Skin cases - December 2009 - Bristol. Dr Paul Craig



1- 52yof SLE. arms worse in sun

HK quite thick epi, vac basal change, lichenoid, thick BM, pig incont,

no dermal muchin, some scarring of deep dermis.

consistent with SLE


2- 42yof sun exposed skin, itchy

hk, focal pk, thin epid, vac basal change, civatte + colloid bodies,

pig incont, perivascular and periadnexal lymphocytic infiltrate.

consistent with lupus.

Since no history of lupus given, would suggest DIF, exclude drugs, gvhd, EM,

dermatomyositis, sunburn, ple (but no dermal oedema).


3- 15yof  pink plaques on face. cheek bx ?Jess, ?lupus

punch bx focal spongiosis epidermis, deep infiltrate and

lichenoid damage to adnexal basal epithelium. granulomatous appearance

of histiocytoid cells and lymphocytes cuffing adnexae. Exclude

atypical infections leprosy, exclude lymphoma (bottom heavy).

More history given in talk and PAS stain shown -

Folliculitis with fungal hyphae - Trichophyton mentagrophytes


Clues, asymmetrical rash unlike lupus


4- 45 yof, back lesions, similar 5 yrs previously

normal epidermis and superficial dermis. deep dermal perivascular and

periadnexal lymphocytic infiltrate. fat necrosis obliteration of

panniculae and fibrosis with inflammation of septae. septal and

lobular panniculitis. no vasculitis. Sometimes calcified but not in this case.

Lupus profundus/ lupus panniculitis.

Always polarise to exclude foreign body. Long term

waxing and waning lesions can predispose to lymphoma


Erythema induratum, often Tb associated immunological reaction, not so

inflammatory as this but can look similar


Plasma cells in skin biopsies. Always think of autoimmune, syphilis,



5- 58yof nodule on R forearm ?Erythema nodosum

skin excision, some hk, no pk, n epiderm. septal panniculitis with ill

defined granuloma-like clusters of inflamm cells, lym, hist, neu. no

eos, no vasculitis.

Septal pann consistent with erythema nodosum

Spectrum of disease. Often bx not diagnostic need large ex bx


6- 65 yof BCC upper lip

heavily sd skin with microcystic prolif. v bland. extends to deep

dermis/sc tissue. perineural invasion very common, use mnf and s100 to


microcystic adnexal ca.


Follicular apocrine and sebaceous diff occur together. Bcc is

follicular. Follicular things calcify squamous doesn't usually


7- 77yof rash elbows/knees. blistering ?DH ?linear IGA ?lich drug

reaction. Immuno neg

punch mild hk. norm epi. perivascular lymp, neut, fibroblasts, mild

interstitial mucin, prominent eos. Quite deep infiltrate


Diag. Interstitial granulomatous drug reaction

Dd interstitial GA, insect bite



8- 55yof rash with pustules, ?sec penicillin

multiple subcorneal neu pustules. neutrophils in dermis. Folliculitis,

plugging. no vasculitis.

Acute generalised exanthematous dermatosis (agep)

Dd bullous impetigo


see article on drug induced cutaneous pathology from JCP


9- 50yom 3/12 itchy skin. ?PV

Focal suprabasal blister at edge of bx

perivascular lymphocytic no much else

Diag. Pemphigus vulgaris

DD. Acantholytic dermatoses


10- 86yof l arm scalp blisters

subcorneal blister, eos

Bullous pemphigoid

Diag.  Bullous Pemphigoid

Salt split skin test to distinguish from epidermolysis bullosa


11- 71yof tense blisters hands and fingers ?pomphylx/pseudoporphoria

(drug induced)

subepithelial. blister a few neuts. Festooning along base of blister.

Diag. Porph or pseudoporph


12- 78yof bullae most of body, bedsores. Immuno pos

scarred dermis, subepidermal blister (much more common than

intraepixermal blisters in exam).  Re-epithelialisation from hair


Diag. Drug induced IgA bullous dermatosis


go to the powerpoint presentations 1, and 2