|Year : 2021 | Volume
| Issue : 1 | Page : 1-6
Clinicopathological study of papulosquamous skin disorders in a tertiary health-care center
Rachel Shimray, Sharmila Laishram, Gayatri Pukhrambam, Kh. Ambala Devi, Paramita Rudra Pal
Department of Pathology, RIMS, Imphal, Manipur, India
|Date of Submission||14-Jan-2021|
|Date of Decision||16-Jan-2021|
|Date of Acceptance||28-Jan-2021|
|Date of Web Publication||04-Aug-2021|
Department of Pathology, RIMS, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Background: Papulosquamous skin disorder is a group of heterogenous dermatoses with a distinct histomorphological feature. The characteristic primary lesion is a papule, usually erythematous, that has a variable amount of scaling on the surface. The most common papulosquamous dermatoses are psoriasis, lichen planus, and pityriasis rosea. Because all papulosquamous disorders are characterized by scaling papules, clinical confusion may result during their diagnosis. Our study is to evaluate histomorphological findings in various papulosquamous skin disorders encountered at RIMS, Imphal.
Materials and Methods: Skin biopsies of clinically diagnosed papulosquamous skin disorders along with their relevant clinical data received during a period of 2 years from September 2017 to August 2019 were included in the study. The diagnosis was confirmed by histopathological examination using hematoxylin and eosin stain.
Results: A total of 115 papulosquamous skin disorders were studied with 75 cases of psoriasis (11–80 years), 36 cases of lichen planus (2–70 years), and 4 cases of pityriasis rosea. Age ranges from 2 to 80 years. Maximum cases were seen in the age group of 31–50 (70.6%) with a mean age of 39.18 years. Both genders were almost equally affected with a male: female ratio of 1.13:1. An analysis of the clinical with histopathological diagnosis of these papulosquamous skin lesions revealed a positive correlation in 76 (66.08%) cases and a negative correlation in 39 (2.9%) cases.
Conclusion: Because of the varied clinical presentation and histopathological patterns of papulosquamous skin disorder, it is important to characterize the types of papulosquamous lesions as far as possible for definitive treatment.
Keywords: Lichen planus, papulosquamous, pityriasis, psoriasis
|How to cite this article:|
Shimray R, Laishram S, Pukhrambam G, Devi KA, Pal PR. Clinicopathological study of papulosquamous skin disorders in a tertiary health-care center. J Med Soc 2021;35:1-6
|How to cite this URL:|
Shimray R, Laishram S, Pukhrambam G, Devi KA, Pal PR. Clinicopathological study of papulosquamous skin disorders in a tertiary health-care center. J Med Soc [serial online] 2021 [cited 2022 Aug 15];35:1-6. Available from: https://www.jmedsoc.org/text.asp?2021/35/1/1/323158
| Introduction|| |
Papulosquamous skin disorder is a group of heterogeneous dermatoses with a distinct histomorphological feature of uncertain etiology. It is characterized by red scaly papules or plaques which is the formed through the coalescence of the primary lesions. A century ago noted Pathologist Rudolph Virchow considered the skin as a protective covering for more delicate internal viscera. But the skin is a complex organ of the body with many functions which regulates cellular and molecular interactions and govern many crucial responses to our environment.
Skin is the largest organ of the body. It is composed of two layers of distinctive structures, properties, and embryological origin. They are the epidermis, an epithelial layer derived from the embryonic ectoderm, and the dermis, a connective tissue layer of mesenchymal origin. Deep to the dermis lies a loose regular connective tissue, the subcutaneous layer or hyperdermis.,
Papulosquamous disorders consist of psoriasis and pustular psoriasis, lichen planus (LP), lichen planus pigmentosus (LPP), lichen nitidus, annular erythema, pityriasis, and erythroderma.
Psoriasis is one of the prototype papulosquamous skin diseases characterized by erythematous papules or plagues with silvery scales. It affects 1%–2% of the world's population. The peak age of incidence being the second decade and elderly people with men more commonly affected than women. It can affect virtually anywhere on the skin but more common on the extensor surfaces of the knees, elbows, and trunk. Mucosa seems to be spared.,
The main clinical findings are well-demarcated erythematous plague with silvery scales, papules, itching, and pinpoint bleeding on scrapping (Auspitz sign).
Lichen Planus is a unique inflammatory disorder of obscure etiology, affecting the skin, mucous membrane, nails, and hair. It is characterized clinically by extremely pruritic, violaceous, flat-topped, polygonal papules of variable size, marked by criss-cross whitish streaks (Wickham's striae), commonly involving the flexural areas of the wrist, legs, and oral and genital mucous membranes of 30–60 years age group. Both genders are commonly affected but uncommon in children.,,
Pityriasis rosea is an acute and self-limited dermatitis usually lasting for 4–7 weeks. The lesions frequently start with a “herald patch,” followed by disseminated eruption. The lesions are round to oval patches and followed the lines of cleavage showing peripherally attached thin-cigarette paper-like scales. The common sites are the trunk, neck, and proximal extremities. Pityriasis rosea are commonly seen in adolescents and young adults.
Papulosquamous skin lesions is one of the most common skin disorders which has a significant impact on the quality of a patient's life. Hence, it is worthwhile to carry out a study on the various characteristic histopathological features for a satisfactory solution and reduce the burden from this disease. The objective of the study is to evaluate the histomorphology of papulosquamous skin disorders and to study its clinicopathological distribution.
| Materials and Methods|| |
This cross-sectional study was conducted in the Department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, in collaboration with the Department of Dermatology RIMS, Imphal. This tertiary hospital caters patients from every part of the state. All the biopsies of papulosquamous skin lesions received in the Department of Pathology, RIMS during the study period between September 2017 and August 2019 were included in the study. Clinical details of all the patients including the age, sex, and site of lesions were collected and analyzed. The skin biopsy specimens received were fixed in 10% buffered formalin and processed in the automatic tissue processor. Sections are cut and stained with hematoxylin and eosin. Stained sections are examined microscopically in detail and histological findings are noted and interpreted. Diagnoses were made based on the histomorphology as given in Lever's histopathology of the skin. All the different histopathological lesions were categorized.
Ethical clearance from the institutional ethics committee was obtained. Independent variables such as age, sex, and site of the lesions were categorized and expressed in percentages. Sensitivity, specificity, and accuracy were calculated to assess the degree of relationship between clinical observations and histological lesions.
| Results|| |
Histopathologically confirmed papulosquamous skin disorders in 115 cases were studied and analyzed in this study. The age of the patients ranged from 2 to 80 years, the youngest patient being a 2-year-old girl and the oldest being an 80-year-old man. Majority of patients belonged to the age group of 41–50 years (26.1%) and the mean age was found to be 39.18 years [Table 1]. Among 115 cases, 61 (53%) cases were male and 54 (47%) were female giving male: female ratio of 1.13:1 [Table 2].Male and female were almost equally affected.
In this study, maximum of the lesions were localized 84 cases (55.7%) and 31 cases (44.3%) were diffused lesions. Maximum cases 50 (43.4%) affect the upper limb, followed by lower limb 30 cases (26%), 10 cases (8.7%) each on the scalp, face, neck, and trunk, and 5 cases (4.5%) on the soles and palm [Table 3].
Out of 115 cases, 75 (65.2%) were histopathologically diagnosed as psoriasis, 36 (31.3%) as lichen planus, and 4 cases (3.5%) as pityriasis rosea. Maximum numbers of the psoriasis patients are in the age group of 20–60 (77.9%) years. The youngest psoriasis patient was an 11-year-old girl and the oldest was an 80-year-old man. Out of the 36 histopathologically diagnosed lichen planus cases, a 2-year-old girl was the youngest and the oldest was a 70-year-old man [Table 4].
|Table 4: Age Wise Distribution Ofpsoriasis, Lichen Planus and Pityriasis Rosea|
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Out of 75 confirmed cases of psoriasis, 70 cases were both clinically and histologically confirmed, whereas in 5 cases, there was no clinical suspicion of psoriasis. Therefore, the sensitivity of diagnosis of psoriasis was 93.33%, specificity was 58.82%, and accuracy rate was 76.92%.
Out of 36 confirmed cases of lichen planus, only 6 cases were both clinically and histologically diagnosed, the remaining 30 cases were confirmed by histology only without clinical suspicion. Hence, the sensitivity of diagnosis was 16.6%, specificity was 100%, and accuracy rate of 71.42%.
All the 4 cases of pityriasis rosea were all clinically diagnosed as psoriasis but histologically confirmed as pityriasis giving a sensitivity of 25%, specificity of 100%, and accuracy rate of 96.52%.
Out of 115 cases of papulosquamous skin lesions, 70 cases of psoriasis and 6 cases of lichen planus were both clinically and histologically confirmed giving a concordance rate of 66.08%.
The various histopathological findings of psoriasis in our study were hyperkeratosis in 50 cases (66.7%), parakeratosis, acanthosis in 45 cases (60%) and elongated rete ridges in 60 (80%) patients, Munro's microabscesses in 15 (2%) patients, Kogoj abscess in 08 (10.7%), and dermal infiltration in 50 (66.7%) patients [Table 5] and [Figure 1]a, [Figure 1]b, [Figure 2]a, [Figure 2]b.
|Figure 1: (a) Psoriasis, multiple scaly papules on the upper limbs, (b) Psoriasis, downward extension of rete ridges with supra papillary thinning H & E 10x|
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|Figure 2: (a) Psoriasis, Auspitz sign showing bleeding points, (b) Psoriasis, Munro microabcesses in the cornified layer. H & E 10x|
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The 36 lichen planus cases showed hyperkeratosis in 30 (83.3%) patients, 31 (86.1%) showed parakeratosis and wedge-like hypergranulosis, acanthosis and sawtooth-like rete ridges in 32 (88.9%), band-like infiltrate in 35 (97.2%), and 15 (41.7%) showed basal layer degeneration [Table 6] and [Figure 3]a and [Figure 3]b.
|Figure 3: (a) Lichen Planus, multiple papules on the upper limb, (b) Lichen Planus, dense band of lymphomononuclear cells infiltrate in the dermoepidermal junction. H & E 10x|
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All the 4 cases of pityriasis rosea in our study showed hyperkeratosis, parakeratosis, thick basement membrane, perivascular lymphocytic infiltrate, and irregular elongation of rete ridges in all the 4 (100%) cases [Table 7] and [Figure 4]a, [Figure 4]b.
|Figure 4: (a) Pityriasis Rosea, multiple follicular papules on the upper limb, (b) Pityriasis Rosea, perivascular dermal infiltrate consisting predominantly of lymphocytes. H & E10x|
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| Discussion|| |
The histopathological findings of the 115 cases in our study were regrouped under 3 common papulosquamous skin disorders, namely psoriasis (75, 65.2%), lichen planus (36, 31.3%), and pityriasis rosea (4, 3.5%).
An analysis of the broad categories revealed that the most frequently encountered lesion in our study is psoriasis constituting 75 (65.2%), followed by lichen planus, 36 cases (31.3%), and pityriasis rosea with 4 (3.5%) cases, respectively. Our results are concurrent with the previous study by Das (102 of the total 156 cases).
Psoriasis is the oldest of all recorded skin disorders characterized by chronic inflammatory and proliferative lesions with well-circumscribed papules and silvery scales as described by Sehgal et al. D'Costa. According to their studies, psoriasis can affect any age group but peak in the second and fifth decades. In our present study, age ranges from 11 to 80 years. The youngest is an 11-year-old girl, a student and the oldest is an 80-year-old man, a retired employee. Both the cases are confirmed from the clinically diagnosed psoriasis.
Our results are comparable with other studies in the age distribution which falls maximum in the age group of 31–50 (70.6%) years. According to Grace et al., psoriasis is less common in younger age group (5.6%) which is compatible with our results. The mean age is 38.7 years.
Our study shows predominance of male patients comprising of 42 (56.2%) and the remaining 33 (43.8%) are female patients. The results are comparable with the previous studies of Younas et al. (60.25%) and Sudho et al. (1.5:1)., According to the study, it is revealed that the lower incidence observed in females may be due to their less attentiveness toward their own health and as psoriasis primarily occurs on the waist and buttocks, and would like to keep it hidden rather than seek medical advice.
The site of the lesions involved in our workup is 50 (43.4%) cases in the upper extremities, followed by lower limbs with 30 (26%) cases, scalp, face, and neck, trunk with 10 (8.7%) cases each, and palm and soles with 5 (4.5%) cases. The results are compatible with the study carried out by D'Costa on 161 (67.79%) cases.
Histopathologically psoriasis is characterized by epidermal hyperplasia, parakeratosis, elongation of rete ridges with thinning of the suprapapillary epidermis, dilated tortuous capillaries, and perivascular lymphocytic infiltration of the superficial dermis as described by King-Man.
The presenting histological findings of our study are hyperkeratosis (50, 66.6%), parakeratosis (45, 60%), acanthosis (60, 80%), elongation of rete ridges (60, 80%), hypogranulosis (40, 53.3%), suprapapillary thinning (60, 80%), with Munro microabscesses (20, 20%) and Kogoj abscess (8, 10.7%), and dermal infiltration (50, 66.7%).
These histological findings are concurrent with that of the discussion described by van de Kherkhof et al.
Lichen planus is a localized or generalized eruption with shining violacious flat-topped papules and scale on the surface. It is noninfectious and noncontagious disorder of the skin of unknown cause. It largely affects the skin, scalp, nails, or genitals. Clinically, a peculiar appearance classically described as Wickham' striae is considered diagnostic of lichen planus as described by D'Costa.
The classic histological features are hyperkeratosis, wedge-shaped areas of hypergranulosis, variable acanthosis, with the sawtooth appearance of rete ridges, and the diagnostic band-like inflammatory cells infiltrate in the upper dermis as described by Sánchez-Pérez et al.
The histopathological features of lichen planus that we observed in our study of 36 cases (31.3%) are hyperkeratosis (30, 83.3%), parakeratosis (25, 69.4%), acanthosis (32, 88.8%), wedge-like hypergranulosis (25, 69.4%), sawtooth rete ridges (32, 88.8%), band-like infiltrate (35, 97.2%), and basal layer degeneration (15, 41.6%), respectively.
Age ranged from 2 to 71 years which is compatible with the study carried out by Sánchez-Pérez et al. Two cases (5.5%) are below 10 years of age and maximum patients present in their second decade 10 cases (27.7%). The youngest is a 2-year-old girl presenting with a lesion on the lower limb as psoriasis, but in our study, it turns out to be lichen planus. The oldest patient is 70-year-old male farmer presenting lesion on the lower limb for 8 years as psoriasis, but histopathologically, it revealed as lichen simplex chronicus in our study.
In our study results, female cases (19, 52.7%) are slightly more than male (17, 47.3%) which are concurrent with the studies carried out by Vega Memije with male: female ratio of 1:1.2.
Persistence of lesions from 2 weeks to >6 months without a family history is the maximum presentation of the cases 22 (61.1%) and our study is compatible with the study carried out by Vega Mimije on 235 patients of lichen planus where the persistence of lesions varied from 1 month to 8 years.
Landis et al. presented a case of previously diagnosed psoriasis which revealed the classic features of lichen planus-wedge-shaped hypergranulosis, saw tooth of rete ridges, and interface change with band-like superficial dermal lymphohistiocytic infiltrate. Their study is concurrent with our results where 27 (75%) cases are clinically diagnosed as psoriasis but turned out to be lichen planus histopathologically.
Out of 36 (31.3%) cases of lichen planus which were confirmed by histopathology, only 6 (16.6%) cases were clinical diagnosed as lichen planus. Hence, there is a clinicopathological discrepancy of 30 cases who were diagnosed clinically as psoriasis 28 (77.7%), eosinophilic folliculitis 1 (2.8%), and pityriasis lichenoides chronic 1 (2.8%) but histopathologically confirmed as lichen planus.
Pityriasis rosea is a relatively common benign self-limited papulosquamous skin disorder characterized by oval lesions on the trunk and proximal areas of the extremities with the peak incidence at 10–35 years of age and the primary lesion called “herald patch” is clinically a diagnostic presentation as described by Younas et al. According to their studies, the diagnostic histopathological features include hyperkeratosis, patchy parakeratosis, acanthosis, thickened basement membrane, thinned out granular layer, irregular elongation of rete ridges, and moderate spongiosis.
In our present study, we encountered 4 cases of pityriasis rosea consisting of two males and two female patients. Out of which, 3 (75%) cases are in the second decade and 1 case in the fifth decade. Rameshwar carried out similar studies and their findings are similar with our results where the lesions are diffusely distributed in 3 cases and localized in 1 case with itchiness for a year. Sites of lesions are equally distributed, two of the cases presented in the upper limb and two in the lower limb.
All the 4 cases were clinically diagnosed as psoriasis which turned out to be pityriasis rosea in our histopathological findings. Our result revealed hyperkeratosis, parakeratosis, thickened basement membrane, perivascular lymphocytic infiltrate, and sparse inflammatory cells around the blood vessels in the upper dermis, and irregular elongation of rete ridges in all the 4 (100%) cases. The result of our study is correlating with the previous studies carried out by Sehgal et al.
In the present study, an analysis of the clinical diagnosis with the histopathological diagnosis of papulosquamous skin disorders of the skin revealed a positive correlation in 76 (66.08%) cases and a negative correlation in 39 (2.9%) cases. In a similar study by Narayankar and Pandit, the positive correlation was found to be 54 (90%) cases and negative correlation in 6 (10%) cases.
| Conclusion|| |
Papulosquamous skin disorder is a group of heterogenous dermatoses with distinct histomorphological features. Because of its varied clinical presentations, histopathological examination is mandatory for a definite diagnosis. However, consideration of both the clinical and histomorphological parameters would better diagnose and differentiate these papulosquamous lesions for proper management.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]