions, and cutaneous T cell dyscrasia. Case 3 - A thirty-eight year-old laboratory technologist developed asymptomatic erythematous, symmetrical plaques on the knees and elbows. Her family history was positive for a similar condition in her mother. Clinical examination showed rounded plaques with a silvery scale which, when lifted off, were associated with bleeding. A skin biopsy was performed. Psoriasis Psoriasis Case 4 - A sixty-five year-old man developed diffuse scaly erythema of the face, the anterior chest and the upper back. This was associated with a scaly, orange-hued discoloration of the palms and soles. Treatment with topical steroids was ineffectual. The rash progressed to cover most of his body, but with islands of spared, normal skin. A skin biopsy was performed. Pityriasis Rubra Pilaris Pityriasis Rubra Pilaris INTERFACE DERMATITIS Cell-poor vaculopathic interface dermatitis Cell-poor vaculopathic interface dermatitis is defined by basilar keratinocyte and subepithelial vacuolopathy unaccompanied by a significant inflammatory cell infiltrate. Usually, there is some lymphocyte tagging along the dermal-epidermal junction pointing to the immunopathogenetic basis, namely, cellular cytotoxicity. This may be either in the context of a type 4 immune reaction or of antibody dependent cellular cytotoxicity. The differential diagnoses of a cell-poor interface dermatitis include: erythema multiforme graft-versus-host disease a morbiliform viral exanthum a morbiliform drug reaction collagen vascular disease, specifically systemic lupus erythematosus, dermatomyositis, and mixed connective tissue disease The concept of cell poor interface dermatitis will be illustrated by a case of Erythema Multiforme. Case 5 - A twenty year-old man developed annular targetoid erythematous lesions on palms and soles accompanied by oral blisters. The lesions appeared shortly after a course of Ampicillin for the treatment of otitis media. A skin biopsy was performed. Erythema Multiforme Case 6 - A thirty-five year-old woman developed an erythematous malar rash and arthralgias involving the joints of the hands and the knees. Serological investigations showed a positive anti-nuclear antibody with a titre of 1:2000. A complete blood count showed leukopenia. A skin biopsy was performed. Interface Dermatitis Of Collagen Vascular Disease - Systemic Lupus Erythematosus Case 7 - A thirty-five year-old woman had difficulty lifting her baby out of the child's crib and also found it hard to comb her hair. Clinical examination showed a dusty, violaceus discoloration of her eyelids. A CT-scan showed bilateral ovarian masses which proved to represent ovarian carcinoma. A skin biopsy was performed. Interface Dermatitis Of Collagen Vascular Disease - Dermatomyositis LYMPHOCYTIC DERMAL INFILTRATES The next topic of consideration will be one of dermal perivascular lymphoid infiltrates. Among the causes are lupus erythematosus, polymorphous light eruption, Jessner's lymphocytic infiltrate of skin, erythema annulare centrifugum, Lyme disease, delayed dermal hypersensitivity reactions and pseudolymphoma. We will illustrate this concept by presenting 2 of the prototypic causes of dermal lymphocytic infiltration: polymorphous light eruption and Jessner's lymphocytic infiltrate of skin. Case 8 - A nineteen year-old woman experienced recurrent erythematous papules on sun-exposed skin every summer. These tended to improve in the fall with diminishing sun exposure. A skin biopsy was performed. Polymorphous Light Eruption Polymorphous Light Eruption Case 9 - A forty year-old woman developed papules and reddish plaques involving the neck and upper back. Connective tissue disease serology was negative. The lesions resolved spontaneously following a skin biopsy. Jessner\'s Lymphcytic Infiltrate Jessner\'s Lymphcytic Infiltrate PERIVASCULAR LYMPHOID INFILTRATES ACCOMPANIED BY DERMAL SCLEROSIS Morphea, the most common of the sclerodermoid tissue reactions, can show prominent perivascular dermal lymphoid hyperplasia and therefore we felt it was only appropriate to discuss this important entity. Case 10 - A twenty-two year-old woman developed an indurated plaque on the trunk. The plaque had an ivory-colored center and a lilac-colored border. A skin biopsy was performed. Morphea Morphea HISTIOCYTIC DERMAL INFILTRATES WITH MINIMAL EPIDERMAL ALTERATION A common reaction pattern in the dermis is one characterized by infiltration of the Interstitum by histiocytes with variable necrobiotic alteration of the collagen. The two classic cutaneous disorders associated with palisading granulomatous infiltrates are GRANULOMA ANNULARE and NECROBIOSIS LIPOIDICA. The concept of palisading granulomatous dermatitis will be illustrated by 2 cases. Case 11 - A fifty-six year-old woman developed yellow-brown atrophic, depressed plaques involving both shins. A skin biopsy was performed. Necrobiosis Lipoidica Necrobiosis Lipoidica Case 12 - A forty-six year-old woman developed papules on her elbows several weeks following a visit with her nephew who had a fiery , erythematous cheek and malaise. His pediatrician subsequently diagnosed parvovirus B19 infection ("fifth disease"). In the interim, one of the woman's papules was biopsied. Granuloma Annulare Granuloma Annulare Granuloma Annulare THE NEUTROPHILIC DERMATOSES The 2 main dermatoses characterized by prominent interstitial neutrophilia are Sweet's syndrome and pyoderma gangrenosum. Other conditions which fall into the interstitial neutrophilic dermatosis category include rheumatoid neutrophilic dermatosis, urticarial vasculitis, and erythema elevatum diutinum. Case 13 - A thirty-six year-old man with intermittent diarrhea, developed violaceus, ulcerating plaques on the lower extremities. One of these was biopsied. Pyoderma Gangrenosum Pyoderma Gangrenosum Case 14 - A forty-eight year-old woman developed reddish-purple plaques, several of which were studded with pustules, involving her face and upper arms. These followed an upper respiratory tract infection for which she did not see a doctor and for which she was not treated. She had an intermittent fever, and a complete blood count showed neutrophilia. Her ESR was elevated. A skin biopsy was performed. Sweet\'s Syndrome THE SUBCUTIS Septal Panniculitis Case 15 - A fifteen year-old girl developed plaques over the pre-tibial surfaces following an episode of pharyngitis. Throat swabs grew Streptococcus sp. A skin biopsy was performed. Erythema Nodosum Erythema Nodosum Lobular Panniculitis Case 16 - A twenty-eight year-old man had a past history of tuberculosis in the Philippines. He developed ulcerating plaques on the posterior calves. A skin biopsy was performed. Erythema Induratum Erythema Induratum Connective Tissue Disease Panniculitis Case 17 - A twenty-four year-old woman with a long-standing history of systemic lupus erythematosus developed plaques involving her upper arms and thighs. A skin biopsy was performed. Lupus Profundus Lupus Profundus Lupus Profundus Opinions stated and/or conclusions reached in this syllabus are the responsibility of the authors and are not necessarily endorsed by the Academy.