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Allergic Contact Dermatitis

Dyshidrotic Eczema

Early Nummular Dermatitis

Id Reaction

Bullous Dermatophyte

Acute spongiosis

Yes

Yes

Yes

Yes

Yes

Periodic acid Schiff/ Grocott methena-mine silver stain for hyphae

Negative

Negative

Negative

Negative

Positive

PITYRIASIS ROSEA Clinical Presentation:

■ Often starts with a herald patch (Fig. 10A), one to four centimeter, round to oval, salmon-pink-patch

■ Central collarette of scale (Fig. 10B)

■ Followed after a few days by a generalized eruption

■ "Fir tree" truncal distribution

■ Usually lasts six to eight weeks

Histology:

■ Mild spongiosis

■ Focal mounds of parakeratosis

■ Mild acanthosis; more prominent in herald patch

■ Erythrocyte extravasation in papillary dermis

■ Mild dermal lymphocytic inflammation

Pathophysiology:

Histologic Differential Diagnosis:

See Table 5.

Chronic spongiotic pattern is commonly seen in these clinical entities:

■ Lichen simplex chronicus

■ Prurigo nodules

■ Chronically traumatized areas

LICHEN SIMPLEX CHRONICUS Clinical Presentation:

■ Thick, lichenified papules, nodules, or plaques (Fig. 11)

■ Often pruritic

Histology (Fig. 12):

■ Hyperkeratotic ortho or parakeratotic stratum corneum

■ Hypergranulosis

Table 5 Histologic Differential Diagnosis: Pityriasis Rosea

■ Moderate to marked irregular epidermal acanthosis

■ Minimal to absent spongiosis

■ Lymphocytic inflammation

■ Thickened suprapapillary plates

■ Dermal fibrosis with vertical "streaking" of thickened collagen bundles in the papillary dermis

Pathophysiology:

■ Lesions secondary to chronic trauma from picking, scratching, rubbing, exogenous devices (e.g., prostheses), occupational/recreational (e.g., surfers)

FUNGAL/DERMATOPHYTE

Clinical Presentation:

■ Faint pink to red scaly thin plaques (Fig. 13)

Pustules:

■ Peripheral "satellite"—common with Candida infections

■ Edge of plaque—dermatophyte erroneously treated with topical steroids

Histology (Fig. 14A):

■ Mild epidermal acanthosis

Mild Spongiosis:

■ Marked spongiosis in bullous dermatophyte

■ Focal parakeratosis

■ Intraepidermal pustules possible

■ PAS or GMS stain positive for organisms within the stratum corneum

■ Spores/Pseudohyphae—Yeast (Candida or Pityrosporum)

Reference:

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

Table 5 Histologic Differential Diagnosis: Pityriasis Rosea

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