Ackerman's New Schema of Eight Basic Patterns of Inflammatory Diseases

Circa 2005

1. Perivascular dermatitis (superficial as well as superficial and deep perivascular)

2. Nodular and diffuse dermatitis

3. Vasculitis

4. Vesicular dermatitis (intraepidermal vesicular and/or subepidermal vesicular dermatitis)

5. Pustular dermatitis (intraepidermal and infundibular epidermal pustular dermatitis)

6. Peri-infundibulitis and perifolliculitis

7. Fibrosing dermatitis

8. Panniculitis (predominantly septal or predominantly lobular)

ability to apply the pattern analysis approach improves with experience.

9. If the lesion is neoplastic:

■ The next critical question is whether the lesion is benign or malignant? Architectural pattern is extremely important in making this important distinction. Size, symmetry, and circumscription patterns outweigh cytology. Table 2 presents an overview of features useful in distinguishing benign versus malignant neoplasms (1).

■ Is the lesion epithelial or nonepithelial?

■ What cells are proliferating? Keratinocytes, melanocytes, fibroblasts, muscle cells, nerve cells, sebo-cytes, ductal cells, lymphocytes, histiocytes, mast cells, and so on.

10. If the lesion is inflammatory, determine the pattern of the inflammatory cells in the dermis and subcutaneous tissue.

■ There are nine major patterns of inflammatory infiltrates (Table 3). Although many more patterns and variations have been described, it is still worthwhile to go back to simple basics and start with the original nine described many years ago.

■ What pattern of change is noted in the epidermis? (spongiosis, interface, psoriasiform hyperplasia, etc.)

■ What types of cells predominate in the infiltrate? (lymphocytes, histiocytes, neutrophils, eosinophils, etc.)


1. Ackerman AB. An algorithmic method for histologic diagnosis of inflammatory and neoplastic skin diseases by analysis of their patterns. Am J Dermatopathol 1985; 7:105-107.

2. Ackerman AB. Histologic Diagnosis of Inflammatory Skin Diseases: A Method by Pattern Analysis. Philadelphia: Lea & Febiger, 1978.

3. Ackerman AB, Ragaz A. The Lives of Lesions: Chronology in Dermatopathology. New York: Masson Publishing, 1984.

4. Ackerman AB. Histologic Diagnosis of Inflammatory Skin Diseases: A Method by Pattern Analysis Supplement to the Fourth Printing. Philadelphia: Lea & Febiger, 1988.

5. Ackerman AB, et al. Histologic Diagnosis of Inflammatory Skin Diseases: An Algorithmic Method Based On Pattern Analysis. Baltimore: Williams and Wilkins, 1997.

6. Ackerman AB. A Philosophy of Practice of Surgical Pathology. Philadelphia: Ardor Scribeni Ltd, 1999.

7. Ackerman AB, Boer A, Bennin B, Gottlieb GJ. Histologic Diagnosis of Inflammatory Skin Dieases: An Algorithmic Method Based on Pattern Analaysis. 3rd ed. New York: Ardor Scribendi, 2005.

8. Chaffins ML, Cockerell CJ. Histopathologic characteristics of common inflammatory skin disorders. Curr Probl Dermatol 1996; 8:189-236.

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