Spongiotic reaction pattern Spongiosis = Intercellular edema Elongation of bridges vesiculation, bullae?mechanism unclear Fluid comes from dermis Impo

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1 Spongiotic Reaction Pattern and review Nathan C. Walk, M.D.

2 Spongiotic reaction pattern Spongiosis = Intercellular edema Elongation of bridges vesiculation, bullae?mechanism unclear Fluid comes from dermis Important points: Nonspecific Histologic hallmark of eczema is spongiosis Spectrum Acute subacute - chronic

3 Spongiotic reaction pattern Irritant contact dermatitis Allergic contact dermatitis i Protein contact dermatitis Nummular dermatitis Seborrheic dermatitis Atopic dermatitis Pompholyx Stasis Autoeczematization Pityriasis rosea Spongiotic drug rxn Chronic superficial dermatitis Light reactions Dermatophytoses Arthropod bites Others.

4 Spongiotic reaction pattern Variants 4 of them (per Weedon) Neutrophilic Eosinophilic Miliarial Follicular

5 Neutrophilic Pustular psoriasis Reiter s syndrome IgA pemphigus Herpetiform pemphigus Infantile acropustulosis AGEP Pl Palmoplantar l pustulosis Dermatophytoses Pustular contact dermatitis

6 Miliarial Intraepidermal edema centered on the acrosyringium Miliaria crystallina stratum corneum Miliaria rubra Miliaria profunda DE junction

7 Follicular Marked Infundibulum Infundibulofolliculitis (Disseminate and recurrent infundibulofolliculitis) Atopic dermatitis (follicular lesions) Eosinophilic folliculitis

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13 Stasis dermatitis Common disorder of middle- aged and older individuals Impaired venous drainage Sites: Lower legs and ankles Early stages -Edema Later -Dry and scaly or crusted and weeping areas may develop Discoloration and ulceration common

14 Histological features of Stasis Dermatitis Focal parakeratosis and serum scale crust Mild spongiosis?spongiotic vesiculation think superimposed contact dermatitis **Dermal changes Proliferation of small blood vessels with RBC extravasation Variable dermal fibrosis Abundant hemosiderin present throughout the dermis Thick walled veins in deep dermis or subcutis

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20 Eosinophilic spongiosis Correlate with clinical Allergic contact dermatitis

21 Differential of eosinophilic spongiotic dermatitis Bullous pemphigoid - early Urticarial stage Can precede the diagnosis i by many years **Prominent dermal eosinophilic infiltrate Remember dermal inflammation important when characterizing vesiculobullous lesions, not the junk in the blister. Pemphigus early Acantholysis Transitional forms between eosinophilic spongiosis and the usual histological findings of pemphigus

22 Differential of eosinophilic spongiotic dermatitis Allergic contact dermatitis Marked lower epidermal spongiosis in early stage Spongiotic vesicles at all levels of epidermis in later stage Exocytosis of lymphocytes and eosinophils Mixed dermal inflammatory infiltrate ** uncommon pattern Incontinentia pigmentosus (first stage) Prominent exocytosis of eosinophils Intraepidermal vesicle formation with eosinophils

23 Other entities that may show eosinophilic spongiotic i dermatitis i Pemphigus vegetans Herpes gestations Idiopathic eosinophilic spongiosis Eosinophilic, polymorphic, and pruritic eruption Atopic dermatitis **Arthropod bites Eosinophilic folliculitis (Ofuji s disease) Drug reaction Id reactions

24 Contact dermatitides often lumped together histologically i ll differences? Allergic contact spongiotic c/w photoallergic versus Irritant contact spongiotic c/w phototoxic With higher concentrations of irritant, get more characteristic pattern of: Ballooning keratinocytes in the upper epidermis Variable necrosis may become confluent + PMNs Allergic contact Spongiotic vesicles at different horizontal and vertical levels Exocytosis of eosinophils

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30 Diagnosis: Spongiotic dermatitis with intraepidermal vesicle formation, consistent with eczema

31 Dyshidrotic eczema = Pompholyx Age of onset: < 40 years M=F Pompholyx ½ have atopic background Confluent tapioca-like vesicles and crusted erosions on the dorsum of fingers Precipitating factors Emotional stress Hot, humid weather Duration - several weeks Symptoms Pruritus Pain in fissures Secondary infection Distribution: hands (80%) and feet Lateral aspects of fingers, palms, soles Dorsa of fingers

32 Histology Eczema = spongiosis With intraepidermal vesicle formation Lymphocytes both inside the vesicles and in upper dermis

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39 Histological features of pityriasis rosea Epidermal changes: Undulating pattern Focal, mounding parakeratosis Spongiosis + Lymphocyte exocytosis forming vesicles resembling small Pautrier microabscesses +/- dyskeratotic cells Dermal changes Red cell extravasation Edema Melanin incontinence Mild to moderate lymphohistiocytic infiltrate

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42 1) Pityriasis Rosea Acute exanthematous eruption 1) Distinctive morphology A single lesion first Herald patch (80%) One or two weeks later, a generalized secondary eruption develops in a Christmas tree distribution Exanthem oval, fine scaling papules and plaques following the lines of cleavage 2) Self-limiting limiting course, remits in 6 weeks without any therapy

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47 Seborrheic dermatitis Histology: Acute lesions Mild spongiosis with mild exocytosis of lymphocytes, overlying scale crust, centered on a follicle Mildly edematous papillary dermis Mild SPLI (superficial perivascular lymphocytic infiltrate) Subacute lesions ++ irregular acanthosis Chronic lesions Psoriasiform hyperplasia Less appreciable spongiosis Presence of scales crusts in a folliculocentric distribution

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49 Unknowns

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