Vous êtes sur la page 1sur 1819

Aung Kyaw Oo

of the Skin
Commissioning Editor: William R. Schmitt
Development Editors: Louise Cook & Rachael Harrison
Editorial Assistant: Kirsten Lowson
Project Manager: Nancy Arnott
Design: Kirsteen Wright
Illustration Manager: Merlyn Harvey
Marketing Manager (USA): Tracie Pasker

Fourth Edition

of the Skin
with Clinical Correlations
Volume 1

Eduardo Calonje MD, DipRCPath Alexander Lazar MD, PhD

Director of Dermatopathology Associate Professor
Department of Dermatopathology Departments of Pathology and Dermatology
St John's Institute of Dermatology Sections of Dermatopathology and Sarcoma Pathology
St Thomas' Hospital Faculty, Sarcoma Research Center and Graduate School
London, UK of Biomedical Science
The University of Texas M.D. Anderson Cancer Center
Thomas Brenn MD, PhD, FRCPath Houston, Texas, USA
Consultant Dermatopathologist and Honorary Senior
Lecturer Editor-in-Chief
Department of Pathology
Western General Hospital and The University
Phillip H McKee MD, FRCPath
Formerly Associate Professor of Pathology and
of Edinburgh
Director, Division of Dermatopathology
Edinburgh, UK
Department of Surgical Pathology
Brigham and Women's Hospital and Harvard Medical
Boston, MA, USA

For additional online references and video content visit expertconsult.com

SAUNDERS an imprint of Elsevier Limited

© 2012, Elsevier Limited All rights reserved.

First edition 1989

Second edition 1996
Third edition 2005
Fourth edition 2012

The right of Eduardo Calonje, Thomas Brenn, Alexander Lazar and Phillip H McKee to be identified as author
of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. No
part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in
writing from the publisher. Details on how to seek permission, further information about the Publisher's
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the
individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they
should be mindful of their own safety and the safety of others, including parties for whom they have a professional
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability
for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

British Library Cataloguing in Publication Data

McKee's Pathology of the Skin. – 4th ed.

1. Skin–Diseases. 2. Skin–Histopathology.
I. Pathology of the skin II. Calonje, Eduardo. III. McKee,
Phillip H. Pathology of the skin.
ISBN-13: 978 1 4160 5649 2

Printed in China
Last digit is the print number: 9  8  7  6  5  4  3  2  1

List of Contributors vii

Preface to the fourth edition  x
Acknowledgements xi
Dedications xii
Glossary xiii

Volume 1

  1 The structure and function of skin  1 11 Diseases of the oral mucosa  362
John A. McGrath Sook-Bin Woo

  2 Specialized techniques in dermatopathology  32 12 Diseases of the anogenital skin  437

Pratistadevi A. Ramdial, Boris C. Bastian, John Goodlad, Eduardo Calonje, Sallie Neill, Chris Bunker,
John K. McGrath and Alexander Lazar Nick Francis, Alcides Chaux and Antonio C Cubilla

  3 Disorders of keratinization  46 13 Degenerative and metabolic diseases  520

Dieter Metze Nooshin Brinster and Eduardo Calonje

  4 Inherited and autoimmune subepidermal blistering 14 Cutaneous adverse reactions to drugs  590
diseases  99 Nooshin Brinster
  5 Acantholytic disorders  151
15 Neutrophilic and eosinophilic
  6 Spongiotic, psoriasiform and pustular dermatoses  631
dermatoses  180
16 Vascular diseases  658
  7 Lichenoid and interface dermatitis  219
17 Idiopathic connective tissue
Wei-Lien Wang and Alexander Lazar disorders  711
Bostjan Luzar and Eduardo Calonje
  8 Superficial and deep perivascular inflammatory
dermatoses  259
18 Infectious diseases of the skin  760
  9 Granulomatous, necrobiotic and perforating Wayne Grayson
dermatoses  281
10 Inflammatory diseases of the subcutaneous fat  326
Bostjan Luzar and Eduardo Calonje

Volume 2

19 Human immunodeficiency virus (HIV) 22 Diseases of the hair  967

and acquired immunodeficiency Rodrigo Restrepo and Eduardo Calonje
syndrome (AIDS)-associated cutaneous
diseases  896 23 Diseases of the nails  1051
Pratistadevi K. Ramdial and Wayne Grayson Josette Andre, Ursula Sass and Anne Theunis

20 Disorders of pigmentation  912 24 Tumors of the surface epithelium  1076

21 Diseases of collagen and elastic tissue  935 25 Melanocytic nevi  1150
Wei-Lien Wang and Alexander Lazar Bostjan Luzar, Boris C. Bastian and Eduardo Calonje
vi Contents

26 Melanoma  1221 30 Cutaneous metastases and Paget's disease

Boris C. Bastian and Alexander Lazar of the skin  1421
Doina Ivan, Alexander Lazar and Eduardo Calonje
27 Tumors of the conjunctiva  1268
Jacob Péer and Shahar Frenkel 31 Tumors of the hair follicle  1445
32 Tumors and related lesions of the sebaceous
28 Sentinel lymph node biopsies  1296
glands  1488
Alistair J. Cochran
33 Tumors of the sweat glands  1508
29 Cutaneous lymphoproliferative
diseases and related 34 Cutaneous cysts  1571
disorders  1311 35 Connective tissue tumors  1588
John Goodlad and Eduardo Calonje

Index  I1

List of Contributors

Josette André, MD Alistair J. Cochran, MD

Head of the Dermatology and Dermatopathology Department. Distinguished Professor of Pathology and Laboratory
CHU Saint-Pierre - CHU Brugmann Medicine and Surgery
Hôpital Universitaire des Enfants Reine Fabiola Department of Pathology and Laboratory Medicine
Université Libre de Bruxelles David Geffen School of Medicine at UCLA
Brussels, Belgium Los Angeles, CA, USA
Ch 23: Diseases of the nails with Ursula Sass and Anne Ch 28: Sentinel node biopsies

Boris C. Bastian, MD Antonio C. Cubilla, MD

Instituto de Patología e Investigación
Chairman, Department of Pathology
Asuncion, Paraguay
The James Ewing Alumni Chair
Ch 12: Diseases of the anogenital skin with Eduardo
Member, Human Oncology and Pathogenesis Program
Calonje, Sallie Neill, Chris Bunker, Nick Francis and Alcides
Memorial Sloan-Kettering Cancer Center
Professor of Pathology
Weill Cornell Medical College
New York, NY, USA Nick Francis, FRCPath
Ch 2: Specialized techniques in dermatopathology with
Consultant Histopathologist
Pratistadevi K Ramdial, John Goodlad, John A. McGrath and
Imperial College Healthcare NHS trust
Alexander Lazar
Honorary Senior Lecturer
Ch 25: Melanocytic nevi with Eduardo Calonje
Imperial College Faculty of Medicine
Ch 26: Melanoma with Alexander Lazar
London, UK
Ch 12: Diseases of the anogenital skin with Eduardo
Nooshin K. Brinster, MD Calonje, Sallie Neill, Chris Bunker, Alcides Chaux, Antonio C
Assistant Professor Cubilla
Department of Pathology and Dermatology
Director of Dermatopathology
VCU Medical Center Shahar Frenkel, MD, PhD
Richmond, VA, USA Ocular Oncologist and Ophthalmic Pathologist
Ch 13: Degenerative and metabolic diseases Specialized Ocular Oncology Service
Ch 14: Cutaneous adverse reactions to drugs Ophthalmic Pathology Laboratory
Jerusalem, Israel
Chris Bunker, MA, MD, FRCP Lecturer in Ophthalmology
Department of Ophthalmology
Consultant Dermatologist
Hadassah – Hebrew University Medical Center
University College and Chelsea and Westminster Hospitals
Jerusalem, Israel
Ch 27: Tumors of the conjunctiva with Jacob Pe'er
Professor of Dermatology
University College London
London, UK John Goodlad, MD, FRCPath
Ch 12: Diseases of the anogenital skin with Eduardo Calonje,
Consultant Haematopathologist and Honorary
Sallie Neill, Nick Francis, Alcides Chaux, Antonio C Cubilla
Senior Lecturer
Department of Pathology
Alcides Chaux, MD Western General Hospital and University of Edinburgh
GU Research Fellow, Edinburgh, UK
Department of Pathology Ch 2: Specialized techniques in dermatopathology with
Johns Hopkins University School of Medicine Pratistadevi K Ramdial, Boris C. Bastian, John A. McGrath and
Baltimore, MD, USA Alexander Lazar
Ch 12: Diseases of the anogenital skin with Eduardo Calonje, Ch 29 Cutaneous lymphoproliferative diseases and related
Sallie Neill, Chris Bunker, Nick Francis, and Antonio C Cubilla disorders with Eduardo Calonje
viii List of Contributors

Wayne Grayson, MBChB, PhD, FCPath(SA) Sallie Neill, MB ChB, FRCP

Consultant Anatomical Pathologist and Dermatopathologist Consultant Dermatologist
AMPATH National Laboratories; Guys and St Thomas' NHS Trust
Honorary Associate Professor London, UK
School of Pathology Ch 12: Diseases of the anogenital skin with Eduardo Calonje,
University of the Witwatersrand, Johannesburg Chris Bunker, Nick Francis, Alcides Chaux, Antonio C Cubilla
Johannesburg, South Africa
Ch 18: Infectious diseases of the skin
Ch 19: Human immunodeficiency virus (HIV) and Jacob Pe'er, MD
acquired immunodeficiency syndrome Professor and Chairman
(AIDS)-associated cutaneous diseases with Department of Ophthalmology
Pratistadevi K Ramdial Jonas Friedenwald Professor of Ophthalmic Research
Hadassah – Hebrew University Medical Center
Jerusalem, Israel
Doina Ivan, MD Ch 27: Tumors of the conjunctiva with Shahar Frenkel
Assistant Professor
Departments of Pathology and Dermatology
Section of Dermatopathology Pratistadevi K. Ramdial, MBChB, FCPath(SA)
The University of Texas M.D. Anderson Cancer Center Professor and Head
Houston, TX, USA Department of Anatomical Pathology
Ch 30: Cutaneous metastases and Paget's disease Nelson R. Mandela School of Medicine
of the skin with Alexander Lazar and Eduardo Calonje University of Kwazulu-Natal and the National Health
Laboratory Service
Durban, South Africa
Boštjan Luzar, MD, PhD Ch 2: Specialized techniques in dermatopathology with
Professor of Pathology Boris C. Bastian, John Goodlad, John A. McGrath and
Consultant Pathologist Alexander Lazar
Institute of Pathology Ch 19: Human immunodeficiency virus (HIV) and acquired
Medical Faculty University of Ljubljana immunodeficiency syndrome (AIDS)-associated cutaneous
Ljubljana, Slovenia diseases with Wayne Grayson
Ch 10: Inflammatory diseases of the subcutaneous fat with
Eduardo Calonje
Ch 17: Idiopathic connective tissue disorders with Eduardo Rodrigo Restrepo, MD
Calonje Director, Dermatopathology Fellowship Program
Universidad CES;
Professor of Dermatopathology
John A. McGrath, MD, FRCP Universidad Pontificia Bolivariana;
Professor of Molecular Pathology Director, Laboratory of Pathology
St John's Institute of Dermatology Clinica Medellin
King's College London Medellin, Colombia
Guy's Hospital Ch 22: Diseases of the hair with Eduardo Calonje
London, UK
Ch 1: The structure and function of skin
Ch 2: Specialized techniques in dermatopathology with Ursula Sass, MD
Pratistadevi K Ramdial, Boris C. Bastian, John Goodlad and Assistant Professor
Alexander Lazar Dermatology and Dermatopathology Department
CHU Saint-Pierre
Université Libre de Bruxelles
Dieter Metze, MD Brussels, Belgium
Professor of Dermatology Ch 23: Diseases of the nails with Josette André and Anne
Director, Dermatopathology Unit Theunis
Department of Dermatology
University Hospital Münster
Münster, Germany
Ch 3: Disorders of keratinization
List of Contributors ix

Anne Theunis, MD Sook-Bin Woo, DMD, MMSc

Assistant Professor Associate Professor
Dermatopathology and Pathology Department Department of Oral Medicine, Infection and Immunity
CHU Saint-Pierre and Institut Bordet Harvard School of Dental Medicine, Boston, MA, USA;
Université Libre de Bruxelles Attending Dentist and Consultant Pathologist
Brussels, Belgium Brigham and Women's Hospital
Ch 23: Diseases of the nails with Josette André and Ursula Boston, MA, USA
Sass Co-Director
Center for Oral Pathology Strata Pathology Services Inc.
Wei-Lien Wang, MD Lexington, MA, USA
Assistant Professor Ch 11: Diseases of the oral mucosa
Department of Pathology
Sections of Dermatopathology and Sarcoma Pathology
The University of Texas M.D. Anderson Cancer Center
Houston, TX, USA
Ch 7: Lichenoid and interface dermatoses with Alexander
Ch 21: Diseases of collagen and elastic tissue with Alexander
Preface to the fourth edition

It is hard to believe that sometime in 1988, when I was just starting my Thomas Brenn and Alex Lazar are also both very close friends and also
training in dermatopathology, I met Phillip McKee at a course on soft tissue regarded by me as members of the family. They both took on much greater
tumors organized in London by an unforgettable teacher, Dr Chris Fletcher. responsibilities in the fourth edition than in the third edition and have done
When Phillip heard about my interest in dermatopathology he said to me a wonderful job. I am deeply indebted to them. Similar to Eduardo this was
“I am writing a textbook in dermatopathology and you must buy it”. So I accomplished in a background of both a heavy routine workload and research
did, little suspecting that I was going to become heavily involved in the third commitment.
edition and the main editor to the fourth edition with the invaluable help When planning a new edition, it has been my practice to try to make the
of Thomas Brenn and Alex Lazar. During the 1980s immunohistochemistry new edition as different as possible from the preceding one to ensure that
was a relatively new diagnostic technique becoming in this age an invaluable people who buy the book get true value for money. To this end, a number
ancillary tool that has been instrumental in research and in diagnostic pathol- of new chapters have been added including, specialized techniques in der-
ogy. During the same period molecular biology was being developed as a matopathology, sentinel lymph node biopsy pathology, the pathology of
powerful research mechanism in pathology, becoming an additional and cru- HIV/AIDS and tumors of the conjunctiva. The oral pathology chapter has
cial aid in diagnosis in the fields of hematopathology and soft tissue tumors in been expanded to include tumors of the salivary glands. We have taken
the 1990s. Furthermore, some of these developments in the latter fields have on a large number of very experienced excellent new authors to bring per-
allowed an understanding of many aspects of the pathogenesis of neoplasia, sonal experience to many of the more difficult topics and this has certainly
and this has led to the ever expanding use of targeted therapy in the 21st cen- paid dividends. Much progress has been achieved in our understanding of
tury. These advances have had an important impact in dermatopathology, and the pathogenesis of disease and this is reflected in the new text with up-to-
more exciting developments have followed in research, diagnosis and under- date scientific data. I am deeply indebted to all of our new contributors.
standing of the pathogenesis of neoplastic processes that are of particular The Fourth edition is certainly a very different book than the first edition
importance in the skin, particularly melanocytic neoplasms. This is ongoing which I wrote for fun almost single handedly as an atlas with integrated
work with many questions still unanswered and although with great limita- text.
tions particularly in the field of diagnosis, it has nonetheless allowed immense In order to increase valuable space for the increased figures, enlarged text and
understanding of pathogenesis and the development of some targeted thera- new chapters, it was decided to make the references an online only component
pies for melanoma some with very promising although limited results. of the book. This has allowed us to considerably expand the text and increase
In this edition we have invited a number of experts to contribute in their the number of figures in the book, a large proportion of which are new.
areas of expertise realizing that it is very difficult if not impossible for a hand- I am also heavily indebted to my two friends in the publishing world -
ful of people to cover such an extensive area as dermatopathology. We have Louise Cook and Bill Schmitt. I have been associated with Louise for more
tried to include as much material as possible encompassing most of what is years than I choose to remember and she has always proven to be a pillar of
new in the literature but realize that inevitably this cannot be achieved to support particularly during the numerous episodes of stress that are inevi-
complete satisfaction. The third edition of this book was received with great table in a task of this magnitude. I thank her for always being there when
enthusiasm by many people all over the world and we hope to have fulfilled help was necessary. I met Bill when I moved to the United States and he has
the task and answered their criticisms in this new edition. also become a great friend in addition to being the senior Elsevier represen-
tative overseeing the progress of the book. Similar to Louise he has had to
Eduardo Calonje
put up with much from me and has always steered the project with a steady
hand during all of its crises which have been innumerable. Producing the
The fourth edition has been a huge undertaking and taken an immense amount
Fourth edition would have been an even harder task without their input.
of time and energy. I would first like to congratulate Eduardo Calonje for doing
More recently I have worked with Nancy Arnott in Edinburgh. She has been
a wonderful job against a background of a heavy daily workload and lecture
the senior editor of the project and most certainly done a wonderful job. The
commitment. I decided that having left hospital practice and been in charge of
editors and contributors owe her an awful lot.
the book for three editions, that it was high time for new blood to take over
Lastly and most importantly, I owe so much as always to Gracie. She has
control of the new edition while I became overall editor-in-chief. I have known
had to put up with me for the past 4 years while working on the new edition.
Eduardo since the early 1980's during which time he has become more than just
This has been no mean feat. She has let my ill temper and moods of depres-
a close friend; both Gracie and I regard him as one of the family. He is a superb
sion and anxiety wash over her and in her own thoughtful quiet way made
dermatopathologist (without question Europe's leading light) and I had every
the seemingly impossible possible. I would never have been able to complete
confidence that he would produce a wonderful new edition of Pathology of the
this task without her loyalty, support and love.
Skin. Needless to say he has gone beyond my greatest expectation and produced
a truly magnificent fourth edition. Words cannot express my gratitude. Phillip H. McKee

Working for so many years on a book of this proportion, especially when the Academic life is a complex web of mentors, colleagues and students. I have
task is something that has to be done as a “hobby” after formal work hours, been lucky to have worked with a number of fine mentors and colleagues
represents a daunting task. I often wondered in times of despair whether the who strongly influenced my thinking in pathology in general and/or in der-
job was ever going to be finished. It has finally been completed and I would matopathology specifically: Chris Fletcher, Scott Granter, George Murphy,
not have been able to achieve this without the invaluable help of many peo- Ramzi Cotran (deceased), Chris Crum, Bill Welch, Rob Odze, Jon Aster,
ple. They not only gave me emotional support but often went out of their Felix Brown (deceased), Jason Hornick, John Iafrate, Marcus Bosenberg,
way to help me with the many details necessary to finalize the numerous Jonathan Fletcher, Marty Mihm, Lyn Duncan, Steve Tahan, Steve Lyle, Victor
tasks that this job entailed. My wife Claudia has always given me her unwav- Prieto, Harry Evans, Sharon Weiss, Bogdan Czerniak, Frasier Symmans,
ering support no matter how trying the challenge ahead. My children Mateo Ken Aldape, Russell Broaddus, Greg Fuller, Mike Davies, Jon Reed, John
and Isabella have given me their patience and understanding. Numerous col- Goldblum, David Berman, Vinay Kumar, Marc Ladanyi, Matt van de Rijn,
leagues, many of them visiting fellows from many different countries, have Brian Rubin, Jesse McKenney, Steve Billings, Howard Gerber, Ron Rapini,
made my life easy in millions of ways and I cannot thank them enough for Julia Bridge, Paula dal Cin, Andre Oliveira, Pancras Hogendoorn, Paulo Dei
their patience, hard work and mainly for being wonderful human beings sup- Tos, Andrew Folpe, Judith Bovee, Lola Lopez-Terrada, Cristina Antonescu,
porting me in what for many reasons were the darkest days of my life. I espe- along with numerous others I have encountered either directly or through
cially want to show my appreciation to Drs Maiko Tanaka, Anoud Zidan, their writing and lecturing. This extended list testifies not only to my good
Vicki Howard, Viky Damaskou, Thomas Brenn, Bostjan Luzar, Ravi Ratnavel, fortune in meeting so many wonderful people, but also the generosity of
Rathi Ramakrishnan and Gregory Spiegel (who sadly died last year). academic pathologists as a group. I have many other friends in pathology
and medicine who shall have to remain nameless due to space constraints,
EC but this line hails that brilliant group. The other authors and editors of
this present work have been a joy to work with and I have benefited much
The path of life is often determined by the people we encounter. There are
from these interactions. The Dermatopathology Section at my institution
many ways in which certain individuals touch our hearts, steer us in the right
has a delightful combination of great people and fascinating diagnostic
direction and help us achieve goals which would have been unattainable oth-
material. My former Chairman of Pathology, Janet Bruner, was enthusi-
erwise. Words aren't ever enough to really show one's true appreciation for
astic and supportive of this project from our first conversation regarding
the generosity, support and motivation received over the years.
it. Another group of colleagues including Ralph Pollock, Dina Lev and the
My wonderful, loving parents, Sonja and Walter, have always been there
entire Sarcoma Research Center have done more than their share to help
for me and supported my every move. My wife and daughter, Anne and Yaëlle,
me balance the demands of clinical work, research, grants, papers and this
have had a terrible time dealing with my tempers throughout the writing of
book. The talented staff at Elsevier provided invaluable support through-
this book. They have always stood by my side and saved a smile for me for
out this project. Last, but certainly not least, I am indebted to my trainees.
which I am ever so grateful. My professional life could have gone very wrong
On a daily basis, they remind me of the marvels of what we do, ask difficult
indeed had it not been for the kindness and gracious support from these truly
and challenging questions, prompt re-examination of assumptions, expose
unique mentors and teachers Uta Francke, Heinz Furthmayr, Ramzi Cotran
biases, and force clarity and reproducibility in diagnostic criteria; may we
and Christopher Fletcher. Finally, there is so much I owe to these two won-
all retain these characteristics of motivated students throughout our career.
derful individuals who have become very close friends, Phillip McKee and
For all of this, I am humbled and grateful.
Eduardo Calonje.

To my wife Claudia who always gives without expecting anything in return.

To my children Mateo and Isabella and to the memory of my parents Julio
and Alicia both of whom passed away while this edition was in production.

To Anne, Yaelle, Sanja and Walter.


I am assured that my two beautiful children, Elliott and Abigail, have no

memories that predate me working on this book. I hope that this example of
what fascination with a subject, continued application to a task, and working
as a disciplined team can accomplish will be a small, but meaningful substi-
tution for the time designated to this endeavor. My wife, Victoria, has been
ever supportive in every way despite having an extremely busy and demand-
ing career in law as has been my mother-in-law Sara. My parents, Joe and
Glenda, always allowed me the freedom to pursue my own interests and the
encouragement and support to accomplish them, a wonderful gift I hope to
pass on to my children as well.

This new edition is dedicated to my wife and best friend Gracie with all my

5-ARD 5-a-reductase CRASP complement regulator-acquiring surface FAMMM familial atypical multiple mole
AA alopecia areata protein melanoma [syndrome]
ACE angiotensin converting enzyme CREST calcinosis, Raynaud’s phenomenon, FAP familial adenomatous polyposis
[inhibitor] esophageal dysfunction, sclerodactyly, FAPA fever, aphthous stomatitis, pharyngitis,
AgNORS argyrophilic nucleolar organizer regions telangiectasis [syndrome] adenitis [syndrome]
AHNMD associated clonal hematological CTCL cutaneous T-cell lymphoma FHIT fragile histidine triad
non-mast cell lineage disease dcSSc diffuse cutaneous systemic sclerosis FIGURE facial idiopathic granulomata with
AIDS acquired immunodeficiency syndrome DDEB dominant dystrophic epidermolysis regressive evolution
AILD angioimmunoblastic lymphadenopathy bullosa FISH fluorescent in situ hybridization
with dysproteinemia DEB dystrophic epidermolysis bullosa GA granuloma annulare
ALA aminolevulinic acid DH dermatitis herpetiformis GABEB generalized atrophic benign
ALK anaplastic lymphoma kinase DIC disseminated intravascular coagulation epidermolysis bullosa
ALK1 activin-like receptor kinase 1 DIMF direct immunofluorescence GCDFP gross cystic disease fluid protein
ALM acral lentiginous melanoma DLE discoid lupus erythematosus G-CSF granulocyte-colony stimulating
AN acanthosis nigricans DNCB dinitrochlorobenzene factor
ANA antinuclear antibodies DSAP disseminated superficial actinic GFAP glial fibrillary acidic protein
ANCA antineutrophil cytoplasmic antibodies porokeratosis GM-CSF granulocyte–macrophage colony
API2 apoptosis inhibitor-2 Dsc desmocollin stimulating factor
ARC AIDS-related complex dsDNA double-stranded DNA GSE gluten-sensitive enteropathy
ATF1 activating transcription factor 1 Dsg desmoglein GVHD graft-versus-host disease
ATLL adult T-cell leukemia/lymphoma DSP disseminated superficial porokeratosis HA hyperandrogenism
BANS back, arm, neck and scalp [sites] EB epidermolysis bullosa HAART highly active antiretroviral therapy
BB mid borderline leprosy EBA epidermolysis bullosa acquisita HAIR-AN hyperandrogenism–insulin resistance–
BCC basal cell carcinoma EBS epidermolysis bullosa simplex acanthosis nigricans [syndrome]
BCG bacille Calmette–Guérin EBS-DM epidermolysis bullosa simplex, HBV hepatitis B virus
B-FGF basic fibroblast growth factor Dowling–Meara HDL high density lipoprotein
BIDS brittle sulfur-deficient hair, intellectual EBS-K epidermolysis bullosa simplex, Koebner HF hemorrhagic fever
impairment, decreased fertility and EBS-MD epidermolysis bullosa simplex with HG herpes gestationis
short stature muscular dystrophy HHV human herpesvirus
BL borderline lepromatous leprosy EBS-WC epidermolysis bullosa simplex, HIT heparin-induced thrombocytopenia
BLAISE Blaschko linear acquired inflammatory Weber–Cockayne [syndrome]
skin eruption EBV Epstein–Barr virus HIV human immunodeficiency virus
BMP bone morphogenetic protein ECE endothelin-converting enzyme HLA human leukocyte antigen
BP bullous pemphigoid ECM extracellular membrane HMFG human milk fat globulin
BPA bullous pemphigoid antigen EDS Ehlers–Danlos syndrome HNPCC hereditary non-polyposis colorectal
BSAP B-cell-specific activator protein EGFR endothelial growth factor receptor carcinoma [syndrome]
BSLE bullous systemic lupus erythematosus ELAM endothelial leukocyte adhesion HPF (hpf) high power fields
BT borderline tuberculoid leprosy molecule HPL hyperlipoproteinemia
C3NeF C3 nephritic factor ELISA enzyme-linked immunosorbent assay HPV human papillomavirus
CAD chronic actinic dermatitis EM electron microscopy HRF histamine-releasing factor
cAMP cyclic adenosine 3'-5'- monophosphate EMA epithelial membrane antigen HSP heat shock protein
c-ANCA cytoplasmic-antineutrophil cytoplasmic ENA extractable nuclear antigen HSV herpes simplex virus
antibodies ENL erythema nodosum leprosum HTLV human T-cell lymphotropic virus
CDC Centers for Disease Control and EPPER eosinophilic, polymorphic and hTR telomerase RNA
Prevention pruritic eruption associated with HUS hemolytic uremic syndrome
CEA carcinoembryonic antigen radiotherapy IBIDS ichthyosis and BIDS (see BIDS above)
CGRP calcitonin-gene-related polypeptide EPPK epidermolytic palmoplantar ICAM intercellular adhesion molecule
CHILD congenital hemidysplasia with keratoderma ICH indeterminate cell histiocytosis
ichthyosiform nevus and limb defects EPS extracellular polysaccharide substance IDL intermediate density lipoproteins
[syndrome] ESR erythrocyte sedimentation rate IEN intraepidermal neutrophilic [IgA
CK cytokeratin ETA exfoliative toxin A dermatosis variant]
CLA cutaneous lymphocyte antigen ETB exfoliative toxin B IFAP ichthyosis follicularis–alopecia–
CLL chronic lymphocytic leukemia EV epidermodysplasia verruciformis photophobia [syndrome]; intermediate
CMG capillary morphogenesis protein EWSR1 Ewing’s sarcoma [proto-oncogene] filament associated protein
CNS central nervous system FACE facial Afro-Caribbean childhood IFN interferon
CP cicatricial pemphigoid (mucous membrane eruption Ig immunoglobulin
pemphigoid) FADS fetal akinesia deformation sequence IIMF indirect immunofluorescence
xiv Glossary

ILVEN inflammatory linear verrucous NFII neurofibromatosis type II SALE summertime actinic lichenoid eruption
epidermal nevus NFP neurofilament protein SALT skin-associated lymphoid tissue
IMF immunofluorescence NIH National Institutes of Health SAPHO synovitis, acne, pustulosis, hyperostosis,
IP inducible protein; immunoprecipitation NISH non-isotopic in situ hybridization osteitis [syndrome]
IR insulin resistance NK natural killer SCC squamous cell carcinoma
ISSVD International Society for the Study of NL necrobiosis lipoidica SCH squamous cell hyperplasia
Vulvovaginal Disease NRAMP1 natural resistance-associated SCID severe combined immunodeficiency
JEB junctional epidermolysis bullosa macrophage protein 1 SCLE subacute cutaneous lupus
JEB-H junctional epidermolysis bullosa, NSAIDs non-steroidal anti-inflammatory drugs erythematosus
Herlitz NSE neuron-specific enolase scRNP small cytoplasmic ribonuclear protein
JEB-nH junctional epidermolysis bullosa, OL-EDA- osteopetrosis, lymphedema, SEA staphylococcal enterotoxin A
non-Herlitz ID anhidrotic ectodermal dysplasia, SEB staphylococcal enterotoxin B
JEB-PA junctional epidermolysis bullosa with immunodeficiency [syndrome] Shh Sonic Hedgehog
pyloric atresia ORF open reading frame SIBIDS osteosclerosis and IBIDS (see IBIDS
KID keratitis–ichthyosis–deafness PAIN perianal intraepithelial neoplasia above)
[syndrome] p-ANCA perinuclear-antineutrophil cytoplasmic SIL squamous intraepithelial lesion
KOH potassium hydroxide antibodies SLE systemic lupus erythematosus
KPAF keratosis pilaris atrophicans facei PAPA pyogenic sterile arthritis, pyoderma SLL small lymphocytic lymphoma
L&H cells lymphocytic and/or histiocytic gangrenosum and acne [syndrome] SMA smooth muscle actin
Reed–Sternberg cell variants PAS periodic acid–Schiff snRNP small nuclear ribonuclear protein
LAD linear IgA disease PBG porphobilinogen SPD subcorneal pustular dermatosis
LATS long-acting thyroid stimulator PCNA proliferating cell nuclear antigen SPRRs small proline rich proteins/cornifins
LCA leukocyte common antigen PCR polymerase chain reaction SPTL subcutaneous panniculitis-like T-cell
LCH Langerhans’ cell histiocytosis PDGFβ platelet-derived growth factor b lymphoma
lcSSc limited cutaneous systemic sclerosis PECAM platelet endothelial cell adhesion SRP signal recognition particle
LDL low density lipoprotein molecule ssDNA single-stranded DNA
LE lupus erythematosus PEComa perivascular epithelioid cell tumor SSSS staphylococcal scalded skin syndrome
LFA lymphocyte function-associated PGL phenolic glycolipid STD sexually transmitted disease
antigen PGP protein gene product sub-LD sub-lamina densa
LH–RH luteinizing hormone–releasing hormone PGWG purely granulomatous Wegener’s TCR T-cell receptor
LL lamina lucida; lepromatous leprosy granulomatosis TEN toxic epidermal necrolysis
LP lichen planus PI protease inhibitor TFIIH transcription/DNA repair factor IIH
LPP lichen planus pemphigoides PIBIDS photosensitivity and IBIDS (see IBIDS TGF transforming growth factor
LS lichen sclerosus above) thio- triethylene thiophosphoramide
LYVE lymphatic vessel endothelial PILA papillary intralymphatic TEPA
[hyaluronan receptor] angioendothelioma TIMP tissue inhibitor of metalloproteinase
MAC membrane attack complex PLEVA pityriasis lichenoides et varioliformis acuta TNF tumor necrosis factor
MAI M. avium intracellulare PNET primitive neuroectodermal tumor TORCH toxoplasmosis, other infections, rubella,
MALT mucosa-associated lymphoid tissue POEMS polyneuropathy, organomegaly, cytomegalovirus and herpes simplex
MART-1 melanoma antigen recognized by endocrinopathy, M-protein and skin [syndrome]
T-cells 1 changes [syndrome] TRAPS tumor necrosis factor receptor-
MBP myelin basic protein PPD purified protein derivative associated periodic syndrome
MC1R melanocortin-1 receptor PPDL pure and primitive diffuse leprosy TSST toxic shock syndrome toxin
MCGN mesangiocapillary glomerulonephritis PPK palmoplantar keratoderma TT tuberculoid leprosy
MCP molecule chemoattractant protein pRB retinoblastoma protein tTA tetracycline transactivator [transcription
M-CSF macrophage colony stimulating factor PSS progressive systemic sclerosis factor]
MCTD mixed connective tissue disease PTEN phosphatase and tensin homolog TTF-1 thyroid-transcription factor 1
MDR multidrug resistance gene PUPPP pruritic urticarial papules and plaques tTG tissue transglutaminase
Mel-CAM melanoma cell adhesion molecule of pregnancy TTP thrombotic thrombocytopenic
MEN multiple endocrine neoplasia PUVA psoralen plus ultraviolet light of purpura
[syndrome] A [long] wavelength UPS undifferentiated pleomorphic sarcoma
MFH malignant fibrous histiocytoma r IL-2 recombinant interleukin 2 URO uroporphyrinogen
MGS/ melanoma growth stimulatory RBC red blood cell URO-D uroporphyrinogen decarboxylase
GRO activity RDEB recessive dystrophic epidermolysis URR upstream regulatory region
MHC major histocompatibility complex bullosa UV ultraviolet
miH minor histocompatibility complex RDEB-HS recessive dystrophic epidermolysis UVA ultraviolet A
MITF microphthalmia transcription factor bullosa, Hallopeau–Siemens UVB ultraviolet B
MMP matrix metalloproteinase RDEB- recessive dystrophic UVL ultraviolet light
MMR mismatch repair nHS epidermolysis bullosa, non-Hallopeau– VCAM vascular cell adhesion molecule
MSA muscle-specific actin Siemens VEGF vascular endothelial growth factor
MSI microsatellite instability RER rough endoplasmic reticulum VEGFR vascular endothelial growth factor receptor
NADH nicotine adenine dinucleotide, reduced RNP ribonucleoprotein VIN vulval intraepithelial neoplasia
nDNA native [double-stranded] DNA RT-PCR reverse transcription polymerase chain VIP vasoactive intestinal peptide
NEMO nuclear factor [NF]-kappaB gene reaction VLDL very low density lipoprotein
modulator SA syphilitic alopecia VZV varicella-zoster virus
NF necrotizing fasciitis SA1 slowly adapting type-1 wrfr wrinkle free [mouse model]
NFI neurofibromatosis type I [mechanoreceptor] XP xeroderma pigmentosum
The structure and function Chapter

for references and
additional material
of skin
John A. McGrath
Properties of skin  1 Melanocytes  10 Dermal elastic tissue  24
Normal epidermal histology  1 Merkel cells  12 Ground substance  26
Regional variations in skin anatomy  2 Intercellular junctions  13 Fibroblast biology  26
Skin development  2 Pilosebaceous units  15 Cutaneous blood vessels and
lymphatics  27
Keratinocyte biology  5 Eccrine glands  17
Nervous system of the skin  28
Epidermal stem cells  6 Apocrine glands  19
Subcutaneous fat  30
Skin barrier  8 Dermal–epidermal junction  21
Skin immunity  9 Dermal collagen  22

Skin is a double-layered membrane covering the exterior of the body and

consists of a stratified cellular epidermis and an underlying dermis of con- Normal epidermal histology
nective tissue. In adults, the skin weighs over 5 kg and covers a surface area
approaching 2 m2. The epidermis is mainly composed of keratinocytes and is Although the basic structure is relatively constant at various skin sites, there
typically 0.05–0.1 mm in thickness. The dermis contains collagen, elastic tis- are often clear differences which enable one to determine the site of origin.
sue and ground substance and is of variable thickness, from 0.5 mm on the The epidermis consists of four clearly defined layers or strata:
eyelid or scrotum to more than 5 mm on the back (Fig. 1.1). • Basal cell layer (stratum basale)
The dermis is subdivided into a more superficial component (the papillary • Prickle cell layer (stratum spinosum)
dermis) which is bounded inferiorly by the superficial vascular plexus and an • Granular cell layer (stratum granulosum)
underlying much thicker reticular dermis. Below the dermis is a layer of sub- • Keratin layer (stratum corneum)
cutaneous fat which is separated from the rest of the body by a vestigial layer An eosinophilic acellular layer known as the stratum lucidum is sometimes
of striated muscle. seen in skin from the palms and soles (Fig. 1.2).
Basal cells are cuboidal or columnar with a large nucleus typically con-
taining a conspicuous nucleolus. Small numbers of mitoses may be evident.
Properties of skin Clear cells are also present in the basal layer of the epidermis; these repre-
sent melanocytes. Cells with clear cytoplasm seen in the stratum spinosum
A key role of skin is to provide a mechanical barrier against the external represent Langerhans cells. Very occasional Merkel cells may also be present
environment. The cornified cell envelope and the stratum corneum restrict but these are not easily identified in hematoxylin and eosin stained sections.
water loss from the skin while keratinocyte-derived endogenous antibiot- Histologically, prickle cells are polygonal in outline, have abundant eosino-
ics (defensins and cathelicidins) provide an innate immune defense against philic cytoplasm and oval vesicular nuclei, often with conspicuous nucleoli.
bacteria, viruses and fungi. The epidermis also contains a network of about Keratohyalin granules typify the granular cell layer (Fig. 1.3). Further matu-
2 × 109 Langerhans cells which serve as sentinel cells whose prime function ration leads to loss of nuclei and flattening of the keratinocytes to form the
is to survey the epidermal environment and to initiate immune responses plates of the keratin layer (stratum corneum). Adjacent cells are united at
against microbial threats. Melanin, which is mostly found in basal keratino- their free borders by intercellular bridges (prickles), which are most clearly
cytes, provides some protection against DNA damage from ultraviolet radia- identifiable in the prickle cell layer and in disease states of the skin where
tion. An important function of skin is thermoregulation. Vasodilatation or there is marked intercellular edema (spongiosis) (Fig. 1.4).
­vasoconstriction of the blood vessels in the deep or superficial plexuses helps Toker cells represent an additional clear cell population, which may be
regulate heat loss. Eccrine sweat glands are found at all skin sites and are found in nipple epidermis of both sexes in up to 10% of the population.1 The
present in densities of 100–600/cm2; they play a role in heat control and cells are large, polygonal or oval and have abundant pale staining or clear
aspects of metabolism. Secretions from apocrine sweat glands contribute to cytoplasm with vesicular nuclei often containing prominent, albeit small,
body odor. Skin lubrication and waterproofing is provided by sebum secreted nucleoli. The cytoplasm is mucicarmine and PAS negative.1 The cells may be
from sebaceous glands. Subcutaneous fat has important roles in cushioning distributed singly but more often they are found as small clusters, not uncom-
trauma as well as providing insulation and a calorie reserve. Fat also has an monly forming single layered ductules.1 They are located along the basal layer
endocrine function and contributes to tissue remodeling and phagocytosis. of the epidermis or suprabasally and are also sometimes seen within the epi-
Nails provide protection to the ends of the fingers and toes as well as being thelium of the terminal lactiferous duct.
important in pinching and prising objects. Hair may have important social Toker cells are of particular importance as they may be mistaken by the
and psychological value. Skin also has a key function in synthesizing various unwary as Paget cells. They are thought to be the source of mammary Paget's
metabolic products, such as vitamin D. disease in those exceptional cases where an underlying ductal carcinoma is
2 The structure and function of skin

Fig. 1.1
Skin from forearm: there is a fairly thin epidermis. Compare the thickness of the Fig. 1.4
dermis with that from the back (see Fig. 1.5). Spongiosis: the
intercellular bridges
(prickles) are stretched
and more visible in this
biopsy from a patient with
acute eczema.

absent.2 Toker cells express CK7, AE1, CAM 5.2, epithelial membrane anti-
gen (EMA), cerbB2, estrogen and progesterone receptors.3,4 They do not
express p53 or CD138. Carcinoembryonic antigen (CEA) may also be present
albeit weakly.4 Paget's cells by way of contrast are often negative for estrogen
and progesterone receptors and are p53 and CD138 positive.4

Regional variations in skin anatomy

There are two main kinds of human skin: glabrous skin (nonhairy skin)
and hair-bearing skin. Glabrous skin is found on the palms and soles. It
has a grooved surface with alternating ridges and sulci giving rise to the
dermatoglyphics (fingerprints). Glabrous skin has a compact, thick stratum
­corneum, and contains encapsulated sense organs within the dermis but no
hair follicles or sebaceous glands. In contrast, hair-bearing skin has both
Fig. 1.2
Skin from palm: note the eosinophilic stratum lucidum clearly separating the
hair follicles and sebaceous glands but lacks encapsulated sense organs.
granular cell layer from the overlying stratum corneum. Hair follicle size, structure and density can vary between different body
sites. For example, the scalp has large hair follicles that may extend into
subcutaneous fat whereas the forehead has only small vellus hair-producing
follicles although sebaceous glands are large. The number of hair follicles
does not alter until middle life but there is a changing balance between vel-
lus and terminal hairs throughout life. In hair-bearing sites, such as the
axilla, there are apocrine glands in addition to the eccrine sweat glands.
Sebaceous glands are active in the newborn, and from puberty onwards,
and the relative activity modifies the composition of the skin surface lipids.
The structure of the dermal–epidermal junction also shows regional vari-
ations in the number of hemidesmosomal-anchoring filament complexes
(more in the leg than the arm). In the dermis, the arrangement and size
of elastic fibers ­varies from very large fibers in perianal skin to almost no
fibers in the scrotum. Marked variation in the cutaneous blood supply is
found between areas of distensible skin such as the eyelid and more rigid
areas such as the fingertips.
Regional variation in skin structure is illustrated in Figures 1.5–1.20.

Skin development
Two major embryological elements juxtapose to form skin. These comprise
Fig. 1.3 the prospective epidermis that originates from a surface area of the early
Skin from palm: there is a conspicuous granular cell layer. ­gastrula, and the prospective mesoderm that comes into contact with the
Skin development 3

Fig. 1.7
Fig. 1.5 Skin from the sole of the foot: this is typified by a thickened stratum corneum
Skin from the lower and prominent epidermal ridge pattern. The dermis is relatively dense at this site.
back: at this site the Similar features are seen on the palms and ventral aspects of the fingers and toes.
dermis is very thick
and is characterized by
broad parallel fascicles of

Fig. 1.8
Skin from the scalp: there are numerous terminal hair follicles with many of the
bulbs in the subcutaneous fat.
Fig. 1.6
Skin of the nose: there are conspicuous sebaceous glands: at this site, they often
drain directly onto the skin surface. These appearances should not be confused 14  to 21, fibroblasts are numerous and active, and perineural cells, pericytes,
with that of sebaceous hyperplasia.
melanoblasts, Merkel cells and mast cells can be individually identified. Hair
follicles and nails are evident at 9 weeks. Sweat glands are also noted at 9
weeks on the palms and the soles.3 Sweat glands at other sites and sebaceous
inner surface of the epidermis during gastrulation. The mesoderm generates glands appear at 15 weeks. Touch pads become recognizable on the fingers
the dermis and is involved in the differentiation of epidermal structures such and toes by the sixth week and development is maximal by the 15th week.
as hair follicles.1 Melanocytes are derived from the neural crest. After gastru- The earliest development of hair occurs at about 9 weeks in the regions of the
lation, there is a single layer of neuroectoderm on the embryo surface: this eyebrow, upper lip and chin. Sebaceous glands first appear as hemispherical
layer will go on to form the nervous system or the skin epithelium, depend- protuberances on the posterior surfaces of the hair pegs and become differ-
ing on the molecular signals (e.g., fibroblast growth factors or bone mor- entiated at 13–15 weeks. Langerhans cells are derived from the monocyte–
phogenic proteins) it receives.2 The embryonic epidermis consists of a single macrophage–histiocyte lineage and enter the epidermis at about 12 weeks.
layer of multipotent epithelial cells which is covered by a special layer known Merkel cells appear in the glabrous skin of the fingertips, lip, gingiva and
as periderm that is unique to mammals. Periderm provides some protection nail bed, and in several other regions, around 16 weeks. Although some cells
to the newly forming skin as well as exchange of material with the amniotic of the dermis may migrate from the dermatome (venterolateral part of the
fluid. The embryonic dermis is at first very cellular and at 6–14 weeks three somite) and take part in the formation of the skin, most of the dermis is
types of cell are present: stellate cells, phagocytic macrophages and granule- formed by ­mesenchymal cells that migrate from other mesodermal areas.4
­secretory cells, either melanoblasts or mast cells (Fig. 1.21). From weeks These ­mesenchymal cells give rise to the whole range of blood and ­connective
4 The structure and function of skin

Fig. 1.9 Fig. 1.11 Fig. 1.12

Skin from axilla: apocrine glands as seen at the Skin from the outer aspect of the lip: note the Mucosal aspect of lip: at this site the squamous
bottom of the field are typical for this site. keratinizing stratified squamous epithelium and epithelium does not normally keratinize. Minor salivary
skeletal muscle fibers. glands as shown in this field are not uncommonly present.

Fig. 1.13
Mucosal aspect of lip:
close-up view of the
salivary gland shown in
Figure 1.12.

Fig. 1.10
Skin of areola: there are abundant smooth muscle
fibers: lactiferous ducts may also sometimes be
present (not shown).

Fig. 1.14
Mucosal aspect of lip:
the cytoplasm of the
keratinocytes is often rich
in glycogen.
Keratinocyte biology 5


Fig. 1.15 Fig. 1.16

Skin from the ear: note the vellus hairs, and a fairly (A, B) Vulval vestibule: at this site the stratum corneum is absent and there is no granular cell layer. The
thin dermis overlying the auricular cartilage. suprabasal keratinocytes have clear cytoplasm due to abundant glycogen and revealed by the periodic ­
acid-Schiff reaction.

Fig. 1.17 Fig. 1.18

Variation of skin: sample of skin from the forearm of a 92-year-old female. Note the Stasis change: skin from the lower leg. Although abnormal, the presence of
epidermal thinning and dermal atrophy. stasis change characterized in this example by papillary dermal lobular capillary
proliferation is a very common feature at this site.

tissue cells, including the fibroblasts and mast cells of the dermis and the fat
7–10 nm in diameter, known as intermediate filaments. There are six types
cells of the subcutis. In the second month, the dermis and subcutis are not
of intermediate filaments of which keratins are the filaments in keratinocytes
discernible as distinct skin layers but collagen fibers are evident in the dermis
(Figs 1.22, 1.23). The human genome possesses 54 functional keratin genes
by the end of the third month. Later, the papillary and reticular layers become
located in two compact gene clusters, as well as many nonfunctional pseudo-
established and, at the fifth month, the connective tissue sheaths are formed
genes, scattered around the genome.1 Keratin genes are very specific in their
around the hair follicles. Elastic fibers are first detectable at 22 weeks.
expression patterns. Each one of the many highly specialized epithelial tissues
has its own profile of keratins. Hair and nails express modified keratins con-
Keratinocyte biology taining large amounts of cysteine which forms numerous chemical cross-links
to further strengthen the cytoskeleton. The genes encoding the keratins fall
The cytoskeleton of all mammalian cells, including epidermal keratinocytes, into two gene families: type I (basic) and type II (acidic) and there is coex-
comprises actin containing microfilaments ≈7 nm in diameter, tubulin contain- pression of particular acidic–basic pairs in a cell- and tissue-­specific manner.
ing microtubules 20–25 nm in diameter, and filaments of intermediate size, Keratin heterodimers are assembled into protofibrils and ­protofilaments by
6 The structure and function of skin

Fig. 1.21
A (A, B)Development of
normal human fetal skin:
(A) at 7 week's gestation,
the epidermis is only
two cell layers thick but
the dermis appears very
cellular; (B) at 19 weeks
gestation the skin has
an outer layer specific
to mammals known as
periderm. This contains
surface blebs which are
Fig. 1.19 full of glycogen (G). Also
Stasis change: high-power present is a hair peg
view. (H). This downgrowth
of the epidermis is the
first histologic step in
B generating a hair follicle.
Bar = 25 μm.

Fig. 1.20
Variation of normal skin: in dark-skinned races, the presence of intense basal cell
melanin pigmentation is a normal histological finding.
Fig. 1.22
Cytoskeleton of a keratinocyte: the major intermediate filament of a keratinocyte is
keratin, highlighted in green.
an antiparallel stagger of some complexity. Simple epithelia are characterized
by the keratin pair K8/K18, and the stratified squamous epithelia by K5/K14.
Suprabasally, keratins K1/K10 are characteristic of epidermal differentiation
genetic disorder of keratin to be described was epidermolysis bullosa sim-
(Fig. 1.24). K15 is expressed in some interfollicular basal keratinocytes as
plex, which involves mutations in the genes encoding K5 or K14 (Fig. 1.25).
well as keratinocytes within the hair-follicle bulge region at the site of pluri-
About half of the keratin genes are expressed in the hair follicle, and muta-
potential stem cells. K9 and K2e expression is site restricted in skin: K9 to
tions in these genes may underlie cases of monilethrix as well as hair and nail
palmoplantar epidermis and K2e to superficial interfollicular epidermis.
ectodermal dysplasias.5
Apart from their structural properties, keratins may also have direct roles
in cell signaling, the stress response and apoptosis.2 In epidermal hyperprolif-
eration, as in wound healing and psoriasis, expression of suprabasal keratins Epidermal stem cells
K6/K16/K17 is rapidly induced.
Currently, 21 of the 54 known keratin genes have been linked to ­monogenic To maintain, repair and regenerate itself, the skin contains stem cells which
genetic disorders, and some have been implicated in more complex traits, reside in the bulge area of hair follicles, the basal layer of interfollicular epi-
such as idiopathic liver disease or inflammatory bowel disease.3,4 The first dermis and the base of sebaceous glands (Fig. 1.26).1 Stem cells are able to
Epidermal stem cells 7

Fig. 1.25
Clinicopathological consequences of mutations in the keratin 14 gene: (left) typical
Fig. 1.23 appearances of Dowling-Meara epidermolysis bullosa simplex which results from
Mid-prickle cell layer of normal epidermis: the abundant keratin filaments heterozygous missense mutations in the KRT14 gene; (right) ultrastructurally, there
(tonofibrils) form a distinct interlacing lattice within the cytoplasm of keratinocytes. is keratin filament disruption and clumping as well as a plane of blistering just above
the dermal–epidermal (DE) junction.


Epidermal Sebocyte
stem cells stem cells

Sebaceous gland
Bulge stem cells

Hair shaft

Fig. 1.24
Normal skin: suprabasal keratinocytes preferentially express keratins 1 and 10 as
Outer root sheath
shown in this picture. Anti-Keratin1 antibody courtesy of I.M. Leigh, MD, Royal
London Hospital Trust, London, UK.

Inner root sheath

self-renew as well as give rise to differentiating cells.2 It is not clear, however,
whether every basal keratinocyte or only a proportion of cells is a stem cell.3
Two possible hypotheses have emerged. One theory divides basal keratino- Dermal papilla
cytes into epidermal proliferation units, which comprise one self-renewing
stem cell and about 10 tightly packed transient amplifying cells, each of which Fig. 1.26
is capable of dividing several times and then exiting the basal layer to undergo Diagrammatic representation of the location of stem cells in human skin: stem cells
terminal differentiation.4 This unit gives rise to a column of larger and flat- are located within the bulge area of hair follicles (where the arrector pili muscle
ter cells that culminates in a single hexagonal surface. The process of divi- attaches) as well as in the basal keratinocyte layer in the interfollicular epidermis
sion of basal cells in this model is viewed as a symmetrical process in which and at the base of sebaceous glands. Stem cells from the bulge area are capable of
equal daughter cells are generated with the basal cells progressively reducing regenerating all parts of the pilosebaceous unit and interfollicular skin.
their adhesiveness to the underlying epidermal basement membrane, delami-
nating and committing to terminal differentiation. The alternative theory is Hair follicle stem cells are found in the bulge regions below the sebaceous
that some basal cells (perhaps up to 70% of cells) can undergo asymmetrical glands. These stem cells are slow cycling and express the cell surface mol-
cell division, shifting their spindle orientation from lateral to perpendicular.5 ecules CD34 and VdR as well as the transcription factors TCF3, Sox9, Lhx2
Asymmetrical cell divisions provide a means of maintaining one proliferative and NFATc1 (Fig. 1.27). The bulge area stem cells generate cells of the outer
daughter while the other daughter cell is committed to terminal differentia- root sheath, which drive the highly proliferative matrix cells next to the mes-
tion. Asymmetrical cell divisions, therefore, can bypass the need for transient enchymal papillae. After proliferating, matrix cells differentiate to form the
amplifying cells. hair channel, the inner root sheath and the hair shaft. Hair follicle stem cells
8 The structure and function of skin

Markers of interfollicular stem cells

α6 integrin
β1 integrin

Markers of hair follicle bulge stem cells

DNA label retention
Vitamin D receptor
Fig. 1.27
Markers of sebocyte stem cells
Molecular markers of stem cells in the
Blimp 1 skin.

can also differentiate into sebocytes and interfollicular epidermis. Despite this
multipotency, however, the follicle stem cells only function in pilosebaceous
unit homeostasis and do not contribute to interfollicular epidermis unless the Fig. 1.28
Granular cell layer: note the keratohyalin and membrane coating granules (arrowed).
skin is wounded.6
Stem cells are also found in the base of sebaceous glands: the progeny of
these cells differentiate into lipid-filled sebocytes. Apart from stem cells in
the hair follicles, sebaceous glands and interfollicular epidermis, other cells the cell membrane. They fuse with the plasma membrane, dispersing their
in the dermis and subcutis may have stem cells properties. These include cells contents into the intercellular space. Polar lipids from the lamellar granules
that have been termed skin-derived precursors (SKPs), which can differentiate are remodeled into neutral lipids in the intercellular space between corneo-
into both neural and mesodermal progeny.7 In addition, a subset of dermal cytes, thereby contributing to the barrier.
fibroblasts can have adipogenic, osteogenic, chondrogenic, neurogenic and Within the granular layer of the epidermis, the main keratinocyte pro-
hepatogenic differentiation potential.8 teins are keratin and filaggrin, which together contribute approximately
80–90% of the mass of the epidermis and are ultrastructurally represented
by the keratohyalin granules (Fig. 1.29). Filaggrin is initially synthesized as
Skin barrier profilaggrin, a ≈500-kDa highly phosphorylated, histidine-rich polypeptide.
During the post-translational processing of profilaggrin, the individual filag-
A major function of the epidermis is to form a barrier against the external grin polypeptides, each ≈35 kD, are proteolytically released. These are then
environment. To achieve this, terminal differentiation of keratinocytes results dephosphorylated, a process that assists keratin filament aggregation and
in formation of the cornified cell envelope. This physical barrier is rendered explains the origin of the name ‘filaggrin’ (filament aggregating ­protein) (Fig.
highly insoluble by the formation of glutamyl-lysyl isodipeptide bonds between 1.30). Typically, there are 10 highly homologous filaggrin units, although the
envelope proteins, catalyzed by transglutaminases.1 Several different proteins number of filaggrin repeat units is variable and genetically determined, with
contribute to construction of the cornified cell envelope, including involucrin,
and the family of small proline-rich proteins (SPR1) including cornifin or
SPR1 and pancornulins. Other envelope proteins include SKALP/elafin and
keratolinin/cystatin. Some precursors of the cornified envelope are delivered
by granules: small, smooth, sulfur-rich L granules contain the cysteine-rich
protein loricrin, and accumulate in the stratum granulosum.2 Loricrin is the
major component of the cornified envelope. Profilaggrin in F granules may
make a minor contribution to the envelope. Membrane-associated proteins
that contribute to the cornified envelope include the plakin family members,
periplakin, envoplakin, epiplakin, desmoplakin as well as plectin. Formation
of the cornified cell envelope is triggered by a rise in intracellular calcium
levels.3 This leads to cross-link formation between plakins and involucrin
catalyzed by transglutaminases. Other desmosomal proteins are then also
cross-linked, forming a scaffold along the entire inner surface of the plasma
membrane. Ceramides from the secreted contents of lamellar bodies are then
esterified onto glutamine residues of the scaffold proteins. The cornified cell
envelope is reinforced by the addition of a variable amount of SPRs, repe-
tin, trichohyalin, cystostatin α, elafin and LEP/XP-5 (skin-specific protein).
Although most desmosomal components are degraded, keratin intermediate
filaments (mostly K1, K10 and K2e) may be cross-linked to desmoplakin and
envoplakin remnants.
In the upper stratum spinosum and stratum granulosum lipid is synthe-
sized and packaged into lamellated membrane-bound organelles known as
membrane-coating granules, lamellar granules or Odland bodies (Fig. 1.28).4
They are found adjacent to the cell membrane with alternating thick and Fig. 1.29
thin dense lines separated by lighter lamellae of equal width, consistent with Stratum corneum:
packing of flattened discs within a membrane boundary. These granules con- keratohyalin granules are
tain phospholipids, glycolipids and free sterols and move towards the plasma present just beneath the
membrane as the cells move through the granular layer where they cluster at keratin lamellae.
Skin immunity 9

Epidermal barrier: Keratohyalin granules composed of profilaggrin Micro-organisms

mechanical strength;
prevent water loss;
restrict allergen penetration External allergens
Stratum corneum
Stratum Filaggrin deaminated Fig. 1.32
corneum and degraded Innate immunity in the
Granular layer
Granular skin: the physical barrier is
layer complemented by an innate
Upper spinous layer immune response that
targets bacteria, viruses
Spinous Inflammatory cells and fungi and prevents
layer them from invading the
Constitutive anti-microbial peptides (psoriasin) skin. These peptides
include constitutive and
Inducible anti-microbial peptides
(β-defensins, RNASE7, LL-37) inducible substances
against a broad range of
Basal layer Pro-inflammatory cytokines (IL-1, TNFα, etc) organisms.

junction Profilaggrin cleaved into Keratinocyte Langerhans cell peptides occurs as a result of unique structural characteristics that enable
10-12 filaggrin peptides Melanocyte
them to disrupt the microbial cell membrane while leaving human cell mem-
Fig. 1.30 branes intact. The antimicrobial peptides can have immunostimulatory and
Function of filaggrin in human skin: this is the major component of keratohyalin immunomodulatory capacities as well as being chemotactic for distinct sub-
granules. In the granular layer profilaggrin is cleaved into filaggrin peptides populations of leukocytes and other inflammatory cells.5 Some peptides have
subsequent deamination and degradation provides the skin with mechanical additional roles in signaling host responses through chemotactic, angiogenic,
strength and restricts transepidermal water loss. Filaggrin also prevents allergen growth factor and immunosuppressive activity. These peptides are known as
penetration. In the absence of filaggrin, for example caused by common mutations
alarmins.6 Alarmins may also stimulate parts of the host defense system, such
in the filaggrin gene, external allergens may penetrate the epidermis and encounter
as barrier repair and recruitment of inflammatory cells.
Langerhans cells. This may lead to the development of atopic dermatitis as well as
other atopic manifestations and systemic allergies. Skin immunity is also provided by a distinct population of antigen present-
ing cells in the epidermis known as Langerhans cells (Fig. 1.33). These are
­dendritic cells that were first described by Langerhans, who demonstrated their
duplications of filaggrin repeat units 8 and/or 10 in some individuals. Fewer existence in human epidermis by staining with gold chloride. Without stimula-
filaggrin repeats leads to dryer skin. Loss-of-function mutations in filaggrin tion, Langerhans cells exhibit a unique motion termed ‘Dendrite Surveillance
are very common, occurring in up to 10% of the European population. These Extension And Retraction Cycling Habitude (dSEARCH)’.7 This is charac-
mutations lead to reduced or absent keratohyalin granules, and are the cause terized by rhythmic extension and retraction of dendritic processes between
of ichthyosis vulgaris as well as constituting a major risk factor for atopic intercellular spaces. When exposed to antigen, there is greater dSEARCH
dermatitis (Fig. 1.31).5 motion and also direct cell-to-cell contact between adjacent Langerhans
cells which function as intraepidermal macrophages, phagocytosing antigens
among keratinocytes. Langerhans cells then leave the epidermis and migrate
Skin immunity via lymphatics to regional lymph nodes. In the paracortical region of lymph
nodes the Langerhans cell expresses protein on its surface to present to a T
Skin possesses both innate and adaptive immune responses to defend against lymphocyte that can then undergo clonal proliferation. Langerhans cells, in
microbial pathogens and thereby prevent infection. One of the primary mech- combination with macrophages and dermal dendrocytes, represent the skin's
anisms is the synthesis, expression and release of antimicrobial peptides (Fig. mononuclear phagocyte system.8 By electron microscopy, Langerhans cells
1.32).1 There are more than 20 antimicrobial peptides in the skin, includ- have a lobulated nucleus, a relatively clear cytoplasm and well-developed
ing cathelicidins, β-defensins, substance P, RANTES, RNase 2, 3, and 7, and endoplasmic reticulum, Golgi complex and lysosomes. They also possess
S100A7. Many of these peptides have antimicrobial action against bacteria, characteristic granules which are rod or racquet-shaped (Fig. 1.34). These
viruses, and fungi. In the stratum corneum there is an effective chemical bar- ‘Birbeck’ granules represent subdomains of the endosomal recycling compart-
rier maintained by the expression of S100A7 (psoriasin).2 This antimicro- ment and form at sites where the protein Langerin accumulates.
bial substance is very effective at killing Escherichia coli. Subjacent to this Besides antigen detection and the processing role by epidermal Langerhans
in the skin there is another class of antimicrobial peptides, such as RNASE7, cells, cutaneous immune surveillance is also carried out in the dermis by an
which is effective against a broad spectrum of microorganisms, especially array of macrophages, T cells and dendritic cells. These immune sentinel and
enterococci.3 Below this in the living layers of the skin are other antimicro- effector cells can provide rapid and efficient immunologic back-up to restore
bial peptides including the β-defensins.4 The antimicrobial activity of most tissue homeostasis if the epidermis is breached. The dermis contains a very

May cause Are the cause of Are a major risk factor Are associated with atopic
hyperlinearity of the palms ichthyosis vulgaris for atopic dermatitis dermatitis persisting into adulthood

Occur in up to 10% Loss-of function Are a major risk factor for

of the population mutations in the FLG gene asthma with atopic dermatitis
Fig. 1.31
Functional consequences of
loss-of-function mutations in the
Are not associated with Can modify clinical Are implicated in development Are associated with increased filaggrin gene, which can affect up to
psoriasis or non-atopic asthma expression of other diseases of systemic allergies severity of atopic asthma
10% of the people in some populations.
10 The structure and function of skin

large number of resident T cells. Indeed, there are approximately 2 × 1010

resident T cells, which is twice the number of T cells in the circulating blood.
Dermal dendritic cells may also have potent antigen-presenting capacities
or the potential to develop into CD1a-positive and Langerin-positive cells.
Dermal immune sentinels are capable of acquiring an antigen-presenting
mode, a migratory mode or a tissue resident phagocytic mode.9

Melanocytes are pigment-producing cells and are found in the skin, inner ear,
choroid and iris of the eye. In skin, melanocytes are located in the basal keratino-
cyte layer. The ratio of melanocytes to basal cells ranges from approximately 1:4
on the cheek to 1:10 on the limbs. They appear as vacuolated cells in hematoxylin
and eosin stained sections (Fig. 1.35). Ultrastructurally, melanocytes have pale
cytoplasm and are devoid of tonofilaments and ­desmosomes (Fig. 1.36). They are
easily recognized by their specific cytoplasmic organelles (melanosomes) which
are derived from the smooth endoplasmic reticulum. Melanosomes are believed
to represent a specialized variant of lysosome (Fig. 1.37). The function of mel-
Fig. 1.33 anocytes is the production of melanin, a ­pigment that varies in color from yel-
Langerhans cells express S-100 protein: note the conspicuous dendritic processes. low to brown or black and accounts for the various skin colors within and

Fig. 1.34
(A, B) Langerhans cell:
(A) note the characteristic
lobulated nucleus. Dendritic
processes are evident,
(B) typical rod forms with
the characteristic trilaminar

Fig. 1.35
(A, B) Normal epidermis:
melanocytes are seen
along the basal layer of the
epidermis. The cytoplasmic
vacuolation is a fixation
artifact; (B) melanocytes
can be highlighted
with S100-protein
A Note the dendritic
Melanocytes 11

Melanin is transferred from melanocytes in melanosomes to neighboring

keratinocytes in the epidermis and into the growing shaft in hair follicles and
can be identified by silver techniques such as the Masson-Fontana reaction
(Fig. 1.38). Transport occurs along the dendritic processes of the melanocytes
and the melanosomes are engulfed as membrane-bound (lysosomal) single
or compound melanosomes by a group of adjacent largely basally located
keratinocytes (epidermal melanin unit) where they are typically seen in an
umbrella-like distribution over the outer aspect of the nucleus (Fig. 1.39).
A compound melanosome typically contains from three to six single melano-
somes. In heavily pigmented skin and dark hair, melanosomes remain solitary
and are longer than those seen in melanogenesis in paler races. Other cells
that may contain compound melanosomes include macrophages (melano-
phages), melanoma cells and, occasionally, Langerhans cells, the other type of
epidermal dendritic cell. Macromelanosomes (giant melanosomes) measure
several microns in diameter and therefore are readily visible in hematoxylin
and eosin stained sections (Fig. 1.40). They may be encountered in normal
skin, in lentigines, dysplastic nevi, Spitz nevi, in the café-au-lait macules of
neurofibromatosis and in albinism. A key protein involved in melanosome
assembly is NCKX5, encoded by the gene SLC24A5.4 Loss of expression of
Fig. 1.36 this gene in mice results in marked changes in skin color with loss of pigment.
Normal melanocyte: it has abundant pale cytoplasm and scattered solitary
melanosomes. Note the absence of tonofibrils and desmosomes.

Fig. 1.38
Normal epidermis: this section of black skin has been stained by the Masson–
Fontana reaction for melanin. Note the heavy pigmentation, which is present in
Fig. 1.37 both melanocytes and keratinocytes.
Melanosome: note the typical striated internal structure.

among races. Melanin protects the mitotically active basal epidermal cells from
the injurious effects of ultraviolet light, which accounts for individuals with
less pigmentation (fair-haired and light-skinned) having a much greater risk of
sunburn and developing cutaneous malignancies (squamous cell and basal cell
carcinomas, and melanoma). The mechanism involves absorbing or scatter-
ing ultraviolet radiation and/or its photoproducts. Other functions of melanin
include control of vitamin D3 synthesis and local thermoregulation.
In skin and hair, two forms of melanin pigment are produced; eumelanin
and pheomelanin. Eumelanin is a brown or black pigment and is synthe-
sized from tyrosine; it is particularly found in dark-colored races, whereas,
pheomelanin has a yellow-red color and is synthesized from tyrosine and
cysteine; it predominates in Caucasian skin.
Melanocytes also possess melanocyte-specific receptors including melano-
cortin-1 (MC1R) and melatonin receptors.1 The activation or the inhibition
of melanocyte-specific receptors can augment normal melanocyte function,
skin color, and photoprotection. Moreover, receptor polymorphisms are
known to underlie red hair phenotypes.2 Hair graying reflects abnormalities
in melanocyte signaling. Notably, Notch transcription factor signaling in mel- Fig. 1.39
anocytes is essential for the maintenance of proper hair pigmentation, includ- Melanin pigment: actinically damaged skin. Note that the melanin pigment is
ing ­regeneration of the melanocyte population during hair follicle cycling.3 located in a ‘cap’ overlying the keratinocyte nuclei.
12 The structure and function of skin

Fig. 1.41
Merkel cells: separated human epidermis showing a striking linear arrangement
Fig. 1.40 (troma-1 antibody). By courtesy of J.P. Lacour, MD, and J.P. Ortonne, MD, University
Macromelanosomes: of Nice, France.
note the large spherical
melanosomes in the
cytoplasm of the

Mature melanosomes of eumelanin are ellipsoidal in shape, while pheomela-

nin-producing melanosomes are spherical.

Merkel cells
Merkel cells are postmitotic cells scattered throughout the epidermis of ver-
tebrates and constitute 0.2–0.5% of epidermal cells.1 Merkel cells represent
part of the affector limb in cutaneous slowly adapting type-1 (SA1) mechano-
receptors and are therefore particularly concerned with touch sensation. They
are located amongst basal keratinocytes and are mainly found in hairy skin,
tactile areas of glabrous skin, taste buds, the anal canal, labial ­epithelium
and eccrine sweat glands. In glabrous skin, the density of Merkel cells is ≈50
per mm2. Sun-exposed skin may contain twice as many Merkel cells as non-
Fig. 1.42
sun-exposed skin.2 Numerous Merkel cells can be found in actinic keratoses.3
Merkel cell: positive labeling for CAM 5.2 identifies Merkel cells in this obliquely
Merkel cells cannot be recognized in conventional hematoxylin and eosin sectioned epidermal ridge.
stained sections. Rather, immunocytochemistry, particularly using antikeratin
antibodies, or electron microscopy, is necessary for their identification (Figs
1.41 and 1.42). Human skin contains an extensive neural network that contains cholin-
Ultrastructurally, Merkel cells appear oval with a long axis of ≈15 μm ori- ergic and adrenergic nerves and myelinated and unmyelinated sensory fibers.
entated parallel to the basement membrane (Fig. 1.43). They also have a large Moreover, the skin also contains several transducers involved in the percep-
bilobed nucleus and clear cytoplasm which reflects a relative scarcity of intra- tion of touch, pressure, and vibration, including Ruffini organs surrounding
cellular organelles. Merkel cells contain numerous neurosecretory granules, hair follicles, Meissner's corpuscles, Vater–Pacini corpuscles located in the
each 50 nm to 160 nm across; these are found opposing the junctions with deep layer of the dermis, and nerve endings which pass through the epider-
the sensory nerve ending (Fig. 1.44). Merkel cells contain keratin filaments, mal basement membrane. Some of these contain Merkel cells which form the
particularly keratin filament types 8, 18, 19, and 20, which are characteris- Merkel cell–neurite complex, while others are free nerve endings. The cell
tic of simple epithelium and fetal epidermis. Immunocytochemically, Merkel bodies for all these neurons reside in the dorsal root ganglion. The Merkel
cells also express neuropeptides including synaptophysin, vasoactive intes- cell–neurite complexes are thought to serve as mechanoreceptors and to be
tinal peptide (VIP) and calcitonin gene-related polypeptide (CGRP).4,5 They responsible for the sensation of touch. They are clustered near unmyelinated
contain neuron-specific proteins including neuron-specific enolase (NSE) and sensory nerve endings, where they group and form ‘touch spots’ at the bottom
protein gene product (PGP) 9.5.6 In addition, Merkel cells express desmo- of rete ridges. These complexes are also known as hair discs, touch domes,
somal proteins, membranous neural cell adhesion molecule and nerve growth touch corpuscles, or Iggo discs. The complex is innervated by a single, slowly
factor receptor.7–9 Merkel cells show a positive uranaffin reaction.10 Merkel adapting type 1 nerve fiber. In hairy skin, Merkel cells also cluster in the
cells form close connections with sensory nerve endings and secrete or express rete ridges and in the outer root sheath of the hair follicle where the arrector
a number of these peptides.11 The close contact between Merkel cells and pili muscles attach. The function of Merkel cells in hair follicles is unclear,
nerve fibers represents a Merkel cell–neurite complex, but there is no clear although they may be involved in the induction of new anagen cycles.
evidence of synaptic transmission, although numerous vesicles can be identi- There are two hypotheses for the origin of Merkel cells: one possibility is
fied in neurons apposed to Merkel cells.12 that they differentiate from epidermal keratinocyte-like cells and the other
Intercellular junctions 13

Intercellular junctions
Desmosomes are the major intercellular adhesion complexes in the epider-
mis. They anchor keratin intermediate filaments to the cell membrane and
link adjacent keratinocytes (Fig. 1.45). Desmosomes are found in the epider-
mis, myocardium, meninges and cortex of lymph nodes. Ultrastructurally,
desmosomes contain plaques of electron-dense material running along
the cytoplasm parallel to the junctional region, in which three bands can
be distinguished: an electron-dense band next to the plasma membrane, a
less dense band, and then a fibrillar area (Fig. 1.46).1 Identical components
are present on opposing cells which are separated by an intercellular space
of 30 nm within which there is an electron-dense midline. There are three
main protein components of desmosomes in the epidermis: the desmosomal
cadherins, the armadillo family of nuclear and junctional proteins, and the
plakins (Fig. 1.47).2 The transmembranous cadherins comprise mostly het-
erophilic ­associations of desmogleins and desmocollins. There are four main
­epidermis-specific desmogleins (Dsg1–4) and three desmocollins (Dsc1–3).
These show differentiation-specific expression. For example, Dsg1 and Dsc1

Fig. 1.43
Merkel cell: a heavily
granulated Merkel
cell is present in the
midfield. This is located
immediately adjacent to a
small nerve fiber.

Fig. 1.45
Mid-prickle cell layer of normal epidermis: there are complex interdigitations
between adjacent cell membranes with numerous desmosomal junctions.

Fig. 1.44
Merkel cell granules: they are membrane bound and measure approximately
150 nm in diameter. By courtesy of A.S. Breathnach, MD (1977) Electron
microscopy of cutaneous nerves and receptors. Journal of Investigative
Dermatology 69, 8–26. Blackwell Publishing Inc., USA.

is that they arise from stem cells of neural crest origin that migrated during
embryogenesis, in similar fashion to melanocytes.13 Merkel cell hyperplasia is
a common histological finding and may accompany keratinocyte hyperpro-
liferation as well as being frequently seen in adnexal tumors such as nevus
sebaceus, trichoblastomas, trichoepitheliomas, and nodular hidradenomas.14
Merkel cell hyperplasia is associated with hyperplasia of nerve endings that
occurs in neurofibromas, neurilemomas, nodular prurigo, or neurodermati-
tis. It is not clear whether Merkel cell carcinoma originates from Merkel cells Fig. 1.46
or their precursors but the latter may be more likely given that many dermal Mid-prickle cell layer of normal epidermis showing the stratified nature of the
Merkel cell carcinomas do not connect with the epidermis. desmosome.
14 The structure and function of skin

Autosomal dominant Autosomal recessive

Ectodermal dysplasia -
Plakophilin 1
Skin fragility syndrome

Arrhythmogenic right Arrhythmogenic right

Plakophilin 2
ventricular cardiomyopathy ventricular cardiomyopathy

Woolly hair, keratoderma, Woolly hair, keratoderma,

cardiomyopathy +/- cardiomyopathy

Arrhythmogenic right
ventricular cardiomyopathy

Striate palmoplantar Lethal acantholytic

keratoderma epidermolysis bullosa

Arrhythmogenic right
Plakoglobin Naxos disease
Desmoglein Plakoglobin Desmoplakin ventricular cardiomyopathy

Desmocollin Plakophilin Keratin Striate palmoplantar

Desmoglein 1
Fig. 1.47
Protein composition of a desmosome junction between adjacent keratinocytes. The Arrhythmogenic right Arrhythmogenic right
Desmoglein 2
keratin filament network of two keratinocytes is linked by a series of desmosomal ventricular cardiomyopathy ventricular cardiomyopathy
plaque proteins and transmembranous molecules to create a structural and
signaling bridge between the cells. Localized recessive
Desmoglein 4

Recessive monilethrix
are found predominantly in the superficial layers of the epidermis whereas
Hypotrichosis with
Dsg3 and Dsc3 show greater expression in basal keratinocytes. The intra- Desmocollin 3
scalp vesicles
cellular parts of the cadherins interact with the keratin filament network
Arrhythmogenic right
via the desmosomal plaque proteins, mainly desmoplakin, plakoglobin and Desmocollin 2
ventricular cardiomyopathy
Clues to the biologic function of these desmosomal components have arisen Hypotrichosis simplex Corneodesmosin
from various inherited and acquired human diseases.3,4 Naturally occurring
Fig. 1.48
human mutations have been reported in ten different desmosome genes with
Genetic disorders of desmosomes: autosomal dominant or autosomal recessive
variable skin, hair and heart abnormalities and several desmosomal proteins mutations in ten different structural components of desmosomes may give rise to
serve as autoantigens in immunobullous blistering skin diseases such as pem- specific diseases that can affect skin, hair or heart or combinations thereof.
phigus (Figs 1.48 and 1.49).5 Antibodies to multiple desmosomal proteins
may develop in diseases such as paraneoplastic pemphigus through the phe-
nomenon of epitope spreading.6 Cleavage of the extracellular domain of Dsg1 Immunobullous diseases
has also been demonstrated as the basis of staphylococcal scalded skin syn-
drome and bullous impetigo.7 Desmoglein 3 Pemphigus vulgaris
Adherens junctions are recognized ultrastructurally as electron-dense trans-
Pemphigus foliaceus
membrane structures, with two opposing membranes separated by approxi- Desmoglein 1
mately 20 nm, that form links with the actin skeleton.8 They are 0.2–0.5 μm Endemic pemphigus
in diameter and can be found as isolated cell junctions or in association with Desmocollin 3 Atypical pemphigus
tight junctions and desmosomes. Adherens junctions are expressed early in
skin development and contribute to epithelial assembly, adhesion, barrier for- Atypical pemphigus
Desmocollin 1
mation, cell motility and changes in cell shape. They may also spatially co-
IgA pemphigus
ordinate signaling molecules and polarity cues as well as serving as docking (sub-corneal type)
sites for vesicle release. Adherens junctions contain two basic adhesive units:
the nectin-afadin complex and the classical cadherin complex.9,10 The nectins Fig. 1.49
form a structural link to the actin cytoskeleton via afadin (also known as Immunobullous diseases of desmosomes: intraepidermal blistering can arise
AF-6) and may be important in the initial formation of adherens junctions. through autoantibody disruption of four separate desmosomal proteins which leads
The cadherins form a complex with the catenins (α-, β-, and p120 catenin) to different clinical variants of pemphigus.
and help mediate adhesion and signaling. Cell signaling via β-catenin can acti-
vate several pathways linked to morphogenesis and cell fate determination. connexons (homotypic or heterotypic) to form a gap junction. To date, 13
Inherited gene mutations of the adherens junction proteins plakoglobin different human connexins have been described. The formation and stabil-
and P-cadherin have been reported. Plakoglobin mutations result in Naxos ity of gap junctions can be regulated by protein kinase C, Src kinase, cal-
disease (woolly hair, keratoderma, cardiomyopathy).3 P-cadherin mutations cium concentration, calmodulin, adenosine 3′,5′-cyclic monophosphate
underlie autosomal recessive hypotrichosis with juvenile macular dystrophy (cAMP) and local pH.14 The connexins are classified into three groups (α,
as well as ectodermal dysplasia-ectrodactyly-macular dystrophy (EEM) syn- β and γ) according to their gene structure, overall gene homology and spe-
drome, in which there is hypotrichosis, macular degeneration, hypodontia cific sequence motifs.15 Apart from the connexins, vertebrates also contain
and limb defects, including ectrodactyly, syndactyly and camptodactyly.11,12 another class of gap junction proteins, the pannexins, which are related to the
Gap junctions represent clusters of intercellular channels, known as innexins found in nonchordate animals. The function of gap junctions is to
­connexons, which form connections between the cytoplasm of adjacent allow sharing of low molecular mass metabolites (<1000 Da) and exchange of
­keratinocytes (and other cells).13 Formation of a connexon involves ­assembly ions between neighboring cells. Gap junction communication is essential for
of six connexin subunits within the Golgi network. This complex is then cell ­synchronization, differentiation, cell growth and metabolic coordination
transported to the plasma membrane where connexons associate with other of avascular organs, including epidermis.14
Pilosebaceous units 15

Deafness with unusual Deafness with e­ ndocuticle, exocuticle and ‘a’ layer.1 Around the cuticle is the inner root
hyperkeratosis and oral erosions Clouston-like phenotype sheath (IRS), which is composed of three distinct layers of cells that undergo
keratinization: the IRS cuticle, the Huxley layer and the outermost Henle
Hystrix-like-ichthyosis Palmoplantar keratoderma layer.2 Differentiation in the IRS involves the development of trichohyalin
deafness syndrome with deafness granules, with 8–10 nm filaments orientated in the direction of hair growth.
Keratitis-ichthyosis - The IRS moves up the follicle, forming a support for the hair fiber, and
26 Bart-Pumphrey syndrome degenerates above the sebaceous gland. The outermost layer is the outer root
deafness syndrome
sheath (ORS), which is continuous with the epidermis and expresses epithe-
Non-syndromic deafness Vohwinkel’s syndrome lial keratins, K5/K14, K1/K10 and K6/K16 in the upper ORS and K5/K14/
Non-syndromic deafness 30 Clouston’s syndrome K17 in the deeper ORS.
Normal growth of the hair fiber is 300–400 μm/day. Hair growth is gener-
Erythro-keratoderma ated by the high rate of proliferation of progenitor cells in the follicle bulb.
There are three phases of cyclical hair growth: anagen, when growth occurs;
Peripheral neuropathy and Erythro-keratoderma catagen, a regressing phase; and telogen, a resting phase. The follicle re-enters
31 anagen, and the old hair is replaced by a new one.
hearing impairment variabilis
Immediately above the basal layer in the hair bulb, cells undergo a sec-
Non-syndromic deafness Charcot-Marie ondary pathway of ‘trichocyte’ or hair differentiation, and express a fur-
tooth disease (X-linked) ther complex group of keratins, the hard keratins.2 Two families of hair
Atrial fibrillation 40 keratins, types I and II, are present in mammals, which have distinctive
Non-syndromic deafness 43 Oculodentodigital dysplasia amino- and carboxy-terminals with high levels of cysteine residues but
lack the extended glycine residues of epidermal keratins. The proteins dif-
Zonular pulverulent
fer from epithelial keratins in position on two-dimensional gels but form
cataract-3 acidic and basic groups. There are four major proteins in each family and
Zonular pulverulent
50 several minor proteins, Ha 1–4 and Hb 1–4. Recent cloning of the hair ker-
cataract -1
atin genes, which cluster on chromosomes 12 and 17, has shown an even
Fig. 1.50 greater number of hair keratin genes, HaKRT1–6 (including 3.1 and 3.2)
Genetic disorders of connexins: nine different human connexin molecules are and HbKRT1–6.
associated with different inherited diseases. Mutations in the four low molecular Mutations in hair keratin genes have been found to cause autosomal domi-
weight connexins shown at the top of the diagram are associated with a spectrum nant forms of the human disease monilethrix. More common hair variants,
of skin pathology, as highlighted.
such as curly hair, may be explained by dynamic changes during hair growth.3
Curvature of curly hair is programmed from the very basal area of the follicle
and the bending process is linked to a lack of axial symmetry in the lower
Inherited abnormalities in genes encoding four different connexins (Cx26, part of the bulb, affecting the connective tissue sheath, ORS, IRS and the hair
30, 30.3 and 31) have been detected in several forms of keratoderma and/or shaft cuticle.
hearing loss (Fig. 1.50). Nondermatologic disorders can also arise from muta- Sebaceous glands usually develop as lateral protrusions from the outer
tions in some higher molecular weight connexins (Cx32, 40, 43, 46 and 50). root sheath of hair follicles, but at certain sites, such as the eyelids, lips, are-
Tight junctions contribute to skin barrier integrity and maintaining cell olae, nipples and labia minora, they appear to arise independently and drain
polarity, although in simple epithelia they are major regulators of perme- directly onto the skin's surface (Figs 1.51 and 1.52). They are widespread in
ability.8 An important function is to regulate the paracellular flux of water- distribution, being found everywhere on the body except on the palms and
­soluble molecules between adjacent cells.16 The main structural proteins of soles. They are particularly abundant on the face and scalp, in the midline
tight junctions are the claudins, of which there are approximately 24 sub- of the back and about the perineum, and are concentrated around the ori-
types, as well as the IgG-like family of junctional adhesion molecules (JAMs) fices of the body (Fig. 1.53). Those of the eyelid are known as the glands
and the occludin group of proteins. The principal claudins in the epidermis
are claudin 1 and 4. These transmembranous proteins can bind to the intrac-
ellular zonula occudens proteins ZO-1, ZO-2, ZO-3 which interact with the
actin cytoskeleton.8,17
Clinically, abnormalities in tight junction proteins can result in skin, kid-
ney, ear and liver disease. Inherited gene mutations in claudin 1 have been
reported in one pedigree with diffuse ichthyosis, hypotrichosis, scarring
­alopecia and sclerosing cholangitis.18

Pilosebaceous units
There are four classes of pilosebaceous unit: terminal on the scalp and beard;
apopilosebaceous in axilla and groin; vellus on the majority of skin; and
sebaceous on the chest, back and face. The dermal papilla is located at the
base of the hair follicle and is associated with a rich extracellular matrix.
Around the papilla are germinative (matrix) cells that have a very high rate
of division, and give rise to spindle-shaped central cortex cells of the hair
fiber, and the single outer layer of flattened overlapping cuticle cells. A cen-
tral medulla is seen in some hairs, with regularly stacked condensed cells
interspersed with air spaces or low-density cores. The cortical cells are filled
with keratin intermediate filaments orientated along the long axis of the Fig. 1.51
cell, interspersed with a dense interfilamentous protein matrix. The cuticu- Sebaceous glands: on the inner aspect of the labia these appear as tiny yellow
lar cells are morphologically distinct, with flattened outward-facing cells, papules (Fordyce spots). By courtesy of S.M. Neill, MD, Institute of Dermatology,
with three layers inside the cuticle of condensed, flattened protein granules: London, UK.
16 The structure and function of skin

Fig. 1.52 Fig. 1.54

Normal vulva: sebaceous glands are conspicuous, but arise independently of a hair Nose: multiple sebaceous glands are evident.
follicle and open directly onto the surface epithelium.

Fig. 1.55
Sebaceous lobule: germinative cells are basophilic and flattened. With maturation
the cells acquire their characteristic ‘bubbly’ cytoplasm.
Fig. 1.53
Nose: sebaceous glands are particularly numerous at this site.

of Zeis and the meibomian glands. Sebaceous glands within the areolae are
known as Montgomery's tubercles. The largest sebaceous glands are associ-
ated with small vellus hairs in specialized pilosebaceous units known as seba-
ceous f­ ollicles (facial pores).
Sebaceous glands consist of several lipid-containing lobules, usually con-
nected to a hair follicle (Fig. 1.54). Each lobule is composed of an outer
layer of small cuboidal or flattened basophilic germinative cells, from which
arises the inner zone of lipid-laden vacuolated cells with characteristic cren-
ated nuclei (Fig. 1.55). The secretions drain into the sebaceous duct, which
joins the hair follicle at the level of the infundibulum (Fig. 1.56). The duct is
lined by keratinizing stratified squamous epithelium and is continuous with
the external root sheath. The glands are holocrine because their secretions
depend on complete degeneration of the acini, with release of all the cells'
lipid contents to become sebum.
Immunohistochemically, the sebaceous cells label strongly for EMA but
they do not express CEA or low molecular weight keratin (CAM 5.2) or
S-100 protein (Fig. 1.57). Ultrastructurally, the mature sebaceous gland
shows gradual accumulation of variably sized, nonmembrane-bound, lipid Fig. 1.56
inclusions in differentiating cells. Numerous mitochondria, ribosomes and Sebaceous duct: this is lined by keratinizing stratified squamous epithelium; it is
membrane-bound vesicles may also be evident. As the cells mature before continuous with the external root sheath.
Eccrine glands 17

Histologically, eccrine sweat glands are divided into four subunits: a highly
vascularized coiled secretory gland, a coiled dermal duct, a straight dermal
duct, and a coiled intraepidermal duct (the acrosyringium) (Fig. 1.59). The
secretory coil is located in the lower dermis, and the duct extends through
the dermis and opens directly onto the skin surface (Figs 1.60, 1.61). The
active sweat glands are present most densely on the sole, forehead and palm,
somewhat less on the back of the hand, still less on the lumber region, and
the lateral and extensor surfaces of the extremities, and least on the trunk
and the flexor and medial surfaces of the extremities. The uncoiled dimen-
sion of the secretory portion of the gland is approximately 30–50 μm in diam-
eter and 2–5 mm in length. The size of the adult secretory coil ranges 1–8 ×
10−3 mm3. The secretory component lies in the lower reaches of the reticular

Fig. 1.57
Sebaceous gland: the epithelial cells normally strongly express EMA.

Fig. 1.58
Sebaceous gland: in this field from the center of a sebaceous lobule, the cytoplasm
is completely distended with lipid droplets. Germinative cells are evident in the ­
right-lower quadrant.

their disintegration, the lipid droplets completely fill the cytoplasm and com-
press the centrally located nucleus (Fig. 1.58).
The secretion of sebaceous glands is sebum, an exceedingly compli-
cated lipid mixture that includes triglycerides (57%), wax esters (26%) and
squalene (12%). Its function includes waterproofing, control of epidermal
water loss, and a protective function, inhibiting the growth of fungi and bac-
teria. Secreted sebum undergoes significant changes due to the presence of
Propionibacterium acnes (triglyceride hydrolysis) within the pilosebaceous Fig. 1.59
Eccrine gland: (A) palmar
canal and Staphylococcus epidermidis (cholesterol ester formation) on the
skin showing numerous
perifollicular skin. Skin surface lipid is composed of a mixture of sebum and eccrine glands located in
epidermal lipids. the deep reticular dermis
and subcutaneous fat,
(B) the secretory unit is in
Eccrine glands the lower field. Sections
through the coiled duct
Human sweat glands are generally divided into two types: eccrine and apo- are evident in the upper
crine.1 The eccrine gland is the primary gland responsible for thermoregula- field. The epithelium of
tory sweating in humans.2 Eccrine sweat glands are distributed over nearly the duct is more darkly
the entire body surface. The number of sweat glands in humans varies greatly, B stained than that of the
ranging from 1.6 to 4.0 million. glandular component.
18 The structure and function of skin

(see below). Sometimes the secretory lobules show striking clear cell change
due to glycogen accumulation (Fig. 1.62). The myoepithelial cells contract
in response to cholinergic stimuli. They have spindled cell morphology and
are distributed in a spiral, parallel array along the long axis of the secretory
tubule. On the basis of their expression of keratin filaments, they appear to
be of ectodermal rather than mesenchymal derivation. They do not label for
vimentin. Myoepithelial cells therefore develop from the epithelial cells of the
tip of the secretory coil and not, as might be expected, from adjacent mesen-
chymal cells. The dermal duct components consist of a double layer of cuboi-
dal basophilic cells. The duct is not merely a conduit, but has a biologically
active function, modifying the composition of eccrine secretion and, particu-
larly, the reabsorption of water. The intraepidermal portion of the sweat duct
opens directly onto the surface of the skin. A myoepithelial layer is absent.
The secretory unit is strongly labeled by CAM 5.2 (both cytoplasmic and
membranous) and Ber-EP4 and there is luminal accentuation (Fig. 1.63). The
ductal component is completely negative. EMA can be detected along the
luminal aspect of the secretory unit and outlining the intercellular canaliculi.
It is also present around the luminal border of the duct, and is often present
in large quantities within the lumen. CEA is present in a similar distribution
to EMA although secretory labeling tends to be rather focal and somewhat
weaker while the ductal lumen is more strongly outlined. The ­myoepithelial

Fig. 1.60
Eccrine gland: high-power
view of eccrine straight

Fig. 1.62
Eccrine gland: excessive glycogen has resulted in vacuolated epithelium.

Fig. 1.61
Eccrine gland: most
superficially, the duct
coils through the stratum

dermis or around the interface between the dermis and subcutaneous fat and
is surrounded by a thick basement membrane and loose connective tissue
often rich in mucin. It embodies an outer discontinuous layer of contractile
myoepithelial cells and an inner layer of secretory cells comprising two cell
types: large clear pyramidal cells, which appear to be responsible for water
secretion, and smaller, darkly staining mucopolysaccharide-containing cells
(probably secreting a glycoprotein), which are much less commonly seen. Fig. 1.63
Between adjacent cells are canaliculi, which open into the lumen of the tubule Eccrine gland: immunohistochemistry.
Apocrine glands 19

cells can be identified by antibodies to S-100 protein, desmin and smooth

muscle actin. The eccrine glands show strong activity for the enzymes
­amylophosphorylase, leucine aminopeptidase, succinic dehydrogenase and
cytochrome oxidase.3 Weak or no activity is seen for NADH ­diaphorase,
esterase and acid phosphatase.
With electron microscopy, the serous cells are characterized by abundant
intracytoplasmic glycogen granules and numerous mitochondria (Figs 1.64,
1.65). Adjacent cell membranes, which show marked interdigitations, may
separate to form microvilli-lined intercellular canaliculi. The mucous cells
contain numerous electron-dense lipid droplets and lysozymes. Myoepithelial
cells are present at the periphery of the secretory coil within the eccrine basal
lamina (lamina densa) and contain abundant myofilaments with characteris-
tic dense bodies. The sweat duct lumen is bordered by conspicuous microvilli
(Fig. 1.66). The cytoplasm contains numerous clear vesicles. Tonofilaments
are characteristically orientated in a circumferential manner deep to the
plasma membrane, the so-called cuticle of light microscopy. This is particu-
larly well developed in the acrosyringium.
Human perspiration is classified into two types: insensible perspiration A B
and active sweating. Insensible perspiration involves water loss from the
Fig. 1.66
Eccrine gland: (A) lumen of the eccrine dermal duct lined by conspicuous microvilli,
(B) high-power view of eccrine dermal duct showing microvilli and circumferentially
orientated tonofilaments.

respiratory passages, the skin, and gaseous exchanges in the lungs. Heat,
exercise and carbon dioxide can all induce active sweating in human beings.
Active sweating may be classified into two types: thermal and mental/emo-
tional. Thermal sweating plays an important role in keeping the body's tem-
perature constant and involves the whole body surface.4 The secretory nerve
fibers innervated in human sweat glands are sympathetic, which appear to be
cholinergic in character as sweating is produced by pilocarpine and stopped
by atropine.5 Vasoactive intestinal peptide (VIP) coexisting in the cholinergic
nerve fibers has been suggested as a candidate neurotransmitter that may con-
trol the blood circulation of the sweat glands. Acetylcholine is the primary
neurotransmitter released from cholinergic sudomotor nerves and binds to
muscarinic receptors on the eccrine sweat gland, although sweating can also
occur via exogenous administration of α- or β-adrenergic agonists. The ini-
tial fluid released from the secretory cells is isotonic and similar to plasma
although it is devoid of proteins. As the fluid travels up the duct towards the
surface of the skin, sodium and chloride are reabsorbed, resulting in sweat
Fig. 1.64 on the surface being hypotonic relative to plasma.6 When the rate of sweat
Eccrine gland: low-power electron micrograph showing the lumen in the upper-right production increases, however, for example during exercise, ion reabsorption
quadrant, granular mucous-secreting cells and serous cells. mechanisms can be overwhelmed due to the large quantity of sweat secreted
into the duct, resulting in higher ion losses. The sodium content in sweat on
the skin's surface, therefore, is greatly influenced by sweat rate.

Apocrine glands
Apart from eccrine glands, the skin also contains apocrine sweat glands.1,2
Apocrine glands have a low secretory output, and hence no significant role in
thermoregulation. Apocrine glands are found predominantly in the anogeni-
tal and axillary regions, but are also located in the external auditory meatus
(ceruminous glands), the eyelid (Moll's gland), and within the areola. They
are derived from the epidermis, and develop as an outgrowth of the follicu-
lar epithelium. They first appear during the fourth to fifth month of gesta-
tion. Their function in humans is unknown, but in other mammals they are
responsible for scent production and have importance in sexual attraction.
As with sebaceous glands, they are smaller in childhood, becoming larger and
functionally active at puberty. The secretions of the ceruminous glands are
believed to lubricate, clean and protect the external ear from bacterial and
fungal infections.
Apocrine glands include two distinct components: a complex secretory
Fig. 1.65 element situated in the lower reticular dermis or subcutaneous fat, and
Eccrine gland: (left) high-power view of clear cell showing conspicuous a tubular duct linking the gland with the pilosebaceous follicle at a site
mitochondria and numerous electron-dense glycogen granules, (right) high-power above the sebaceous duct. Microscopically, the secretory portion comprises
view of secretory granules in a dark cell. an outer discontinuous layer of myoepithelial cells and an inner layer of
20 The structure and function of skin

­cuboidal to columnar eosinophilic cells (Figs 1.67, 1.68). Although a histo-

logical artifact, secretory droplets, which appear to be pinched off from the
superficial aspect of the columnar cells (decapitation secretion), can be seen
on light microscopy. The duct portion is formed by a double layer of cuboi-
dal epithelium. It is morphologically indistinguishable from the eccrine
duct. The inner layer of the secretory portion contains a single columnar
secretory cell type containing numerous large dense granules located at the
apical aspect, which contribute to the lipid-rich secretion produced. The
inner layer is also surrounded by a fenestrated layer of myoepithelial cells
but the lumen may be larger in diameter than that present in eccrine tissue
The apocrine excretory duct does not have any known reabsorptive func-
tion and consists of a double layer of cuboidal cells that merge distally with
the epithelium of the hair follicle, resulting in emptying of the secretion into
the hair follicle.
Immunohistochemically, the secretory unit shows very strong labeling
with the antibody CAM 5.2 (both cytoplasmic and membranous), and there
is luminal accentuation. The apocrine duct is negative (Fig. 1.69). EMA labels
the cytoplasm of the secretory cells, and is accentuated along the luminal
border. It is also present along the luminal aspect of the apocrine duct. With
CEA, there is faint, focal staining of the secretory epithelium. The luminal Fig. 1.69
Apocrine gland: immunohistochemistry (CAM 5.2 and EMA).

aspect of the duct is strongly outlined. Cytoplasmic granules express epider-

mal growth factor. The myoepithelial cells of the secretory unit are reactive
for S-100 protein and smooth muscle actin (Fig. 1.70). The apocrine secre-
tory epithelium strongly expresses the enzymes NADH diaphorase, esterase,
acid phosphatase and β-glucuronidase. There is weak or absent reactivity for
amylophosphorylase, leucine aminopeptidase, succinic dehydrogenase and
cytochrome oxidase. The apocrine gland also can be stained with cationic
colloidal gold at pH 2.0.3
Ultrastructure of the apocrine reveals cuboidal to columnar secretory cells
containing numerous osmiophilic secretory vacuoles. Mitochondria are pres-
ent in large numbers. While some show obvious double cristae, others are so
electron dense that the internal structure is obscured. The Golgi is conspicu-
ous. The luminal border is lined by prominent microvilli (Fig. 1.71).
The mechanism of apocrine secretion and control of apocrine glands is
uncertain, but there is adrenergic sympathetic innervation, and secretion is
provoked by external stimuli such as excitement or fear. The unpleasant odor
of apocrine secretion, which is odorless in itself, is due to breakdown prod-
ucts produced by cutaneous bacterial flora.
Fig. 1.67 A third type of intermediate sweat gland, the apo-eccrine gland, has
Apocrine gland: this specimen from normal axillary skin shows apocrine secretory also been described in axillary skin but its existence is not universally
lobules in the subcutaneous fat. Ducts are present in the upper right of the field. accepted.

Fig. 1.68
Apocrine gland: lobules are lined by tall columnar cells with intensely eosinophilic Fig. 1.70
cytoplasm. ‘Decapitation secretion’ is conspicuous. Apocrine gland: immunohistochemistry (S-100 protein and SMA).
Dermal–epidermal junction 21

Basal keratinocyte

Keratin filaments

Hemidesmosomal inner plaque

Hemidesmosomal outer plaque

Cell membrane
Sub-basal dense plate
Lamina lucida
Anchoring filaments

Lamina densa

Anchoring fibrils
Fig. 1.71
Apocrine gland: close-up view showing microvilli and decapitation secretion.
Papillary dermis

Dermal–epidermal junction Fig. 1.73

Schematic representation of a hemidesmosome-anchoring filament-anchoring
The interface between the lower part of epidermis and the top layer of dermis
fibril complex at the dermal–epidermal junction. A continuum of adhesive proteins
consists of a complex network of interacting macromolecules that form the extends from the keratin tonofilaments within basal keratinocytes through to
cutaneous basement membrane zone (BMZ) (Figs 1.72, Fig. 1.73).1 Many of dermal collagen. This complex represents the main adhesion unit at the dermal–
these components are glycoproteins and thus the BMZ can be recognized his- epidermal junction.
tologically as staining positive with PAS staining (Fig. 1.74). Ultrastructural
examination of the BMZ by transmission electron microscopy shows two
layers with different optical densities (Fig. 1.75).2 The upper layer, the lam-
ina lucida, is a low electron density region of 30–40 nm in breadth which is
directly subjacent to the plasma membranes of basal keratinocytes. Below the
lamina lucida is the lamina densa, an electron-dense region, 30–50 nm across,
which interacts with the extracellular matrix of the upper dermis. Within
the cutaneous BMZ distinct adhesion complexes are evident. Extending from

5 & 14


integrin Type XVII Fig. 1.74
collagen The basement membrane region stains strongly with periodic acid-Schiff.

Type IV inside the basal keratinocytes, through the lamina lucida and lamina densa,
collagen and into the superficial dermis are ultrastructurally recognizable attachment
structures. The components of these adhesion units are the hemidesmosomes,
anchoring filaments and anchoring fibrils.3 The importance of these struc-
Type VII tural complexes in securing adhesion of the epidermis to the underlying der-
collagen mis is highlighted by both inherited and acquired subepidermal blistering skin
diseases (Figs 1.76, Fig. 1.77). The precise role of individual proteins in adhe-
sion is demonstrated by the group of inherited skin blistering diseases, epi-
dermolysis bullosa, in which components in the hemidesmosomal structures,
Fig. 1.72 anchoring filaments, or anchoring fibrils are genetically defective or absent.4
The macromolecular components of the dermal–epidermal junction centered on This leads to fragility at the dermal–epidermal junction as a result of minor
a hemidesmosome-anchoring filament-anchoring fibril complex. Protein–protein trauma.
interactions between these molecules secure adhesion between the epidermis and The hemidesmosomes extend from the intracellular compartment of the
the subjacent dermis. basal keratinocytes to the cell membrane adjacent to the lamina lucida in
22 The structure and function of skin

5 & 14
Bullous Plectin
pemphigoid-like 230-kDa
BP Ag Mucous
Bullous α6β4 pemphigoid
pemphigoid-like integrin Type XVII
collagen Laminin-332 membrane

Fig. 1.75
Transmission electron microscopy of the dermal–epidermal junction. Bar = 200 nm.
EB acquisita Type VII
Bullous SLE collagen

EB simplex
5 & 14 Fig. 1.77
Recessive Acquired disorders of hemidesmosomal proteins. Autoantibodies directed against
EB simplex EB simplex components of the hemidesmosome-anchoring filament-anchoring fibril complex
EB simplex with give rise to specific subepidermal autoimmune blistering diseases.
muscular dystrophy 230-kDa
EB simplex with Non-Herlitz
pyloric atresia junctional EB ­structure of laminins contains both globular and rodlike segments which con-
α6β4 tribute to interactions with other extracellular matrix molecules, as well as
integrin Type XVII
Herlitz & cell attachment and spreading, and cellular differentiation. The critical role
Junctional EB with collagen of laminin 332 in providing integrity to the cutaneous BMZ is evident from
Laminin-332 non-Herlitz
pyloric atresia
junctional EB findings that mutations in any of the three polypeptide subunits (the α3, β3,
or γ2 chains) can result in junctional forms of epidermolysis bullosa.
The major component of the lamina densa is type IV collagen, which in
skin is mainly composed of the α1 and α2 chains.7 Type IV collagen is assem-
bled to form a complex hexagonal arrangement which allows high flexibility
Dominant and to the BMZ and facilitates interactions with other collagenous and noncollag-
Type VII
collagen enous proteins (Fig. 1.79). Other BMZ components at the dermal–­epidermal
dystrophic EB
junction include the glycoprotein nidogen (previously known as entactin)
which interacts with type IV collagen either alone or as part of a laminin-
nidogen complex. Also present are the heparan sulfate proteoglycans, which
are highly negatively charged and hydrophilic and capable of interacting with
Fig. 1.76 a number of basement membrane components and thus contribute to the
Genetic disorders of hemidesmosomal proteins. Mutations in components of the architectural organization of the BMZ.8
hemidesmosome-anchoring filament-anchoring fibril network give rise to specific
Anchoring fibrils are ultrastructurally recognizable fibrillar structures
variants of epidermolysis bullosa (EB).
which extend from the lower part of lamina densa to the upper reticular der-
mis. The main component of anchoring fibrils is type VII collagen (Fig. 1.80).9
Individual type VII collagen molecules are ≈450 nm long and by complexing
the upper portion of the dermal–epidermal basement membrane. The inner
as antiparallel dimmers and aggregating laterally, they forms loops which are
plaques of hemidesmosomes serve as attachment sites for keratin filaments
traversed by interstitial dermal collagens (types I, III and V) to adhere the
while the outer plaques associate with anchoring filaments that traverse the
BMZ to the underlying dermis.10 Type VII collagen is synthesized by both
lamina lucida. Subjacent to the hemidesmosomal outer plaques in the lamina
dermal fibroblasts and epidermal keratinocytes. Also inserting into the lam-
lucida are the sub-basal dense plates which contribute to the structural orga-
ina densa at the dermal–epidermal junction are elastic microfibrils, contain-
nization of the attachment complex. Intracellular hemidesmosomal proteins
ing proteins such as fibrillin. Fibrillin-containing microfibrils may exist as a
include the 230-kD bullous pemphigoid antigen 1 and the 500-kD plectin
fibrillar mantle surrounding an elastin core or be found independently as elas-
protein. Transmembranous hemidesmosomal proteins comprise the 180-kD
tin-free microfibrils. The latter, located beneath the lamina densa, are known
bullous pemphigoid antigen (also known as type XVII collagen), and the α6
as the dermal microfibril bundles (Fig. 1.81)
and β4 integrin molecules.5 The hemidesmosomes are associated with anchor-
ing filaments in the lamina lucida, thread-like structures 3–4 nm in diameter
that span the lamina lucida to the lamina densa. Dermal collagen
Located at the lamina lucida–lamina densa interface are the laminins.
The major laminin within the cutaneous BMZ is laminin 332, previously The major extracellular matrix component in the dermis is collagen.
known as laminin 5 (Fig. 1.78). In addition, laminin 111 (laminin 1), laminin Currently, 29 distinct collagens have been identified in vertebrate tissues
311 (laminin 6), laminin 321 (laminin 7) and laminin 511 (laminin 10) are and each is designated a Roman numeral in the chronological order of its
also integral components of the dermal–epidermal junction.6 The cruciform ­discovery. At least eight different collagens are found in human skin. All collagen
Dermal collagen 23


β3 γ2

Fig. 1.78
Laminin-332 is a major
adhesion protein at the dermal–
epidermal junction: (A) the
protein is composed of three
polypeptide chains: α3, β3, and
γ2; (B) Laminin-322 identified by
B immunofluorescence in a sample
of split skin.

­molecules ­consist of three subunit polypeptides which can either be iden-

tical in homotrimers or can consist of two or even three genetically differ-
ent polypeptides in heterotrimeric molecules. Since the different subunits
are all distinct gene products, there are well over 40 different genes in the
human genome that encode the different subunit polypeptides.1 Collagens
demonstrate considerable tissue specificity and are synthesized by a number
of different cell types, including dermal fibroblasts, keratinocytes, vascular
endothelial cells, and smooth muscle cells. A characteristic feature of col-
lagen is the presence of hydroxyproline and hydroxylysine residues, amino
acids that are post-translationally synthesized by hydroxylation of proline
and lysine residues, respectively. These hydroxylation reactions take place in
the rough endoplasmic reticulum by prolyl and lysyl hydroxylases, respec-
tively, enzymes that require ascorbic acid, molecular oxygen and ferrous iron
as cofactors. The hydroxylation of prolyl residues is necessary for stabili-
zation of the triple-helical conformation at physiologic temperatures, and
hydroxylysyl residues are required for formation of stable covalent cross-
links. In the rough endoplasmic reticulum, trimeric molecules are formed
and following the prolyl hydroxylation reactions, triple helices are generated
which are then secreted through Golgi vesicles into the extracellular space.
Here, parts of the noncollagenous peptide extensions are cleaved by specific
proteases, and the collagen molecules undergo supramolecular organization.
To acquire fibrillar strength, the fibers are then covalently linked together by
specific intra- and intermolecular cross-links. The most common forms of
cross-links in type I collagen are derived from lysine and hydroxylysine resi-
dues, and in some collagens there are also cysteine-derived disulfide bonds.

Fig. 1.80
Normal skin: the anchoring fibrils are composed predominantly of type VII collagen
as shown in this immunogold electron microscopic preparation.

On the basis of their fiber architecture in tissues, collagens can be divided

into different classes. Types I, II, III, V and IX align into large fibrils and
are designated as fibril-forming collagens. Type IV is arranged in an inter-
lacing network within the basement membranes, while type VI is a distinct
microfibril-forming collagen and type VII collagen forms anchoring fibrils.
FACIT collagens (fibril-associated collagens with interrupted triple-heli-
ces), include types IX, XII, XIV, XIX, XX, and XXI.2 Many of the FACIT
­collagens ­associate with larger collagen fibers and act as molecular bridges
stabilizing the organization of the extracellular matrices.
Fig. 1.79 Type I collagen, the most abundant form of collagen, is the predomi-
Basement membrane: basement membrane staining with type IV collagen. nant collagen in human dermis, accounting for approximately 80% of total
24 The structure and function of skin

Fig. 1.82
Normal skin of forearm:
Fig. 1.81 in the papillary dermis
Normal skin: this view the collagen fibers are
shows a well-formed fine and sometimes have
dermal microfibril bundle a vertical orientation.
(arrowed). Masson's trichrome.

c­ ollagen. Type I collagen associates with type III collagen to form broad,
extracellular fibers in the dermis. Mutations in the type I and III collagens or
in their processing enzymes can result in connective tissue abnormalities seen
in different forms of the Ehlers-Danlos syndrome, and mutations in the type
I collagen gene lead to osteogenesis imperfecta.3
Type III collagen accounts for about 10% of the total collagen in adult der-
mis, although it is the predominant dermal collagen in the fetus. It predomi-
nates in vascular connective tissues, the gastrointestinal tract, and the uterus,
and mutations in the type III collagen gene occur in the vascular type of the
Ehlers-Danlos syndrome.
Type V collagen is present in most connective tissues, including the der-
mis, where it represents less than 5% of the total collagen. Type V collagen is
located on the surface of large collagen fibers in the dermis, and its function
is to regulate their lateral growth. A lack of type V collagen leads to vari-
able collagen fiber diameters and an irregular fiber contour in cross-section.
Such fibers are seen in autosomal dominant forms of Ehlers-Danlos syndrome
associated with mutations in the type V collagen gene.
Mature collagen fibers are relatively inert and can exist in tissues under
normal physiologic conditions for long periods. However, there is some
continuous turnover of collagen that involves a number of enzymes of Fig. 1.83
the matrix metalloproteinases (MMP) family. These proteinase families Normal skin of back: broad bundles of collagen typify the reticular dermis.
include the collagenases, gelatinases, stromelysins, matrilysins, and the Masson's trichrome.
membrane-type MMPs.4 The MMPs are synthesized and secreted as inert
proenzymes which become activated proteolytically by removal of the
approximately 64 nm (Fig. 1.84). The cross-striations are seen because of
propeptide. The MMPs are zinc metalloenzymes and require calcium for
the longitudinal overlap of individual collagen molecules, which occurs dur-
their activity. The MMPs also have specific small molecular weight pep-
ing assembly of the mature fibril. Fibrous long-spacing collagen is a vari-
tide inhibitors, known as tissue inhibitors of metalloproteinases (TIMPs).
ant with a periodicity of 90–120 nm (Fig. 1.85). It is characteristically seen
These proteins stoichiometrically complex with MMPs to prevent colla-
in peripheral nerve and central nervous system tumors. Collagen bundles
gen degradation. In normal human skin, a number of MMPs are syn-
exhibit anisotropy and are therefore birefringent when viewed with polar-
thesized and secreted by fibroblasts and keratinocytes. The expression of
ized light (Fig. 1.86).
these enzymes is enhanced in various pathologic states, including inva-
sion and metastasis of cutaneous malignancies, as well as during dermal
wound healing. Dermal elastic tissue
Within the papillary dermis, collagen fibers are fine and often verti-
cally orientated whereas reticular dermal collagen consists of broad, thick The elastic fiber network provides resilience and elasticity to the skin.1 Elastic
bundles generally arranged parallel to the surface epithelium (Figs 1.82, fibers are a relatively minor component in normal sun-protected adult skin, com-
1.83). When longitudinal sections of collagen are examined by transmis- prising less than 2–4% of the total dry weight of the dermis. The ­configuration
sion electron microscopy they show cross-striations with a periodicity of of elastic fibers in the reticular dermis consists of horizontally orientated fibers
Dermal elastic tissue 25

which interconnect (Fig. 1.87).2 Extending from these into the papillary ­dermis
is a network of vertical extensions of relatively fine fibrils which consist either
of bundles of microfibrils (oxytalan fibers) or of small amounts of cross-linked
elastin (elaunin fibers) (Fig. 1.88).3 Elastic fibers have two principal compo-
nents: elastin, which is a connective tissue protein that forms the core of the
mature fibers, and the elastin-associated microfibrils which consist of a family
of proteins. Examination by transmission electron microscopy reveals an elas-
tin core that makes up over 90% of the elastic fiber and which is surrounded
by more electron-dense microfibrillar structures (Fig. 1.89).
Elastin is initially synthesized as a precursor polypeptide, tropoelastin,
which consists of approximately 700 amino acids with a molecular mass of
≈70 kD.4 The amino acid composition of tropoelastin is similar to collagen in
that about one-third of the total amino residues consist of glycine but the pri-
mary sequence is different, with domains rich in glycine, valine, and proline,
alternating with lysine- and alanine-rich sequences: a characteristic sequence
motif is the presence of two lysine residues separated by two or three alanine
residues. The lysine residues in tropoelastin are critical for the formation of
covalent cross-links between desmosine and its isomer, ­isodesmosine, which
appear to be unique to elastin. The first step in formation of these elastin-
Fig. 1.84 specific cross-links is oxidative deamination of three lysine residues to form
Collagen: it is characterized by cross-striations with a periodicity of 64 nm.

Fig. 1.85 Fig. 1.87

Fibrous long-spacing collagen: compare with the adjacent conventional collagen Reticular dermis: the elastic fibers are long and fairly thick and tend to run parallel to
fibers. There is a very different periodicity. the surface epithelium.

Fig. 1.86 Fig. 1.88

Collagen of the reticular dermis: note the birefringence when viewed with polarized Papillary dermis: the elastic fibers are delicate and orientated perpendicular to the
light. Masson's trichrome. epithelial surface. Weigert–van Gieson stain.
26 The structure and function of skin

Fig. 1.90
Fig. 1.89 Ground substance: an eccrine gland from the sole of the foot shows an abundance
Elastic fiber: this consists of microfibrils embedded in an electron-dense matrix of glycosaminoglycans.
called elastin.

aldehydes, known as allysines. These aldehydes, with additional lysine, fuse enriched in dermal fibroblasts, facilitates the adherence of cells in conjunc-
to form a stable desmosine compound which covalently links two of the tro- tion with other extracellular matrix binding molecules, such as the integrins.3
poelastin polypeptides. Addition of desmosines to other parts of the molecule Proteoglycans also interact with other extracellular matrix molecules besides
progressively converts tropoelastin molecules into an insoluble fiber struc- collagen; notably, chondroitin sulfate and dermatan sulfate bind fibronectin
ture. The oxidative deamination of lysyl residues to corresponding aldehydes and laminin. The largest extracellular GAG, hyaluronic acid, plays an impor-
is catalyzed by a group of enzymes, lysyl oxidases, which require copper for tant role in providing physical and chemical properties to the skin, mediated
their activity. Thus, copper deficiency can lead to reduced lysyl oxydase activ- in part by its hydrophilicity and viscosity in dilute solutions. Of particular
ity and synthesis of elastic fibers that are not stabilized by sufficient amounts note, hyaluronic acid has an expansive water-binding capacity, providing
of desmosines. In such a situation, the individual tropoelastin polypeptides hydration to normal skin. Indeed, water makes up ≈60% of the weight of
remain soluble and susceptible to non-specific proteolysis, and the elastin-rich normal human skin in vivo. Other properties attributed to large proteogly-
tissues are fragile. The metabolic turnover of elastin is slow, but is increased cans complexes, such as those formed with the versican or basement mem-
in some forms of cutis laxa and cutaneous aging. Elastic fibers are degraded brane proteoglycans, include their ability to serve as ionic filters, regulate salt
by elastases and metalloelastases. and water balance, and provide an elastic cushion.1
The elastin-associated microfibrils consist of tubular structures of ≈10– Except when present in very large amounts, ground substance cannot be
12 nm in diameter. These proteins include fibrillin, the latent transforming easily detected by routine hematoxylin and eosin staining (Fig. 1.90). Cationic
growth factor-β binding family of proteins, and the fibulins. Other compo- dyes, such as Alcian blue at appropriate pH and electrolyte concentration, are
nents comprise the families of microfibril-associated glycoproteins and micro- usually necessary for its demonstration.
fibril-associated proteins (MFAP), the emilins and certain lysyl oxidases. The
importance of the fibrillin is illustrated by mutations resulting in Marfan
syndrome with skeletal abnormalities, aortic dilatation, subluxation of the Fibroblast biology
ocular lens, and cutaneous hyperextensibility.5 Likewise, the significance of
The main cell responsible for the synthesis of collagens, elastic tissue and
certain fibulins is evident from mutations resulting in cutis laxa, manifesting
proteoglycan/glycosaminoglycan macromolecules in the dermis is the fibro-
with loose and sagging skin and loss of elastic recoil.
blast.1 In the mid-dermis of postnatal skin, the number of fibroblasts ranges
from 2100 to 4100 per mm3, and the cells have a limited replicative capacity
Ground substance ranging from 50–100 cell divisions. Fibroblasts also play a significant role
in epithelial–mesenchymal interactions, secreting various growth factors and
Proteoglycans form a number of subfamilies defined by a core protein to which cytokines that have a direct effect on epidermal proliferation, differentiation
polymers of unbranched disaccharide units, glycosaminoglycans (GAGs), are and formation of extracellular matrix. The term fibroblast refers to a fully
linked.1 The core proteins can be intracellular, reside on the cell surface, or differentiated, biosynthetically active cell, while the term fibrocyte refers to
be part of the extracellular matrix and the GAGs are highly charged polyan- an inactive cell.
ionic molecules that vary greatly in size. For example, dermal fibroblasts can Myofibroblasts are a specialized form of fibroblast found in granulation
synthesize versican which consists of a core protein with attachment sites for tissue and are involved in wound contraction. They are functionally distinct
12 to 15 GAG side chains. The GAGs in versican are primarily chondroitin from other fibroblasts with ultrastructural, biochemical and physical fea-
sulfate or dermatan sulfate, but versican can also bind hyaluronic acid, result- tures of smooth muscle cells. Moreover, myofibroblasts are characterized
ing in formation of large aggregates. Proteoglycan/GAG complexes have mul- by the presence of intracellular bundles of α smooth muscle actin, which is
tiple functions. For example, the proteoglycans containing heparan sulfate the actin isoform expressed by smooth muscle cells. Currently it is thought
and dermatan sulfate have the ability to bind extracellular matrix compo- that the evolution of myofibroblasts involves a preceding form known as
nents, including various collagens.2 In addition, these proteoglycans bind the protomyofibroblast, although the latter do not always become the fully
several growth factors, cytokines, cell adhesion molecules, and growth fac- differentiated myofibroblast. In contrast to myofibroblasts, protomyofibro-
tor binding proteins, thereby influencing the bioactivity of these molecules. blasts have stress fibers but no α smooth muscle actin filaments. A bio-
They can also serve as antiproteases. In addition to binding to a number synthetically active fibroblast has an abundant cytoplasm, well-developed
of extracellular molecules, proteoglycans also play a role in the adhesion of rough endoplasmic reticulum, and prominent ribosomes attached to the
cells to the extracellular matrix. For example, syndecan-4, which is selectively membrane surfaces.
Cutaneous blood vessels and lymphatics 27

Fibroblasts from different anatomical sites all have similar morphology

but fibroblasts in different sites have their own gene-expression profiles and
characteristic phenotypes, synthesizing extracellular matrix proteins and
cytokines in a site-specific manner.2 Papillary dermis
Dermal fibroblasts have numerous functions, not only in synthesizing and Superficial
depositing extracellular matrix components, but also in proliferation and migra- vascular plexus
tion in response to chemotactic, mitogenic and modulatory cytokines, and also
autocrine and paracrine interactions. Autocrine activity includes the trans-
forming growth factor (TGF)-β-induced synthesis and secretion of connective
tissue growth factor which promotes collagen synthesis as well as fibroblast Reticular dermis
proliferation. Paracrine activity affects keratinocyte growth and differentiation,
specifically through fibroblast secretion of keratinocyte growth factor (KGF),
granulocyte-macrophage colony-stimulating factor, interleukin (IL)-6 and fibro-
blast growth factor (FGF)-10. Fibroblasts also contribute to basement membrane vascular plexus
formation partly by producing type IV collagen, type VII collagen, laminins and
nidogen, but also through the secretion of cytokines, such as TGF-β, that stimu-
late keratinocytes to produce basement membrane components.
Neovascularization and lymphangiogenesis are also important processes for Subcutaneous fat Fig. 1.91
the maintenance of normal skin homeostasis and wound healing, for which Relationship of the
superficial and deep
fibroblasts have an important paracrine role. Members of the vascular endothe-
vascular plexuses.
lial growth factor (VEGF) family include VEGF-A, -B, -C, and -D, which are
produced by normal human fibroblasts and are important in regulating vascu-
lar and lymphatic endothelial cell proliferation through specific receptors. constituting the external elastic lamina. Small arterioles have an endothelium
There is, however, considerable heterogeneity within fibroblast popula- surrounded by a single layer of smooth muscle. Capillaries consist of a single
tions. For example, fibroblasts isolated from the papillary dermis compared layer of endothelial cells, but may have adjacent pericytes, which have less
to the reticular dermis have higher rate of synthesis of type III collagen and well-developed dense bodies and fewer filaments than smooth muscle cells.
there can be as much as 30-fold differences in the level of fibronectin expres- Endothelial cells and pericytes form tight junctions. Venous capillaries have
sion within individual cells. Fibroblasts from the papillary dermis appear numerous pericytes and a multilayered basement membrane in contrast to
smaller, grow faster and have a longer replicative lifespan.3 When co-cultured arterial vessels where the basement membrane is solitary and homogeneous.
with keratinocytes, papillary dermal fibroblasts produce a more differentiated Each dermal papilla is supplied by a single capillary loop. Endothelial cells
and organized epidermis with complete formation of the dermal–epidermal contain vimentin filaments, Weibel-Palade bodies measuring approximately
junction. Papillary dermal fibroblasts also produce more granulocyte–mac- 0.1 × 3.0 μm (containing factor VIII) and numerous pinocytotic vesicles (Figs
rophage colony-stimulating factor (GM-CSF) and relatively less keratinocyte 1.93, 1.94). Postcapillary venules are larger, but have the same basic struc-
growth factor (KGF) than reticular dermal fibroblasts. In addition, there are ture as capillaries. Their wall is devoid of smooth muscle. The small muscu-
differences in the synthesis of some extracellular matrix components, such lar venules into which the postcapillary venules drain have an intima made
as decorin. While fibroblasts demonstrate certain variability in their gene up of flattened endothelial cells surrounded by a smooth muscle layer one or
expression profiles they are considered fully differentiated cells with relatively two cells thick. They are therefore similar to small arterioles, but with much
little plasticity. Recent observations, however, suggest that fibroblasts can be wider lumina. Veins are composed of an endothelium surrounded by a muscle
induced to become pluripotent stem cells (iPS), essentially indistinguishable coat several layers thick. Typically, an internal elastic lamina is poorly repre-
from the embryonic stem cells, by transduction of cultured fibroblasts with sented. There is usually a thick connective tissue adventitia, but elastic fibers
four transcription factors, Oct4, Sox2, Klf4, and c-myc.4 are absent; only very large muscular veins have elastic tissue (Fig. 1.95).
Also present in the dermis are veil cells, which surround all the microves-
sels and separate them from the adjacent connective tissue. Veil cells are long,
Cutaneous blood vessels and lymphatics thin cells with an attenuated cytoplasm, and they more closely resemble fibro-
blasts than pericytes. They do not have a basement membrane investment and
The skin receives a rich blood supply from perforating vessels within the skele- are located outside the vessel wall.
tal muscle and subcutaneous fat.1 Most of the blood flow is directed toward the The capillary loop in the dermal papilla has an ascending arterial compo-
more metabolically active constituents of the skin, namely the epidermis, hair nent and an intrapapillary segment, which is characterized by a hairpin turn
papillae and the adnexal structures. While the dermal papillae are richly vascu- and a descending venous capillary segment. Capillary loops run perpendicular
larized, no capillaries actually enter the epidermis, which receives its nutrition to the skin surface, except in the nail where they have a parallel orientation.
by diffusion. The subcutaneous vessels give rise to two vascular plexuses linked The dermis is richly supplied with arteriovenous anastomoses. Specialized
by intercommunicating vessels: the deep vascular plexus lies in the region of the shunts (glomus bodies), found primarily in the dermis of the fingertips, con-
interface between the dermis and subcutaneous fat, and the superficial vascu- sist of an arterial segment (Sucquet-Hoyer canal), which connects directly
lar plexus lies in the superficial aspects of the reticular dermis and supplies the to the venous limb (Fig. 1.96). The canal is surrounded by several layers of
papillary dermis with a candelabra-like capillary loop system (Fig. 1.91). Each modified smooth muscle cells (glomus cells) with a particularly rich nerve
loop consists of an ascending arterial limb and a descending venous limb. The supply. Glomus bodies function as sphincters, allowing the capillaries of the
vessels of the dermal papillae comprise terminal arterioles, arterial and venous superficial dermis to be bypassed, therefore increasing the venous return from
capillaries, and postcapillary venules, with the last predominating. Within the the extremities.
deep vascular plexus are small muscular arteries, which give rise to the arteri- Cutaneous blood flow (under hypothalamic control) is of extreme impor-
oles that supply the superficial vascular plexus (Fig. 1.92). tance in thermoregulation. Mediated by the autonomic nervous system, heat
The histology of these plexuses is similar, the difference being one of size loss can be increased or decreased by varying the blood flow to the superficial
rather than structure (arterioles have a diameter of less than 0.3 mm).2 From vascular plexuses. If the environmental temperature exceeds that of the body,
the lumen outwards the arteriole consists of a very thin intima resting against a then the blood flow to the papillary dermis increases. A concomitant increase
conspicuous internal elastic lamina. Next to this is the media, consisting of two in eccrine sweat gland secretion, evaporation of which cools the outer parts
layers of smooth muscle, which constitutes the bulk of the vessel. The adven- of the body, lowers the temperature of the circulating blood and maintains a
titia surrounding the media is composed of loose connective tissue. In small stable core temperature. Temperature control therefore depends on a delicate
muscular arteries (but not arterioles), the adventitia often contains elastic fibers interplay between both vascular and sweat gland functions.
28 The structure and function of skin

Fig. 1.92
Small muscular artery from the deep vascular plexus from
the lower leg of an elderly man with endarteritis (intimal
thickening): note the thick muscle coat and conspicuous
internal elastic lamina, the latter accentuated by the
Weigert–van Gieson reaction. (A) Hematoxylin and eosin;
A B (B) Weigert–van Gieson.

trunks are very thick and muscular and can be confused with an artery
(Fig. 1.98). The absence of an internal elastic lamina readily allows their
distinction. Vascular endothelial cells may be identified by the monoclo-
nal antibody CD31 or by an anti-von Willebrand factor antibody. Vascular
endothelial growth factor receptor 3 (VEGFR-3) has not lived up to its
promise to be a useful lymphatic endothelial cell marker.5,6 Lymphatic vessel
endothelial hyaluronan receptor 1 (LYVE-1), Prox-1 and podoplanin may
be more useful.7

Nervous system of the skin

The skin may be innervated with around one million afferent nerve fibers.
Most terminate in the face and extremities; relatively few supply the back.
The cutaneous nerves contain axons with cell bodies in the dorsal root gan-
glia. Their diameters range from 0.2 to 20.0 μm. The main nerve trunks enter-
ing the subdermal fatty tissue each divide into smaller bundles. Groups of
myelinated fibers fan out in a horizontal plane to form a branching network
from which fibers ascend, usually accompanying blood vessels, to form a
Fig. 1.93 web of interlacing nerves in the superficial dermis. The cutaneous nerves sup-
Normal dermal capillary: note the lining of endothelial cells surrounded by a pericyte ply the skin appendages and form prominent plexuses around the hair bulbs
cell process and adjacent basal lamina. The lumen contains erythrocytes (E). and the papillary dermis. The afferent receptors consist of free nerve endings,
nerve endings in relation to hair, and encapsulated nerve endings. Free nerve
endings, of both myelinated and nonmyelinated types and with a low conduc-
The dermis also contains an extensive lymphatic system, which is closely tion speed, are mainly responsible for the appreciation of temperature, itch
associated with the vascular plexuses.3 Although largely disregarded except and pain. Hair follicles are supplied by an intricate network of myelinated
for their role in tumor spread, lymphatics are of major importance in fibers, some of which ramify as free nerve endings in the periadnexal fibrous
removing the debris of daily wear and tear including fluid, cells and macro- tissue sheath, while others enter the epidermis to terminate as expansions
molecules (Fig. 1.97). They also represent the primary disposal mechanism in intimate association with Merkel cells in the external root sheath. The
for contaminating microorganisms. Lymphatics have been shown to supply hair disc is a complex structure consisting of basally situated Merkel cells
the major route for epidermal Langerhans cells to reach the regional lymph and an associated myelinated peripheral nerve fiber. Despite the name, it has
node following antigen stimulation. Under normal circumstances these deli- an inconstant association with hair follicles. Hair discs are slowly adapting
cate vessels are collapsed and are difficult to detect. They are supported by mechanoreceptors. Throughout their course the axons of cutaneous nerves
delicate elastic tissue scaffolding and consist of a large thin-walled collapsed are enveloped in Schwann cells but, as they track peripherally, an increas-
vessel lined by attenuated endothelium and characterized by the presence of ing number lack myelin sheaths. Most end in the dermis; some penetrate the
multiple valves. Their presence is much more obvious in obstructive situ- basement membrane, but do not travel far into the epidermis.
ations (e.g., lymphedema or due to the presence of metastases). Dermal Sensory endings are of two main kinds: corpuscular, which embrace non-
lymphatics are loosely aggregated into a superficial and deep plexus, which nervous elements; and ‘free’, which do not. Corpuscular endings can, in turn,
drain into muscularized lymphatic trunks.4 In the lower limbs the lymphatic be subdivided into encapsulated receptors, of which a range occurs in the
Nervous system of the skin 29


Fig. 1.94
(A) Small dermal arteriole: the lumen is compressed to a narrow slitlike space; (B) high-power view of typical Weibel–Palade bodies. These are characteristic of blood vessel


Fig. 1.95
Companion vein to Figure 1.92: note the wide diameter of the lumen in comparison to the relatively thin muscle coat. There is a little elastic tissue but no discernible internal
elastic lamina. (A) Hematoxylin and eosin; (B) Weigert–van Gieson.

dermis, and nonencapsulated, exemplified by Merkel's ‘touch spot’, which Meissner's corpuscles are characteristic of the papillary ridges of glabrous
is epidermal. skin in primates. They have a thick, lamellated capsule, 20–40 μm in diameter
The most striking of the encapsulated receptors is the Pacinian corpuscle. and up to 150 μm long (Fig. 1.100).1 Meissner's corpuscles are involved in the
It is an ovoid structure about 1 mm in length, which is lamellated in cross- appreciation of touch sensation (rapidly adapting mechanoreceptors) and are
section like an onion, and is innervated by a myelinated sensory axon, which found predominantly in the dermal papillae of the hands and feet, the lips,
loses its sheath as it traverses the core (Fig. 1.99). Pacinian corpuscles are and on the front of the forearm. They comprise a perineural-derived lamel-
responsible for the appreciation of deep pressure and vibration and are found lated capsule surrounding a core of cells and nerve fibers, and are supplied by
predominantly in the subcutaneous fat of the palms and soles, dorsal surfaces myelinated and nonmyelinated nerve fibers. They make intimate contact with
of the digits, around the genitalia, and in ligaments and joint capsules. the basal keratinocytes. Meissner's corpuscles have a multiple nerve supply
The Golgi-Mazzoni corpuscle found in the subcutaneous tissue of the and each nerve may also supply multiple corpuscles. Of somewhat different
human finger is similarly laminate but of much simpler organization. Another structure are the terminals first described by Ruffini in human digits, in which
classical receptor is the Krause end bulb, an encapsulated swelling on myeli- several expanded endings branch from a single, myelinated afferent fiber. The
nated fibers situated in the superficial layers of the dermis. endings are directly related to collagen fibrils. ‘Free nerve-endings’, which
30 The structure and function of skin

Fig. 1.96 Fig. 1.99

Glomus body: note the arterial and venous limbs connected by a vascular channel Pacinian corpuscle: note the characteristic lamellar internal structure.
rich in glomus cells.

Fig. 1.97
Lymphatics: these exceedingly thin-walled channels are normally not visible in the
dermis. They become readily apparent, however, when obstructed, as in this patient
with lymphedema.

Fig. 1.100
Meissner's corpuscle within a dermal papilla: with hematoxylin and eosin staining it
appears as perpendicularly orientated lamellae of Schwann cells.

appear to be derived from nonmyelinated fibers, occur in the superficial der-

mis and in the overlying epidermis.2 Those in the dermis are arranged in a
tuftlike manner and have thus been designated penicillate nerve endings.

Subcutaneous fat
Fat is a major component of the human body. In nonobese males, 10–12% of
body weight is fat, while in females the figure is 15–20%. Eighty per cent of fat
is under the skin; the rest surrounds internal organs. Fat comprises white and
brown adipose tissue, the latter being more common in infants and children
Fig. 1.98 and is characterized by different mitochondrial properties and increased heat
Skin of lower leg: muscular lymphatic trunks can be readily mistaken for arteries. production.1 Historically, fat has been thought to provide insulation, mechani-
An internal elastic lamina is characteristically absent. cal cushioning and an energy store but recent data suggest that it also has an
Subcutaneous fat 31

endocrine function, communicating with the brain via secreted molecules such ­ ediastinum. The brown coloration is due to the high cytochrome con-
as leptin to alter energy turnover in the body.2 Adipocytes also have important tent. The brown fat cytoplasm contains numerous, somewhat pleomorphic,
signaling roles in osteogenesis and angiogenesis. Indeed, multipotent stem cells mitochondria. Endoplasmic reticulum and a Golgi apparatus are not usually
have been identified in human fat which are capable of developing into adi- visible. The adipocytes have a bubbly appearance with the nucleus located
pocytes, osteoblasts, myoblasts and chondroblasts. Biological clues to genes, towards the center of the cell (Fig. 1.103).
proteins, hormones and other molecules that influence fat deposition and
distribution are gradually being realized, from both research on rare inher-
ited disorders (such as the lipodystrophies or obesity syndromes) as well as
­population studies on more common forms of obesity.3
The subcutaneous fat is divided into lobules by vascular fibrous septa, and
its cells are characterized by the presence of a large single globule of lipid,
which compresses the cytoplasm and nucleus against the plasma membrane
(Fig. 1.101). The adipocyte is large, measuring up to 100 μm in diameter. The
cytoplasm contains numerous mitochondria. Smooth endoplasmic reticulum
is prominent and a Golgi is often conspicuous. Processing for routine histo-
logical preparation dissolves the lipid, but the use of special stains on fro-
zen sections will reveal its presence (Fig. 1.102). The subcutaneous fat may
­contain large numbers of mast cells.
Deposits of brown fat may be seen in the newborn and occasionally
in adults, particularly in the interscapular region, the back, thorax and

Fig. 1.102
Adult fat in frozen section stained by the Sudan IV technique.

Fig. 1.101
The lipid contents of fat cells are dissolved during processing using conventional
(paraffin-embedding) techniques. The cells therefore appear empty and have Fig. 1.103
peripheral compressed nuclei. Typical brown fat showing pink granular cytoplasm.
Specialized techniques in
2 dermatopathology
Pratistadevi K. Ramdial, Boris C. Bastian, John Goodlad, John A. McGrath and
Alexander Lazar
for references and
additional material

Specimen fixation, grossing/put-through, Immunofluorescence  35 Polymerase chain reaction (PCR)  43

processing, embedding and
Electron microscopy  37 Diagnosis of lymphomas  43
sectioning  32
PCR analysis of cutaneous lymphoid infiltrates  44
Diagnosis of inherited skin diseases  37
Routine and ‘special’ stains  33 TCR gene rearrangement in cutaneous
Molecular techniques  39 lymphoproliferations  44
Immunohistochemical techniques  34 IG gene rearrangement in cutaneous
Chromosomal karyotyping  39
Immunohistochemical techniques and Allelic imbalance  39 lymphoproliferations  45
trouble shooting  34 Fluorescence in situ hybridization (FISH)  39
Comparative genomic hybridization (CGH)  42

specimens embedded with the cut surfaces down. The eccentric sectioning
Specimen fixation, grossing/ put-through, ensures that the lesion is not missed. Biopsies less than 4 mm are put through
processing, embedding and sectioning in toto.9,10
Tissue processing refers to a series of steps that effect the removal of
The aim of fixation in dermatopathology is to maintain clear and consistent extractable water from biopsies to ensure sections of optimal diagnostic qual-
morphological features and to preserve tissue in an optimal state suitable for ity.9 These include fixation, dehydration, clearing, infiltration and embedding
a range of staining and ancillary histopathological techniques.1,2 Most fixa- in a support matrix. Use of manual and automated tissue processing achieves
tion methods employed during tissue processing depend on chemical fixa- this goal, including:
tion of tissue in liquid fixatives.3 Tissue fixation may also be accomplished • carousel-type processors,
by physical (heat, microwave, freeze-drying and freeze substitution) and/or • self-contained vacuum tissue processors,
chemical (coagulant and cross-linking) methods.4 The most commonly used • microwave tissue processing.
fixative is 10% neutral-buffered formalin solution. The quality of fixation is In most laboratories, overnight processing runs are the norm. 9
affected by: However, microwave-assisted tissue processing facilitates shorter pro-
• the size of the specimen, cessing times of one to two hours. Dehydrating reagents promote the
• duration and temperature of fixation, removal of unbound water and aqueous fixatives from the tissue.
• pH, Clearing reagents serve as an intermediary between the dehydrating and
• concentration, infiltrating solutions, being miscible with both. Paraffin is the most pop-
• osmolality, ular infiltration and embedding medium, being suitable for the major-
• ionic composition of fixatives and additives contained in the fixative.5 ity of routine and special stains. The important principle to be adhered
Formalin fixation occurs at an approximate rate of 1 mm per hour.4,6,7 to during embedding of skin biopsies is that the orientation of the skin
The volume of the fixative should be at least 10 times the volume of the sample should offer the least resistance to the blade during microtomy.
specimen.7 Large specimens, such as tumors, may require sectioning into Skin biopsies are usually cut in a plane at right angles to the epidermis
5-mm thick slices, covering with fixative soaked gauze or cloth and fixation so that the epidermal surface is sectioned last, minimizing its compres-
overnight.5,7 sion and distortion.
Diagnostic dermatological biopsies may be: Suboptimally processed tissue may result in incomplete tissue sections and
• small incisional (shave, core, punch), expansion or disintegration of sections in the water bath. Incorrectly embed-
• excisional specimens.8 ded tissue may result in poorly orientated incomplete sections. Faulty micro-
Prior to put-through, excisional specimens that require an appraisal of tome mechanisms, loose, dull or damaged blades and inaccurate clearance
margins should be inked. If localization sutures have been inserted by sur- angles may be the causes for:
geons then four-quadrant, four-color painting or two-color painted halves • thick and thin sections,
(Fig. 2.1) may be appropriate. Shave biopsies are used to sample or remove • folds (Fig. 2.2),
lesions, and if of appropriate size, may be divided into sections, bisected or • holes (Fig. 2.3),
trisected and embedded on edge. Edge embedding is critical in a shave exci- • scores (Fig. 2.4),
sion of a lesion such as a small melanoma so that the width and depth of • chatter.10
invasion can then be quantified.8,9 The main purpose of core or punch biop- The presence of calcified areas and suture in skin tissue and nicks in the
sies, which generally measure 2–8 mm in diameter, is to sample large lesions. blade may result in chatter or splitting of sections at right angles to the knife
Biopsies larger than 4 mm in size should be bisected eccentrically and the edge.
Routine and ‘special’ stains 33


Fig. 2.1
Gross representation of basal cell carcinoma: (A) with two-color painting of the
inferior surface (B). A 2-mm thick gross sections demonstrating the black and
blue painting at put through (C) and in paraffin blocks (D). By courtesy of Dr. J.
Deonarain, Department of Anatomical Pathology, National Health Laboratory
Service, Durban, South Africa.

Fig. 2.3
Technical artifact: holes in
tissue sections because
tissue sections were cut
too thin.

Fig. 2.2
Technical artifact: folds in tissue sections because of poor water bath floating

Routine and ‘special’ stains

With the advent of immunohistochemistry, special stains are less commonly
employed, but can still play an important role in highlighting certain tissue
characteristics or for detection of infectious organisms.
Diagnostic sections are usually stained with hematoxylin and eosin (H&E),
the most widely used routine stain.1 The hematoxylin component stains the
nuclei blue-black and the eosin stains the cytoplasmic compartment and con-
nective tissue in variable shades and intensity of pink, orange and red. The
periodic acid-Schiff (PAS) technique is used widely to demonstrate: Fig. 2.4
Technical artifact: score
• glycogen, in tissue section because
• starch, of a damaged microtome
• sialomucin, blade.
• neutral mucin,
• basement membranes,
• α1-antitrypsin, charides are not. Mucicarmine demonstrates acidic epithelial mucins.2 It is
• reticulin, useful for the diagnosis of adenocarcinomas and the mucoid C. neoformans
• Russell bodies of plasma cells, capsule. Alcian blue highlights acidic mucopolysaccharides, staining the muci-
• fungi.2 nous components of dermal mucinoses, granuloma annulare, scleredema of
The PAS technique is therefore employed to demonstrate basement mem- Bushke, lupus erythematosus and metastatic adenocarcinomas. Alcian blue
brane thickening in lupus erythematosus, porphyria cutanea tarda and in demonstrates heterogeneity of staining that is pH based: sialomucins are
some tumors. Glycogen is digested by diastase, while neutral mucopolysac- demonstrated at pH 2.5 and sulfamucins at pH 1.0.3
34 Specialized techniques in dermatopathology

Table 2.1
The more commonly used histochemical stains
Stain Component Outcome
A. Routine
Hematoxylin- Cells, connective Nuclei: blue
eosin tissue Cytoplasm: pink/red
Extracellular matrix:
B. Carbohydrates &
Periodic acid-Schiff Neutral mucins, glycogen Magenta
PAS-diastase Glycogen, Resistant to
proteoglycans, HA diastase
resistant sialomucin digestion
Alcian blue, pH 2.5 Labile sialomucin Blue
Alcian blue, pH 1.0 Sulfomucin, resistant Blue
Mucicarmine Sialomucin, sulfomucin Pink
Colloidal iron Sialomucin, sulfomucin Blue
Fig. 2.5 HA, proteoglycans
Special stains: Warthin-Starry silver stain demonstrating Donovan bodies. High iron diamine Proteoglycans, Blue
Toluidine blue Sulfomucin Blue
Hyaluronidase HA Sensitive to HA
While colloidal iron, initially described by Hale for the identification of
acid mucopolysaccharides, is as sensitive as Alcian blue for this purpose, C. Connective tissue
its specificity and selectivity are debatable and background staining may be fibers
problematic.4 However, reduction of pH of the colloidal iron solution and Masson trichrome Collagen Blue or green
Muscle, nerve Red
inclusion of acetic acid washes may reduce this artifact.3–5 The high iron
Verhöeff-van Gieson Elastic fibers Black
diamine stain, in contrast to colloidal iron, stains highly acidic sulfamu- Pinkus acid orcein Elastic Dark brown
cins but does not stain sialomucins or hyaluronic acid.5–7 Connective tissue Silver nitrate Reticulum fibers Black
stains highlight collagen, elastic and reticulin fibers. The trichrome stain, a
D. Infective stains
combination of three dyes, is employed for the differential demonstration
Ziehl Neelsen Acid fast bacilli Red
of muscle, collagen fibers, fibrin and erythrocytes.8 Elastic fibers may stain
Fite-Faraco (weakly) acid fast bacilli Red
with eosin, phloxine, Congo red and PAS stains but are demonstrated well Periodic acid-Schiff Fungi, parasites Magenta
with the Verhöeff method in the diagnosis of scleroderma, anetoderma and Mucicarmine Cryptococcus sp Red
pseudoxanthoma elasticum. Silver stains are useful to demonstrate reticulin Giemsa Leishmania sp, Red
fibers, melanin and the identification of infective agents. While methenamine Donovan bodies Metachromatically
silver and Gomori Grocott methenamine silver stains highlight fungi and purple
bacteria, Warthin-Starry, Dieterle and Steiner silver stains are particularly Methenamine silver Fungi, bacteria Black
useful in the demonstration of spirochetes, B. henselae and Donovan bodies Grocott Fungi Black
(Fig. 2.5). Masson-Fontana silver staining is pivotal to the staining of the methenamine
cell wall of C. neoformans, especially in the identification of capsule-deficient
Warthin Starry silver Spirochetes, bacteria Black
C. neoformans. The role of the more commonly used special stains is sum-
Dieterle and Spirochetes, bacteria Black
marized in Table 2.1. Steiner silver
E. Other
Immunohistochemical techniques Perl's potassium Hemosiderin Blue
Since the first practical application of antibodies using the peroxidase labeled Oil red O Lipids Red
antibody method on paraffin-embedded tissues in 1968, immunohistochemis- Scarlet Red Lipids Red
Von Kossa Phosphate (often as Black
try (IHC) has emerged as a powerful supplementary investigation to histomor-
calcium phosphate) Black
phologic assessment.1–3 IHC has widespread dermatopathologic diagnostic,
Alizarin red S Calcium Orange-Red
prognostic, therapeutic and pathogenetic applications, not only in a range of Alkaline Congo Red Amyloid Apple green
neoplastic (Table 2.2), immunobullous and infective disease, but also in the birefringence
distinction between reactive and neoplastic disorders.4–14 Immunohistologic Chloro-acetate Myeloid series Red granules
techniques can be performed manually or in automated platforms. While esterase
automation allows enhanced quality and reproducibility of staining, detailed,
exact IHC protocols are critical in the many laboratories that still perform Key: HA, hyaluronic acid

manual IHC, to achieve optimal, reproducible results.

assess histomorphology with the latter.1 The peroxidase-antiperoxidase
(PAP) technique, was replaced by alkaline phosphatase-antialkaline phos-
Immunohistochemical techniques and phatase (APAAP) techniques and avidin-biotin labeling.1,2 Although the
trouble shooting ­streptavidin-biotin labeling system gained popularity, the endogenous biotin-
associated background staining under certain circumstances has resulted in
In many centers, IHC is now the most commonly utilized ancillary test for increasing use of labeled polymer-based detection systems, suitable for man-
clinical tissue samples. ual and automated IHC platforms (Fig. 2.6).3
Historically, the introduction of enzymes as labels in IHC overcame dif- The direct conjugation of the primary antibody to the label formed the
ficulties associated with immunofluorescence, including the inability to principle of the initial, traditional direct technique, in which the labeled
Immunofluorescence 35

Table 2.2 animal.1 The secondary antibody binds to the primary antibody with the
Some diagnostic immunohistochemical applications for cutaneous tumors4–13 biotinylated end being available for binding to a third layer. This layer may
Stain Application bind either to enzyme-labeled streptavidin or to a complex of enzyme-labeled
biotin and streptavidin. The enzyme may be horseradish peroxidase or alka-
Epidermal and appendageal neoplasms
line phosphatase. An appropriate chromogen is used for detection. In the per-
AE1/AE3 Pan-keratin. Confirms epithelial lineage oxidase method, peroxidase-oriented chromogens such as diaminobenzidine
CAM 5.2 CKs 8,18. Confirm epithelial lineage. Useful to confirm or 3-amino-9 ethylcarbazole are appropriate. Indole reagents (red), naphthol
glandular neoplasms
fast red (red) or NBT / BCIP (blue) are the chromogens used in the alkaline
MNF 116 CKs 5, 6, 8, 17, 19. Useful in diagnosis of SCC with
single cell infiltration
phosphatase-streptavidin method.1,4
BerEP4 Positive in BCC. Negative in SCC. The presence of endogenous biotin and resultant background staining led
CK 7 Confirmation of mammary and extra-mammary Paget's to the introduction of the increasingly popular polymer-based immunohis-
disease tochemical methods. In the new direct Enhanced Polymer One Step (EPOS)
p63 Distinguish primary cutaneous spindle SCC from technique, approximately 70 enzyme molecules and 10 primary antibodies
mesenchymal spindle cell tumors & primary are conjugated to a dextran ‘backbone’. While the entire IHC procedure is
cutaneous adnexal from metastatic adenocarcinomas completed in one step, the method is limited to highly select manufacturer-
CD10 Trichoepithelioma: positive in stroma and papillae, specific primary antibodies. Other newer polymer detection systems with a
negative in epithelium. BCC: positive in epithelium, dextran backbone to which multiple enzyme molecules may attach are avail-
negative in stroma.
able for manual and automated IHC. These quick, reliable and reproducible
bcl2 Positive in BCC, negative in SCC.
techniques are also characterized by greater sensitivity. Single-, dual-, and
Vascular proliferations triple-color staining with different chromogens is possible.1,2,4,5
CD31 High specificity and good sensitivity for endothelial tumors Background staining is a common difficulty that has multiple predispos-
CD34 High sensitivity but low specificity for endothelial tumors ing causes.6 While monoclonal antibodies reduce non-specific background
Fli-1 Nuclear staining of endothelial tumors staining, not only must antibody concentrates and prediluted preparations be
GLUT 1 Positive in endothelial cells of all juvenile hemangiomas. optimized for usage at the correct dilution in different laboratories (Figs
Usually negative in congenital hemangiomas 2.7 and 2.8), diluent pH is also critical in ensuring the absence of antibody
(rapidly involuting congenital hemangioma and non-
degeneration and resultant background staining. Avidin-biotin detection sys-
involuting congenital hemangioma)
tems and horseradish peroxidase systems may require biotin blocking and
Melanocytic tumors endogenous peroxidase quenching steps to decrease unnecessary background
S-100 protein Most widely used melanocytic marker. It is highly sensitive staining. Polymer-based detection systems can effectively eliminate biotin-
but not as specific as other melanocytic markers induced false-positive staining. While antigen retrieval techniques are criti-
HMB 45 Good specificity but relatively low sensitivity.Tends to cal for antigen unmasking, optimal results require control of the pH and
be negative in spindle cell melanoma. Also positive in temperature of retrieval solutions and controlled enzymatic digestion (Fig.
PEComa. 2.9).7–10 The latter causes excessive background staining when sections are
Melan A/Mart 1 Similar specificity to HMB45. Tends to be negative in exposed to increased digestion time, inappropriate high temperature and
spindle cell melanomas.
inadequate rinsing, causing protein diffusion into or deposition in skin sec-
Ki-67 Higher proliferation index in melanoma (13–35%)
than in nevi (<5%). Useful in the evaluation of some
tions and b­ ackground staining.
melanocytic tumors, mainly nevoid melanoma Chromogen entrapment, precipitation and contaminants may lead to false-
positive interpretation of an IHC test. Depletion of peroxidase or alkaline
Neuroectodermal and neural tumors phosphatase chromogenic activity, a consequence of the breakdown of chro-
S-100 protein Positive in neuroectodermal, neuronal, nerve sheath, mogens because of the sensitivity to light and heat, results in a background
chondroid tumors, some sweat gland tumors and blush. A  similar effect is seen when there is inadequate chromogen rinsing
myoepithelioma or prolonged chromogen time. Filtering of the chromogen is effective in pre-
NSE Merkel cell carcinoma venting chromogen precipitation. Chatter, tears, folds and wrinkles and poor
CK 20 Merkel cell carcinoma adhesion of sections to slides causes entrapment and suboptimal rinsing of
Neurofilament Merkel cell carcinoma chromogen (Fig. 2.10). Skin sections with a thick stratum corneum, dermal
Chromogranin Merkel cell carcinoma calcification, or sclerosis may be prone to these artifacts, requiring meticulous
Synaptophysin Merkel cell carcinoma microtomy to prevent its occurrence. The handling of water baths, tissue sec-
TTF1 Negative in most Merkel cell carcinoma
tions and slides with ungloved hands may cause contamination of sections
with squames.1
Myogenic/myofibroblastic differentiation
False-negative immunostaining may also compromise IHC interpreta-
MSA Tumors of muscle origin
tion. Incomplete deparaffinization causes suboptimal or incomplete staining
Desmin Tumors of muscle origin (smooth muscle and skeletal
because of incomplete tissue penetration by the antibody. Overdigestion of
muscle, rarely and focally in myofibroblastic tumors)
Myogenin Positive in rhabdomyosarcoma tissue sections by proteolytic enzymes can destroy the tissue sections with
SMA Positive in smooth muscle tumors, glomus tumor, attendant loss of antigen for antibody binding. Other causes of false-negative
myopericytoma, dermatomyofibroma immunostaining include:
• incorrect temperature of reagents, including retrieval solutions,
BCC, basal cell carcinoma; SCC, squamous cell carcinoma; SMA, anti-smooth muscle
actin; MSA, muscle specific actin; CK, cytokeratin.
• expired antibodies,
• inappropriate dilutions,
• suboptimal storage of antibodies .1,3
a­ ntibody reacted directly with the tissue antigen.1 In the two-step indirect
technique, labeled secondary antibody directed against the immunoglobulin
of the animal in which the primary antibody was raised was used to visual- Immunofluorescence
ize an unlabeled primary antibody.4 The labeled streptavidin-biotin (LSAB)
method is a three-step technique. An unconjugated primary monoclonal Immunofluorescent techniques have the potential to define antigen-antibody
or polyclonal antibody, attached to the tissue antigen forms the first layer, interactions at a subcellular level.1 This interaction requires the irreversible
­creating an antigen-antibody complex. The second layer is formed by a bioti- binding of a readily identifiable label for its recognition.1,2 Fluorochromes
nylated secondary antibody raised against the same species of the primary such as rhodamine or fluorescein are labels that can absorb radiation in the
36 Specialized techniques in dermatopathology

P Antigen

P Peroxidase

P B P Primary

Secondary Antibody on
a polymer backbone Fig. 2.6
Immunohistochemical techniques:
(A) direct, (B) indirect (C)
streptavidin biotin (D) polymer
chain. By courtesy of Dr. J.
Ag Ag Ag Ag Ag Deonarain, Department of
Direct method Indirect method Avidin-biotin method Polymer chain two step direct method Anatomical Pathology, National
Health Laboratory Service, Durban,
A B C D South Africa.

Fig. 2.7 Fig. 2.9

Technical artifact: poor tissue fixation resulting in incomplete sections, Technical artifact p53 stain: wrinkling and background staining of tissue sections
fragmentation and suboptimal AE1/AE3 stained section. because of erroneously high temperature heat-assisted microwave antigen retrieval
exposure of sections in EDTA buffer (pH 8.0).

Fig. 2.8 Fig. 2.10

Technical artifact: suboptimal antibody concentration of CD3 antibody resulting in Technical artifact: HHV8 stained sections demonstrating chromogen entrapment in
background staining. stratum corneum.
Diagnosis of inherited skin diseases 37

form of ultraviolet or visible light.1–5 Direct and indirect immunofluorescence between the dermatopathologist and molecular laboratory is absolutely criti-
(IMF) techniques demonstrate a range of tissue antigens of dermatopatho- cal for efficient use of molecular techniques.
logic importance, including the diagnosis of infectious and autoimmune blis- Analysis of the inherited skin blistering disorder known collectively as epi-
tering disorders.3 In the direct IMF technique, antibody is conjugated directly dermolysis bullosa (EB) discussed in detail in Chapter 4 demonstrates the
with a fluorochrome and is used to detect an antigen in a tissue section using complex, multifaceted approach to diagnosis required in such cases. EB has
ultraviolet light microscopy.1–3 In the indirect IMF technique, patient serum been shown to result from mutations in genes encoding at least 11 different
(containing the antibodies) interacts with a tissue section containing the anti- structural proteins at or close to the dermal–epidermal junction (Fig. 2.11).1
gen. Antibody to a human immunoglobulin, conjugated to a fluorochrome, is Clinically, the different types of EB are characterized by widely differing
applied thereafter.1–7 The successful demonstration of the antigen requires the prognoses, from death in early infancy to blistering that may become milder
antigen to remain sufficiently insoluble in situ. Skin biopsies for direct immu- in later life.2 The clinical presentation in neonates, however, can be confusing
nofluorescence can be transported fresh on saline-soaked gauze in a container to dermatologists and pediatricians because of the overlapping features (Fig.
on ice, or in a transport medium such as Michel medium.8 The transport 2.12). In these circumstances, skin biopsy, usually a superficial shave biopsy
medium must be maintained at a pH of 7.0 to 7.2.1,3,5 The main uses for IMF since the key region is the dermal–epidermal junction, can provide critical
in dermatopathology are in the interpretation of the autoimmune blistering
diseases, lupus erythematosus, and vasculitis.6,7 In general, immunofluores-
cence has the following advantages over immunohistochemistry:
• more sensitive detection of antigen. Keratins
• use of special fixation that preserves ‘difficult’ antigens. 5 & 14
EB simplex

Electron microscopy EB simplex

with muscular Plectin
Electron microscopy is less utilized than in the past. Immunohistochemical 230-kDa
approaches are preferred in those instances where they are a reasonable
substitute. junctional EB
Transmission electron microscopy offers better resolution than light α6β4
EB with Type XVII
microscopy.1 To optimize this, tissue has to be embedded in extremely rigid integrin Herlitz &
pyloric atresia collagen
material to allow sectioning at 80 nm. In most circumstances, hydrophobic Laminin-332 non-Herlitz
epoxy resins are preferred. When a specimen is removed for ultrastructural junctional EB
examination, it must be fixed in a suitable fixative immediately. The volume
of the fixative should be 10 times the sample size. The final specimen size is
1 mm2.1 Fixation is affected by:
• pH,
Dominant and
• osmolarity, recessive
Type VII
• ionic composition of buffer, dystrophic EB
• fixative concentration,
• temperature,
• duration of fixation.
Primary fixation in an aldehyde, usually gluteraldehyde, and secondary
Fig. 2.11
fixation in osmium tetroxide are standard procedures. Advances in immu-
Basement membrane region: protein components at the dermal–epidermal junction
nohistochemistry have decreased the dependence on electron microscopy for and the subtypes of EB that result from mutations in the genes encoding these
ultrastructural confirmation of cell lineage. Notwithstanding, dermatologic proteins.
ultrastructural investigations are important in the diagnosis of:
• undifferentiated tumors,
• immunobullous disease,
• cerebral autosomal dominant arteriopathy with subcortical infarcts and
leucoencephalopathy (CADSIL),
• amyloidosis,
• metabolic storage diseases.2–7
Intercellular junctions, Weibel-Palade bodies, melanosomes, and premelano-
somes may help in the diagnosis of carcinomas, endothelial tumors, and mel-
anocytic tumors, respectively.3 In CADSIL, extracellular, electron-dense granular B
material is present in an indentation in vascular smooth muscle cells.5,6 Amyloid
is identifiable as randomly arranged, extracellular, nonbranching fibrils of inde-
terminate length and 7–10 nm diameter.7 Transmission electron microscopy
remains a valuable tool in the ongoing evaluation of the structure of normal and
pathological human cell and tissue components and infective agents.8–10

Diagnosis of inherited skin diseases

An efficient approach to genetic testing often relies on initial traditional his-
tologic characterization of skin biopsies.
Recent advances in molecular genetics and gene sequencing have led to
Fig. 2.12
many inherited skin diseases being diagnosed or confirmed by clinical molec- Epidermolysis bullosa: clinical appearances of neonates with different forms of
ular biologists rather than dermatopathologists. Analysis of skin biopsies still inherited EB. All three cases have similar blisters and erosions but their respective
remains vital for the accurate diagnosis of several genodermatoses, and often prognoses differ considerably; (A) Severe, generalized recessive dystrophic EB; (B)
provides a guide for subsequent molecular analyses. Examination of the skin Dowling-Meara EB simplex; (C) Herlitz junctional EB. Skin biopsy is fundamental to
biopsy informs the selection of additional molecular testing. Communication establishing the subtype of severe forms of EB.
38 Specialized techniques in dermatopathology


Fig. 2.13 Fig. 2.15

Optimal skin biopsy for diagnosing EB: following local anesthesia, the normal- Specific antibody probes to subtype inherited EB: (A) immunostaining of normal
appearing skin is gently rubbed, and then a superficial shave biopsy is taken. The control skin with an antibody to type VII collagen shows bright linear labeling at the
skin sample can then be subdivided for immunolabeling of frozen sections as well dermal–epidermal junction; (B) in contrast, the complete absence of labeling in skin
as being processed for transmission electron microscopy. from an individual with EB (case illustrated in Fig. 2.12a) indicates a diagnosis of severe,
generalized recessive dystrophic EB. (Bar = 50 μm.)

diagnostic and prognostic information. Typically, nonblistered skin from any antibodies can be used either to determine the level of cleavage in the
body site is sampled. Just before the biopsy is taken, the skin is rubbed gently skin (antigen mapping) or to see if there is a reduction or absence of
in an attempt to induce fresh microsplits at the dermal–epidermal junction, to immunostaining for a particular antigen.4 Figure 2.14 , for example,
facilitate the microscopic subtyping of EB (Fig. 2.13). demonstrates labeling using an antibody against type IV collagen in skin
The most informative investigation is immunolabeling of the der- from the neonate illustrated in Figure 2.12a . In this example, labeling
mal–epidermal junction using a panel of basement membrane anti- maps to the roof of the split. This indicates that the lamina densa is in
bodies. Skin biopsies can be transported in Michel's medium to a the blister roof and that there is a sublamina densa plane of blister for-
diagnostic laboratory at ambient temperature: this fixative is extremely mation. These findings support a diagnosis of dystrophic EB. This diag-
useful since basement membrane zone immunoreactivity is main- nosis can be refined by immunolabeling with an antibody to type VII
tained for at least 6 months. 3 For the immunolabeling, frozen skin collagen, as shown in ( Fig. 2.15 ). In normal skin there is bright, linear
sections are used rather than formalin-fixed paraffin-embedded mate- labeling at the dermal–epidermal junction; however, in the skin from the
rial because the antigenic epitopes of several transmembranous pro- neonate shown in Figure 2.12a , there is a complete absence of type VII
teins may be lost in routine skin processing. The basement membrane collagen immunoreactivity. All other antibodies show normal ­reactivity

Fig. 2.14
Antigen mapping to diagnose the subtype of inherited EB: this picture shows
immunolabeling of rubbed skin from an individual with EB (case illustrated in Fig. 2.16
Fig. 2.12a) with an anti-type IV collagen antibody. Rubbing the skin induces microsplits Transmission electron microscopy of skin in Dowling-Meara EB simplex (case
at the dermal–epidermal junction (asterisk). The type IV collagen reactivity maps to the illustrated in Fig. 2.12b): within the basal keratinocyte cytoplasm the keratin
roof of the dermal–epidermal junction (arrows). This indicates a sub-lamina densa plane filaments are condensed and form clumps and there is cytolysis that occurs just
of cleavage and establishes a diagnosis of dystrophic EB. (Bar = 25 μm.) above the dermal–epidermal junction. (Bar = 1 μm.)
Molecular techniques 39

at the dermal–epidermal junction. These findings therefore establish a

diagnosis of severe, generalized recessive dystrophic EB. Reduced or Molecular techniques
absent immunolabeling with specific basement membrane antibodies is
an extremely useful and rapid means of diagnosing recessive forms of Chromosomal karyotyping
EB. For example, skin from the neonate shown in Figure 2.12c demon-
This technique can be used as an initial screen to demonstrate gross chromo-
strated a lack of reactivity against laminin-332 but normal immunos-
somal aberrations associated with certain tumors. Most skin tumors are small
taining for all other antibodies. These findings establish a diagnosis of
and thus tissue is generally not set aside for karyotype analysis.
Herlitz junctional EB.
Chromosomal karyotyping is the historical gold standard for detecting
The development of a panel of basement membrane antibodies, most of
chromosomal aberrations in neoplastic tissue (Fig. 2.17). Fresh tumor tissue is
which are commercially available, has led to decreased emphasis on transmis-
required to grow the cells and the cytogenetic preparations and interpretation
sion electron microscopy as a diagnostic tool in EB.5 Ultrastructural analysis,
require skilled personnel. Nonetheless, this technique provides an open, unbi-
however, can be useful in confirming the plane of cleavage and in establish-
ased look at all of the chromosomes of a particular tumor. Total chromosomal
ing the diagnosis of certain dominant forms of EB. Skin from the neonate
gains and losses and also translocations between chromosomes can be demon-
illustrated in Figure 2.12b, for example, shows normal intensity basement
strated. Some of these chromosomal translocations are virtually diagnostic of
membrane zone reactivity for all diagnostic probes but transmission electron
certain tumors, particularly soft tissue and hematopoietic tumors.1 Other chro-
microscopy (Fig. 2.16) identifies discrete clumps of tonofilament and basal
mosomal changes can be suggestive of certain tumor types. While most trans-
keratinocyte cytolysis, characteristic of the Dowling-Meara variant of EB
locations are now confirmed by the other molecular methods described below,
simplex. For recessive forms of EB, however, immunolabeling of basement
traditional chromosomal karyotyping retains a role as an initial examination
membrane proteins has become the most important diagnostic approach.6,7
of the chromosomal complement of a neoplasm and an important tool for dis-
Reduced or absent staining for a particular protein provides a rapid diagnosis
covery of new chromosomal aberrations.2 Indeed, over time, the discovery of
as well as a means of identifying the encoding gene (or genes) in which the
chromosomal translocations within specific tumor types is proportional to the
underlying pathogenic mutations are present. Thus the skin biopsy findings,
number of cases karyotyped.3 Additional methodologies discussed below such
both histologic and immunohistochemical, provide a direct guide to molecu-
as spectral karyotyping (SKY) or multiplexed fluorescence in situ hybridiza-
lar screening tests, most of which are PCR-based, as discussed below. This
tion (mFISH) can aid in the interpretation of complex karyotypes.
molecular information can then be used for genetic counseling, carrier screen-
ing, and DNA-based prenatal testing, if indicated.
While the details of the initial analysis change in the diagnostic work-
Allelic imbalance
up of various inherited skin diseases, in many cases, preliminary histologic Gains or losses of specific regions of DNA, often containing particular genes
and other testing is performed in an attempt to determine which molecular of interest, can provide diagnostic insight.
diagnostic test is most relevant. This is important, as such testing is difficult An allele is a variant of a particular genetic locus or region of DNA such
and expensive and thus selection of which gene to examine is important for as a gene. Detection of allelic imbalance or loss of heterozygosity (LOH) is a
­efficient diagnostic work-up. method that can detect the presence of deletions or gains of specific alleles in

Fig. 2.17
Genetics of clear cell sarcoma: (A) this complicated karyotype shows derivative chromosomes 12 (blue box) and 22 (orange box). While recurrent translocation-associated
karyotypes are initially simple, they can become more complex with tumor progression. (B) The mechanism of chromosomal translocation involves breaks in chromosomes
12 and 22 that recombine to produce novel derivative chromosomes 12 and 22. The active fusion gene (EWSR1-ATF1) is produced on der(22). The fusion genes can be
produced by a variety of breakpoints within the introns of the involved genes making multiple exon combinations (C). This complicates the design of PCR-based detection
methods, as does substitution of the CREB1 gene for ATF1 on occasion.
40 Specialized techniques in dermatopathology

paraffin-embedded material.4 This usually corresponds to regions of a particu-

lar gene(s) of interest. For this approach, PCR is used to amplify small genomic
fragments that carry common polymorphisms and thus have a high likelihood
of being present in two different variants (alleles) in an individual. Ideally, these
variants are of different size so that they can easily be detected on an electro-
phoretic gel; DNA sequencing can be used if this is not possible. Only if two
different alleles in the normal tissue of a patient are present is this technique
informative. Imbalance (loss of one allele) is implied if one detects only one
of the alleles in the tumor tissue. More detailed analysis can distinguish those
which are true losses. Sites of recurrent losses are typically areas that harbor
tumor suppressor genes. This method can detect losses that would not be dem-
onstrated in a traditional chromosomal karyotype analysis and can be readily
adapted to formalin-fixed, paraffin-embedded (FFPE) tissue. The limitations of
LOH analysis include that it is sensitive to contamination by normal (stromal)
cells that can make it difficult to decide whether an allele is lost. Another draw-
back is its inability to determine whether the imbalance is caused by the loss of
one marker or by a copy number increase of the other marker.

Fluorescence in situ hybridization (FISH)

FISH uses specific probes to determine the number of copies of a specific
region of DNA that are present or whether a particular locus has been rear-
ranged as part of a chromosomal translocation.
FISH utilizes fluorescently labeled probes that are complementary to and
thus specifically hybridize a specific region of genomic DNA, allowing it to
be visualized.5,6 The labeled probe and the target genomic DNA, which can be
metaphase spreads, interphase nuclei (Fig. 2.18), or nuclei in ­formalin-fixed,
paraffin-embedded tissue sections (Fig. 2.19), are denatured and brought
into contact for several hours to days. Given appropriate hybridization con- Fig. 2.18
ditions, the labeled probes will anneal with the corresponding sequence Four-color FISH to two interface nuclei and metaphase chromosomes: the upper
portion shows two interface nuclei with the hybridization signals for the four
in the target DNA. This is easiest if probes are targeted to chromosomal
colors detectable as discrete spots. In the metaphase spread underneath, the
regions that are rich in repetitive sequences such as the centromeres. In these
hybridization signals can be seen to map to chromosome 6p (purple), 6 centromere
regions the probe can hybridize multiple times, resulting in hybridization (light blue), 6q (yellow), and chromosome 11q13 (green).
signals that are large and easy to detect. However, these regions typically do
not contain any functional genes, and while increases in chromosome copy
number can be recognized, no direct information on the copy number of a
specific cancer gene or locus can be obtained. Human cancers, including
melanoma, frequently have aberrations that involve only fragments of the
chromosome. The detection of these types of aberrations requires probes
targeted to unique, i.e., non-repetitive, sequences of DNA. Unique sequence
probes give smaller hybridization signals and can be more difficult to detect.
However, by using larger probe sizes of 100–300 kb, detection of unique
sequences is possible in paraffin sections (see Fig. 2.17). The advantage of
FISH is that it can detect cells with aberrations in the presence of signifi-
cant numbers of normal cells, provided that the neoplastic cells can be mor-
phologically identified in the hybridized section. Combinations of FISH and
immunofluorescence have been developed to assist in the identification of
the target cell population, but the compromises that have to be made to
accommodate antigen preservation by maintaining acceptable hybridization
Fig. 2.19
efficiency restrict its application for routine use in paraffin-embedded tissue. FISH to tissue sections of a melanoma (left panel) and nevus (right panel): the
Detection of heterozygous deletions is more difficult with FISH in tissue sec- panels show 400-fold magnifications of two nests of melanocytes with the nuclei
tions, because truncation of nuclei in tissue sections cut at normal thickness stained in blue. The green probe for chromosome 11q13 shows amplification in the
results in random loss of hybridization signals. Similarly, increased ploidy of melanoma as evident by a marked copy number increase compared to the purple
the neoplastic tumor cell population can simulate a gain of the target locus. signals representing chromosome 6p. By contrast, the melanocytes of the nevus in
These problems can be compensated by simultaneously hybridizing multiple, the right panel do not show significant differences for these two loci.
differentially labeled, probes to several loci in the genome and by analyzing a
larger number of cells. Comparing a probed locus to a centromeric probe on the flanking probes are fluorescently labeled in two different colors such as
the same chromosome in an alternate color can also compensate for cell ane- green and red, and when they are in close proximity in an intact chromo-
uploidy. A common example of this technique is comparison of the hybrid- some, the spectral overlap leads to two yellow signals, one for each normal
ization signals for the HER2 locus on 17q with centromere 17. This allows chromosome. In a cell with a rearrangement of a gene such as EWSR1 at
one to detect and distinguish both increased copy number of chromosome 22q12 in clear cell sarcoma, nuclei are seen with one intact chromosome 22
17 and specific amplification of the HER2 locus. with EWSR1 producing a yellow signal. In addition, the centromeric probe is
FISH using probes that flank a potential breakpoint associated with a chro- retained on the derivative (rearranged) 22 chromosome while the telomeric
mosomal translocation can be used to demonstrate rearrangement of that probe is transferred to the recipient chromosome (12 in the case of clear cell
locus (Fig. 2.20). This can be diagnostically helpful in certain hematopoi- sarcoma) leading to separate red and green signals in the nucleus. This method
etic malignancies with recurrent translocations, e.g., large cell anaplastic lym- only indicates that a locus is rearranged, not the identity of the chromosomal
phoma and some soft tissue tumors that can involve the skin.7,8 In this method, partner and gene. Thus caution must be used in interpretation as different
Molecular techniques 41

der(22) d(22)
22 22
12 R
der(12) 22

Probe Y G
Active breakpoint

Probes Probe
(q12) Silent breakpoint


Fig. 2.20
Break-apart fluorescent in situ hybridization (FISH) technique: the 12;22 translocation associated with clear cell sarcoma is depicted; (A) when the EWSR1 locus is intact, the
probes hybridize to the centromeric (red) and telomeric (green) regions flanking the gene. The spectral overlap of the two signals in juxtaposition produce a yellow signal.
Thus in cell lacking rearrangement of this locus, two yellow signals are present, representing the two copies of chromosome 22 lacking rearrangement (right); (B) When
rearrangement occurs, such as the balanced translocation with chromosome 12 depicted here, the centromeric probe (red) is retained by the derivative chromosome
22 while the green probe is transferred to the derivative chromosome 12. Thus in the nuclei one yellow signal indicates the intact chromosome 22 while the derivative 12
and 22 chromosomes segregate freely as single green and red signals, respectively (right).

Desmoplastic small
round cell tumor

WT1 NR4A3(TEC) Extraskeletal myxoid

11p13 9q22 chondrosarcoma


posarcoma 12q13 22q12

ATF1 ETS family Ewing
fibrous / PNET
12q13 FLI1 11q24 sarcoma
ERG 21q22
FEV 2q36
Clear cell sarcoma 16p11 Acute myeloid leukemia
ETV1 7p22 Fig. 2.21
ETV4 17q12 (FUS-ERG) Multiple translocations involve EWSR1 and the
(EWSR1-CREB1) 2q32
ZSG 22q12 Ewing homologous gene, FUS: both EWSR1 and FUS
7q33 sarcoma can often substitute for one another and both are
involved in balanced translocations with multiple
CREB3L1 genes resulting in a variety of neoplasms. Since
11p11 FISH only indicates that a single locus, such as
EWSR1, is re-arranged and nothing about the fusion
partner, results must be interpreted carefully within
the clinical and morphologic context of a tested
Low grade
case. Sometimes techniques such as RT-PCR must
fibromyxoid sarcoma
be used to verify the fusion partner.

translocations seen in different ­neoplasms can be associated with the same

probed locus. For instance, EWSR1 is rearranged in clear cell sarcoma, Ewing nuclei have to be counted. The latter restriction has been partially overcome
sarcoma, extraskeletal myxoid chondrosarcoma, angiomatoid fibrous histio- by the development of computer-based counting algorithms.9
cytoma, and some cases of myxoid liposarcoma (Fig. 2.21). Careful correla- In situ hybridization can also employ chromogenic probes such that
tion with the clinical and histologic features can help avoid confusion in these light microscopy can be used to visualize signals (termed CISH). This
situations. method is useful for detecting amplification of a genetic locus and tech-
The disadvantage of FISH is that it can only look at a few loci at a time, nically can be utilized in a break-apart probe strategy to detect trans-
and that analysis is time-consuming because signals in a large number of locations, but in practice this latter application can be very difficult to
42 Specialized techniques in dermatopathology

interpret. Probably the most common use for CISH is in direct detection
of nucleic acids associated with infections in cells such as human papil-
lomavirus (HPV) or Epstein-Barr virus. In HPV, this technique can be use
to type the virus and determine whether it is high risk (e.g., 16 and 18)
or low risk (6 and 11). In this application, ISH is used to demonstrate the
presence of viral DNA that is not present in a cell until infection occurs.
Modifications of this technique can be used to detect messenger RNA in
tissue sections as well.
In situ hybridization, fluorescent or chromogenic, is best used to
• amplification of a specific gene,
• rearrangement of a specific gene,
• presence of ‘foreign’ (infection-related) DNA or RNA.

Comparative genomic hybridization (CGH)

Comparative genomic hybridization can be used to demonstrate gains and
losses of DNA through the entire genome of a tumor sample. While this is
mainly a research tool at this time, its application has lead to important dis-
coveries that have been translated into focused genetic tests.
CGH demonstrates for the entire genome:
• regions of chromosomal loss (often containing tumor suppressor genes),
• regions of chromosomal gains (often containing oncogenes),
• overall patterns of gains and losses (rather than just a few focused
As originally described, CGH detects and maps DNA sequence copy num- Fig. 2.22
ber variation throughout the entire genome onto a cytogenetic map supplied Comparative genomic hybridization (CGH) on a metaphase chromosome spread
by metaphase chromosomes (Fig. 2.22).10 CGH can be regarded as a varia- (upper panels) and a microarray (lower panels): the regions of the chromosomes
tion of FISH in which the entire genome of a sample such as DNA from a skin (upper panel) that appear red are affected by deletions, whereas the regions that
tumor is used as a hybridization probe. The tumor is freed from contaminat- appear green are affected by gains or amplifications (bright green). Yellow indicates
ing normal cells by manual dissection, the DNA extracted, and labeled with a an area with normal DNA complement-no gain or loss. The lower panel on the right
fluorochrome (green, for example). In addition, a reference probe of normal shows a DNA microarray with approximately 2500 targets printed as triplicates
genomic DNA from a healthy donor is labeled with a different fluorochrome spots. Triplets that appear green indicate gains whereas those that appear red
indicate loss. The array targets are not printed in order of their genomic position
(red, for example). Equal amounts of the green- and red-labeled DNA are
which can help control for technical variations. The precise genomic location of
mixed and hybridized onto a substrate, which represents the entire human the DNA copy number changes detected by the measurement only becomes
genome. Originally, these were metaphase spreads of normal human chro- apparent after plotting the average ratios of red to green fluorescence intensities
mosomes prepared from lymphocytes of a healthy donor that represented a corresponding to their genomic position as illustrated in Figure 2.23
cytogenetic map. More recently, this substrate has been replaced by manu-
factured microarrays composed of nucleotide probes that are printed at high
density on a solid surface.11 Depending on the number and lengths of these
nucleotide probes, the entire genome can be represented on an array. By using
smaller probes, higher resolution of genetic gains and losses can be achieved.
During the hybridization, the red- and green-labeled DNA populations com-
pete for binding to corresponding regional microarray targets. For each
array target (or region of a chromosome in the original protocol) the ratio
of red and green fluorescence intensity ratio is determined. A ratio of 1 indi-
cates a balanced situation at this locus, i.e., no gain or loss in the tumor (see
Fig. 2.23). In the presence of deletions in the tumor genome, less green probe
will be available to hybridize to the corresponding targets, which will result
in a decreased green to red fluorescence intensity ratio (< 1). In the presence
Fig. 2.23
of increased copies, the corresponding targets still show a green to red fluo-
DNA copy number changes as detected by array CGH of an acral melanoma: the
rescence intensity ratio greater than 1. The ratio of red and green fluores- graph shows the log2 of the ratio of the fluorescence intensity ratios of tumor
cence intensity can be used to quantify the copy number change. A ratio of to reference DNA plotted according to their genomic position on the x-axis. The
1 indicates normal copy number, a ratio < 1 indicates a loss, and a ratio > 1 numbers at the top and at the bottom indicate the chromosomes. A log2 ratio of
indicates a gain. Gains with a high ratio that only affect portions of a chro- zero corresponds to normal copy number. As can be seen, multiple contiguous
mosomal arm are called amplifications. They arise from multiple independent chromosomal regions showed losses and gains. The arrow corresponds to an
events (chromosomal breakage and fusions) that accumulate under positive amplification of chromosome 11q13 interval containing the gene that encodes
selection, typically because the genomic region present in the amplicon con- cyclin D1.
tained an oncogene, i.e., a gene that provided a growth advantage to the
tumor cells with increased copies of the gene. analysis of solid tumors. Compared to conventional cytogenetic analysis,
The full experimental protocol for CGH is slightly more complex than CGH does not require culture of cells for karyotypic analysis, which brings
outlined above. A third, unlabeled DNA population is needed to ascertain the major advantage that CGH can be performed on archival tissue. It is
that repetitive regions that are scattered throughout the genome do not cross- important to note that the DNA copy number measurement obtained with
hybridize and interfere with the measurement. This blocking DNA is highly CGH represents an average of the entire cell population from which the DNA
enriched for repetitive regions and suppresses unwanted cross-hybridization was extracted. For this reason, only the copy number alterations present in
between repetitive regions in the labeled DNA populations and the chro- a substantial portion of the cells are detected by the method. Depending on
mosomes which serve as substrate. CGH has revolutionized the cytogenetic the type of aberration – amplifications can be detected most easily – the copy
Diagnosis of lymphomas 43

number change needs to be present in about 30% to 50% of the cells in

order to be identifiable. Alterations affecting only a minority of cells remain
undetected. A further limitation is that CGH only detects genomic aberra-
tions that result in DNA copy number changes. Balanced translocations and
Primer Primer Primer Primer
point mutations are not detected. Copy number neutral rearrangements that
arise through chromosomal recombination and LOH (see above) are also not EWSR1 ATF1
detectable by CGH. More recent implementations that use oligonucleotides EWSR1 / ATF1 Fusion
to determine single nucleotide polymorphisms (SNPs) allow the genome-wide
simultaneous assessment of DNA copy number and LOH in unfixed tumor
tissue.12,13 However, these methods are still being optimized to allow broad
applicability to routinely fixed tissue. No Amplification Amplification

Polymerase chain reaction (PCR)

1 2
In the diagnostic setting, PCR is used primarily to acquire sufficient DNA for
analysis by sequencing or other methods, primarily to demonstrate a muta-
tion or other genetic change or the presence of a specific gene or messenger Type 2
PCR is an extremely flexible technique and can be adapted to: fusion amplicon
• detect mutations (base pair substitutions, insertions and deletions) in
• demonstrate novel fusion transcripts (gene fusions), Fig. 2.24
Use of reverse transcription-polymerase chain reaction (RT-PCR) to detect fusion
• demonstrate clonality,
transcripts: this technique uses reverse transcription to convert RNA to cDNA that
• demonstrate loss of heterozygosity (loss of one allele), can then be amplified by PCR. This step is necessary as the breakpoints in the
• detect DNA or RNA associated with infectious organisms, usually large intronic regions of genomic DNA within a gene are essentially random,
• detect the levels of expression of messenger RNA. making it extremely difficult to amplify such large regions to identify the breakpoints
The ability to specifically amplify and detect any segment of DNA in the using genomic DNA as the template. When the gene is transcribed to RNA, the
human genome has opened many diagnostic doors. In this technique, a pair introns are removed during splicing and introns are directly juxtaposed
of short sequences of DNA (called primers) that hybridize to two sequences (Fig. 2.11c) allowing more ready detection of the novel juxtaposition of exons from
of genomic DNA (or RNA reverse transcribed to DNA) are designed to two different genes. When primers are designed for the exons of each of the two
amplify a specific region of DNA. Using a DNA polymerase that is stable genes involved in a translocation, amplification only occurs of the cDNA of the fusion
at high temperatures, a series of annealing, extending, and melting/denatur- transcript as these introns would not be adjacent in normal tissue. This product
ing cycles amplifies the DNA between the two probes. This technique can be will have a specific size and can be detected on a gel, but direct DNA sequencing
or other methods should be used to confirm its identity. Amplification of normal
used on nucleic acids extracted from formalin-fixed, paraffin-embedded tis-
housekeeping gene transcripts are used to ensure the quality of the cDNA.
sue, although probes must be designed to amplify shorter segments of DNA
since the starting material has been cross-linked and fragmented from the
formalin treatment. A variety of techniques based on PCR can be used to
amplify DNA and then determine its sequence. Direct sequencing of genomic
was not valuable, at least in part because of the presence of nodal nevi which
DNA allows detection of point mutations in cancer, such as BRAF or NRAS
would also be detected by this technique. While widely used in the research
in melanoma.14 Generally, one can detect a mutation in 1 in 5 cells with this
arena, other diagnostic approaches based on detection of gene expression will
technique. More sensitive techniques such as pyrosequencing can reduce this
likely evolve with time.
to 1 in 10 or 20 cells by analysis for a precise mutation. Finally, allele-­specific
It is often advantageous to have multiple methodologies for detecting vari-
PCR can be used to detect a known point mutation in as little as 1 in 50
ous molecular defects, as they are used in different situations and provide
or 100 cells. This technique has applications such as detecting KIT D816V
slightly different information. Figure 2.25 depicts this for the translocation
mutation in mastocytosis in skin where the neoplastic cells may be sparse
present in clear cell sarcoma.
relative to the surrounding normal tissue.15 Insertions and deletions in genes
can also be detected, usually by Sanger sequencing.8
Reverse transcribing RNA to DNA can allow specific detection of fusion Diagnosis of lymphomas
genes produced by chromosomal translocations such as seen in clear cell
sarcoma or dermatofibrosarcoma protuberans.16,17 This technique is partic- The diagnosis and subclassification of lymphomas has transformed dramati-
ularly valuable as there is no amplification product in the absence of tumor cally in the last three decades. Prior to this, the classifications in general use
as the translocations are not seen in normal tissue or other tumors (see were based purely on the morphological features of the neoplastic lympho-
Fig. 2.24). Because the two genes involved in a translocation event may cytes.1,2 However, modern classification systems also utilize all available immu-
have breaks at multiple introns (the noncoding region of DNA between the nophenotypic, genetic, and clinical information to group cases together for
protein encoding exon segments), multiple primer pairs may be necessary to the purposes of treatment and prognostication.3–7 Immunohistochemical and
detect all of the possible translocation types. Also, since multiple genes can molecular techniques therefore form an integral part of the diagnostic process,
be involved, for instance clear cell sarcoma can contain either an EWSR1- and are routinely employed in the assessment of suspect cutaneous lymphop-
ATF1 or EWSR1-CREB1 fusion, additional primer sets will be required for roliferations in order to discriminate reactive from neoplastic processes, and
detection of these as well (see Fig. 17.11c).18,19 In hematopoietic malignan- to subclassify the latter once identified. A battery of antibodies and molecular
cies, detection of fusion transcripts can be used to detect minimal residual techniques are now available to the practicing pathologist. 8–14
disease in the peripheral blood or marrow to measure tumor DNA as a sur- This section focuses specifically on amplications of the polymerase chain
rogate of tumor load to assess response to therapy or allow early detection reaction (PCR) to diagnostic hematopathology, the molecular technique in
of recurrence. This approach may be applied to solid tumors in the future. most common usage, for the detection of antigen receptor gene rearrange-
PCR can be used to detect normal genes as well. An instance of this in der- ment. The relevant immunophenotypic and genetic features of specific
matopathology was the attempt to detect melanocyte-specific RNA (reverse lymphoma subtypes are detailed in Chapter 29. In addition, FISH-based tech-
transcribed to DNA) in sentinel lymph nodes that might have been missed by niques can also be used to demonstrate translocation associated primarily
histology and immunohistochemical screening.20–22 Ultimately, this technique with B-cell lymphomas.
44 Specialized techniques in dermatopathology

Fig. 2.25
Multiple modalities for detection of recurrent translocations. Traditional karyotypes use metaphase chromosomes spreads to detect translocations and other structural
genetic aberrations using banding (staining) techniques. FISH uses less condensed interphase chromosomes to detect rearrangements or amplifications. RT-PCR can detect
the precise exons involved in a fusion RNA transcript. Each is a valid method for demonstrating chromosomal translocations, but each has applicability to different sample
types and provides different information.

PCR analysis of cutaneous lymphoid

The diagnosis of cutaneous lymphoma relies on a constellation of morpho-
logic, immunophenotypic, and clinical features, and may be difficult, par- * *
ticularly in the early stages. Molecular genetic findings are increasingly
incorporated into the diagnostic process. Often, their role is confirmatory,
demonstrating clonality in a lesion already thought to be lymphomatous on
the basis of pathological findings. However, in a significant proportion of
cases, a definitive diagnosis cannot be reached with certainty on the basis of
histology and immunophenotype. In such instances, the results of molecular
clonality studies may provide sufficient additional information for a diagno-
* *
sis to be assigned and/or to guide patient management. However, PCR analy-
sis of skin biopsies is subject to the same limitations and pitfalls as described
above. Therefore, the results of such studies must always be interpreted with
caution and only following close discussions between the pathologist, molec-
ular biologist, and clinician.

TCR gene rearrangement in cutaneous

Unlike the testing of solid tumors, PCR-based testing of lymphoid infiltrates
can take advantage of TCR receptor gene rearrangements to establish clonal-
ity, although this does not always equate to malignancy.
Clonality studies may be useful in identifying the early stages of myco-
sis fungoides or other cutaneous T-cell lymphomas. Dominant clones can
be demonstrated in the early lesions of mycosis fungoides and in cases of
cutaneous T-cell lymphoma which could not otherwise be identified using
conventional morphology (Fig. 2.26).1–6 They have also been said to facil-
itate discrimination between mycosis fungoides and inflammatory derma-
toses, and simulators of mycosis fungoides such as actinic reticuloid.3–8 PCR
is also useful in identifying the underlying disease in erythroderma when it is
due to cutaneous T-cell lymphoma, rather than inflammatory processes such
as eczema, contact dermatitis, drug reactions, pityriasis rubra pilaris, pso-
riasis, and pemphigus foliaceus.5,9–12 In addition, there are certain variants
and malignant mimics of cutaneous T-cell lymphoma, in which absence of a Fig. 2.26
clonal TCR gene rearrangement helps confirm the diagnosis. These include Mycosis fungoides: TCR gene rearrangement (photo of gel). Red astrixes indicate
extranodal NK/T-cell lymphoma of nasal type, CD4+/CD56+ hematodermic dominant clonal T-cell gene rearrangement shown as discrete bands rather than a
neoplasm and leukemia cutis. smear demonstrating numerous clones and non-rearranged receptors.
Diagnosis of lymphomas 45

However, clonality does not always equate with a diagnosis of malignant

lymphoma. Monoclonal TCR gene rearrangements have been demonstrated Constant Variable Disulphide Heavy Light
domain domain chain chain
in otherwise typically benign dermatoses. These include: bonds

• discoid lupus erythematosus,

• lichen planus,
• lichen sclerosus.13–15
Bona fide T-cell clones may also be found in examples of cutaneous T-cell
pseudolymphoma, particularly those associated with reversible hypersensitivity
drug reactions, and in some instances the same clone has been demonstrated
in biopsies from the same patient taken at different sites.15–19 There is also a
group of disorders which generally run a benign clinical course, but can be
associated with progression to cutaneous T-cell lymphoma, usually mycosis
fungoides but occasionally cutaneous anaplastic large cell lymphoma or some
other form of cutaneous T-cell lymphoma. These include:
• pigmented purpuric dermatosis,
• pityriasis lichenoides chronica,
• pityriasis lichenoides et varioliformis acuta, Fig. 2.27
Structure of Ig. The two
• lymphomatoid papulosis.20–34 epitope binding sites are
A variable, but often high, incidence of monoclonality is found when series of formed primarily by the
these conditions are analyzed by PCR for the TCRG and/or TCRB gene, and the two variable domains.
same clone is usually found in follow-up biopsies when lymphoma ensues.18,25,32–39
Another similar group comprises cutaneous T-cell lymphoproliferative dis- cases using PCR techniques designed to detect IG gene rearrangements as part
orders that are currently thought to represent very indolent or prelymphoma- of the routine diagnostic work-up (Figs 2.27 and 2.28).1–4 However, even
tous forms of recognized subtypes of cutaneous T-cell lymphomas including: using BIOMED-2 protocols, there may be a significant false-negative rate.
• large plaque parapsoriasis,15,19,40 This is particularly the case if the only primers used are for the framework
• idiopathic follicular mucinosis,15,41 regions on the IG heavy chain gene, one study detecting clonality in only 67%
• syringolymphoid hyperplasia with alopecia,42–44 of primary cutaneous B-cell lymphomas.4 This is likely to be due to the rela-
• hypopigmented mycosis fungoides.45 tively high proportion of lymphomas of germinal center, or postgerminal cen-
These are thought to be related to variants of mycosis fungoides. Idiopathic ter origin encountered in the skin, since these are associated with high levels
erythroderma has similarities to Sezary syndrome46 and atypical lymphocytic of somatic hypermutation. Detection levels increase when assays targeting IG
lobular panniculitis to subcutaneous panniculitis-like T-cell lymphoma.47,48 light chains, including the Kde, are introduced.2
These entities are typically monoclonal and share many characteristics with Clonality assays are not a reliable way of differentiating B-cutaneous lym-
the lymphomas to which they are putatively related. However, they lack full phoid hyperplasia from cutaneous B-cell lymphoma. Monoclonal immuno-
morphologic and/or phenotypic evidence of lymphoma, and although most globulin gene rearrangements have been demonstrated in lesions designated
run a recalcitrant course resistant to topical therapy, and some progress to B-cutaneous hyperplasia (or synonyms thereof), even when less sensitive
overt malignant lymphoma, most have an innocuous clinical outcome. Southern blotting techniques have been used.5–9 However, in series quoting
It has been proposed that the following be encompassed under the rubric high levels of monoclonal B-CLH, relatively few cases progress to overt lym-
of ‘cutaneous T-cell lymphoid dyscrasia’49: phoma.5,7,8 These lesions may therefore be analogous to the cutaneous T-cell
• idiopathic pigmented purpuric dermatosis, dyscrasias described above, in that they may run a protracted but ultimately
• pityriasis lichenoides, benign clinical course, only rarely progressing to overt malignancy.
• large plaque parapsoriasis,
• idiopathic follicular mucinosis,
• syringolymphoid hyperplasia with alopecia,
• hypopigmented mycosis fungoides,
• idiopathic clonal erythroderma,
• atypical lymphocytic lobular panniculitis.
The concept is similar to that of monoclonal gammopathy of uncertain sig-
nificance, already well established for plasma cell dyscrasias.46 ‘Cutaneous T-cell
lymphoid dyscrasia’ is used to convey the limited but real malignant potential
of these monoclonal and oligoclonal lymphoproliferations, and is preferred by
the authors to terms such as ‘premycotic’, because evolution to overt cutaneous
T-cell lymphoma is uncommon. It is hypothesized that T-cell clones develop as
a result of chronic antigenic stimulation. Acquisition of genetic abnormalities
by an expanded clone results in an ability for autonomous growth. This is ini-
tially held in check by the host immune cells, and only when these are overcome
does the fully malignant clone emerge. Entities that occasionally harbor clonal
populations of T cells, but have no malignant potential (such as drug-induced
pseudolymphoma), are excluded from this category.

IG gene rearrangement in cutaneous

Fig. 2.28
A number of variant gene rearrangements often involve the promoters of
B-cell lymphoma: Ig gene rearrangement
immunoglobulin genes to drive the expression of oncogene critical to lym- (photo of gel). The upper bands arrowed in
phomagenesis. The current World Health Organization (WHO) classification lanes two and three indicate non-rearranged
scheme relies on these molecular results for precise classification. IG with the astrix in lane two indicates a
The clonal nature of cutaneous B-cell infiltrates in both primary and sec- polyclonal IG population. The lower band in
ondary cutaneous B-cell lymphomas can be confirmed in a high percentage of lane three shows a dominant IG clone.

3 Disorders of keratinization
Dieter Metze
for references and
additional material

Ichthyosis  46 Lichen spinulosus  66 Marginal papular acrokeratoderma  82

Ichthyosis vulgaris  46 Phrynoderma  67 Huriez syndrome  82
X-linked recessive ichthyosis  49 Keratosis pilaris  67 Vohwinkel's syndrome  83
Syndromes with steroid sulfatase Keratosis pilaris atrophicans  68 Loricrin keratoderma  84
deficiency  50 Clouston's syndrome  84
Acquired ichthyosis-like conditions  69
Multiple sulfatase deficiency  50 Olmsted syndrome  85
Pityriasis rotunda  70
Refsum syndrome  50 Papillon-Lefèvre syndrome  86
Autosomal recessive lamellar ichthyoses  51 Erythrokeratodermas  71 Naxos syndrome  87
Harlequin ichthyosis  54 Erythrokeratoderma variabilis  71 McGrath syndrome  87
Autosomal dominant lamellar ichthyosis  55 Progressive symmetric erythrokeratodermia  73 Pachyonychia congenita type I  88
Congenital bullous ichthyosiform Keratitis-ichthyosis-deafness Pachyonychia congenita type II  88
erythroderma  55 syndrome  73 Tyrosinemia type II  89
Ichthyosis bullosa of Siemens  58 Hystrix-like ichthyosis with deafness  74 Carvajal Huerta syndrome  89
Linear epidermolytic epidermal nevus  59 Howell-Evans syndrome  90
Palmoplantar keratoderma  75 Schöpf-Schulz-Passarge syndrome  91
Epidermolytic acanthoma  59
Keratosis palmoplantaris diffusa
Focal epidermolytic hyperkeratosis  60
Vörner-Unna-Thost  76 Acquired palmoplantar keratoderma and
Peeling skin syndrome  60
Epidermolytic hyperkeratosis with polycyclic internal malignancy  91
Ichthyosis hystrix Curth-Macklin  60
psoriasiform plaques  77 Keratoderma climactericum  91
Congenital reticular ichthyosiform
Diffuse nonepidermolytic palmoplantar Clavus  91
erythroderma  61
keratoderma  77 Callus  91
Comèl-Netherton's syndrome  61
Progressive palmoplantar keratoderma  78 Acrokeratosis verruciformis of Hopf  91
Sjögren-Larsson syndrome  63
Keratolytic winter erythema  78 Porokeratosis  92
Conradi-Hünermann-Happle syndrome  65
Mal de Meleda  79 Hyperkeratosis lenticularis perstans  95
Other congenital ichthyotic Keratosis palmoplantaris areata Granular parakeratosis  96
syndromes  65 et striata  80 Circumscribed palmar or plantar
Follicular ichthyosis  66 Keratosis palmoplantaris nummularis  80 hypokeratosis  96
Ichthyosis follicularis with alopecia and Punctate palmoplantar keratoderma  81
photophobia  66 Keratosis punctata of the palmar creases  81

• Congenital ichthyoses present with collodion membrane or ichthyosiform

Ichthyosis erythroderma at birth or manifest within 4 weeks.
• Variants in which the skin lesions are but one facet of a more sinister
The term ichthyosis (Gr. ichthys, fish) is applied to a number of heterogenous systemic illness (syndromic ichthyosis).
genetic disorders characterized by permanent and generalized abnormal kera- The development of a diffuse ichthyosis-like scaling during life should not
tinization.1,2 The clinical features range from mild involvement, often passed be confused with ichthyotic skin disorders. These acquired ichthyosis-like
off as ‘dry skin’ (xerosis), through to severe widespread scaly lesions causing (ichthyosiform) skin conditions can be caused by different underlying dis-
much discomfort and social embarrassment (Fig. 3.1). The scales are often eases (see below). 4
shed as clusters rather than as single cells as is the norm.1 The pathogenesis of
the ichthyoses is very complex but ultimately depends upon two distinct final
common pathways: one relates to retention of corneocytes (e.g., ichthyosis
Ichthyosis vulgaris
vulgaris, recessive X-linked ichthyosis), the other involves epidermal hyper-
proliferation (e.g., congenital ichthyosiform erythroderma, bullous ichthyo- Clinical features
sis, Sjögren-Larsson syndrome and Refsum's disease).3 This relatively common disorder (incidence of 1:250 to 1:1000 births) has
Ichthyotic skin disorders are classified into the following groups3a an autosomal dominant mode of inheritance.1,2 It may present initially as
(Tables 3.1, 3.2): keratosis pilaris (follicular hyperkeratosis) on the arms, buttocks and thighs.
• Noncongenital ichthyoses develop 4 weeks after birth and spare flexures, The disease is usually fairly mild and becomes apparent within the first few
palms and soles. months or years of life. It affects the sexes equally and presents as dryness
Ichthyosis 47

Fig. 3.1
(A, B) Severe generalized ichthyosis: this was an
A B incidental finding at postmortem. Ichthyosis can be very
disfiguring and a considerable social disadvantage.

Table 3.1 those on the face and scalp. The rims of the ears are often scaly.3 There is sea-
Non-congenital ichthyoses sonal variation, with improvement of the condition in the summer months,
Isolated (nonsyndromic With associated symptoms particularly in humid climates.2 The palms and soles show increased palmar
ichthyosis) (syndromic ichthyosis) and plantar markings in contradistinction to sex-linked ichthyosis and may
Autosomal dominant ichthyosis Syndromes with steroid sulfatase also show mild hyperkeratosis.3 An association with keratosis punctata of
vulgaris deficiency the palms and soles has also been documented.4 Chapping of the hands and
feet can be a problem.5 There is no evidence of hair, nail, or teeth involve-
Recessive X-linked ichthyosis Multiple sulfatase deficiency
ment. There is an increased incidence of atopic disorders.5 Serum lipids are
Refsum's disease

Table 3.2 Pathogenesis and histological features

Congenital ichthyoses Ichthyosis vulgaris is characterized by deficiency of profilaggrin, a major con-
stituent of the keratohyalin granules.6,7 Flaky tail mice, which represent an ani-
Isolated (nonsyndromic With associated symptoms
mal model of ichthyosis vulgaris, produce defective profilaggrin with resultant
ichthyosis) (syndromic ichthyosis)
absence of filaggrin.8 Ultrastructurally, the keratohyalin granules are reduced,
Autosomal recessive lamellar Comèl-Netherton's syndrome
spongy or crumbly and associated with decreased amounts of filaggrin.9 The
ichthyoses (nonbullous congenital Sjögren-Larsson syndrome
clinical severity of ichthyosis vulgaris correlates with the reduction of keratohy-
ichthyosiform erythroderma)
alin granules, which reflects a defective epidermal synthesis of filaggrin. Using
Harlequin ichthyosis Conradi-Hünermann-Happle fluorescein-labeled filaggrin antibodies demonstrates the severity of the defect
syndrome (chondrodysplasia (H. Traupe and V. Oji, unpublished observation). Filaggrin aggregates keratin
puncta type 2)
intermediate filaments in the lower stratum corneum and is subsequently prote-
Autosomal dominant lamellar Ichthyosis prematurity syndrome olyzed to form free amino acids including urocanic and pyrrolidone carboxylic
ichthyosis acids critical as water-binding compounds in the stratum corneum.
Bullous congenital ichthyosiform Gaucher syndrome, Type 2 Linkage analysis of the epidermal differentiation complex on chromosome
erythroderma Dorfman-Chanarin syndrome 1q21 has identified mutations in the gene encoding filaggrin. Parents with one
Ichthyosis bullosa of Siemens Trichothiodystrophy heterozygous filaggrin mutation may be asymptomatic, whereas affected off-
spring with two mutations often show classic ichthyosis vulgaris.10 Since the
Peeling skin syndrome Ichthyosis follicularis with atrichia filaggrin gene is a major susceptibility gene for atopic dermatitis, ­mutations
ichthyosis hystrix Curth-Macklin and photophobia
have also been shown in atopic dermatitis.11
Congenital reticular ichthyosiform Ichthyosis vulgaris is characterized by mild to moderate orthohyperkera-
erythroderma tosis associated with a hyperplastic, atrophic or normal epidermis. The key
feature is a thin or absent granular cell layer (Fig. 3.3).12,13 Regional vari-
ation in the thickness and/or presence of the granular cell layer may be a
(xerosis) and slight to moderate fine scaling, particularly involving the exten- ­feature and therefore it is best to take the biopsy from a site of maximal scal-
sor surfaces of arms and legs and characteristically sparing the flexures (Fig. ing. The lesions of keratosis pilaris show dilated follicles containing large
3.2). The light-gray scales vary in quality from thick adherent shiny plates keratin plugs. In the upper dermis a mild perivascular lymphocytic infiltrate
to simply dusty accumulations which, when scratched, leave a mark just as may be present. When ichthyosis vulgaris is associated with atopic dermatitis,
when one touches a dusty surface. The truncal lesions tend to be thicker than ­parakeratosis and other signs of a spongiotic dermatitis can be found.
48 Disorders of keratinization

Differential diagnosis
The histologic differential diagnosis includes other diseases character-
ized by orthohyperkeratosis and a reduced or absent stratum granulosum
(Table 3.3)

Table 3.3
Histologic patterns in ichthyotic skin disorders

Orthohyperkeratosis & stratum granulosum reduced or absent

Ichthyosis vulgaris (w/o atopic dermatitis)
Acquired ichthyosis-like condition
Refsum syndrome
Dorfman syndrome
Trichothiodystrophy syndrome
Fig. 3.2 Conradi-Hünermann-Happle syndrome
Ichthyosis vulgaris: Orthohyperkeratosis & stratum granulosum well developed
abdominal involvement
is most noticeable in this
AR-lamellar ichthyosis
patient. Sparing of the
Harlequin ichthyosis
flexures is characteristic
Acquired ichthyosis-like condition
of this variant of
(Lichen simplex chonicus)
ichthyosis. By courtesy
of W.A.D. Griffiths, MD, Hyperkeratosis with ortho- and parakeratosis and stratum granulosum
Institute of Dermatology, prominent
London, UK. AD-lamellar ichthyosis
Sjögren-Larsson syndrome
Harlequin ichthyosis
Inflammatory skin disease
Epidermolytic hyperkeratosis
Bullous ichthyotic erythroderma Brocq
Annular epidermolytic ichthyosis
Ichthyosis bullosa Siemens
Epidermal nevi
Epidermolytic acanthoma/leukoplakia
Epidermolytic palmoplantar keratoses
Incidental finding
Perinuclear vacuoles and binucleated keratinocytes
With parakeratosis:
Congenital reticular
Ichthyosiform erythroderma
With orthokeratosis:
Ichthyosis hystrix Curth-Macklin
A Differential diagnosis:
Epidermolytic ichthyoses (Keratin clumps !)
Follicular hyperkeratosis
Keratosis pilaris, lichen spinulosus, phrynoderma
Keratosis pilaris atrophicans
Ichthyosis vulgaris with follicular keratosis
Lamellar ichthyosis
Sjögren-Larsson syndrome
Ichthyosis follicularis with alopecia and photophobia
Congenital atrichia
HID-, KID syndrome
Hereditary mucoepithelial dysplasia
Pachyonychia congenita
Ectodermal dysplasias
Darier's disease
Pityriasis rubra pilaris
Psoriasis-like features
Psoriasis vulgaris
Comèl-Netherton's syndrome
B Annular epidermolytic ichthyosis
CHILD syndrome
Fig. 3.3 Papillon-Lefèvre syndrome
(A, B) Ichthyosis vulgaris: there is hyperkeratosis. The granular cell layer is absent.
Ichthyosis 49

X-linked recessive ichthyosis

Clinical features
Also known as steroid sulfatase deficiency and ichthyosis nigricans, this
X-linked, recessively inherited disorder has an incidence of 1:6000 male
births.1–3 The disease is exceedingly rarely expressed in females.4 Cutaneous
lesions tend to be more conspicuous and severe than in the autosomal dom-
inant variant.2 The scales are large and dark and are seen particularly on
the trunk, the extensor surface of the extremities, the scalp, the preauricular
region, and the neck (Figs 3.4–3.7).2 Mild Involvement of the flexures is also
present (Fig. 3.8).1 However, differentiation from ichthyosis vulgaris can be
difficult as some patients present with fine, light scales and the flexures may
be spared. The palms and soles are usually unaffected and keratosis pilaris is
not a feature. Involvement of the trunk and neck often gives the skin a dirty
appearance. Lesions may improve or disappear in warm weather.2 The hair,
nails, and teeth are not affected.
Corneal opacities due to comma-shaped deposits in the posterior capsule
of Descemet's membrane or corneal stroma, visible with slit-lamp exami-
nation (Fig 3.9), are characteristic and may be detected in female carriers.5 Fig. 3.5
Inadequate cervical dilatation may lead to prolonged delivery of affected Sex-linked ichthyosis: the scale is coarser than that seen in ichthyosis vulgaris.
male newborns. Undescended testes and hypogonadism can be a feature in By courtesy of the Institute of Dermatology, London, UK.
as many as 25% of affected patients.6–8 Rarely, testicular cancer has been

Pathogenesis and histological features

The disease is associated with a deficiency of the microsomal enzyme, ste-
roid sulfatase/STS (sterol sulfate sulfohydrolase/arylsulphatase C).9 This is a
membrane-bound enzyme, which hydrolyses the 3-β-sulfate esters of choles-
terol and the sulfated steroid hormones.10 Absence of this enzyme is associ-
ated with persistence of the sulfate moiety on a number of sulfated steroid
hormones and cholesterol sulfate.3
X-linked recessive ichthyosis is characterized by a raised serum choles-
terol sulfate.10 The corneocytes contain excess cholesterol 3-sulfate and
diminished free sterol.11 Steroid sulfatase deficiency possibly results there-
fore in persistence of the lipid contents of the membrane-coating granules
and hence increased or persistent adhesion between adjacent keratin plates
in the stratum corneum. Beyond that, increased amounts of cholesterol sul-
fate may inhibit the epidermal serine protease activity, which results in reten-
tion of corneodesmosomes leading to less shedding of scales and retention
hyperkeratosis. Steroid sulfatase deficiency can be detected using the patient's

Fig. 3.6
Sex-linked ichthyosis: the scales are large and disfiguring. By courtesy of
R.A. Marsden, MD, St George's Hospital, London, UK.

­ eripheral leukocytes and cultured skin fibroblasts. Diagnosis may also be

affected by lipoprotein electrophoresis, which shows increased mobility of
low density and very low density beta-lipoproteins in addition to the steroid
sulfatase deficiency.12,13
The gene locus for recessive X-linked ichthyosis is within the Xp22.3
region of the X chromosome.14–16 Recently, indirect genotypic analysis using
polymorphic DNA markers closely linked to the STS gene has been shown
to be a reliable method of detection of the carrier status.14,17 Complete dele-
tions of structural STS gene have been reported in 90% of patients with
X-linked ichthyosis;14,16–19 the other 10% show partial deletions or point
mutations.1 Carrier status can also be confirmed by fluorescent in situ
hybridization (FISH) analysis.19 Recently, rapid diagnosis and differentia-
tion from ichthyosis vulgaris using polymerase chain reaction (PCR) has
been documented.20 Other important genes are located close to the steroid
sulfatase gene.
Fig. 3.4 Lesions show non-specific features of compact hyperkeratosis and slight
Sex-linked ichthyosis: there is severe involvement. Note the large, dark confluent acanthosis associated with a granular cell layer, which may be normal
scales. or increased in thickness (Fig. 3.10).21,22 Keratohyalin granules show no
50 Disorders of keratinization

Fig. 3.7
Sex-linked ichthyosis:
in this example the
scales appear dirty. This
can be an extremely
embarrassing condition.
By courtesy of the
Institute of Dermatology,
London, UK.

Fig. 3.9
(A) Sex-linked ichthyosis: characteristic linear opacities at the level of Descemet's
membrane. Slit-lamp photograph. (B) Same lesion viewed by specular microscopy.
By courtesy of R.J. Buckley, MD, Moorfield's Eye Hospital, London, UK.

Syndromes with steroid sulfatase

A number of other important genes are located close to the steroid sulfatase gene.
If a deletion is larger, it may include some of these genes, producing a contigu-
ous gene syndrome.1 Two closely linked genes are those for Kallmann syndrome
(hypogonadotropic hypogonadism and anosmia) and X-linked recessive chon-
drodysplasia punctata.2 Possible linkage to a gene for hypertrophic pyloric steno-
sis has also been described.2 Thus patients may present with the skin changes of
X-linked recessive ichthyosis but with a whole spectrum of other problems.2
Fig. 3.8
Sex-linked ichthyosis: Multiple sulfatase deficiency
involvement of the
flexures is sometimes a
Multiple sulfatase deficiency is a severe neuropediatric disorder inherited as an
feature of this variant. By autosomal recessive. Patients develop normally for the first several years and
courtesy of the Institute then begin to show striking loss of mental capacity and motor ­abilities. They
of Dermatology, London, usually die before puberty. The ichthyosis is typically mild and the least of
UK. their problems. In multiple sulfatase deficiency patients the ­ichthyosis is simi-
lar to but usually less severe than in X-linked recessive ­ichthyosis. Therefore,
ichthyosis in a child with unexplained neurological symptoms should always
prompt measurement of steroid sulfatase levels.1
abnormality. Follicular plugging is not a feature. Paradoxically, biopsies of
thicker scales can show massive orthohyperkeratosis with reduction of the
granular layer and a thin epidermis, causing confusion with ichthyosis vul-
Refsum syndrome
garis. A discrete lymphocytic perivascular inflammatory cell infiltrate may
be evident. Clinical features
Ultrastructural features include a high number of transitional cells and an Refsum syndrome (hereditary motor and sensory neuropathy type 4, here-
abnormal persistence of desmosomal disks in the horny layer while keratohy- dopathica atactica polyneuritiformis, phytanic acid deficiency) is a rare type
alin granules are normal. An increased melanosome transfer accounts for the of an autosomal recessive syndromic ichthyosis.1 The skin changes appear
dark appareance of the scales.23 in childhood and are similar to those seen in ichthyosis vulgaris including
Ichthyosis 51

The more severe noneyrthrodermic phenotype of lamellar ichthyosis has an

estimated prevalence of 1:200 000–300 000. The infant is often born encased
in a thick ‘collodion’ plate-like shell of keratin (Figs 3.11, 3.12), and while
the term ‘collodion baby’ is most often applied to cases of lamellar ichthyosis,
similar appearances are sometimes found in a number of other disorders such
as autosomal dominant lamellar ichthyosis, Netherton's syndrome, Sjögren-
Larsson syndrome, trichothiodystrophy, and infantile cerebral Gaucher
syndrome.3,4 Hence, colloidon baby is a clinical description but not a dis-
ease. Within a few days the shell is shed to reveal a mild ­erythroderma with

Fig. 3.11
Autosomal recessive
lamellar ichthyosis: the
collodion membrane
is best seen on the
forehead. There is scaling
and erythema on the
trunk. By courtesy of
R.A. Marsden, MD,
St George's Hospital,
Fig. 3.10 London, UK.
(A, B) Sex-linked ichthyosis: there is hyperkeratosis and mild acanthosis. The
granular cell layer is normal.

hyperlinear palms. Due to lipid storage, melanocytic nevi may show a yellow
hue. Associated symptoms include loss of vision from retinitis pigmentosa,
in which night blindness is often the first problem, anosmia, cardiac arrhyth-
mias, and a whole spectrum of neurological problems including bilateral
sensorineural deafness, cerebellar ataxia, and peripheral polyneuropathies.2

Pathogenesis and histological features

Refsum syndrome is generally caused by a mutation in a gene encoding
perioxisomal phytanol-CoA hydroxylase, although it can also be caused by
­specific ­mutations in the peroxisomal receptor gene PEX7.3,4 Peroxisomes are
involved in the metabolism of bile acid and cholesterol biosynthesis. Elevated
levels of ­phytanic acid in plasma and tissue are diagnostic. Low-phytol diet
is mandatory.5
Routine histology of a skin biopsy does not differ from ichthyosis vulgaris.
When a biopsy is fixed in alcohol and a Sudan stain performed, lipid drop-
lets are found in the keratinocytes, in particular in biopsies from melanocytic
nevi. The same inclusions can be shown by ultrastructural examination.6 Fig. 3.12
Autosomal recessive
lamellar ichthyosis: note
Autosomal recessive lamellar ichthyoses the erythema. The skin
is shiny, taut, and shows
Clinical features fissuring around the
anterior aspect of the
Autosomal recessive lamellar ichthyoses include a group of mostly mono- ankle. By courtesy of D.
genetic disorders presenting at birth with generalized hyperkeratosis and Atherton, MD, Children's
­scaling (ichthyosis congenita). The clinical presentation varies considerably Hospital at Great Ormond
in ­severity and clinical course.1–5 Street, London, UK.
52 Disorders of keratinization

g­ eneralized scaling (Fig. 3.13). In nonerythrodermic phenotype of lamellar described including ichthyosis, keratinization, hyper- and parakeratosis, and
ichthyosis the scales are large, dark and platelike and cover the entire body papilla development. The teeth are not affected.3
including the palms, soles, scalp, and flexures.5–8 Fissuring of the hands and In contrast, other individuals show a more pronounced erythroderma
feet occurs and the skin around the joints may become verrucous. There is with fine, white scaling (non-bullous congenital ichthyosiform erythroderma,
often associated difficulty with sweating, and hyperpyrexia may be a feature.7 NCIE). A collodion membrane is often present at birth.1 After shedding, the
There is nail dystrophy, hair involvement (scarring alopecia), severe ectro- infant typically presents with an intense generalized erythroderma.2 While
pion (up to 80% of patients) and eclabium are characteristic (Fig. 3.14). The platelike scales may be seen on the extensor surfaces of the legs, the scalp,
ectropion is of the cicatricial type and develops as a consequence of exces- face, upper extremities and trunk are covered with fine white scaling (Figs
sive dryness and associated contracture of the anterior lamella of the eye- 3.15–3.20).8 Mild ectropion and eclabium may be complications and palmo-
lid. Complications include corneal ulceration, vascularization, and corneal plantar keratoderma is often more severe than in noneyrthrodermic forms of
­scarring with eventual ­blindness.9 Primary conjunctival lesions have also been AR-lamellar ichthyosis.3 Exceptionally, congenital ichthyosiform erythroderma
has been associated with retinitis pigmentosa.10 There is an increased risk of
developing skin cancer including basal and squamous cell carcinoma.11

Fig. 3.13
Autosomal recessive
lamellar ichthyosis:
note the widespread
Fig. 3.15
and prominent large
Nonbullous congenital
dark brown scales. By
courtesy of D. Atherton,
erythroderma: there is
MD, Children's Hospital
intense erythema and fine
at Great Ormond Street,
scaling is also present.
London, UK.
The scalp hair is sparse
and the eyebrows are
absent. By courtesy of
D. Atherton, MD, Children's
Hospital at Great Ormond
Street, London, UK.

Fig. 3.14
Autosomal recessive
lamellar ichthyosis: in
this infant, there is gross
ectropion and eclabion.
By courtesy of D. Atherton, Fig. 3.16
MD, Children's Hospital Nonbullous congenital ichthyosiform erythroderma: there is marked erythema with
at Great Ormond Street, severe scaling. Blistering is not seen in this variant of ichthyosis. By courtesy of
London, UK. D. Atherton, MD, Children's Hospital at Great Ormond Street, London, UK.
Ichthyosis 53

Fig. 3.17 Fig. 3.19

Nonbullous congenital ichthyosiform erythroderma: there is intensive erythema and Nonbullous congenital ichthyosiform erythroderma: the scales are large, thick and
fine scaling. By courtesy of the Institute of Dermatology, London, UK. white. By courtesy of the Institute of Dermatology, London, UK.

Fig. 3.20
Nonbullous congenital ichthyosiform erythroderma: there is severe palmar
involvement and constriction bands are evident. By courtesy of the Institute of
Dermatology, London, UK.

Other variants of transglutaminase mutations are characterized by dis-

tinct clinical features. In self-healing collodion baby the ­transglutaminase-1
mutation is pressure-sensitive so that while in utero the enzyme cannot
Fig. 3.18 function properly, it resumes normal function after birth. About 10% of
Nonbullous congenital ichthyosiform erythroderma: there is generalized platelike collodion babies fall into this group.19 In bathing suit ichthyosis (BSI) the
scaling. By courtesy of the Institute of Dermatology, London, UK. mutation in transglutaminase-1 appears to be temperature sensitive so that
the face and extremities are almost completely spared apart from skin areas
overlaying blood vesssls. Digital thermography has validated a striking cor-
Pathogenesis and histological features relation between warmer body areas and the presence of ­scaling, suggesting
The most common cause of lamellar ichthyosis is transglutaminase-1 deficiency a decisive influence of the skin temperature. In situ TGase testing in skin
which accounts for 30–40% of cases. Mutations in the ­transglutaminase-1gene of BSI patients has also demonstrated a marked decrease of enzyme activity
result in markedly diminished or lost enzyme activity and/or protein. In some when the temperature is increased from 25 to 37 degrees Celsius.20
cases, this enzyme is present but there is little detectable activity, and in other The second most common mutation in lamellar ichthyosis can be found
clinically similar cases, transglutaminase-1 levels appear to be normal.12–17 in the binding cassette protein.21,22 Missense mutations cause lamellar ich-
Since conventional enzyme assays and mutational analyses are tedious, an thyosis while deletions are responsible for the far more dramatic harlequin
assay for the rapid screening of transglutaminase-1 activity using covalent fetus.23 Mutations in either transglutaminase-1 or the lipoxygenases are most
incorporation of biotinylated substrate peptides into skin cryostat sections often responsible for the nonbullous congenital ichthyosiform erythroderma
has been developed.18 Coupled with immunohistochemical assays using phenotype. The ichthyin mutation also usually produces nonbullous con-
transglutaminase-1 antibodies, this allows rapid identification of those cases genital ichthyosiform erythroderma (Table 3.4).24–28 Attempts to refine the
caused by alterations in this enzyme.18 classification of non erythrodermic and erythrodermic phenotypes by the use
54 Disorders of keratinization

Table 3.4
Types of autosomal recessive lamellar ichthyosis (LI)

Type Locus Gene Protein Defect

LI 1 14q11 TGM1 Transglutaminase-1 Impaired cross-linking of proteins and
lipids to the cornified cell envelope
LI 2 2q34 ABCA12 ATP binding cassette Abnormal lamellar body function and
lipid trafficking
LI 3 / LI 4 19p12-q12 FLJ39501 Cytochrome P450 family protein Epidermal lipid metabolism
LI 5 17p13 ALOX12B 12R-lipoxygenase Epidermal lipid metabolism
ALOXE3 Lipoxygenase-3
LI 6 5q33 ICHYN Ichthyin Transmembrane protein

of clinical, biochemical, and ultrastructural observations have so far failed to is occasionally a feature.4 Dilatation and tortuosity of the dermal capillaries is
yield a consistent scheme.29–31 This difficulty is illustrated by the fact that the sometimes evident. Follicular hyperkeratosis may occasionally be seen.
same transglutaminase-1 mutation can give rise to different phenotypes.31 Ultrastructural studies show a variety of features including defective devel-
Histologically, the epidermis in autosomal recessive lamellar ichthyosis opment of the cornified cell envelopes and electron-dense debris adjacent to
shows marked hyperkeratosis (which may be extreme in the collodion baby) the plasma membranes, cholesterol clefts, lipid vacuoles, increased numbers
and mild acanthosis with a normal or thickened granular cell layer (Fig. 3.21). of small and dysmorphic lamellar bodies, elongated membrane structures,
The hyperkeratosis is much less marked in erythrodermic than in noneryth- or membrane packages.32–34 Prenatal diagnosis of lamellar ichthyosis can be
rodermic forms. Epidermal papillomatosis associated with a psoriasiform achieved by fetoscopy and biopsy.35
appearance has also been documented. A perivascular lymphocytic infiltrate
Harlequin ichthyosis
Clinical features
Harlequin ichthyosis (harlequin fetus, ichthyosis fetalis, ichthyosis congenita
gravis) is an extreme and rapidly fatal subtype, where babies are born with
a fissured ‘armor-plated’ skin (Fig. 3.22).1–4 Ectropion and eclabium are fre-
quent complications, and the ears and nose are often malformed.2 Harlequin
fetus has a very high mortality due to respiratory and feeding difficulties
accompanied by excessive fluid loss.3 Sometimes, treatment by retinoids and
intensive care is successful. Long-term survivors, following shedding of the
scales, develop a severe erythroderma reminiscent of nonbullous ichthyosi-
form erythroderma.5 Fortunately, antenatal diagnosis is possible.6,7

Pathogenesis and histological features

This very rare form of ichthyosis is due to an apparently dramatic loss of
function of the lamellar bodies, which results from nonsense mutations in
the ABCA12 gene. Less severe missense mutations cause a variant of lamellar
ichthyosis. This indicates that a severely truncated protein is the molecular
cause of Harlequin ichthyosis.8 The ATP-binding cassette (ABC) transporter
family encompasses a variety of membrane proteins involved in the energy-
dependent transport across membranes. In the epidermis, ABCA12 may have
an important function for the lamellar bodies, through exocytosis traffic of
lipids or proteases across the apical keratinocyte membrane.
The lesions are characterized by massive hyperkeratosis (sometimes
with lipid deposits) associated with a normal or absent granular cell layer
(Fig. 3.23). The hair follicles are usually affected first, during the second tri-
mester.2,7 Parakeratosis may also sometimes be evident.9 Acanthosis is often
marked and papillomatosis is sometimes a feature. A sparse mixed inflamma-
tory cell infiltrate can be present in the superficial dermis.7
Ultrastructurally, the harlequin fetus has recently been shown to be associated
with deficient or morphologically abnormal lamellar bodies ­(including concen­
trically lamellated forms) and deficient intercellular lipid lamellae within the
stratum corneum.1,2,9 Small vesicles, devoid of internal lamellation, may be pres-
ent in the granular cell layer (and retained in the stratum corneum), but show no
association with the keratinocyte cell membranes as is typical of normal lamel-
lar bodies.1,9 Recent immunohistochemical evidence suggests that these vesicles
­represent abnormal lamellar bodies characterized by an inability to discharge
B their lipid contents into the intercellular space. Keratin and filaggrin expression
have also been shown to be defective.2 In the harlequin fetus, the keratinocytes
Fig. 3.21 may display the hyperproliferative keratins K6 and K16 and show an inability to
Autosomal recessive lamellar ichthyosis: (A) there is very marked hyperkeratosis convert profilaggrin to filaggrin.2 The results of ultrastructural and ­biochemical
and the epidermis shows papillomatosis; (B) high-power view. analyses suggest that the harlequin fetus is a heterogeneous condition.
Ichthyosis 55

Fig. 3.22
(A, B) Harlequin ichthyosis: the most extreme form
of congenital ichthyosis. There is an exceedingly high
A B mortality. The scales are very thick and are often referred to
as armor-plating.

Histologically, there is an acanthosis, papillomatosis, and compact ortho-

hyperkeratosis with focal parakeratosis that, paradoxically, is associated with
a thickened stratum granulosum (Fig. 3.24).2
Electron microscopy shows a high number of transitional cells and a
spongy appearance of the keratohyaline granules.2

Differential diagnosis
The differential diagnosis includes lichen simplex chronicus which, however,
differs by the presence of inflammatory changes and fibrosis of the papillary
dermis (see Table 3.3).

Congenital bullous ichthyosiform

Clinical features
Congenital bullous ichthyosiform erythroderma (also known as epidermo-
lytic hyperkeratosis, bullous ichthyosis, bullous ichthyosiform erythroderma of
Brocq) is a very rare disease (incidence of 1:300 000 births) and, although some-
Fig. 3.23 times inherited by an autosomal dominant mode, it more often appears to arise
Harlequin ichthyosis: there is massive hyperkeratosis associated with a by spontaneous mutation. At birth the infant may show marked hyperkerato-
conspicuous granular cell layer and a papillomatous epithelium. The dilated spaces sis, erythroderma, or even present as a collodion baby. Although the scales are
in the stratum corneum represent dilated ostial of eccrine ducts. By courtesy of soon lost, leaving a generalized moist, tender erythroderma, re-epithelialization
M.M. Black, MD, Institute of Dermatology, London, UK. leads to further scale production followed by the development of widespread
blistering (Fig. 3.25) which heals without scarring. As the patient becomes
Autosomal dominant lamellar ichthyosis older, the erythema and blistering become less apparent and, later, the disease is
complicated by the development of verrucous hyperkeratosis, especially in the
flexures (Figs 3.26–3.31). In some cases, the scales have been said to assume
Clinical features a porcupine quill-like appearance (ichthyosis hystrix) and scalp involvement
Autosomal dominant lamellar ichthyosis is characterized by generalized scal- may simulate tinea capitis.1 The nape, axilla, groin, and flexural folds are sites
ing with palmoplantar keratoderma.1 Patients may present as a collodion of predilection. Occasional blisters still arise, often in summertime and at sites
baby. They are later covered by diffuse dark-gray scales that involve all areas of pressure. In patients with keratin 1 but not with keratin 10 mutations, pal-
of the body but are most prominent on the extensor surfaces. Backs of the moplantar keratoderma is often present. Nail dystrophy may sometimes be a
hands and feet are characterized by lichenification. There may be massive feature. The patients suffer from an offensive body odor. Congenital bullous
plantar hyperkeratosis with thick, yellow scales. The palms are usually only ichthyosiform erythroderma is associated with considerable morbidity and sig-
minimally involved and show accentuated markings.1 nificant mortality due to sepsis, fluid loss, and electrolyte imbalance.1
A nevoid variant in which the lesions follow Blaschko's lines is also rec-
Pathogenesis and histological features ognized.2 In the past, such lesions may have been mistaken for epidermal
This disorder appears to be genetically and clinically heterogeneous and of nevi showing epidermolytic hyperkeratosis. Due to the possibility of gonadal
variable penetrance. Its genetic defect has not been identified. Biochemically, mutations, children of affected patients with the nevoid variant may develop
an abnormal lipid profile has been detected in the scales.2 generalized congenital bullous ichthyosiform erythroderma
56 Disorders of keratinization

Fig. 3.26
Congenital bullous
Hyperkeratosis and scales
follow re-epithelialization
of widespread blistering.

Fig 3.24
(A, B) Autosomal dominant lamellar ichthyosis: in this example there is marked
compact hyperkeratosis. The granular cell layer is prominent and there is focal

Fig. 3.27
Congenital bullous
erythroderma: adult
showing very generalized
scaling, particularly
severe on the legs. By
courtesy of the Institute
of Dermatology, London,

Pathogenesis and histological features

There is considerable evidence in the recent literature confirming that con-
genital bullous ichthyosiform erythroderma represents a genetic disorder of
Fig. 3.25 keratin expression associated with hyperproliferation of the epidermis.5,6 In
Congenital bullous ichthyosiform erythroderma: close-up view of an infant showing the skin, basal keratinocytes predominantly express keratin 5 and 14, while
intense erythema and blistering. By courtesy of M. Liang, MD, The Children's suprabasal cells switch to the expression of keratin 1 and 10. Keratin mono-
Hospital, Boston, USA. mers form obligate heterodimers in pairs of acidic (type I) and basic (type
II) keratins, which assemble into keratin intermediate filaments building a
An annular variant has also been described. Patients may have mild eryth- cytoskeleton for the structural stability and flexibility of epidermal cells.
roderma and blisters at birth, but the characteristic feature is the presence of Transgenic mouse studies using a truncated human keratin 10 gene have
many annular gray hyperkeratotic plaques with a peripheral erythematous been shown to result in the pathobiological and biochemical phenotype of
border. 3,4 epidermolytic hyperkeratosis.7 Epidermolytic hyperkeratosis shows linkage
Ichthyosis 57

Fig. 3.28
Congenital bullous Fig. 3.30
ichthyosiform Congenital bullous
erythroderma: same ichthyosiform
patient as Figure erythroderma: blistering
3.27, showing elbow may sometimes be seen
involvement. By courtesy in adulthood. By courtesy
of the Institute of of the Institute of
Dermatology, London, UK. Dermatology, London, UK.

Fig. 3.31
Fig. 3.29 Congenital bullous
Congenital bullous ichthyosiform erythroderma: the hands are particularly affected. ichthyosiform
By courtesy of the Institute of Dermatology, London, UK. erythroderma: adult
showing very severe
verrucous flexural scaling.
By courtesy of R.A.J.
to the keratin gene cluster either on chromosome 12q11–13 (type II keratin) Eady, MD, Institute of
or chromosome 17q21-q22 (type I keratin).8–10 Direct sequencing of keratin Dermatology, London, UK.
1 and 10 genes has identified point mutations in a number of affected fami-
lies.11–17 Most mutations are missense and clustered at the ends of the central
helical rod domains. Keratin 1 mutations are associated with severe pal-
moplantar hyperkeratosis while keratin 10 mutations are not because kera- formation may be present. There is massive orthohyperkeratosis, papillo-
tin 10 is physiologically substituted by keratin 9 on palmoplantar skin.15 matosis, and acanthosis. The granular cell layer is prominent and contains
Mutations in the keratin 1 or 10 gene exhibiting mosaicism explain the coarse and irregular keratoyhaline granules (Fig. 3.32).
nevoid variant of congenital bullous ichthyosiform erythroderma.18,19 The By immunohistochemistry, epidermolytic hyperkeratosis shows a normal
annular variant shows minor mutations in keratin 1 or 10 genes on distinct distribution pattern of keratins 5/14 and 1/10, but in addition there is over-
keratin domains.4 expression of keratin 14 in the suprabasal epithelium accompanied by quite
The histological features are known as epidermolytic hyperkeratosis or marked labeling of the upper epithelial layers by keratin 16, as would be
granular degeneration and are very striking.20,21 Suprabasal keratinocytes expected in a hyperproliferative state.5,22
appear vacuolated and typically contain distinct eosinophilic intracytoplas- Ultrastructural studies have shown that the intracytoplasmic inclusions
mic inclusions. The cell borders are ill defined and intraepidermal blister seen on light microscopy are composed of abnormally aggregated keratin
58 Disorders of keratinization

Fig. 3.33
Congenital bullous
erythroderma: striking
perinuclear keratin
clumping is evident.
By courtesy of R.A.J.
Eady, MD, Institute of
Dermatology, London,

Ichthyosis bullosa of Siemens

Clinical features
Ichthyosis bullosa of Siemens is inherited as an autosomal dominant. The
condition, which is milder than congenital bullous ichthyosiform eryth-
roderma, presents at birth with blistering subsequently replaced by dark
­lichenified hyperkeratosis of the limbs, predominantly affecting the ­flexures
and shins (Fig. 3.34).1,2 The skin remains fragile and blisters on mild trauma,
­giving rise to characteristic superficial peeling with a molting-like ­appearance
(Mauserung phenomenon) (Fig. 3.35).2,3 Symptoms usually improve with
age. Erythroderma is typically absent. Rarely, pustulation and ­hypertrichosis
may be additional features.3,4 There is considerable clinical overlap between
­ichthyosis bullosa of Siemens and congenital bullous ichthyosiform
­erythroderma, and their distinction can best be achieved by molecular genetic
B analysis.

Fig. 3.32
Congenital bullous ichthyosiform erythroderma: (A) there is massive hyperkeratosis
and acanthosis. The epidermis shows conspicuous superficial vacuolation which has
resulted in vesiculation, (B) there is intracellular edema, and irregular eosinophilic
granules (representing dense abnormal aggregates of keratin filaments) are present
in the superficial layers of the epidermis.

filaments. Since large areas of the cytoplasm lack a regular keratin skeleton,
the suprabasal keratinocytes appear vacuolated and contain irregular kera-
toyhaline granules. Impairment of desmosome-keratin complexes accounts
for the fragility of the epidermis (Fig. 3.33).18 These ultrastructural changes
may form the basis of prenatal diagnosis including amniotic fluid squame
Immunoelectron microscopy has identified that the keratin clumps are
composed of keratins 1 and 10.22

Differential diagnosis
Epidermolytic hyperkeratosis is a histopathologic pattern that is seen in
many conditions including ichthyosis bullosa of Siemens, epidermal nevus,
epidermolytic keratoderma, epidermolytic acanthoma, and epidermolytic
leukoplakia (see Table 3.3). It may also represent an incidental finding in
seborrheic keratosis, actinic keratosis, in situ squamous cell carcinoma, inva-
sive squamous cell carcinoma, melanocytic nevi, and epidermal and pilar Fig. 3.34
Bullous ichthyosis
cysts.23 Epidermolytic hyperkeratosis may also be seen in normal and par-
Siemens: flexural
ticularly actinically damaged skin. In such incidental lesions, the changes are hyperkeratosis with early
limited to the epidermis overlying just one or two dermal papillae in contrast blister formation.
to the much more extensive involvement of the other conditions mentioned By courtesy of W.A.D.
above. Therefore, accurate clinical information is necessary to avoid diagnos- Griffiths, MD, Institute of
tic confusion. Dermatology, London, UK.
Ichthyosis 59

Fig. 3.35
Bullous ichthyosis Siemens: marked hyperkeratosis is present over the knees.
By courtesy of W.A.D. Griffiths, MD, Institute of Dermatology, London, UK.

Pathogenesis and histological features

Bullous ichthyosis is associated with a point mutation in the keratin 2e gene
on chromosome 12q11-q13.4–9 Since this keratin is not expressed on volar
skin, palmoplantar keratoderma does not develop.
Histologically and by electron microscopy, the features are indistinguish-
able from congenital bullous ichthyosiform erythroderma except that they
are milder and the vacuolation of the keratinocytes and cytoplasmic inclu-
sions are restricted to the more superficial prickle and granular cell layers
as opposed to involving almost the entire epidermis as is typical of the latter
condition. Subcorneal separation may be evident.10

Linear epidermolytic epidermal nevus Fig. 3.36

Linear verrucous epidermal nevi occasionally show the features of epi- Linear epidermolytic epidermal nevus: (A) low-power view showing massive
dermolytic hyperkeratosis (Fig 3.36). Some patients with such a lesion, hyperkeratosis and papillomatosis (B) high-power view showing epidermolytic
although by no means all, in reality suffer from the nevoid variant of con-
genital bullous ichthyosiform erythroderma.1–4 It is therefore important that
patients with apparent epidermolytic epidermal nevi are offered genetic

Epidermolytic acanthoma
Clinical features
Isolated epidermolytic acanthoma (also termed disseminated epidermolytic
acanthoma) is an acquired lesion that presents as a verrucous papule or
plaque approximately 1.0 cm in diameter and sometimes resembles a viral
wart, nevus or seborrheic keratosis.1–3 Lesions may present at any site, but
the scrotum, head, neck, and leg are particularly affected.2,3 Although usually
solitary, occasional patients may present with multiple localized or dissemi-
nated lesions.4–8 Variants affecting the mucosae of the oral cavity and female
genital tract have also been documented.9,10 Caucasians and the Japanese are
predominantly affected.3

Pathogenesis and histological features Fig. 3.37

Although not proven, it has been suggested that epidermolytic acanthoma Epidermolytic acanthoma: the lesion is papillomatous with massive hyperkeratosis.
develops as a consequence of keratin 1 and 10 gene mutation.3 There is a superficial perivascular chronic inflammatory cell infiltrate.
The lesion is characterized by hyperkeratosis, parakeratosis, acanthosis,
and papillomatosis (Fig. 3.37).1,2 The upper prickle cell and granular cell lay- Epidermolytic acanthoma displays diminished expression of keratins
ers show features of epidermolytic hyperkeratosis (i.e., marked vacuolation 1 and 10 and increased expression of the hyperproliferative keratins 6
of the keratinocytes with eosinophilic keratin inclusions) (Fig. 3.38). and 16.3
60 Disorders of keratinization

Fig. 3.38 Fig. 3.39

Epidermolytic acanthoma: there is superficial cytoplasmic vacuolation and Peeling skin syndrome: Erythematous lesions show peeling of the skin leaving
eosinophilic inclusions are conspicuous. superficially denuded red patches. By courtesy of H.Traupe MD and V.Oji MD,
Department of Dermatology, Munster, Germany.
Differential diagnosis
Identical histological changes are seen in congenital bullous ichthyosiform
erythroderma, linear epidermolytic epidermal nevus, epidermolytic palmo-
plantar keratoderma, and in focal epidermolytic hyperkeratosis (see Table
3.3). Clinical information is usually necessary to avoid diagnostic confusion.

Focal epidermolytic hyperkeratosis

Focal epidermolytic hyperkeratosis (incidental epidermolytic hyperkeratosis)
represents a non-specific finding of epidermolytic hyperkeratosis in the epi-
dermis overlying or adjacent to an unrelated lesion. It is very common and
has been described, for example, in seborrheic keratoses, overlying scars and
fibrous histiocytoma, in banal and dysplastic nevi, actinic keratosis, squamous
cell carcinoma in situ, and melanoma. It may also be seen in normal skin. 1–5

Peeling skin syndrome

Clinical features
Peeling skin syndrome (familial continual skin peeling, keratolysis exfoliativa Fig. 3.40
congenitale) is characterized by a spontaneous, lifelong peeling of the stratum Peeling skin syndrome:
corneum without bleeding or pain.1–6 The mode of inheritance is autosomal The skin of the backs
of hand and feet shows
recessive.1 Three types can be distinguished:
reddish scaly patches. By
• In type A a generalized continued shedding or peeling of the entire skin courtesy of H.Traupe MD
without signs of inflammation or other symptoms is present from birth and V Oji MD, Department
or develops during childhood (Fig. 3.39).2 of Dermatology, Munster,
• Type B appears, resembles and is characterized by isolated erythematous Germany
lesions which then peel, leaving burning superficially denuded red
patches with a peripheral collarette.3 Only recently a mutation of
corneodesmosin has been identified.3a
• In type C (acral peeling skin syndrome), involvement is confined to the backs Ichthyosis hystrix Curth-Macklin
of the hand and feet (Fig. 3.40).4,5 A homozygous missense mutation in the
gene of transglutaminase-5 has been identified in two unrelated families.6 Clinical features
‘Ichthyosis hystrix’ is a descriptive name for cornification disorders with spiny
Histological features and dark hyperkeratosis. Ichthyosis hystrix Curth-Macklin is characterised
• In type A, histology shows a plane of separation either within the lower by generalized verrucous plaques, involving the entire trunk, the flexural sur-
part of an otherwise normal horny layer or above the granular cell faces of the extremities and the palms and soles. The autosomal dominant
layer. Ultrastructural analysis reveals an intracellular splitting within the disorder sometimes resembles bullous ichthyosiform erythroderma, but there
corneocytes.2 is no clinical or histological evidence for blistering. 1–3
• In type B, the epidermis is psoriasiform with an absent or reduced
granular cell layer and marked parakeratosis. The split occurs at the level Pathogenesis and histological features
of the granular cell layer.3 Recent evidence suggests that in ichthyosis hystrix Curth-Macklin a mutation
• In type C peeling skin syndrome, the horny layer is detached from the in a keratin gene affecting the variable tail domain (V2) of keratin 1 results
stratum granulosum (Fig. 3.41).4,5 in a failure in keratin intermediate filament bundling and retraction of the
Ichthyosis 61

Fig. 3.41
Peeling skin syndrome: the biopsy is taken from the edge of the lesion. Note that
the stratum corneum is clearly separated from the underlying epidermis.

cytoskeleton from the nucleus.2 This is the first in vivo evidence for the crucial
role of a keratin tail domain in supramolecular keratin intermediate filament
organization and barrier formation.2
Histologically, the epidermis is acanthotic and orthohyperkeratotic. The
suprabasal keratinocytes are vacuolated and a few of them appear ­binucleated.
In contrast to epidermolytic hyperkeratosis, eosinophilic intracytoplasmic
inclusions are not present.4
The significant ultrastructural observation in ichthyosis hystrix Curth-
Macklin is the presence of perinuclear concentric shells of tonofilaments. In
contrast to keratin mutations of the rod domain in epidermolytic hyperkera-
tosis, aggregations and clumping of keratin filaments are absent.4

Congenital reticular ichthyosiform B

Fig. 3.42
Ichthyosis variegata: (A) there is hyperkeratosis and well-developed psoriasiform
Clinical features hyperplasia; (B) there is parakeratosis with prominent nuclei. Note the cytoplasmic
Congenital reticular ichthyosiform erythroderma is a rare inherited disorder vacuolation. Eosinophilic intracytoplasmic inclusions are absent.
of keratinization.1 Since only sporadic cases have been recognized, the mode of
inheritance is unknown. Most of the patients have been female. The patients an apoptotic mode of cell death.9 Uptake and processing of melanosomes is
are born with congenital ichthyosiform erythroderma. During ­childhood the irregular. The basic genetic defect in congenital reticular ichthyosiform eryth-
integument clears gradually so that enlarging patches of normal skin appear roderma is due to dominant mutations is keratin 10 that causes mislocalisa-
to be enclosed by erythrokeratotic and hyperpigmented areas in a reticular tion to the nucleolus and disruption of the keratin filament network.9,10
arrangement. Because of this clinical appearance the genodermatosis has also
been termed ichthyosis ‘en confettis’ or, more precisely, ichthyosis variegata.2–8 Differential diagnosis
Associated features are hypertrichosis, and palmoplantar hyperkerato-
The absence of keratin clumping clearly distinguishes congenital reticular
sis, and, in single cases, hypogonadism, growth retardation, hepatomegaly,
ichthyosiform erythroderma from keratinization disorders characterized by
­keratoacanthoma or squamous cell carcinoma.1,5,7
epidermolytic hyperkeratosis. Ichthyosis hystrix Curth-Macklin shares the
intraepidermal formation of binucleate, vacuolated keratinocytes but lacks
Pathogenesis and histological features
parakeratosis and shows formation of perinuclear shells of tonofibrils (see
Histologically, the epidermis is pale staining and there is psoriasiform hyper- Table 3.3).
plasia. The horny layer is thickened and parakeratotic. The parakeratotic
corneocytes have enlarged nuclei. The keratinocytes of the upper layers show
prominent perinuclear vacuolation and contain few keratohyalin granules.
Comèl-Netherton's syndrome
Their cell borders are well defined and intracytoplasmic eosinophilic granules
are absent. Some of the vacuolated keratinocytes are binucleate (Fig. 3.42). Clinical features
The dermal vessels are dilated, and there is a sparse perivascular inflamma- Comèl-Netherton's syndrome (Netherton's syndrome, ichthyosis linearis cir-
tory cell infiltrate with scattered melanophages. cumflexa) is a rare genodermatosis inherited as an autosomal recessive. It
While keratin 2e is missing, the other epidermal keratins are regularly is characterized by the triad of congenital ichthyosiform erythroderma, hair
expressed. At the ultrastructural level the arrangement of the keratin skeleton shaft anomalies, and a severe atopic diathesis with high IgE blood levels and
is highly disturbed. Immuno-electron microscopy reveals complete absence eosinophilia.1 It is believed to affect approximately 1:200 000 of the pop-
of keratin filaments in the perinuclear cytoplasm.1–3 The number of transi- ulation.2 Generally, the congenital ichthyosiform erythroderma gradually
tional cells is increased and nick end labeling (TUNEL) for DNA fragmenta- evolves into a milder ichthyosis linearis circumflexa which is characterized
tion shows strong labeling of the parakeratotic corneocytes consistent with by an erythematous, scaly rash predominantly affecting the trunk and limbs.3
62 Disorders of keratinization

It is composed of polycyclic, migratory, annular and serpiginous lesions Patients with Netherton's syndrome may in addition suffer from life
with characteristic two parallel lines of scale at the periphery, the so-called threatening neonatal dehydration with hypernatremia, failure to thrive, and
­double-edged scale (Figs 3.43–3.45). In infancy, erythema and scaling may recurrent skin infections often caused by Staphylococcus aureus,4,8,9 amino-
be widespread, but later the face is often predominantly affected (particularly aciduria,5 mental retardation,5,7 and immune defects.1,5 An impaired epider-
marked around the mouth and eyes), along with the perineum,4 and as such mal barrier is a potential risk for increased and even toxic absorption of
the eruption can be mistaken for acrodermatitis enteropathica (Fig. 3.46).1 topical medications.
Later the scalp, face, and eyebrows may show a yellowish scaling.5 Ichthyosis
linearis circumflexa is typically nonpruritic,5 and the nails and teeth are not Pathogenesis and histological features
involved.3 Rarely, infants may also show palmoplantar hyperkeratosis.6 Netherton's syndrome results from mutations in the SPINK5 gene which
Comèl-Netherton's syndrome is often misdiagnosed as seborrheic dermatitis, has been localized to 5q32.10,11 Nonsense, frameshift deletions and inser-
atopic dermatitis, and psoriasis vulgaris. tions and splice site defects resulting in premature termination codons and
Trichorrhexis invaginata (due to a transient and repeated defect of ker-
atinization, with resultant hair shaft intussusception)7 presents clinically as
coarse and lusterless hair, which is short, brittle, and fragile (Fig. 3.46). Pili
torti and trichorrhexis may also be evident (Fig. 3.47).5

Fig. 3.45
Fig. 3.43 Comèl-Netherton's
Comèl-Netherton's syndrome: ichthyosis linearis circumflexa. Note the serpiginous syndrome: there is
lesions with characteristic double border. By courtesy of M. Judge, MD, Institute prominent involvement of
of Dermatology, London, UK. the trunk and limbs.

Fig. 3.44
Comèl-Netherton's syndrome: (A) hyperkeratotic lesions
may sometimes be prominent; (B) note the focal loss of the A B
polycyclic pattern.
Ichthyosis 63

Fig. 3.46
Comèl-Netherton's syndrome: (A) there is profound
erythema with scaling; (B) the hair is dull and appears short
and thin. The eyebrows are deficient. (A) By courtesy of M.
Judge, MD, Institute of Dermatology, London, UK,
A B (B) By courtesy of A. Griffiths, MD, Institute of
Dermatology, London, UK.

Sudan black positive and are thought to represent an influx of serum exu-
dates resulting from the accompanying dermal inflammation.4 Similar ‘inclu-
sions’ have been described in psoriasis and atopic eczema16 and as such they
are not specific. Rarely, the parakeratotic scale may be associated with the
presence of Munro microabscesses.6 Biopsies from the center of the lesion
shows the features of atopic dermatitis.
Electron microscopy reveals reduced numbers of lamellar bodies in kera-
tinocytes and the presence of lysosomal inclusion bodies with intercellular
amorphous deposits in the horny layer.14,16
Immunohistochemistry can demonstrate the absence of LEKTI antigen
and is highly specific.17

Differential diagnosis
The histologic distinction from psoriasis vulgaris may be histologically
extremely difficult (if not impossible) in the absence of clinical information.
Other genodermatoses, dermatophytosis, and inflammatory skin diseases
with a psoriasiform-like pattern must be differentiated (see Table 3.3). Atopic
dermatitis is another important differential diagnosis.

Fig. 3.47
Sjögren-Larsson syndrome
syndrome: bamboo hair
(trichorrhexis invaginata). Clinical features
By courtesy of M. This autosomal recessive inherited disorder combines the features of ichthyo-
Judge, MD, Institute of
sis, spastic bi- or quadriplegia and mental retardation.1–5 It is rare, with an
Dermatology, London,
incidence of 0.4 per 100 000 of the population.4 Although the disease may
be encountered worldwide, the prevalence is particularly high in Northern
a defective serine protease inhibitor, i.e., Lympho-Epithelial Kazal Type The ichthyosis, which develops in the first year of life with a diffuse scal-
Inhibitor (LEKTI), have been identified.11–13 The lack of LEKTI consequently ing, affects the entire body with the exception of the central face and is typi-
leads to a hyperactivity of the proteases involved in the desquamation pro- cally intensely pruritic (Fig. 3.49).3,5 Later, the skin has a brownish-yellow
cess or inflammatory response (kallikreins) and accounts for the ichthyotic color and shows a cobblestone-like lichenification.4 Hyperkeratosis around
and inflammatory skin phenotype, which is associated with an extremely the umbilicus is said to be characteristic.5 Erythroderma is not a feature and
impaired epidermal barrier. the hair, nails, and sweat glands are unaffected.3,4 The diagnosis should be
For diagnostic features, the biopsy must be taken from skin just preced- especially considered in preterm babies with congenital ichthyosis.5
ing the lesion's scaly margin (Fig. 3.48).14,15 In this region the epidermis may The spasticity, which presents in early childhood, predominantly affects
show psoriasiform hyperplasia with associated spongiosis. There is a thick the legs and is often associated with contractures. The majority of patients are
adherent parakeratotic scale. Small, dark, round or oval granules can be iden- wheelchair bound.4 Kyphoscoliosis may also be present.3 Mental retardation
tified within the stratum granulosum. These are diastase-resistant, PAS and is typically present but is not invariable.1 Epilepsy is sometimes a feature.3
64 Disorders of keratinization

Visual acuity is often impaired and photophobia is a frequent complaint.

Macular degeneration associated with crystal deposition is characteristic
(Fig. 3.50).6

Pathogenesis and histological features

Sjögren-Larsson syndrome results from deficiency of microsomal fatty alde-
hyde dehydrogenase (FALDH).7 The gene has been mapped to 17p11.2 and
multiple mutations including missense mutations, deletions, and insertions
have been identified.8–10 The abnormal level of free fatty alcohols in cultured
fibroblasts, direct testing of FALDH activity, or the presence of LTB4 metabo-
lites in urine can provide biochemical screening and/or confirmation of the
clinical diagnosis, prior to molecular mutation analysis of the FALDH gene.5
Epidermal hyperproliferation has been demonstrated in Sjögren-Larsson
Histologically, there is papillomatosis, acanthosis, and basket-weave hyperk-
eratosis with scattered mild parakeratosis and occasional follicular hyperkeratosis
(Fig. 3.51).12 The granular cell layer may be slightly thickened. A light lymphohis-
tiocytic infiltrate is sometimes present around the superficial dermal vasculature.
Ultrastructurally, there are lamellar inclusions in the prickle and granular
cell layers.12 Lipid inclusions are not a feature.

Fig. 3.48
Comèl-Netherton's syndrome: (A) scanning view showing a detached Fig. 3.50
thickened stratum corneum and psoriasiform hyperplasia; (B) note the marked Sjögren-Larsson syndrome: characteristic macular crystals. By courtesy of
parakeratosis. M. Willemsen, MD, University Medical Center, Nijmegen, Belgium.

Fig. 3.49 Fig. 3.51

Sjögren-Larsson syndrome: there is severe scaling and the skin has a yellowish- Sjögren-Larsson syndrome: there is hyperkeratosis, hypergranulosis and mild
brown color. By courtesy of M. Willemsen, MD, University Medical Center, papillomatosis. A light superficial perivascular lymphocytic infiltrate is present. By
Nijmegen, Belgium. courtesy of M. Willemsen, MD, University Medical Center, Nijmegen, Belgium.
Other congenital ichthyotic syndromes 65

Conradi-Hünermann-Happle syndrome
Clinical features
Conradi-Hünermann-Happle syndrome is an X-linked dominant congeni-
tal ichthyosis with associated chondrodysplasia punctata. It is lethal in the
majority of male embryos. Chondrodysplasia punctata is defined as a ­stippled
calcification of the epiphyses. There are several forms but only the type
2 variant presents with severe ichthyosiform erythroderma. Later the
­erythema clears and a whorled scaling following the lines of Blaschko ­persists
(Fig. 3.52).1,2
Associated symptoms are scarring alopecia, follicular atrophoderma,
localized hypo-and/or hyperpigmentation, sectorial cataracts, and skeletal
­dysplasia, which leads to asymmetric shortening of the long bones or severe
kyphoscoliosis. Due to the individual differences in X-inactivation, ­expression
of the disease is rather variable even within families.1,2

Pathogenesis and histological features Fig. 3.53

Biochemical analyses using gas chromatography-mass spectrometry show Conradi-Hönermann-Happle syndrome: there is hyperkeratosis and acanthosis.
elevated plasma levels of 8-dehydrocholesterol and 8(9)-cholesterol, result-
ing from a block of a key enzyme in sterol metabolism, namely the 8–7 ste-
rol isomerase. This enzyme is encoded by the emopamil-binding protein
gene, which shows heterozygous mutations in Conradi-Hünermann-Happle
The histologic features resemble those of ichthyosis vulgaris (Fig. 3.53).
There is hyperplasia of the epidermis, orthohyperkeratosis, a reduced stra-
tum granulosum, and dilated hair infundibula with follicular plugs. As a
pathognomonic finding in newborns, von-Kossa staining demonstrates cal-
cium deposits in the corneocytes which allows for discrimination of other
ichthyoses that share the feature of a reduced stratum granulosum (Fig. 3.54)
(see Table 3.3). At a later age the calcification is difficult to detect histologi-
cally but electron microscopy may reveal cytoplasmic vacuoles and electron-
dense calcium crystals in the granular cell layer.4

Other congenital ichthyotic syndromes

Many syndromes can be associated with congenital ichthyosis. In ichthyosis
prematurity syndrome there is associated polyhydramnios and the premature
neonates may suffer from transient asphyxia. The infants have a thick cheesy

Fig. 3.54
Conradi-Hönermann-Happle syndrome: (A) the granular cell layer is absent. Note
the basophilic deposits within the thickened stratum corneum, (B) the basophilic
Fig. 3.52 deposits represent calcium as seen in this von Kossa preparation.
Happle syndrome:
membrane which desquamates and then the skin improves within some weeks.
Scaly erythema follow
the whorled lines of
The skin shows compact orthohyperkeratosis and acanthosis. At ultrastruc-
Blaschko. By coutesy of tural level, characteristic masses of lipid membranes in lentiform paranuclear
H Traupe MD, Dept of swellings of granular and horn cells can be demonstrated which has lead to
Dermatology, Munster, the designation ichthyosis congenita type 4.1 A novel locus for the ichthyosis
Germany. prematurity syndrome has been assigned to chromosome 9q33–34.2
66 Disorders of keratinization

Type II or infantile cerebral Gaucher syndrome presents as a collodion

baby. The diagnosis of this fetal metabolic disease can be made by measure-
ment of glucocerebrosidase activity in peripheral blood leukocytes or in
extracts of cultured skin fibroblasts.3
Dorfman-Chanarin syndrome is a triglyceride storage disease with
impaired long-chain fatty acid oxidation resulting in cataract, hepatospleno-
megaly, neurosensorial deafness, myopathy or developmental delay. At birth,
generalized white scaling and a variable degree of erythema are present. The
skin findings resemble congenital ichthyosiform erythroderma although the
stratum granulosum may be thinned. Intracellular lipid vacuoles can be pres-
ent in circulating neutrophils, as well as in a variety of other cells including
keratinocytes. Thus a skin biopsy fixed in alcohol may be useful. Lipid vac-
uoles may also be found in the obligate carrier parents. Refsum syndrome
patients also have epidermal lipid vacuoles, but in Dorfman-Chanarin syn-
drome patients, the phytanic acid levels are normal.4
Trichothiodystrophy represents a heterogeneous group of autosomal
recessive disorders that share brittle hair and an abnormally low hair shaft
sulfur content (decrease of cysteine). Trichoschisis and alternating light and A
dark banding by polarizing microscopy are typical findings.5 At least two
subtypes of trichothiodystrophy are associated with congenital ichthyo-
sis: the acronym IBIDS (‘Tay syndrome’) refers to the clinical findings of
­ichthyosis (e.g., collodion membrane), brittle hair, intellectual impairment,
decreased fertility, and short stature. Other features are microcephaly, dys-
plasia of nails, failure to thrive, ‘progeria’-like symptoms, cataracts, and
photosensitivity (» PIBIDS).6 Half of all trichothiodystrophy patients show
an abnormal nucleotide excision repair of UV-damaged DNA.7 Histology of
the ichthyotic skin shows acanthosis with orthohyperkeratosis and a reduced
stratum granulosum.

Follicular ichthyosis
Clinical features
Follicular ichthyosis (ichthyosis follicularis) is a poorly documented ­condition
in which patients present with horny, follicular lesions which, although
­usually generalized, show a predilection for the head and neck (Fig. 3.55).1,2 B
In the report by Hazell and Marks, associated clinical findings included
pseudoacanthosis nigricans affecting the axillae, comedones on the cheeks Fig. 3.55
and ­fingers, and dental malocclusion.2 Literature subsequent to these two Follicular ichthyosis: (A) there are bilateral follicular lesions; (B) the follicles are plugged
papers has focused on the association of ichthyosis follicularis with alopecia with thornlike scale. By courtesy of the Institute of Dermatology, London, UK.
and photophobia (see below).3

Pathogenesis and histological features Pathogenesis and histological features

The mode of inheritance and pathogenesis of this disorder is unknown
Follicular ichthyosis (ichthyosis follicularis) is an umbrella term or histologic
although autosomal dominant and X-linked recessive forms have been
pattern that is present in many conditions and is defined by follicular ortho-
described. The complete IFAP phenotype seems to be only observed in male
hyperkeratosis with or without hypergranulosis in the infundibulum.
patients. It is therefore thought to be of X-linked recessive inheritance. Female
For differential diagnosis see Table 3.3.
carriers may present with linear ‘lesions of Blaschko’ showing circumscribed
hairless, anhidrotic or ichthyotic areas of skin 2,5,6
Ichthyosis follicularis with alopecia and The follicular lesions are characterized by projecting hyperkeratotic plugs
showing focal parakeratosis and associated hypergranulosis.7 Hair follicles
photophobia are atrophic and lack hair shafts and sebaceous glands (Figs 3.57, 3.58).1
Sweat glands are normal but hyperkeratosis of the acrosyringia may occlude
Clinical features the openings of sweat ducts.5
Ichthyosis follicularis with alopecia (atrichia) and photophobia (IFAP syn- The psoriasiform plaques show hyperkeratosis with parakeratosis, acan-
drome) is an exceedingly rare disorder characterized by the presence of thosis, spongiosis, and a bandlike upper dermal lymphohistiocytic infiltrate.7
non-inflammatory thorn-like (filiform) follicular hyperkeratosis that often
improves during the first year of life (Fig. 3.56). Other features are ichthyosi- Differential diagnosis
form dry skin, generalized complete nonscarring alopecia (with absence of Other forms of atrichia and follicular keratosis should be considered (see
eyelashes and eyebrows), and severe photophobia.1–6 Ocular findings may Table 3.3).
include corneal deformity and opacity with surface vascularization.6 Angular
cheilitis, keratotic psoriasiform plaques on the extensor surfaces of the
extremities, and nail dystrophy with chronic infection may also be present.2,6
Lichen spinulosus
Additional findings including hypohidrosis, recurrent respiratory infections,
skeletal abnormalities, cryptorchidism or progressive deteriorating neuro- Clinical features
logic symptoms such as generalized seizures and cerebellar symptoms have Lichen spinulosus is a rare dermatosis of unknown etiology which par-
been reported.5 ticularly affects the extensor surfaces of the arms and legs, back, chest,
Other congenital ichthyotic syndromes 67

Fig. 3.58
Ichthyosis follicularis with alopecia and photophobia: there is hyperkeratosis
centered on an acrosyringium.

buttocks, face, and neck.1 Occasionally, lesions are generalized. Lesions pres-
ent in the second and third decades as round to oval, 2–6-cm flesh-colored
and sometimes pruritic, symmetric plaques composed of multiple 1–3-mm
thorny, grouped follicular papules which protrude above the surface of the
skin.1–3 The texture has been likened to a nutmeg grater. Males are affected
more often than females. There is no racial predilection.2 Other than a cos-
metic nuisance, the condition is of no clinical significance. Lichen spinulosus
has been described in association with Crohn's disease, human immunodefi-
ciency virus (HIV) infection, and as an adverse drug reaction.4–7

Histological features
Lichen spinulosus is characterized by keratotic plugging of dilated follicular
B infundibula and a perivascular and perifollicular lymphohistiocytic infiltrate.1
Sebaceous glands may be atrophic or absent. Perforating folliculitis-like fea-
Fig. 3.56 tures can be superimposed.
Ichthyosis follicularis with alopecia and photophobia: (A) the skin is dry and
ichthyosiform, (B) on the scalp a non-scarring alopecia with follicular hyperkeratosis Differential diagnosis
is characteristic. By courtesy of H Traupe MD, Dept of Dermatology, Munster, There is considerable histological overlap with keratosis pilaris and the follic-
Germany. ular lesions of pityriasis rubra pilaris. The distinction is best made clinically.

Clinical features
Phrynoderma (toad skin) most often develops as a consequence of vitamin A
deficiency.1–4 Other proposed etiological factors include deficiencies of the vita-
min B complex, riboflavin, vitamin C, vitamin E, and essential fatty acids.4 In
Western countries most cases develop as a result of malabsorption.4,5 Patients
present with xerosis, hyperpigmentation and multiple 2–6-mm, red-brown,
dome-shaped papules with a central folliculocentric crater filled with lami-
nated keratinous debris.1,4 The elbows and knees are predominantly affected
but lesions may extend to involve the thighs, upper arms and buttocks.1

Histological features
The papules consist of a cystically dilated follicular infundibulum filled with
keratinous debris.4

Keratosis pilaris
Clinical features
Fig. 3.57 This fairly common condition, which has an autosomal dominant mode of
Ichthyosis follicularis with alopecia and photophobia: there is marked follicular inheritance, is probably a follicular variant of ichthyosis and, indeed, fre-
atrophy. Note the small arrector pili muscles. quently accompanies ichthyosis vulgaris.1–3 The age at presentation is most
68 Disorders of keratinization


Fig. 3.59
Keratosis pilaris:
(A) typical follicular
papules and pustules on
the thigh; (B) note the
conspicuous plugged
follicles. (A) By courtesy
Fig. 3.60
of R.A. Marsden, MD,
Keratosis pilaris: (A) there
St George's Hospital,
is follicular dilatation and
London, UK, (B) By
plugging; (B) note the
B courtesy of the Institute of
B atrophy of the infundibular
Dermatology, London, UK.

often in the first two decades with a peak during adolescence.2 Up to 40% Keratosis pilaris atrophicans
of adults may be affected.2 There is no racial predilection. There is an appar-
ent increased incidence in females and lesions present as pruritic small fol- Clinical features
licular keratoses, sometimes containing small distorted hairs. They are most Keratosis pilaris atrophicans combines the features of follicular hyper-
often found on the lateral aspects of the arms and thighs, although the face, keratosis and scarring.1 Although some authors believe this to represent a
trunk, and buttocks may also be affected (Fig. 3.59).2 Seasonal variation, ­single ­disease entity, others prefer to subdivideit into a number of categories
with lesions being much more severe in winter, is often documented.2 There is ­including ulerythema ophryogenes, atrophoderma vermiculata, and keratosis
an increased incidence of atopy.2 ­follicularis spinulosa decalvans.2 Evidence of different modes of inheritance,
Although keratosis pilaris most often presents as an isolated phenom- clinical differences, and variable associations supports the latter.2
enon, occasionally it may develop in association with systemic disease Ulerythema ophryogenes (keratosis pilaris atrophicans facei, KPAF) pres-
including Hodgkin's lymphoma, vitamins B12 and C deficiency, hypo- ents at birth or in early infancy with follicular papules and surrounding ery-
thyroidism, Cushing's disease, and treatment with adrenocorticotropic thema followed by atrophic scarring affecting the lateral aspect of the eyebrows
hormone.3,4,5 (Fig. 3.61).3–5 The cheeks, forehead, temples, and neck may also be involved
(Fig. 3.62). Later on, the entire eyebrow may be lost. Keratosis pilaris affect-
Histological features ing the extensor aspects of the arms and thighs is also sometimes present.3 The
Keratosis pilaris is characterized by follicular dilatation and keratin plugs, condition is believed to be inherited as an autosomal dominant.
which may contain a single or several distorted hair shafts (Fig. 3.60).4 A It may be associated with a number of other inherited disorders including
mild, non-specific chronic inflammatory cell infiltrate surrounds the dermal Noonan's syndrome, woolly hair, cardiofaciocutaneous syndrome, Cornelia de
blood vessels and sometimes involves the hair follicles themselves. Lange syndrome, Rubinstein-Taybi syndrome, and partial monosomy 18.3,6–12
Acquired ichthyosis-like conditions 69

Fig. 3.61
Ulerythema ophryogenes: there is intense erythema with loss of follicles. The
eyebrow is a commonly affected site. By courtesy of the Institute of Dermatology,
London, UK.

Fig. 3.63
Keratosis pilaris atrophicans: (A) low-power view showing gross follicular
hyperkeratosis and dilatation of the ostium; (B) high-power view. Note the
perifollicular fibrosis.

hyperkeratosis, photophobia, and punctate keratitis.18 In some patients it

is inherited as an X-linked recessive disorder which has been mapped to
Fig. 3.62
Ulerythema ophryogenes:
Xp21.13-p22.2.21,22 X-linked dominant and autosomal dominant variants
the cheek is also have also been proposed.19
frequently involved. By
courtesy of the Institute Pathogenesis and histological features
of Dermatology, London, The pathogenesis of keratosis pilaris atrophicans is unknown although it
UK. involves blockage of the follicular ostium by a keratinous plug.
All variants of keratosis pilaris atrophicans are characterized by follicular
hyperkeratosis with ostial dilatation, atrophy of the sebaceous gland, and a
The association with Noonan's syndrome is of particular importance since
scanty perifollicular or perivascular lymphohistiocytic infiltrate. Comedones
such patients suffer from potentially life-threatening congenital pulmonary
and milia may be found. There is a variable perifollicular fibrosis that extends
stenosis. Ulerythema ophryogenes is also associated with atopy.13
into the reticular dermis (Fig. 3.63).3,11,12,16
Atrophoderma vermiculata (ulerythema acneiforme, atrophoderma ver-
miculatum, atrophoderma reticulata, acne vermoulante, folliculitis ulery-
thema reticulata, folliculitis ulerythematosa, honeycomb atrophy) is an Acquired ichthyosis-like conditions
exceedingly rare form of atrophic keratosis pilaris thought to be inherited as
an autosomal dominant. Patients present with follicular keratoses and pit- Acquired ichthyosis-like or ichthyosiform conditions refer to patients who
ted depressions separated by normal skin (worm-eaten appearance) affect- develop diffuse ichthyosis-like scaling during their life (Table 3.5). The adult
ing the cheeks, ears, and forehead (honeycomb atrophy).2,14–17 The disorder onset renders the term acquired ichthyosis inappropriate. It is an important
presents in patients after 5 years of age.2 Unilateral nevoid variants following paraneoplastic manifestation of a number of malignancies: Hodgkin's lym-
Blaschko's lines have been documented.15–17 phoma is most often encountered, but non-Hodgkin's lymphoma including
Keratosis follicularis spinulosa decalvans is characterized by diffuse mycosis fungoides and a range of carcinomas have all been associated.1–8
atrophic keratosis pilaris associated with scarring alopecia affecting the Ichthyosiform skin changes may also accompany malnutrition, HIV and
scalp.18–20 Other conditions sometimes present include atopy, palmoplantar other infectious diseases, sarcoidosis, collagenoses, celiac disease and other
70 Disorders of keratinization

Table 3.5
Acquired ichthyosis-like conditions

Etiology Diseases
Dry skin None
Paraneoplastic Hodgkin and non-Hodgkin lymphoma
Kaposi sarcoma
Various carcinomas
Infections Leprosy
Malnutrition Pellagra
Vitamin A deficiency
Drugs Lipid-lowering agents (statins)
Nicotinic acid
Lithium A
Gastrointestinal diseases Crohn's disease
Celiac disease
Endocrinopathies Hyperparathyroidism
Miscellaneous Renal insufficiency
Graft-versus-host disease
Dermatomyositis and systemic lupus
Down's syndrome

gastrointestinal diseases, renal insufficiency, hypothyroidism, and graft-

­versus-host disease.4,9–15 Ichthyosiform skin changes following administra-
tion of lipid-lowering agents and other various drugs or kava consumption
has been documented.13,14 Dry skin, especially in blacks, leads to the develop- B
ment of lamellar scales on the legs and trunk. The features of acquired ich-
thyosis-like skin conditions most often resemble those of ichthyosis vulgaris Fig. 3.64
both clinically and histologically (Figs 3.64–3.67). Acquired ichthyosis: (A) cutaneous manifestations most often resemble ichthyosis
Clinical differential diagnosis includes xerosis cutis which lacks thick vulgaris; (B) close-up view of the scale. By courtesy of the Institute of Dermatology,
scales, develops at later age, and can be easily treated by fatty emolients. London, UK.

Pityriasis rotunda
Clinical features
Also known as pityriasis circinata, this acquired disorder of keratinization
was originally described in the Japanese.1 It is also not uncommon in South
Africans (Bantu) and West Indian blacks,2,3 but has only rarely been reported in
Caucasians with the exception of a subpopulation of Italians in Sardinia.4–7 Fig. 3.65
Patients present with persistent, very sharply defined, circular or oval areas Acquired ichthyosis:
of hyper- or hypopigmentation associated with a fine scale (Fig. 3.68). Lesions, there is intense erythema
which are usually multiple and frequently numerous, are characteristically non- and scaling. This patient
inflammatory and asymptomatic. Often, they are confluent. They measure 0.5– also suffered from graft-
28 cm in diameter and are particularly located on the trunk and limbs. The sex versus-host disease.
incidence is equal. Lesions are sometimes associated with gradual remission By courtesy of B. Solky,
during the summer months and relapse in winter.6 The maximum incidence is MD, Department of
Dermatology, Brigham
in the third to fifth decades. There is often a family history of ichthyosis vul-
and Women's Hospital
garis.8 It may occasionally be associated with a familial incidence.8,9 and Harvard Medical
Pityriasis rotunda sometimes appears to be a cutaneous marker of severe inter- School, Boston, USA.
nal disease including tuberculosis,1 cancer (particularly hepatoma),10,11 leukemia,12 cir-
rhosis,6 ovarian and uterine disease,13 undernutrition, and favism.8 Pityriasis rotunda
might best be regarded as an acquired circumscribed variant of ichthyosis.12 Increased pigmentation of the basal keratinocytes may be evident. A mild
perivascular chronic inflammatory cell infiltrate is sometimes present in the
Histological features superficial dermis. A superficial fungal infection, for example tinea (pityr-
The histological features are subtle and comprise hyperkeratosis with a dimin- iasis) versicolor, should always be excluded by a PAS reaction or silver
ished or absent granular cell layer and loss of the epidermal ridge pattern. stain.14
Erythrokeratodermas 71

Fig 3.66
Acquired ichthyosis: this patient developed ichthyosis in a background of mycosis Fig. 3.68
fungoides. Low-power view showing marked focally compact hyperkeratosis and Pityriasis rotunda: characteristic lesion showing circumscription, scaling, and
acanthosis. hyperpigmentation. By courtesy of R.A. Marsden, MD, St George's Hospital,
London, UK.

transmembrane proteins that form gap junctions and are involved in epider-
mal differentiation.The KID/HID syndrome and Vohwinkel's syndrome are
associated with sensorineural hearing loss. In others, the genetic defect has
yet to be identified.2

Erythrokeratoderma variabilis
Clinical features
This rare ichthyosiform dermatosis generally has an autosomal dominant
mode of inheritance although an autosomal recessive variant has recently
been described.1–5 Lesions usually present soon after birth or during the first
year of life and are of two types, typically present simultaneously:
• Type 1 lesions are symmetrically distributed, discrete figurate, and
often bizarre patches of erythema, which vary in size, shape, number,
and location over periods of hours and days (Fig. 3.69).3 These are
sometimes temperature or stress related.1,6
Fig 3.67 • Type 2 lesions are well-defined, fixed geographical, reddish-yellow-
Acquired ichthyosis: high-power view to emphasize the atypical lymphocyte population brown greasy, hyperkeratotic plaques arising either within the
and atypia. Note the well-developed retraction artifact so typical of this condition. erythematous lesions or, more often, independently (Fig. 3.70). Lesions
are usually asymptomatic although occasionally mild pruritus or burning
sensations are a feature.4
Erythrokeratodermas The condition particularly affects the face, buttocks, and extensor surfaces
of the extremities.7 While cold weather in winter and emotional ­problems
‘Erythrokeratoderma’ or ‘erythrokeratodermia’ refers to a group of geno- may sometimes exacerbate the condition, the symptoms often improve in the
dermatoses characterized by localized erythematous lesions, hyperkeratotic summer months.4 Erythrokeratoderma variabilis is occasionally ­associated
plaques, and, infrequently, a mild palmoplantar keratosis.1 Many of these with high estrogen levels and symptoms may worsen with estrogen-contain-
diseases represent connexin mutations (Table 3.6). Connexin genes code for ing oral contraceptive therapy.1,2,4 Hypertrichosis (of vellus hairs) and mild
Table 3.6
Diseases with connexin mutations

Disease Inheritance Locus Gene Protein

Erythrokeratoderma variabilis AD or AR 1q35.1 GJB3 Connexin 31
AD 1q35.1 GJB4 Connexin 30.3
Erythrokeratoderma variabilis with AD 1q35.1 GJB4 Connexin 30.3
erythema gyratum repens-like lesions
Keratitis-ichthyosis-deafness syndrome/Hystrix-like- AD 13q11-12 GJB2 Connexin 26
ichthyosis deafness syndrome (KID/HID Syndrome)
Oculodentodigital dysplasia AD 6q22-24 GJA1 Connexin 43
Vohwinkel keratoderma AD 13q11-12 GJB2 Connexin 26
Hidrotic ectodermal dysplasia of Clouston AD 13q11-12 GJB6 Connexin 30
72 Disorders of keratinization

Fig. 3.69
Erythrokeratoderma variabilis: annular and serpiginous erythematous lesions
showing scaling and the characteristic trailing edge. By courtesy of R.A. Marsden,
MD, St George's Hospital, London, UK.

Fig. 3.71
Erythrokeratoderma variabilis: (A) low-power view showing hyperkeratosis,
acanthosis with an undulating skin surface and a very light superficial perivascular
chronic inflammatory cell infiltrate; (B) high-power view showing marked
parakeratosis overlying a thickened orthokeratotic stratum corneum. Note the
presence of a granular cell layer.

erythrokeratoderma variabilis harbor Cx31 or Cx30.3 mutations.8–11 A subset

Fig. 3.70
of patients with connexin 30.3 mutations manifest with a unique clinical
variabilis: in these lesions feature, namely transient erythematous patches with a peculiar, circinate or
there is more pronounced gyrate border reminiscent of erythema gyratum repens, i.e., erythrokerato-
scaling. derma with erythema gyratum repens-like lesions.12
The histopathological features of this disease are not specific, consisting of
orthohyperkeratosis, variable parakeratosis, irregular acanthosis, and papil-
lomatosis with an undulating skin surface (Fig. 3.71).3,13 Dyskeratotic cells
­ eratoderma of the palms and soles may additionally be evident.3,6 The
k with pyknotic nuclei reminiscent of the grains of Darier have been described
mucous membranes, hair, teeth, and nails are unaffected and there are no in one case.6 The granular cell layer appears normal. A perivascular lympho-
associated systemic manifestations.4 histiocytic inflammatory cell infiltrate may be present in the superficial der-
mis. Pilosebaceous follicles and sweat glands are normal.13
Pathogenesis and histological features Connexin immunohistochemistry discloses an irregular distribution of the
Connexin genes code for proteins that form intercellular channels called gap epidermal gap junction proteins.14
junctions that allow for transport and signaling between neighboring cells Ultrastructural observation have shown an increased number of gap junc-
in the epidermis. In the skin, Cx31 and Cx30.3 are expressed in the stra- tions, some of which display four layers, suggesting a loosened connection of
tum granulosum of the epidermis with a suggested role in late keratinocyte the keratinocyte plasma membrane through the gap junctions.15 Other studies
differentiation.8 have revealed markedly diminished numbers of Odland bodies in the granu-
Initially linked to the RH1 locus on 1p, erythrokeratoderma variabilis lar cell layer.6,14 Conspicuous nonmyelinated nerve fibers and Schwann cells
has been mapped to 1p34-p35, which includes the connexion genes GJB3 have been described in the papillary dermis.6,14 These, however, are not con-
and GJB4.7,8 However, erythrokeratoderma variabilis appears to be hetero- sistent findings.16 Nuclear encirclement by condensed keratin filaments and
geneous since not all individuals that have been clinically diagnosed with keratohyalin has also been recorded.16
Erythrokeratodermas 73

Differential diagnosis mitochondria in the granular cell layer are said to be a helpful ultrastructural
diagnostic pointer.3–5,7
Progressive symmetrical erythrokeratoderma is characterized by symmetrical
distribution and a more fixed or very slow progression of erythema and scaly
plaques. Since mutations in the the loricrin gene have been identified (loricrin ker- Differential diagnosis
atoderma), this condition should no longer be grouped as a connexin disorder. Progressive symmetric erythrokeratodermia can be distinguished from pso-
riasis by the absence of suprapapillary plate thinning, neutrophil infiltration,
Progressive symmetric erythrokeratodermia and Munro microabscesses.2 In addition, the parakeratosis tends to be very
focal and hypergranulosis is usually present.
Clinical features
Also known as erythrokeratodermia progressiva symmetrica or Gottron's
syndrome, this condition is inherited as an autosomal dominant with incom-
Keratitis-ichthyosis-deafness syndrome
plete penetrance, although sporadic cases may also be encountered.1,2 It usu-
ally presents in the first year of life with fixed, symmetrical, and sometimes Clinical features
pruritic, erythematous scaly plaques on the extensor surfaces including Keratitis-ichthyosis-deafness syndrome (KID syndrome, palmoplantar ectoder-
the elbows, knees, buttocks, dorsal surfaces of the feet and hands, and head mal dysplasia type XVI) is a very rare genodermatosis. Spontaneous mutations,
(Fig. 3.72).1–5 The face, chest, and abdomen are typically unaffected.2 The autosomal dominant, and autosomal recessive modes of inheritance have all
plaques gradually extend during the first few years and then become static.3 been documented.1–4 There is an equal sex incidence.5 It may present at birth
Additional features include palmoplantar keratoderma and pseudoainhum as a ‘vernix-like’ covering, which soon progresses to a dry, scaling erythema,
(constriction bands on the fingers and toes). The sex incidence is equal.2 There particularly affecting the face (especially the cheeks) and extremities, including
is clinical overlap with erythrokeratoderma variabilis and indeed patients the palms and soles.1,3,4,6,7 The skin may be thickened and leathery.7,8 Later the
may present with features of both diseases. However, progressive symmetric lesions become verrucous and hyperkeratotic, brownish-yellow, sharply circum-
erythrokeratoderma lacks transient migratory erythema.1 scribed plaques (Fig. 3.73).1 Circumoral furrows may lead to a progeria-like
appearance.9 Follicular keratoses sometimes develop on the head and extremi-
Pathogenesis and histological features ties and a ‘prickly’ spiculated appearance on the backs of the hands is occasion-
A mutation in the loricrin gene on chromosome 1q21 has been identified in ally evident.3,4,8 Palmar and plantar involvement with accentuation of the skin
one family with progressive symmetric erythrokeratoderma.6 Similar muta- markings has been likened to heavily grained leather.10 There does, however,
tions have been reported in the ichthyotic variant of Vohwinkels's syndrome. appear to be some variation in presentation.1 Some patients have therefore been
As a result, more definitive genotype-phenotype correlation within the con- described as being normal at birth, developing dry, scaly skin in later childhood,
nexin gene disorders or other causative genes will have to be established to while others have been reported as ‘red and wizened at birth’.11,12
define symmetrical progressive erythrokeratoderma as a separate entity. Inflammation of the cornea with photophobia is usual and a vascularizing
Histologically, there is marked basket-weave hyperkeratosis with focal keratitis leads to severe visual impairment.8 The end result is destruction of
parakeratosis, hypergranulosis, and psoriasiform hyperplasia.2,3 Paranuclear the cornea by a pannus of vascular or fibrous tissue (keratoconus).1
vacuolation may be evident in the granular cell layer.3,7 A perivascular lym- Deafness is of the congenital neurosensory type, but is occasionally due to
phocytic infiltrate is present in the superficial dermis.5 recurrent otitis media; conduction defects may also be present.1,7,8 It is often
Ultrastructurally, characteristic loricrin-rich intranuclear granules are seen total and frequently present at birth although not usually recognized until
in the granular cell layer.6 Lamellar granules are increased in number and lipid sometime later in early childhood.8
droplets may be evident in the cornified cells.3 Immunohistochemically, the Ectodermal dysplasia is variably present and features include alope-
cornified cell envelopes show greatly reduced staining for loricrin.6 Swollen cia (either partial or complete, including eyebrows and eyelashes), small

Fig. 3.73
KID syndrome: there is
Fig. 3.72 marked scaling of the
Progressive symmetric scalp with alopecia. Note
erythrokeratodermia: the facial erythema and
Erythematous scaly dark plaques on the
plaques gradually appear cheeks. By courtesy
on the extensor surfaces of R.J.G. Rycroft, MD,
on the extremities and St John's Dermatology
then persist. Centre, London, UK.
74 Disorders of keratinization

malformed teeth with increased caries, scrotal tongue, leukokeratosis, and a

variety of dystrophic nail changes including fragility, hyperkeratosis, dyspla-
sia, leukonychia, and aplasia.1,4,8
Additional features that may be detected include increased susceptibility to
superficial and systemic chronic infections (bacterial and fungal), neuromus-
cular disease, retraction of the Achilles tendon, hypohidrosis, heat intolerance,
and growth deficiency.1,3,8,13–15 The reason for the increased risk of cutaneous
infection is unknown. While an abnormality of immunity has been proposed,
it is felt more likely that colonization of greatly increased and degenerate
keratin is the more important etiological factor.16 No consistent abnormal-
ity of immune function has so far been reported.3,11,14 Mental retardation is a
rare feature, which may be seen in patients with the autosomal recessive vari-
ant.1 Liver disease including cirrhosis has been present in autosomal recessive
patients.1,2 Squamous carcinoma of the tongue and skin (sometimes multiple)
are important complications (Fig. 3.74).3,13,17–19

Pathogenesis and histological features

KID syndrome, at least in some families, has been shown to be associated Fig. 3.75
with mutations in the connexin 26 gene.20,21 KID syndrome: scanning
The histological appearances of the skin lesions are non-specific and view showing basket-
include basket-weave hyperkeratosis with occasional foci of parakerato- weave hyperkeratosis. In
sis, acanthosis, and papillomatosis (Figs 3.75, 3.76).8 Some authors have this example the eccrine
observed prominence and vacuolization of the stratum granulosum.22,23 sweat glands are normal.
Follicular plugging is commonly present and occasionally the orifices of the
eccrine ducts are similarly affected.5,11 A superficial perivascular lymphohistiocytic
infiltrate is sometimes evident.8 Eccrine sweat glands may be diminished in num-
ber and atrophic, with thickened, hyalinized basement membranes and absent or
atrophic hair follicles are seen in the areas of alopecia.3,8,22 Electron microscopic
studies of the epidermis have revealed no significant abnormalities.7,15
A recently reported autopsied case has described both ocular and aural
• Ocular changes were limited to the cornea and conjunctiva. Dyskeratosis
and atrophy of the corneal surface epithelium accompanied by
neovascularization and mild chronic inflammation of the substantia
propria were evident. The bulbar conjunctiva showed epithelial
atrophy, dyskeratosis, and mild chronic inflammation. Late changes are
characterized by the development of an inflammatory and vascular pannus.8
• Aural changes related not only to epithelial maturation abnormalities
of the external auditory meatus and tympanic membrane, but also to
cochleal maldevelopment.16 The essential features of the former included

Fig. 3.76
KID syndrome: high-power view emphasizing the basket-weave keratin overlying a
zone of compact keratin. There is focal parakeratosis. There is vacuolization of the
granular cell layer.

parakeratosis of the squamous epithelium overlying the tympanic

membrane. Immaturity and parakeratosis of the ridge pattern of the
epithelium covering the bony aspect of the external auditory meatus may
also be present. Changes of the internal ear included maldevelopment of
the cochlea and absence of the tectorial membrane and organ of Corti,
accompanied by reduction in the number of nerve fibers and spiral
ganglion nerve cells.16 These features are very much in keeping with
sensorineural deafness of cochleal origin.
The liver changes include micronodular cirrhosis, cholestasis, Kupffer cell
hyperplasia, abundant Mallory's hyaline and marked copper storage.1

Hystrix-like ichthyosis with deafness

Fig. 3.74
KID syndrome: squamous Clinical features
carcinoma on the knee.
Tumors may be multiple.
Hystrix-like ichthyosis-deafnesss (HID) syndrome (ichthyosis hystrix type
By courtesy of M. Judge, Rheydt) presents with spiky and cobblestone-like hyperkeratosis.1,2 There
MD, Institute of are many similarities with keratitis-ichthyosis-deafness syndrome. However,
Dermatology, London, HID patients show multiple red patches shortly after birth, which develop
UK. into ichthyotic erythroderma. In contrast to the KID syndrome, patients with
Palmoplantar keratoderma 75

HID show a more widespread involvement of the trunk but less palmoplan-
tar hyperkeratosis. Keratitis of the eyes is less prominent in HID patients, but Palmoplantar keratoderma
they also suffer from neurosensorial deafness, proneness to mycotic/bacterial
skin infections, and skin cancer.2 The palmoplantar keratodermas (PPKs) consist of a large heterogeneous
group of localized cornification disorders characterized by hyperkeratosis
of the palms and soles. Ichthyotic skin disorders and erythrokeratoderma
Pathogenesis and histological features may also show palmoplantar hyperkeratosis but mainly affect other body
Both HID and KID syndromes are associated with an identical connexin areas. PKKs are classified on the basis of mode of inheritance, distribution of
26 missense mutation.3 Therefore they may represent a spectrum of pheno- lesions, additional clinical features, and associated abnormalities.1–5 Many of
typic variability instead of separate entities.3 these genodermatoses have a late onset. At least 30 subtypes are recognized
Histologically, there is orthohyperkeratosis with foci of parakeratosis, and subdivided into two broad subtypes, one in which lesions are restricted
acanthosis, and the nuclei are surrounded by empty spaces reminiscent of to the skin (Table 3.7) and the other in which there is a much broader spec-
a bird's eye. At the ultrastructural level, keratinocytes show reduction of trum of ectodermal defects affecting skin, mucosae, nails, hair, teeth and neu-
tonofibrils and abnormal membrane-bound granules containing mucous sub- rological abnormalities (Table 3.8).4,5 Where more than a single ectodermal
stances that are discharged into the intercellular spaces.4 The absence of these structure is involved Stevens et al. coined the term ‘palmoplantar ectodermal
features in KID syndrome may result from sampling errors, with some skin dysplasia’ to emphasize the generalized nature of the disorder and identified
areas being more severely affected than others.3 a total of 19 subtypes.6

Table 3.7
Isolated palmoplantar keratodermas (PPK)
Palmoplantar keratoderma Inh. Locus Protein Disease
Diffuse AD 17q12-q21 Keratin 9 Epidermolytic palmoplantar keratoderma (Vörner-Unna-Thost)
12q11-13 Keratin 1 Epidermolytic PPK Vörner-Unna-Thost, Epidermolytic hyperkeratosis
with polycyclic psoriasiform plaques
12q11-13 Keratin1 Progressive palmoplantar keratoderma (Greither) and other
nonepidermolytic palmoplantar keratoderma
8p22-23 unknown Keratolytic winter erythema
AR 8qter SLURP1 Mal de Meleda
12q11-13 unknown Gamborg-Nielson palmoplantar keratoderma
Circumscribed AD 18q12.1-12.2 Desmoglein1 Keratosis palmoplantaris areata et striata (type 1–3)
6q24 Desmoplakin
12q Keratin1
unknown unknown Keratosis palmoplantaris nummularis (hereditary painful callosities)
Punctate AD 8q24 unknown Punctate palmoplantar keratoderma (Buschke-Fischer-Brauer)
unknown unknown Marginal papular acrokeratoderma

Table 3.8
Palmoplantar keratodermas (PPK) with associated symptoms

keratoderma Disease Inh Locus Protein Symptoms
Diffuse Huriez syndrome AD 4q23 ? Sclerodactyly, nail dystrophy, squamous cell
carcinomas in atrophic areas
Vohwinkel syndrome 13q11-12 Connexin 26 Mutilating keratoderma, sensorineural deafness
Loricrin keratoderma 1q21 Loricrin Associated ichthyosis
Clouston syndrome 13q12 Connexin 30 Diffuse palmoplantar keratoderma, alopecia, nail
Olmsted [1927] syndrome ? ? ? Diffuse mutilating palmoplantar, periorificial
keratoses, ectodermal dysplasia
Papillon-Lefèvre AR 11q14 Cathepsin C Diffuse palmoplantar keratosis with severe
syndrome periodontitis
Naxos syndrome 17q21 Plakoglobin Wooly hair, cardiomegaly, tachycardia
McGrath syndrome 1q32 Plakophilin 1 Painful diffuse palmoplantar keratosis, Skin
fragility, dystrophic nails, sparse hairs
Circumscribed Pachyonychia congenita 1 AD 12q13 Keratin 6A Thickened nails, focal palmoplantar keratoderma,
Jadassohn-Lewandowsky 17q12-q21 Keratin 16 folliculare hyperkeratosis, leukokeratosis
Pachyonychia congenita 2 12q13 Keratin 6B Thickened nails, focal palmoplantar keratoderma,
  Jackson-Lawler 17q12-q21 Keratin 17 cysts, natal teeth
Howel-Evans syndrome 17q24 ? Association with carcinoma of esophagus
Tyrosinemia II AR 16q22.1-q22.3 Tyrosine ­ Focal, often painful palmoplantar keratoderma
(Richner-Hanart amino-transferase
Carvajal-Huerta syndrome 6p24 Desmoplakin Epidermolytic PPK, wooly hair, arrhythmogenic
left cardiomyopathy
Punctate Schöpf-Schulz-Passarge ? ? ? PPK with lid cysts, hypodontia and hypotrichosis
76 Disorders of keratinization

Table 3.9
Histologic patterns of PPK

Epidermolytic hyperkeratosis Epidermolytic palmoplantar

keratoderma (Vörner-Unna-Thost)
Keratosis palmoplantaris
PKK with polycyclic psoriasiform
Carvajal-Huerta syndrome
Hyperkeratosis overlying depressed Keratosis palmoplantaris punctata
area of the epidermis
Paranuclear eosinophilic globular Pachyonychia congenital
inclusions Tyrosinemia type II
Orthohyperkeratosis and, Other forms of PKK
focal parakeratosis, epidermal
hyperplasia, discrete perivascular
inflammation Fig. 3.77
Diffuse palmoplantar
keratoderma Vörner-
Unna-Thost: there is
There are three major clinical categories: diffuse, circumscribed, and punctu- hyperkeratosis affecting
ate (Tables 3.7 and 3.8).4,5 Histologically, there are four main histologic patterns the entire sole of the foot.
that are characterized by epidermolytic hyperkeratosis, orthohyperkeratosis By courtesy of W.A.D.
with hypergranulosis and acanthosis, hyperkeratosis ­overlaying depressed areas Griffiths, MD, Institute of
Dermatology, London, UK.
of the epidermis, and paranuclear eosinophilic inclusions (Table 3.9). In many
subtypes, the underlying molecular defect has been ­identified and can be related
to structural proteins (keratins), cornified envelope (loricrin, transglutaminase),
cohesion (plakophilin, desmoplakin, desmoglein1), cell-to-cell communication
(connexins), and transmembrane signal transduction (cathepsin C).7

Keratosis palmoplantaris diffusa

Clinical features
Keratosis palmoplantaris diffusa Vörner-Unna-Thost is an epidermolytic pal-
moplantar keratoderma (PPK) and represents the most common form of pal-
moplantar keratoderma with an incidence of 1:100 000. Reinvestigation of
the original family with Unna-Thost PPK showed that epidermolytic forms
existed within the family as has been described by Vörner. Therfore, it is not
justified to separate Vörner disease from Unna-Thost disease.1
The condition is inherited as an autosomal dominant and usually presents
in the first months or else when the patients start running.1–6 Patients pres-
ent with symmetrical, well-demarcated yellowish, smooth and waxy plaques
covering the palms and soles, and, to some extend, the ventral surface of Fig. 3.78
fingers and toes (Figs 3.77, 3.78). The lesions reach the lateral aspects of Diffuse palmoplantar keratoderma Vörner-Unna-Thost: in this patient the palms
hands and feet but not beyond. The periphery is bordered by an erythematous of the hands were also affected. By courtesy of W.A.D. Griffiths, MD, Institute of
margin (Fig. 3.79).2 Painful blisters are not uncommon. Hyperhidrosis and Dermatology, London, UK.
maceration may be present and facilitate dermatophytosis.3,6 Rarely, associ-
ated knuckle pads or clubbed digits have been documented.7 Identification the rod domain are associated with only mild focal signs of epidermolytic
of the epidermolytic form of PPK has therapeutic consequences since lesions hyperkeratosis in the spinous layer of palmoplantar epidermis.11
become inflammatory and erosive with systemic retinoid therapy. Epidermolytic palmoplantar keratoderma is not associated with malig-
nancy. Patients in one large kindred showed a high incidence of breast and
Pathogenesis and histological features ovarian cancer.10 It is now believed that this represented a coincidental co-
Epidermolytic palmoplantar keratoderma was initially mapped to17q12-q21, the segregation of a keratin 9 mutation with a BRCA1 mutation on 17q21.2
locus of the type I acidic keratin cluster where different point mutations of keratin Histologically, there is a massive orthohyperkeratosis, hypergranulosis,
9 were identified.8 Epidermolytic palmoplantar keratoderma, however, has also papillomatosis, and acanthosis accompanied by features of epidermolytic
been reported to be associated with keratin 1 mutations that map to 12q11–13, hyperkeratosis in the prickle and the granular cell layers with unstained,
the site of the keratin II genes.9,10 Keratin 1 and 9 are the major structural keratins vacuolated cytoplasm, intracytoplasmic eosinophilic granules, and coarse
in the suprabasal keratinocytes of palmoplantar epidermis. Mutations in keratin keratohyalin granules (Figs 3.80, 3.81). A superficial dermal perivascular
9 are associated with more severe manifestations than mutations in keratin 1. lymphohistiocytic infiltrate may sometimes be present. Epidermal spongiosis
Most of the keratin mutations affect the central regions of the protein, and vesiculation may indicate mycotic superinfection.
which are important for filament assembly and stability of the keratin skel- Electron microscopy shows aggregations of keratin filaments and keratin
eton. As a consequence, tonofilament clumping causes cellular degeneration clumps that accounts for the intracytoplasmic eosinophilic granules seen by
and disruption, e.g., epidermolytic palmoplantar keratoderma. Mutations in light microscopy. Large areas of the cytoplasm that are devoid of a keratin
Palmoplantar keratoderma 77

Fig. 3.79 Fig. 3.81

Diffuse palmoplantar keratoderma Vörner-Unna-Thost: the border of the lesion is Diffuse palmoplantar keratoderma Vörner-Unna-Thost: high-power view
marked by a linear zone of erythema. By courtesy of W.A.D. Griffiths, MD, Institute demonstrating the features of epidermolytic hyperkeratosis.
of Dermatology, London.

Histological features
Histopathologic examination of the psoriasiform plaques demonstrates the
characteristic features of epidermolytic hyperkeratosis. Sequencing of the ker-
atin 1 gene in affected family members reveals a mutation within the highly
conserved helix termination motif of the helix 2B segment.1

Diffuse nonepidermolytic palmoplantar

Clinical features
Diffuse nonepidermolytic palmoplantar keratoderma is a heterogenous, ill-
defined group of conditions. It includes an autosomal recessive disorder with
a high incidence in Sweden and characterized by a thick, horny layer sharply
demarcated from the normal skin and knuckle pads on the dorsal aspect of
the finger joints.1 Symptoms usually present in the first 3 years of life.1 Many
patients suffer from increased sweating and, therefore, maceration is com-
Fig. 3.80 mon. There is a greatly increased risk of dermatophyte infections.1 Patients
Diffuse palmoplantar with this variant may also show axillary and groin involvement, subungual
keratoderma Vörner- hyperkeratosis, onychodystrophy, and central facial lesions.2 Another non-
Unna-Thost: scanning epidermolytic variant of diffuse PPK is Mal de Meleda (see below).
view showing massive Although diffuse palmoplantar keratoderma was originally believed
hyperkeratosis, to be associated with esophageal carcinoma (Howell-Evans syndrome),
papillomatosis, and
­re-examination of the affected kindreds disclosed that the keratoderma would
better be classified as focal (see focal nonepidermolytic palmoplantar kera-
toderma with esophageal squamous carcinoma).3 There are, however, rare
instances of diffuse palmoplantar keratoderma associated with cutaneous
skeleton explain the vacuolar change. Keratohyalin granules cluster in a ran- squamous cell carcinoma, for example Huriez syndrome (palmoplantar kera-
dom fashion around the keratin aggragates. toderma with sclerodactyly) and Schöpf-Schulz-Passarge syndrome (palmo-
plantar keratoderma with squamous carcinoma arising in the areas affected
Epidermolytic hyperkeratosis with polycyclic by keratoderma).4,5
Acquired diffuse palmoplantar keratoderma may also be associated with
psoriasiform plaques malignancy.6

Clinical features Pathogenesis and histological features

Epidermolytic hyperkeratosis with polycyclic psoriasiform plaques is a Diffuse nonepidermolytic palmoplantar keratoderma has been mapped to 12q11–
unique palmoplantar keratoderma with an autosomal dominant inheri- 13, the site of the keratin II genes.7,8 The disease mutation described by Kimonis
tance.1 Clinically, affected individuals manifest transient blistering at birth and coworkers was the first to be identified in a keratin chain variable end region.9
followed by chronic diffuse palmoplantar keratoderma. Intermittent flares The fact that epidermolysis was not present suggests that the amino-terminal
of fixed polycylic erythematous psoriasiform plaques which characteristi- domain of keratins may be involved in supramolecular interactions of keratin fila-
cally deteriorate and then improve are seen although there is marked indi- ments rather than stability.9 There is, however, genetic heterogeneity.10
vidual variation in both the severity and duration of lesions, ranging from This disorder is characterized by marked hyperkeratosis, hypergranulosis,
weeks to months.1 acanthosis, and an exaggerated epidermal ridge pattern (Fig. 3.82). A chronic
78 Disorders of keratinization

Fig. 3.82
Diffuse nonepidermolytic
keratoderma: there is
massive hyperkeratosis,
hypergranulosis, and

inflammatory cell infiltrate is sometimes evident in the superficial dermis. The

presence of spongiosis and vesiculation should suggest a concomitant der-
matophyte infection and prompt evaluation of a PAS or silver stained section
(Figs 3.83, 3.84).11 In the diffuse recessive variant, the hyperkeratosis is even
more marked than in the dominant form and the epidermis shows prominent
psoriasiform hyperplasia.1

Progressive palmoplantar keratoderma B

Clinical features Fig. 3.83

Progressive palamoplantar keratoderma, (syn: Greither syndrome, keratosis Diffuse nonepidermolytic palmoplantar keratoderma: (A) in this example, there
palmoplantaris diffusa transgrediens et progrediens) is an autosomal dom- is massive hyperkeratosis with an undulating growth pattern. Intra-epidermal
inantly inherited disease. In childhood, a diffuse symmetric palmoplantar vesiculation is apparent, (B) high-power view.
keratoderma with small pits or fissures and hyperhidrosis develops that pro-
gressively extends to the back of the hands and feet, the region of the Achilles
tendon, ankles, knees or elbows where patchy hyperkeratosis develops. In the
middle of life amelioration occurs (Figs 3.85, 3.86).1

Pathogenesis and histological features

The previously reported cases of Greither's syndrome showed phenotypic
variability suggestive of different underlying gene defects. At least some cases
of Greither's syndrome are caused by keratin mutations.2
Histopathology shows acanthosis with focal orthohyperkeratosis located
on delled areas of the epidermis (Fig. 3.87). There are generally no features
of epidermolytic hyperkeratosis with the exception of a case where a keratin
mutation was detected.3

Keratolytic winter erythema

Clinical features
Keratolytic winter erythema (synonyms: erythrokeratolysis hiemalis,
Oudtshoorn disease) is an autosomal dominant disorder first described in
South Africa.1 Sporadic cases have been reported from other countries.2,3 The
disorder manifests at an early age and is characterized by recurring cycles of
erythema involving the palms and soles, followed by mild hyperkeratosis and
nonpruritic and nonpainful peeling. In severe cases the limbs and trunk are Fig. 3.84
affected with gyrate scaling erythemas. Most remarkably, the onset of symp- Diffuse nonepidermolytic palmoplantar keratoderma: fungal hyphae are apparent in
toms occurs during cold weather.2 the thickened stratum corneum (PAS stain).
Palmoplantar keratoderma 79

Fig. 3.85
Progressive palmoplantar
keratoderma: (A) diffuse
hyperkeratosis with fissures
progressively extends to the
back of the hands and feet
A B and (B) affects the region of
the Achilles tendon.

Fig. 3.86 Fig. 3.87

Progressive palmoplantar Progressive palmoplantar keratoderma: massive hyperkeratosis with a central small
keratoderma: Patchy dell (arrowed).
hyperkeratosis develops
on the knees.

Mal de Meleda
Pathogenesis and histological features
The disorder has been mapped to chromosome 8p22–23 with some genetic Clinical features
heterogeneity, but a causative gene has not yet been identified.4,5 Mal de Meleda is inherited as an autosomal recessive with a high prevalence
The epidermis is acanthotic with a thickened stratum granulosum. in Meleda in the Adriatic Sea. The diffuse keratoderma progresses onto the
At the advancing edge spongiosis and vesicle formation can be observed. dorsal aspects of the fingers and toes (keratosis palmoplantaris transgre-
More centrally, the stratum granulosum becomes pale staining and diens et progrediens Meleda). Further features are inflammatory borders,
pyknotic. Concommitantly, parakeratotic layers form on top. In the severe hyperhidrosis, maceration, and unpleasant smell. In addition, con-
horny layer a cleft appears that contains remnants of parakeratotic cells.1 stricting bands (pseudoainhum), brachydactyly, nail dystrophy, lesions on
A superficial perivascular lymphocytic infiltrate has been reported by knees and elbows, the perioral region and even oral leukokeratosis can be
some authors.3 observed.1,2
80 Disorders of keratinization

Pathogenesis and histological features

Mutations have been identified in the ARS component B gene on chromo-
some 8, encoding a protein named SLURP1.3–6 It is postulated that SLURP1
interacts with neuronal acetylcholine receptors present in keratinocytes and
sweat glands. Since SLURP1 may act as a secreted epidermal neuromodula-
tor essential for both epidermal homeostasis and inhibition of TNF-alpha
release by macrophages during wound healing, this may explain both the
hyperproliferative as well as the inflammatory clinical phenotype of Mal de
Histology shows orthohyperkeratosis with focal parakeratosis, acanthosis
without epidermolytic changes, and a superficial perivascular lymphocytic

Keratosis palmoplantaris areata et striata

Clinical features
Keratosis palmoplantaris areata et striata (striate palmoplantar keratoderma,
Brünauer-Fuchs-Siemens syndrome, acral keratoderma) is an autosomal dom-
Fig. 3.88
inant disorder characterized by linear bands of keratoderma affecting the pal-
Keratosis palmoplantaris areata et striata: linear hyperkeratotic bands are present
mar aspects of the palms and fingers (Fig. 3.88) accompanied by island-like best seen along the ulnar border of the palm. By courtesy of the Institute of
areas of hyperkeratosis on the soles of the feet.1,2 Lesions typically present Dermatology, London, UK.
in adolescence or early adulthood and are exacerbated by manual labor. A
background palmar hyperkeratosis may be present and fissuring can also be
seen.3 Abnormalities of the nails (ridging and cuticle hyperkeratosis), teeth,
described.6 The granular/filamentous material represents condensed kera-
and hair (wooly hair) may also sometimes be encountered.3,4 There are no
tin filaments. Premature expression of involucrin and filaggrin has been
systemic associations.
found.9 In one family, immunohistochemistry demonstrated diminished
lesional desmoplakin staining.6 Electron microscopy displays diminished
Pathogenesis and histological features
numbers of small and/or rudimentary desmosomes accompanied by keratin
Striate palmoplantar keratoderma is a heterogeneous condition. A transi- filament aggregates and enlarged malformed keratohyalin granules.6,8,9
tion mutation in desmoglein 1, mapped to chromosome 18q12.1, has been
identified in one family.5–7 In another, a transition mutation in desmoplakin,
mapped to chromosome 6p21, was identified, and in a third type, mutation
Keratosis palmoplantaris nummularis
of keratin 1 with partial loss of the glycine loops in the V3 domain has been
reported.3,8 Clinical features
Histologically, striate palmoplantar keratoderma is characterized by In keratosis palmoplantaris nummularis (hereditary painful callosities)
massive hyperkeratosis, hypergranulosis, and acanthosis (Fig. 3.89). patients present with nummular keratotic lesions overlaying plantar pres-
Dark-staining granular and filamentous material within the prickle cell sure points. Keratoses develop when children start to walk. Pain is the major
layer accompanied by slight separation of the keratinocytes has also been complaint.1

Fig. 3.89
Keratosis palmoplantaris areata et striata: (A) there
A B is massive hyperkeratosis with hypergranulosis and
acanthosis; (B) high-power view.
Palmoplantar keratoderma 81

Pathogenesis and histological features

The gene defect has not been identified as yet.
Histology shows epidermolytic hyperkeratosis similar to epidermolytic
palmoplantar keratoderma of Vörner-Unna-Thost.1

Punctate palmoplantar keratoderma

Clinical features
Punctate palmoplantar keratoderma (keratosis punctata palmaris et plan-
taris, keratoderma hereditarium dissipatum palmare et plantare, Buschke-
Fischer-Brauer disease, Davis-Colley disease) is characterized by an autosomal
dominant mode of inheritance.1–4 There is an increased incidence in blacks.2
Sometimes, lesions are associated with excessive manual labor.2 In an estab-
lished case, the patient has numerous discrete yellow-brown, small (1–3 mm),
depressed keratotic lesions on the palms and soles and also on the ventral
aspects of the fingers and toes (Figs 3.90, 3.91).5 If the keratin plug is dis-
lodged, a deeply depressed pit remains. Lesions are usually asymptomatic,
but occasionally pain, tenderness or burning are features.2,5
Fig. 3.91
There are occasional reports of punctate palmoplantar keratoderma asso-
Punctate palmoplantar keratoderma: close-up of lesions shown in Figure 3.90.
ciated with internal malignancies including carcinomas of the colon, kidney,
By courtesy of the Institute of Dermatology, London, UK.
breast, and pancreas and Hodgkin's lymphoma.6,7
Punctate keratoderma-like lesions affecting the palms and the soles have
been described as a complication of dioxin exposure.8

Pathogenesis and histological features

The pathogenesis is unknown. A locus has been genetically mapped on chro-
mosome 15q22-q24. The keratin gene clusters have been excluded by linkage
Histologically marked hyperkeratosis is seen overlying areas of epithelial
depression (Fig. 3.92).

Keratosis punctata of the palmar creases

Clinical features
Keratosis punctata of the palmar creases (keratotic pits of the palmar creases)
is a variant of punctate keratoderma in which the lesions are confined to
the palmar and digital creases.1–5 The soles of the feet and heels may also be

Fig. 3.92
Punctate palmoplantar keratoderma: there is massive hyperkeratosis overlying a
dell to the right of center.

involved.3,6 The sexes are equally affected and the disease is predominantly
seen in young to middle-aged adults.7 Although very rare in white patients,
it is common in black adults.3,5,8,9 The development of lesions appears to be
trauma related in many patients since outdoor workers are particularly affected
and the condition improves during a vacation. Although in the majority of
patients the condition appears to be a sporadic occurrence, in some reports an
autosomal dominant mode of inheritance has been documented.2,4
Lesions are small (1–3 mm) depressed yellowish keratotic plugs which are
usually asymptomatic but sometimes may be painful. They are localized to the
flexor creases and when removed leave a cone-shaped depression (Fig. 3.93).
Although usually seen as an incidental finding, on occasions they have been asso-
ciated with ichthyosis vulgaris.4,7 There are also reports of keratosis punctata of
Fig. 3.90 the palmar creases developing in patients with Dupuytren's contracture, derma-
Punctate palmoplantar titis herpetiformis with psoriasis, striate keratoderma, and knuckle pads.7,10
discrete yellow foci Histological features
of hyperkeratosis are
present over the weight- The lesions are characterized by a hyperkeratotic plug, sometimes with foci of
bearing surfaces. By parakeratosis below which are deep cone-shaped depressions sometimes cen-
courtesy of the Institute tered on the acrosyringium.4 The adjacent epidermis shows acanthosis with
of Dermatology, London, hypergranulosis and in some cases a perivascular lymphohistiocytic infiltrate
UK. is present in the superficial dermis.
82 Disorders of keratinization

Fig. 3.93 Fig. 3.95

Keratosis punctata of the palmar creases: minute punctate lesions are localized Acrokeratoelastoidosis: knuckle pads are conspicuous in this patient. By courtesy of
solely to the palmar creases. There is often a history of manual labor. the Institute of Dermatology, London, UK.
By courtesy of the Institute of Dermatology, London, UK.

Focal acral hyperkeratosis is clinically identical to acrokeratoelastoidosis,

Marginal papular acrokeratoderma patients presenting with keratotic papules along the sides of the hands, fingers, and
feet.7,8 It has also been designated acrokeratoelastoidosis without elastorrhexis.9
Clinical features Other reported cases have been mistakenly documented as acrokeratoel­astoidosis.10
Marginal papular acrokeratoderma refers to a complex, confusing, and Females are affected more often than males. Although originally thought to be a
overlapping group of disorders which includes acrokeratoelastoidosis ­disorder of black children, more recently it has been described in whites.11
of Costa, focal acral hyperkeratosis, mosaic acral keratosis, degenerate Mosaic acral keratosis is similar if not identical to focal acral hyper­
collagenous plaques of the hands, digital papular calcific elastosis, and keratosis, being characterized by keratotic papules distributed in a mosaic
keratoelastoidosis marginalis of the hands.1 All present with frequently or ­jigsaw-puzzle pattern along dorsal aspects of the feet and adjacent lower
crateriform, keratotic papules along the borders of the hands and feet legs.12 Hyperkeratosis may be seen on the palms and soles.1 Only females,
(Fig. 3.94).1 Although usually discrete, in some patients the papules may predominantly black, are affected.1
coalesce into plaques. Degenerative collagenous plaques of the hands affect the sun-damaged
Acrokeratoelastoidosis presents in childhood and adolescence with yel- skin of the elderly and present as symmetrical yellowish, keratotic or smooth
lowish, warty, and crateriform keratotic or pearly papules predominantly papules and plaques affecting the thumb, first web, and side of the index
affecting the sides of the hands, wrists, fingers, and feet.2–5 There is no racial ­finger.4,13–18 The ulnar border of the hand and volar aspect of the wrist may
predilection and the sexes are affected equally. Patients may also develop cir- also be involved. Keratoelastoidosis marginalis of the hands is a similar
cumscribed keratodermatous knuckle padlike lesions, palmoplantar hyperk- ­condition described in Australians in which keratotic papules develop at sites
eratosis, and hyperhidrosis (Fig. 3.95).1,3 Sporadic and autosomal dominant of trauma along the index finger and thumb.19 The skin is typically grossly
variants have been described. The disorder may be linked to chromosome 2.6 sun damaged. Calcified variants of degenerative collagenous plaques are
Repeated trauma is believed to be of etiological importance. known as digital papular calcific elastosis.20,21

Histological features
Acrokeratoelastoidosis is characterized by massive orthohyperkeratosis over-
lying a crateriform dell lined by acanthotic epidermis. Hypergranulosis may
be present. The dermis shows fragmentation and loss of the elastic tissue
(elastorrhexis) (Fig. 3.96). Collagen may be disorganized or appear homog-
enized and pale staining.2,3
Focal acral hyperkeratosis and mosaic acral keratosis are histologically
identical with the exception that the elastic tissue appears normal.7–12
Degenerative collagenous plaques of the hands are characterized by a
dense zone of thickened and distorted collagen with fragmentation of elastic
fibers and overlying hyperkeratosis and acanthosis.4,13–18 The papillary dermis
is spared. Calcification is sometimes a feature (digital papular calcific elasto-
sis).19–21 Telangiectatic vessels may also be seen and increased dermal mucin
has been described.19

Huriez syndrome
Clinical features
In Huriez syndrome (keratosis palmoplantaris diffuse with sclerodactyly, scle-
Fig. 3.94 rothylosis) patients present with a diffuse mild palmoplantar keratoderma,
Marginal papular acrokeratoderma: there is a linear band of scaling along the border scleroatrophic skin of the limbs, hypohidrosis, hypoplasia, and dystrophy of
of the foot. By courtesy of the Institute of Dermatology, London, UK. the nails (Fig. 3.97).1 Aggressive squamous cell carcinoma may develop in the
Palmoplantar keratoderma 83

Fig 3.96
(A) there is marked
hyperkeratosis; (B) there is
A B diminution of the dermal
elastic tissue.


Fig. 3.97
Huriez syndrome: (A) the leading features are sklerodactyly, hypotrophic and dystrophic nails, (B) there is mid palmar keratosis.

affected skin in approximately 15% of the cases. It has an early onset with a ectodermal dysplasia type VII) is a rare keratoderma which is usually inher-
high risk of metastasis in the third to fourth decades.1 ited as an autosomal dominant although a recessive variant has also been
described.1–3 Onset is in infancy or early childhood.2 Caucasians are pre-
Pathogenesis and histologic features dominantly affected and there is a predilection for females.3 The clini-
The genetic cause of this autosomal dominant condition is still unknown. cal features include palmoplantar keratoderma with a yellowish papular
Histology shows a mild acanthosis, orthohyperkeratosis and well developed and honeycomb-like appearance and hyperhidrosis. Other characteristics
granular layer (Fig. 3.98). Most interestingly, immunohistochemical and ultra- are starfish-like keratoses affecting the dorsal surfaces of the hands, feet,
structural studies revealed an absence of Langerhans cells in involved skin.2 wrists, forearms, elbows. and knees (Figs 3.99 and 3.100).3 Flexion con-
tractures and circumferential hyperkeratotic constriction bands (pseudoain-
hum) affecting the interphalangeal joints associated with autoamputation
Vohwinkel's syndrome are also present.2,3 Additional features include alopecia, nail dystrophy, and
onychogryphosis.2 In the classical variant, sensorineural deafness is an inte-
Clinical features gral feature.1,4,5 The ichthyosis-associated variant of Vohwinkel is a com-
Vohwinkel's syndrome (keratoderma hereditarium mutilans, keratosis pal- pletely different entity (see Loricrin keratoderma or Camisa variant form of
moplantaris mutilans, mutilating palmoplantar keratoderma, palmoplantar Vohwinkel's syndrome).6–9
84 Disorders of keratinization

Fig. 3.100
Vohwinkel’s syndrome: in
Fig. 3.98 this example there is very
Huriez syndrome. There are mild acanthosis, orthohyperkeratosis and well disfiguring keratoderma,
developed granular layer. hence the alternative title,
keratoderma hereditarium
mutilans. By courtesy
of W.A.D. Griffiths, MD,
Institute of Dermatology,
London, UK.

Pathogenesis and histologic features

Mutations on chromosome 1q21 that result in aberrant, elongated C-terminal
domains of one loricrin allele may lead to an abnormal loricrin expression, and
impairment of cross-linking to itself and other cornified envelope ­proteins.3–5
Loricrin keratoderma and some cases of progressive symmetrical erythro-
keratoderma may share the mutation and light and ultrastructural ­features.6
Therefore some authors have proposed that the loricrin keratoderma should
include cases of what has been termed either (Vohwinkel's) keratoderma with
ichthyosis and progressive symmetrical erythrokeratoderma.7
As with progressive symmetrical erythrokeratoderma acanthosis, a promi-
nent stratum granulosum and parakeratosis is present in loricrin keratoderma
(Figs 3.102, 3.103).
Electron microscopy characteristically reveals formation of a well-formed
transitional layer, intranuclear granules in the upper stratum granulosum, and
Fig. 3.99
a thin cornified envelope.4 Immunoreactivity for loricrin can be detected in
Vohwinkel's syndrome: there is marked palmoplantar keratoderma. By courtesy of
W.A.D. Griffiths, MD, Institute of Dermatology, London, UK.
the nuclei of the stratum granulosum and of the parakeratotic cells.4 Mutant
loricrin in the nucleus is thought to impair the function of profilaggrin to
mediate nuclear dissolution in the course of apoptosis which represents an
Pathogenesis and histological features integral part of keratinocyte terminal differentiation.6
Classical, deafness-associated Vohwinkel's syndrome is due to mutations in
the connexin 26 gene.8 Clouston's syndrome
Histologically, the keratoderma is characterized by hyperkeratosis, hyper-
granulosis, and acanthosis.3 Clinical features
Clouston's syndrome (hidrotic ectodermal dysplasia, palmoplantar ectoder-
mal dysplasia type X) is an uncommon disorder with an autosomal dominant
Loricrin keratoderma mode of inheritance. Nail dystrophy is often predominant, but hair defects
and palmoplantar keratoderma are also found (Fig. 3.104).1–7 Rare manifesta-
Clinical features tions include sensorineural deafness, ocular abnormalities, skin hyperpigmen-
Loricrin keratoderma (Camisa variant form of Vohwinkel's syndrome, tation, polydactyly, syndactyly, mental retardation, epilepsy, and dwarfism.5,6
Vohwinkel keratoderma with ichthyosis) is inherited in an autosomal dom- Changes in the nails are variable, but usually they are short and thickened
inant fashion and characterized by a diffuse palmoplantar keratoderma with longitudinal striations, often with discoloration, and may have grooves,
that is very similar to that of Vohwinkels' syndrome including the honey- pits and ridges.5,6 Development of paronychia is a frequent complication.
comb-like appearance (Fig. 3.101).1 In contrast, however, the palmoplantar Scalp alopecia (from hair thinning to complete baldness) is the rule, and facial,
­keratoderma is less mutilating, and warty papules and starfish-like keratosis axillary, and pubic hair is usually sparse or totally absent.6 The patients have a
are absent. A concomitant ichthyosis with generalized fine scaling is a con- normal facies and no involvement of the dentition or abnormal sweating.
stant feature and often presents congenitally prior to the development of the Although hidrotic ectodermal dysplasia has been documented predomi-
palmoplantar keratoderma.2 The patients also do not suffer from the deafness nantly in French Canadian families, kindreds have been described in French,
seen in Vohwinkel's keratoderma. Scottish-Irish, and Indians.4,7–10
Palmoplantar keratoderma 85

Fig. 3.101
Loricrin keratoderma:
(A) there is a generalized fine
scaling and (B) palmoplantar
keratoderma with a yellowish
popular and honeycomb-like
appearance less mutilating
A B than in classical Vohwinkel's

Fig. 3.102 Fig. 3.103

Loricrin keratoderma: there is hyperkeratosis and mild acanthosis. Loricrin keratoderma: the stratum granulosum is prominent. Scattered cells (on
the right side of the field) show perinuclear vacuolization and the parakeratotic
keratinocytes in the lower horny layer represent transitional cells.
Pathogenesis and histological features
The gene responsible for this condition has been mapped to 13q11–
12.1.11–14 Hidrotic ectodermal dysplasia results from a connexin 30 one family.6 There is no racial predilection. There is a striking predominance
mutation.15–18 in males (5:1).
The palmoplantar keratoderma is typified by hyperkeratosis, thickening The keratoderma is present at birth or begins in early infancy and when
of the granular cell layer, and acanthosis.5,7 Elsewhere, eccrine sweat glands fully developed presents as bilateral and symmetrical massively thickened,
are normal, but hair and sebaceous glands are greatly reduced in number and yellow, macerated, keratotic plaques covering the whole of the sole and palm
apocrine glands completely absent.8 and often extending to the lateral and even the dorsal surface of the hands
and feet (Fig. 3.105).3,4 The heels and forearms may also be affected. The
border of the plaque is sharply defined and surrounded by a pruritic ery-
Olmsted syndrome thematous border. Lesions are often fissured and extremely painful, mak-
ing walking exceedingly difficult or impossible.3,4 Blistering has occasionally
Clinical features been described.5 Flexion contractures, ainhum-like constriction bands, and
Olmsted syndrome is exceedingly rare and combines the features of mutilat- autoamputation are common complications. Superinfection with bacteria
ing palmoplantar keratoderma with periorificial plaques. Approximately 20 and fungi, particularly Candida albicans, contributes to the problems and as
cases have been documented.1–5 It is usually associated with sporadic occur- a result lesions are frequently very malodorous. Squamous carcinoma is an
rence although X-linked dominant transmission has been suggested at least in occasional complication.7,8
86 Disorders of keratinization

The plaques show increased mitotic activity, increased Ki-67 expres-

sion and increased argyrophilic nucleolar organizer regions (AgNORS).4,9
Keratinization is abnormal with aberrant expression of keratins 5, 10 and
14, filaggrin, and involucrin.4,5 It has, however, been proposed that the kera-
tin abnormalities might be a result of isotretinoin and etretinate therapy.10

Papillon-Lefèvre syndrome
Clinical features
Palmoplantar keratoderma with periodontopathia (palmoplantar kerato-
derma with periodontopathia, palmoplantar ectodermal dysplasia type IV)
is rare and has an autosomal recessive mode of inheritance.1 The incidence
is 1–4 per million of the population.2 There is an equal sex incidence and
onset is usually in the first decade. It is characterized by symmetrical and
marked palmoplantar keratoderma sometimes affecting the dorsal aspects of
the hands and feet (Fig. 3.106).3 Hyperhidrosis may also be present, associ-
ated with gingivitis and marked periodontosis involving both deciduous and
permanent teeth.4,5 Periodontosis is unrelated to oral hygiene and results in
Fig. 3.104 loss of attachment of teeth to the periodontal ligament (Fig. 3.107) and atro-
Clouston's syndrome: there is nail dystrophy accompanied by hyperkeratosis of the phy of the alveolar processes (maxillar and mandibular) with eventual loss
fingertips, thereby accentuating the epidermal surface ridges. of teeth. The periodontal ligament, which is a dense fibrous band, attaches
By courtesy of D. Atherton, MD, the Children's Hospital at Great Ormond Street, the tooth to the alveolar bone and carries the blood vessels, lymphatics, and
London, UK.
nerves.6 Psoriasiform lesions may be evident on the knees and elbows and

Fig. 3.105
Olmsted syndrome: in this variant, the lesions are very disfiguring. Constriction
bands and autoamputation are important complications. By courtesy of W.A.D.
Griffiths, MD, Institute of Dermatology, London, UK.

Affected children also develop erythematous keratotic papules and plaques

around the body orifices including the mouth, nares, ears, and anus.3,4 The eye-
lids, umbilical region, inguinal region, and gluteal cleft can also be involved.
Additional features include scarring alopecia, keratosis pilaris, and nail
dystrophy including ridging, transverse striae, thickening, curvature, subun-
gual keratosis, and infection.3,4 Hyperkeratotic linear streaks may develop in Fig. 3.106
the axillae and cubital fossae. Growth retardation, laxity of the large joints, Papillon-Lefèvre
and corneal involvement are occasional manifestations.3,4 syndrome: (A) there is
marked hyperkeratosis
Histological features affecting the soles of the
The plaques are characterized by massive hyperkeratosis, often with foci of feet; (B) in this patient,
the dorsal aspects of
vertically orientated parakeratosis.2–5 There is hypergranulosis with large
the hands, particularly
coarse granules under the former whereas the granular cell layer is absent the knuckles are also
beneath the areas of parakeratosis. The epidermis is acanthotic and shows affected. By courtesy
psoriasiform hyperplasia or papillomatosis and there is edema and increased of W.A.D. Griffiths, MD,
vascularity of the superficial dermis where a lymphohistiocytic infiltrate is B Institute of Dermatology,
also seen. London, UK.
Palmoplantar keratoderma 87

Fig. 3.107
Papillon-Lefèvre syndrome: gingival inflammation and swelling with the particularly
characteristic irregular positioning of the teeth which, as a result of destruction of Fig. 3.109
supporting tissues, have shifted under the forces of mastication. This patient is Papillon-Lefèvre
a 12-year-old child, but the severity of the periodontal destruction is what might syndrome: there
be expected in a person aged 60 years. By courtesy of R.A. Cawson, MD, Guy's is hyperkeratosis,
Hospital, London, UK. hypergranulosis and

onychogryphosis has been documented (Fig. 3.108).3 The adnexae are not granule serine proteases with resultant defective bacterial phagocytosis.11,12
usually affected. Presentation is usually in the early years of life (2–4 years The cathepsin C gene is also expressed in squamous epithelium of the palms,
of age). soles, knees, and the oral keratinized gingiva.9 At this site, its function is
There is sometimes associated calcification of the falx cerebri and chor- unknown.
oid plexus.6 Other features, which may sometimes be present, include deaf- The histopathological features of the palmoplantar lesions show marked
ness, deformity of the terminal phalanx, follicular hyperkeratosis, and mental hyperkeratosis with acanthosis and a thickened granular cell layer (Fig.
retardation. Patients show an increased risk of infection, particularly furun- 3.109).3 Parakeratosis and epidermal psoriasiform hyperplasia have also
culosis; this has been associated with defective neutrophil chemotaxis and been described.7 The elbow and knee lesions show epidermal psoriasiform
phagocytosis and impaired B- and T-cell mitogenic responses.7 hyperplasia with parakeratosis, elongation of the dermal papillae, and dilata-
tion of the superficial dermal vasculature.3
Pathogenesis and histological features
Papillon-Lefèvre syndrome has been mapped to 11q14–21.8 The disease
is associated with missense and nonsense mutations, deletions, and inser-
Naxos syndrome
tions in the gene for the lysosomal cysteine protease cathepsin C (dipeptidyl
aminopeptidase I).9–12 In homozygous patients, loss of cathepsin C activ- Clinical features
ity results in impaired activation of bone marrow myeloid and macrophage Naxos syndrome (keratosis palmoplantaris with arrhythmogenic cardiomy-
opathy) is an autosomal recessive inherited disease defined by palmoplan-
tar keratoderma, curly hair, and other ectodermal features associated with
dilatative cardiomyopathy leading to arrhythmogenic episodes.1,2 It was first
reported in families on the Greek island of Naxos.1

Pathogenesis and histological features

A deletion in the plakoglobin gene which results in a frameshift mutation in
plakoglobin, an important component of desmosomes, has been identified in
Naxos syndrome.3 Histology shows compact hyperkeratosis, hypergranulo-
sis, and acanthosis.2

McGrath syndrome
Clinical features
McGrath syndrome (skin fragility and hypohidrotic ectodermal dysplasia) is
inherited in an autosomal recessive mode and is characterized by a diffuse,
sometimes verruciform palmoplantar keratoderma, trauma-induced skin
­fragility, and congenital ectodermal dysplasia affecting nails, hair, and sweat
glands.1 In some cases plantar hyperkeratosis is painful and there is disabling
Fig. 3.108 cracking. The nails are thickened and markedly dystrophic. The integument
Papillon-Lefèvre syndrome: a scaly psoriasiform plaque is present over the elbow. shows fragility, with trauma-induced blisters and crusting on pressure points.
By courtesy of W.A.D. Griffiths, MD, Institute of Dermatology, London, UK. Hairs are noted to be short and sparse. Sweating may be reduced.
88 Disorders of keratinization

Pathogenesis and histologic features described.11 The follicular lesions show plugging of the ostia with surround-
ing hyperkeratosis, parakeratosis, and acanthosis (Fig. 3.114).6 A mononu-
The disease has been shown to be associated with mutations in the
clear perivascular chronic inflammatory cell infiltrate may be present in the
­ lakophilin-1 gene (PKP1) leading to complete ablation of plakophilin 1
superficial dermis. The oral lesions are indistinguishable from those of the
which is responsible for recruitment of desmosomal proteins to the plasma
white sponge nevus, consisting of parakeratosis, acanthosis, and epithelial
membrane and keratin interaction.1,2
vacuolation (Fig. 3.115). No evidence of dysplasia is seen.
Light microscopy of the skin shows thickening of the epidermis and exten-
sive widening of keratinocyte intercellular spaces, extending from the first
suprabasal layer upward. There is complete absence of cutaneous immunos- Pachyonychia congenita type II
taining for plakophilin-1. Electron microscopy reveals loss of keratinocyte–
keratinocyte adhesion. Desmosomes, particularly in the lower suprabasal
layers, are small and reduced in number. The inner and outer desmosomal
Clinical features
plaques are poorly developed.3 Pachyonychia congenita type II (palmoplantar ectodermal dysplasia type
II, Jackson-Lawler syndrome, Jackson-Sertoli syndrome) is inherited as an
autosomal dominant. It is characterized by limited and usually mild focal
Pachyonychia congenita type I
Clinical features
Focal (nonepidermolytic) palmoplantar keratoderma with oral hyperkera-
tosis (Jadassohn-Lewandowsky syndrome, focal palmoplantar keratoderma
with oral hyperkeratosis, palmoplantar ectodermal dysplasia type I) is usu-
ally associated with an autosomal dominant mode of inheritance although an
autosomal recessive variant has been described.1,2 It has a high incidence in
Croatia and Slovenia and also appears to be more commonly seen in Jews.3,4
Clinical features may be present at birth or appear within the first 6 months
of life.1,5 The sex incidence is equal.
The features include massive hyperkeratosis of the distal nail beds of the
fingers and toes, resulting in elevation and apparent thickening of the nail
plate (Fig. 3.110). Also present are palmoplantar keratoderma, hyperhidro-
sis and follicular keratosis, xerosis, and verrucous lesions, which most often
arise on the elbows, knees, and lower legs (Fig. 3.111). Patients also develop
alopecia and nail bed infections.1,5,6 Erythema and blistering of the soles of the
feet, and to a lesser extent on the palms of the hands, are sometimes present;
leukokeratosis oris is almost invariably evident (Fig. 3.112).1,6,7 Laryngeal
involvement has also been documented.8 Fig. 3.111
Pachyonychia congenita
Pathogenesis and histological features type 1: discrete, yellow,
hyperkeratotic plaques on
This variant of focal palmoplantar keratoderma is heterogeneous. Mutations
the soles of the feet are
have been described in keratin K16 and K6a genes.9–14 a common manifestation.
The nail beds show massive hyperkeratosis.1 The palmoplantar lesions By courtesy of R.A.
are characterized by hyperkeratosis, hypergranulosis, and acanthosis (Fig. Marsden, MD, St
3.113).1 Round to oval darkly staining perinuclear inclusions represent- George's Hospital,
ing densely aggregated keratin filaments in the prickle cell layer have been London, UK.


Fig. 3.110
Pachyonychia congenita type 1: (A) there is gross nail deformity with transverse arching of the distal portion. Although the nail plate appears to be thickened, most of the
changes are, in fact, due to massive hyperkeratosis of the nail bed, resulting in elevation and bending of the nail plate; (B) in this view, the subungual hyperkeratosis is more
obvious. (A) By courtesy of R.A. Marsden, MD, St George's Hospital, London, UK, (B) By courtesy of W.A.D. Griffiths, MD, Institute of Dermatology, London, UK.
Palmoplantar keratoderma 89

Fig. 3.112 Fig. 3.114

Pachyonychia congenita type 1: leukoplakia of the buccal mucosa is a frequent Pachyonychia congenita
accompanying feature. By courtesy of R.A. Marsden, MD, St George's Hospital, type 1: follicular lesion
London, UK. showing keratin plugging
of the ostium with
adjacent hyperkeratosis
and associated

Tyrosinemia type II
Clinical features
Tyrosinemia type II (Richner-Hanhart syndrome, tyrosine aminotransferase
deficiency, keratosis palmoplantaris with corneal dystrophy) is an oculocu-
taneous syndrome characterized by herpetiform corneal ulcers that develop
during the first months of life. Later painful punctuate, sometimes striated
and circumscribed hyperkeratoses of digits, palms, and soles evolve, often
accompanied by hyperhidrosis. Aberrant keratotic plaques have been sporad-
ically observed on the elbows, knees, and even the tongue. Other symptoms
include severe mental and somatic retardation.1

Pathogenesis and histological features

Tyrosinemia type II is caused by autosomal recessively inherited deficiency
of hepatic tyrosine aminotransferase. Point mutations in the tyrosine amin-
otransferase gene have been identified which map to the long arm of chro-
Fig. 3.113 mosome 16. 2,3 Diagnosis can be confirmed by identifying tyrosinemia and
Pachyonychia congenita phenylacetic acidemia with excessive levels of P-hydroxyphenylactic acid in
type 1: volar skin showing
the urine. Clinical and biochemical improvement may be achieved by a low
massive hyperkeratosis,
hypergranulosis, and
phenylalanine-low tyrosine diet.1
acanthosis. Histologically the epidermis is acanthotic, the granular layer is thickened,
and the keratinocytes contain eosinophilic globular inclusions. 4
Electron microscopy demonstrates an increased synthesis of tonofibrils
and keratohyalin, large numbers of microtubules, and unusually tight pack-
palmoplantar keratoderma over pressure areas, subungual hyperkeratosis, ing of tonofibrillar masses, which contain tubular channels or inclusions
epidermal cysts, steatocystoma multiplex, abnormal eyebrows and body of microtubules.4 Presumably, excessive amounts of intracellular tyrosine
hair (pili torti), natal teeth, angular cheilosis, and hoarseness.1,2 Plantar enhance cross-links between aggregated tonofilaments leading to a globular
lesions may be delayed until late childhood. In contrast to pachyonychia appearance.4
congenita type I, patients do not develop leukokeratosis oris. This palmo-
plantar ectodermal dysplasia has no known association with malignancy.
Carvajal-Huerta syndrome
Pathogenesis and histological features
Pachyonychia congenita type II results from mutations in keratin 17 and ker- Clinical features
atin 6b genes.3–7 Interestingly, mutations in keratin 17 may also result in ste- The Carvajal-Huerta syndrome is an autosomal recessively inherited dis-
atocystoma multiplex in isolation.3 ease with palmoplantar keratoderma, woolly hair, and dilated cardiomy-
Histologically, the subungual changes and keratoderma are similar to opathy.1,2 The patients are born with woolly hair. Around the first year,
those described in the type I variant, although milder. The epidermoid cysts palmoplantar keratoderma and other keratotic signs appear. The clinical
and steatocystomata show typical features. symptoms of Carvajal-Huerta syndrome resemble those of Naxos disease
90 Disorders of keratinization

At the ultrastructural level, loosening of intercellular connections, disrup-

tion of desmosome–keratin intermediate filament interactions, and rudimen-
tary desmosomal structures can be demonstrated.2

Howell-Evans syndrome
Clinical features
The combination of autosomal dominant focal nonepidermolytic palmoplan-
tar keratoderma with esophageal squamous carcinoma was first recognized
in 1958 and subsequently termed the Howell-Evans syndrome.1–5 Although
initially regarded as a diffuse keratoderma, a subsequent clinical re-evalu-
ation determined that the lesions were focal, sparing nontraumatized areas
(Fig. 3.116).4 The condition typically presents between 6 and 15 years of
age. The patients develop painful hyperkeratoses on the pressure areas,
which ­disappear with prolonged bed rest.5 Palmar involvement may be seen


Fig. 3.115
Pachyonychia congenita type 1: (A) scanning view of oral mucosa showing
massive acanthosis with large blunt rete ridges; (B) high-power view showing focal
parakeratosis and vacuolization of superficial keratinocytes. A single dyskeratotic
cell is evident (arrowed).

but the PPK in the former is of a striated and not diffuse type. The first car-
diac abnormalities are exclusively electrocardiographic and occur in asymp-
tomatic patients. In these patients, dilatation of the left ventricle, together
with alterations in muscle contractility, may lead to congestive heart failure
and death.

Pathogenesis and histological features

Mutations in the gene on chromosome 6p24 encoding desmoplakin have
been found.3 Desmoplakin is a major constituent of desmosomes and as such B
is crucial for the rigidity and strength of the epidermis and cardiac tissue.
Biopsies of skin lesions show features of epidermolytic hyperkeratosis.1 Fig. 3.116
Immunohistochemistry confirms perinuclear localization of keratin in the Howell-Evans syndrome: (A) focal autosomal dominant palmoplantar keratoderma
suprabasal keratinocytes. This suggests collapse of the intermediate filament is associated with an increased risk of esophageal squamous carcinoma; (B) in
network as a response to the failure of desmoplakin to attach the intermediate this patient, the palms were also severely affected. By courtesy of the Institute of
filaments to the desmosomes. Dermatology, London, UK.
Acquired palmoplantar keratoderma and internal malignancy 91

in ­manual workers. This syndrome, also termed palmoplantar ectodermal Keratoderma climactericum
dysplasia type III, includes keratosis pilaris particularly affecting the upper
arms and thighs, multiple epithelial cysts, and gray-white buccal mucosal
hyperkeratosis (This last feature typically predates the onset of keratoderma
Clinical features
and may therefore represent a clinical diagnostic clue of early involvement in Keratoderma climactericum (Haxthausen's disease, climacteric kerato-
family members of a pedigree.).5–9 Nails are unaffected.6 In the largest kin- derma) is an acquired disorder which is restricted to menopausal women.1,2
dred reported to date, 28% developed esophageal squamous carcinoma (89 Lesions present on the weight-bearing surfaces of the sole of the foot as ery-
affected members) of whom 84% died of their tumor.4 thematous hyperkeratotic and fissured plaques and then spread to involve
the rest of the plantar skin (Fig. 3.118). Patients are often overweight.
Pathogenesis and histological features Palmar involvement is sometimes seen with lesions affecting the area
between the thenar and hypothenar eminences.2 Similar lesions have been
The condition has been mapped to 17q23-qter region (TEC locus) distal to
documented in younger women who have undergone bilateral oophorec-
the keratin gene cluster, thereby excluding a keratin gene mutation.10–12
tomy.3 The condition is distinguished from congenital palmoplantar kerato-
The cutaneous lesions are characterized by hyperkeratosis, hypergranulo-
derma by its late onset.
sis, and acanthosis. Features of epidermolytic hyperkeratosis are absent.
The buccal mucosal lesions are characterized by parakeratosis, acantho-
sis, and spongiosis accompanied by cytoplasmic vacuolation of the prickle
Histological features
cell layer.4 The plantar skin shows massive hyperkeratosis, hypergranulosis, acanthosis,
and spongiosis with lymphocytic exocytosis.2 A superficial perivascular der-
mal lymphohistiocytic infiltrate is present and vertically orientated dermal
Schöpf-Schulz-Passarge syndrome collagen associated with atypical myofibroblasts is often seen.2

Clinical features
The Schöpf-Schulz-Passarge syndrome (palmoplantar keratoderma with eye-
lid cysts, hypodontia, and hypotrichosis) is probably inherited in an auto- Clavi (corns) are extremely common painful keratotic lesions that develop
somal recessive pattern.1 Patients have a relatively mild, diffuse erythematous on the dorsal or lateral aspect of the toes, often as a consequence of ill-fitting
keratoderma association with hypodontia, hypotrichosis, nail dystrophies, shoes. Histologically, they are characterized by a deep keratin-filled depres-
and late-onset eyelid cysts. sion often associated with atrophy of the underlying epidermis (Fig. 3.119).
They are distinguished from plantar warts by the absence of koilocytes and
Histological features irregular keratohyalin granules.
The eyelid lesions represent apocrine hidrocystomas. Multiple eccrine syrin-
gofibroadenomas and squamous cell carcinomas may arise on the acral sur- Callus
faces in older patients.1,2 The underlying defect remains unknown.3 In contrast to a clavus, a callus is a nonpainful localized focus of hyperkerato-
sis usually arising on the ball of the foot or heel from pressure or foot defor-
Acquired palmoplantar keratoderma and mity. Palmar lesions arise as a consequence of chronic rubbing. Histologically,
they are similar to a clavus, consisting of a keratin-filled epidermal dell with
internal malignancy hypergranulosis. Parakeratosis is often present.
Acquired diffuse palmoplantar keratoderma may represent a paraneoplas-
tic phenomenon associated with a number of internal malignancies includ- Acrokeratosis verruciformis of Hopf
ing carcinoma of the bronchus, esophagus, stomach, urinary bladder, and
myeloma (Fig. 3.117).1–6 There are also reports of acquired filiform (filiform Clinical features
palmoplantar keratoderma) and punctate (punctate porokeratotic kerato- This is an exceedingly rare dermatosis with an autosomal dominant mode of
derma) variants associated with a range of visceral cancers including breast, inheritance.1–3 The disease presents in infancy or early childhood as dry, rough,
kidney, colon, and lung.7,8 brownish or skin-colored verrucoid, keratotic papules, located particularly on

Fig. 3.117
Acquired palmoplantar
keratoderma: acquired
disease may be a
manifestation of
underlying malignancy. By
courtesy of the Institute Fig. 3.118
of Dermatology, London, Keratoderma climactericum: there is massive hyperkeratosis with fissuring over the
UK. heels. By courtesy of the Institute of Dermatology, London, UK.
92 Disorders of keratinization

Fig. 3.120
verruciformis: numerous
brown flat-topped
papules are symmetrically
distributed over the dorsal
aspects of the hands.
Fig. 3.119 By courtesy of
Clavus: massive R.A. Marsden, MD,
hyperkeratosis overlies an St George's Hospital,
epidermal depression. London, UK.

the backs of the hands (Fig. 3.120) and feet, and on the knees and elbows.4
Keratotic punctate pits are found on the palms and soles. Lesions, which are
clinically and histologically indistinguishable, may occasionally be seen in
Darier's disease.5–7 Exceptionally, a similar association with Hailey-Hailey dis-
ease has been documented and there is a report of acrokeratosis verruciformis
presenting in a patient with nevoid basal cell carcinoma syndrome.8,9 Nail
involvement, including longitudinal splitting, striations and subungual hyper-
keratosis may also be seen.10

Pathogenesis and histological features

Loss of function of the sarco- (endo-) plasmic reticulum Ca2+ ATPase2
mutant in acrokeratosis verruciformis provides evidence that acrokeratosis
verruciformis and Darier's disease are allelic disorders.11 However, identifica-
tion of mutations in genes other than ATP2A2 suggests genetic heterogeneity
of acrokeratosis verruciformis.12
The lesions are acanthotic with a prominent granular cell layer, typically
showing a ‘church spire’ appearance (Fig. 3.121). There is usually moderate
to marked hyperkeratosis. Parakeratosis is not a feature. Step sections some-
times reveal acantholytic dyskeratosis in those cases associated with Darier's Fig. 3.121
disease. Acrokeratosis verruciformis: there is hyperkeratosis and church-spire papillomatosis.

Differential diagnosis
Acrokeratosis verruciformis-like features may occasionally be seen in lin- presents in adulthood as persistent lesions that are highly resistant to
ear epidermal nevi.13 There is also considerable histological overlap with therapy.
stuccokeratosis. • Localized porokeratosis usually consists of a single large lesion.
• Disseminated superficial actinic porokeratosis, the most common variant,
is characterized by numerous small, dry, shallow lesions arising on
Porokeratosis the sun-damaged skin of adults (Figs 3.123 and 3.124).2 It may also
complicate PUVA therapy and develop in the immunosuppressed.3–5 It
Clinical features presents in the third and fourth decades and, despite its relationship
Porokeratosis is a not uncommon pathological process. It consists of a pig- to sunlight, rarely affects the face. The legs, forearms, back, upper
mented or reddish atrophic center bordered by a peripheral grooved keratotic arms, and thighs are most commonly affected, in decreasing order of
ridge, from the center of which a keratotic core (cornoid lamella) projects frequency.6
at an obtuse angle.1 There are six major categories: classical, localized, lin- • Disseminated superficial (nonactinic) porokeratosis (porokeratosis
ear, punctate, disseminated superficial porokeratosis (DSP), and disseminated palmoplantaris et disseminata) is characterized by asymptomatic lesions
superficial actinic porokeratosis (DSAP), all of which may be inherited as an with a tendency to involve the trunk, genitalia, palms, and soles. An
autosomal dominant, but sporadic cases also occur. intensely itchy eruptive variant of this has recently been described.7
• In the classical variant described by Mibelli, patients develop one or • In linear porokeratosis, the lesion is clinically reminiscent of an epidermal
several plaquelike lesions on the extremities (Fig. 3.122). It usually nevus affecting the extremities and usually presents in infancy or early
Acquired palmoplantar keratoderma and internal malignancy 93

Fig. 3.122
Porokeratosis of Mibelli: (A) these lesions have an
extensive and linear distribution; (B) the lesions are
erythematous, atrophic and scaly, with sharply defined and
A B slightly raised margins By courtesy of M.M. Black, MD,
Institute of Dermatology, London, UK.

Fig. 3.124
Fig. 3.123 Disseminated superficial actinic porokeratosis: in this variant, the lesions are small
Disseminated superficial and discrete. Note the characteristic raised edge. By courtesy of the Institute of
actinic porokeratosis: Dermatology, London, UK.
there are numerous small,
reddish or brownish carcinoma.1,8,10–15 The reported incidence has varied from 6.8% to 11.6%.10,13,14
keratotic macules on sun In some instances there is a probable causal relationship with previous treat-
damaged skin. ment with radiotherapy.10 Tumors usually develop many years after the onset
of the disease, are frequently multiple, and arise most often on large or coalesc-
childhood (Fig. 3.125).8 A zosteriform variant has also been described ing lesions.8,10,16 They are most often found on the trunk and extremities.8
which generally affects children and shows a predilection for the lower
limbs, upper limbs, and trunk.9 Pathogenesis and histological features
• In punctate porokeratosis (porokeratosis palmoplantaris punctata, spiny The pathogenesis of porokeratosis is unknown. The presence of localized
keratoderma) tiny spines develop on palms and soles in the second or dysplastic features was suggested by Reed and Leone to indicate that the
third decade. Some argue that the typical ultrastructural changes of disease represented a focal, expanding clone of abnormal keratinocytes asso-
porokeratosis of Mibelli are not present. It must be distinguished from ciated with the development of a cornoid lamella.17 The more recent literature
other forms of punctate keratoderma.6 appears to support this claim.
Porokeratosis may involve the mucous membranes, cause nail dystrophy, Porokeratotic lesions have been shown to be associated with abnormal
and result in patchy alopecia. It is associated with a slightly increased risk of epidermal DNA ploides in association with increased DNA indices, midway
cutaneous neoplasia. Lesions of porokeratosis may therefore be complicated between normal skin and Bowen's disease.18,19 Uninvolved skin, however, is
by the development of Bowen's disease, and basal cell and squamous cell usually diploid.8 Chromosomal abnormalities have been identified within
94 Disorders of keratinization

cultured keratinocytes and fibroblasts derived from patients suffering from causally related to hepatitis C infection, Crohn's disease, renal failure, and
both the localized and Mibelli variants.8,10,20,21 These findings have since been hemodialysis.25–29
confirmed in both cultured fibroblasts from normal untreated skin and lym- p53 and pRb proteins are overexpressed within keratinocytes immedi-
phocytes, and it has been shown that chromosome 3 is preferentially affected.22 ately beneath and adjacent to the cornoid lamellae; mdm-2 and p21waf-1 are
Mutations in the proximal segment of the short arm of chromosome 3 have reduced.30–33 This imbalance in cell cycle control mechanisms offers a poten-
been associated with a wide variety of malignancies.22 Ionizing radiation, ultra- tial explanation for the development of malignancy in porokeratosis although
violet light including sun tanning beds, and PUVA may be associated with the to date p53 mutation has not been identified.32,34
development of new skin lesions in porokeratosis.23 The first may be of par- Recently, a gene for disseminated superficial actinic porokeratosis has been
ticular relevance to the development of malignancy in these lesions.14,24 mapped to chromosome 12q23.2–24.1 in a large Chinese family.35
Cultured fibroblasts from porokeratosis patients have been shown to be The biopsy must be taken through the peripheral grooved ridge. If the long
hypersensitive to the lethal effects of X-radiation, but not ultraviolet radia- axis of the specimen does not transact the border, the diagnostic features will be
tion.21,22 This has been shown to be associated with chromosomal instability missed. These consist of a keratin-filled epidermal invagination with an angu-
in approximately 50% of patients.20 While it has been proposed that this may lated parakeratotic tier, the cornoid lamella (Fig. 3.126). Despite its name,
result from abnormal DNA repair mechanisms (see xeroderma pigmentosa) the lesions of porokeratosis are rarely related to the ‘pore’ of the eccrine duct.
the evidence necessary to support such a hypothesis is not yet available.21 While they may involve the follicle, their most common origin is from nonad-
Porokeratosis of Mibelli, disseminated superficial porokeratosis, and nexal epithelium. The corneocytes of the cornoid lamella contain characteristic
disseminated superficial actinic porokeratosis may also develop against a PAS-positive granules. The epithelium deep to the tier is vacuolated and devoid
background of solid organ transplantation or blood transfusion, possibly of a granular cell layer (Fig. 3.127). Dyskeratotic cells may be present and

Fig. 3.127
Fig. 3.125 Porokeratosis of Mibelli:
Linear porokeratosis: in the epidermis at the base
this variant, the lesion of the cornoid lamella
has a linear, nevoid is vacuolated and the
distribution. granular cell layer absent.


Fig. 3.126
Porokeratosis of Mibelli: (A) there is hyperkeratosis with two well-developed cornoid lamellae. Note the epidermal depression at their bases. (B) The cornoid lamella can be
seen to be composed of an angulated tier of parakeratosis.
Acquired palmoplantar keratoderma and internal malignancy 95

Fig. 3.128
Disseminated superficial actinic porokeratosis: in this example, the cornoid lamella
has arisen overlying an acrosyringium. The epidermis towards the center on the
lesion appears atrophic and the papillary dermis contains ectatic blood vessels.

epithelial dysplasia, ranging from mild changes through to carcinoma in situ, A

is occasionally a feature. Liquefactive degeneration of the basal cell layer of the
epithelium is sometimes present and occasionally there are conspicuous cytoid
bodies. The adjacent epithelium towards the center is often atrophic, but may
be of normal thickness or even acanthotic. In the dermis, a non-specific chronic
inflammatory cell infiltrate and telangiectatic vessels are sometimes seen. The
typical features are best seen in the Mibelli variant. The changes tend to be less
pronounced in the other subtypes (Fig. 3.128). In the actinic variant there is
often solar elastosis and atrophy of the adjacent epidermis.6

Differential diagnosis
With the appropriate clinical information, the histopathological changes
of porokeratosis are diagnostic. Cornoid lamella formation, however, does
occur as a non-specific finding in a variety of conditions including psoriasis
vulgaris, seborrheic, solar keratosis, verruca vulgaris, and squamous cell and
basal cell carcinomas.36 Cornoid lamellae are also features of verrucous epi-
dermal nevus and porokeratotic eccrine nevus.37,38 They are also not uncom-
mon in normal, and particularly actinically damaged, skin. PAS-positive
structures in the cornoid lamella may be a useful marker for porokeratosis
although this has not been authors experience.39 Fig. 3.129
Flegel's disease: (A) there are characteristic disseminated erythematous scaly
lesions; (B) the lower legs are commonly affected. Lesions are small, multiple
Hyperkeratosis lenticularis perstans and covered by a well-developed scale. By courtesy of M. Price, MD, Institute of
Dermatology, London, UK.

Clinical features
Hyperkeratosis lenticularis perstans (Flegel's disease) is a not uncommon der-
matosis that is sometimes mistaken for Kyrle's disease.1–5 It has an equal sex
incidence and patients present most often in their fourth or fifth decade. It is Pathogenesis and histological features
characterized by a very protracted course, many patients having lesions for Flegel's disease is of unknown etiology and pathogenesis and is characterized
decades. Patients present with large numbers of 1–5-mm discrete, gray, gray- by focal areas of abnormal hyperkeratinization.7–10 Early lesions are not diag-
brown or red-brown, circular scaly papules (Fig. 3.129). Initial lesions often nostic, showing merely lamellar hyperkeratosis, focal parakeratosis, and an
arise on the dorsum of the foot. Other sites of predilection include the lower essentially normal epidermis. In an established lesion, in addition to hyper-
legs, upper arms, and pinnae. The buttocks, trunk, and dorsal aspects of the keratosis and occasional parakeratosis, there is epidermal atrophy with an
hands may also be affected, and punctate keratoses have been described on inconspicuous or absent granular cell layer (Figs 3.130, 3.131). The lower
the palms and soles. The lesions are either asymptomatic or mildly pruritic. layers of the epithelium may show intercellular edema and occasional foci of
Characteristically, removal of the scale is associated with pinpoint bleeding, basal cell degeneration. Cytoid bodies are sometimes evident. Typically, the
a feature that distinguishes this disorder from stucco keratoses. Other than papillary dermis is edematous and a chronic inflammatory cell infiltrate is
an isolated report of an increased incidence of both basal cell and squamous often present, adopting a perivascular or lichenoid distribution. Pigmentary
carcinomas, there is no particular associated disease process (compare incontinence is not usually a feature.
with Kyrle's disease).6 Although most cases appear to be sporadic, there is The lymphocytes are an admixture of CD4+ T-helper cells and, less fre-
some ­evidence to support an autosomal dominant mode of inheritance in a quently CD8+ T-suppressor cells.8,9 Sézary-like forms have been described.
­proportion of cases. Langerhans cells are highly reduced.9 In the atrophic areas, differentiation
96 Disorders of keratinization

Fig. 3.131
Flegel's disease: high-power view showing spongiosis with microvesiculation,
cytoid bodies, and a predominantly lymphocytic infiltrate.

less commonly, in nonintertriginous skin including the lower back, buttocks,

and flanks.5–8 Women are affected more commonly than males. The disease
mainly affects the middle aged to elderly; children are rarely involved.8–10
It presents as pruritic or burning erythematous, hyperpigmented, and
hyperkeratotic patches, papules, or plaques (Fig. 3.132). Fissures and a
­‘cobblestone’ appearance may be seen. The condition has been documented
to respond to retinoids and to calcipotriene and ammonium lactate.11,12

Pathogenesis and histological features

B The etiology is unknown. It has been suggested that the condition develops
as a result of a contact reaction to an antiperspirant or as a result of exces-
Fig. 3.130 sive use of other topical products including creams, shampoos, and soaps.1–6,8
Flegel's disease: (A) scanning view of an established lesion showing focal However, this does not explain the involvement of areas distant from the
hyperkeratosis, parakeratosis, and a superficial bandlike chronic inflammatory axilla. The molecular mechanism proposed to explain the disease consists of
cell infiltrate; (B) there is hyperkeratosis, focal epidermal atrophy and basal cell a failure to transform profilaggrin to filaggrin with the resultant failure in
liquefactive degeneration. Note the cytoid bodies
degradation of keratohyalin granules.1,7
The histological appearances typically consist of a massive hyperkerato-
sis with parakeratosis and retention of keratohyalin granules in the stratum
markers such as cytokeratin 1 and 10, filaggrin, and loricrin are absent. corneum (Fig. 3.133). The underlying epidermis may show mild acanthosis
Ultrastructurally, the most commonly documented changes have been or even some degree of thinning. Hair infundibula are occasionally affected.
­rudimentary keratohyalin granules, absence, vacuolation or abnormally Necrotic areas with invasion of neutrophils or perforation of the epidermis
lamellated membrane coating (Odland) bodies, failure to form a compact are rarely found. The superficial dermis contains a sparse perivascular lym-
keratin, and cornified envelope in the corneocytes.8,9 phocytic infiltrate.1–7
Differential diagnosis
Clinically, Flegel's disease differs from Kyrle's disease by the absence of Differential diagnosis
­keratin-filled penetrating plugs and the frequent presence of palmar and plan- Apart from representing a dermatosis, granular parakeratosis is a diagnos-
tar lesions, which are not seen in Kyrle's disease. Flegel's disease is sometimes tic feature in solitary keratosis, i.e., granular parakeratotic acanthoma.13
confused with stuccokeratoses, but these do not affect the trunk, palms, and Granular parakeratosis can be also found as an incidental finding in many
soles and the lesions may be readily removed without bleeding. Histologically, diseases, e.g., dermatophytosis, molluscum contagiosum, dermatomyositis,
stucco keratoses are characterized by orthohyperkeratosis and ‘church spire’ solar keratosis, squamous cell carcinoma, keratoacanthoma, lymphomatoid
papillomatosis. Although there may be histological overlap with other condi- papulosis, and basal cell carcinoma (Fig. 3.134).14 As such, granular parak-
tions showing lichenoid features, the striking keratotic tier with parakeratosis eratosis can best be considered as a histologic pattern similar to focal acan-
and absent granular cell layer are useful diagnostic pointers. tholytic dyskeratosis or epidermolytic hyperkeratosis.14

Granular parakeratosis Circumscribed palmar or plantar

Clinical features hypokeratosis
Granular parakeratosis is a distinctive acquired disorder of keratinization
originally reported in 1991.1–4 The condition most often affects the axillae Clinical features
but it has also been described involving other intertriginous areas including Circumscribed palmar or plantar hypokeratosis is a recently described
submammary and intermammary skin, groins, vulva, perianal region and, entity that is characterized by the development of well-circumscribed,
Acquired palmoplantar keratoderma and internal malignancy 97

Fig. 3.132
Granular parakeratosis: (A)
in the axilla of a middle-
aged woman erythematous,
hyperpigmented and
hyperkeratotic papules
develop in a reticulated
A B fashion, (B) a few of them
are erosive.


Fig. 3.133
Granular parakeratosis: (A) there is marked thickening of the horny layer with parakeratosis, (B) high-power view showing retention of the keratohyalin granules.

depressed, ­erythematous lesions on the thenar and hypothenar regions of of the continuous growth of some lesions, and suggest a trauma or a human
the palms or the medial side of the soles (Fig. 3.135).1 The lesions some- papillomavirus type 4 as a causative.1–5
times have an arcuate or polycyclic outline, a slightly scaling border, range Histologically, the lesional depression relates to a sharply circumscribed
in diameter from a few millimeters up to 3 centimeters, and are symp- loss of the cornified layer above an otherwise normal epidermis (Fig. 3.136).1–7
tomless. All patients were middle aged or elderly with a predominance of Other authors observed a thin layer of parakeratosis in the hypokeratotic
women.2 zone and some psoriasiform hyperplasia of the epidermis with expression of
the hyperprolifertaive keratin 16.6,7
Pathogenesis and histological features Additional features are hyperplasia of sweat ducts, and tortuous and elongated
The pathogenesis of circumscribed palmar or plantar hypokeratosis is a mat- capillaries in the papillary dermis; still, an inflammatory cell infiltrate is lacking.5
ter of debate. While some authors favor the interpretation of an epidermal Ultrastructurally, breakage of the corneocytes within their cytoplasm
malformation in view of persistence over years, others dispute this because ­suggests enhanced corneocyte fragility.7
98 Disorders of keratinization

Fig. 3.134
Granular parakeratosis:
(A) this example arose
against a background of
A B lymphomatoid papulosis;
(B) high-power view.

Fig. 3.136
Circumscribed palmar or plantar hypokeratosis: (A) scanning view from the edge of
a lesion, (B) note the focal thinning of the stratum corneum.

Fig. 3.135
Circumscribed palmar or plantar hypokeratosis: (A) on the thenar a well-
circumscribed, depressed, erythematous lesion is present, (B) a closer view reveals
a scaly border.
Inherited and autoimmune Chapter

for references and
additional material
subepidermal blistering diseases
Split skin immunofluorescence 100 Lichen planus pemphigoides  131 Dermatitis herpetiformis  144
Immunoperoxidase antigen mapping  101 Mucous membrane pemphigoid (cicatricial Linear IgA disease  147
pemphigoid)  133
Epidermolysis bullosa  101
Epidermolysis bullosa acquisita (dermolytic
Bullous pemphigoid  117
pemphigoid)  137
Pemphigoid gestationis  127
Bullous systemic lupus erythematosus  142

Blisters, which are clinically subdivided into vesicles (L. vesicula, dim. of substrate as a mechanism of localizing the site of epidermodermal ­separation.1
­vesica, bladder) and bullae (L. bubble), are defined as accumulations of fluid If a sample has not been taken for indirect immunofluorescence, immunoper-
either within or below the epidermis and mucous membranes. Although oxidase antigen mapping on paraffin-embedded material may on occasions
somewhat arbitrary, the term ‘vesicle’ is applied to lesions less than 0.5 cm in be of value at least as a screening procedure. Although the results of electron
diameter and ‘bulla’ to those greater than 0.5 cm. Subepidermal blisters, i.e., microscopic investigations and, in particular, molecular studies have formed
those that develop at the epidermal or mucosal basement membrane region, the basis of the current classification of subepidermal bullous dermatoses,
include inherited variants and acquired (often autoimmune mediated) such techniques are usually not essential to the everyday investigation of a
­conditions. The former are usually classified as noninflammatory (cell-poor) patient with an acquired blistering disorder.
­blisters whereas the latter are commonly inflammatory (cell-rich) in nature The mechanisms involved in the development of a subepidermal blister are
(Fig. 4.1). variable. They include inherited mutational defects of basement membrane
Subepidermal blisters may develop within the lower epidermis, the lamina proteins, i.e., epidermolysis bullosa, acquired autoimmune bullous diseases
lucida (e.g., bullous pemphigoid) or deep to the lamina densa (e.g., such as bullous pemphigoid, cellular immunity-mediated disorders (e.g.,
­epidermolysis bullosa acquisita) (Fig. 4.2). In addition to clinical observa- ­erythema multiforme and toxic epidermal necrolysis), metabolic ­diseases
tions, the precise diagnosis of a blistering disorder requires careful histologi- including porphyria cutanea tarda, and profound subepidermal edema such
cal and immunofluorescence correlation. When possible, the last should as may be seen in bullous arthropod bite reactions and dermal acute
include indirect studies and, in particular, NaCl-split skin should be used as ­inflammatory processes (e.g., Sweet's disease).

Fig. 4.1
Classification of subepidermal
blisters: lesions may be
A B subdivided into (A) cell-poor
and (B) cell-rich variants.
100 Inherited and autoimmune subepidermal blistering diseases

Intact skin
K5, K14 (IF)

Plectin BP230

CM Dermis
BP180 b4

NaCL split skin
LD Epidermis


AP Artificial
blister cavity

Fig. 4.2
Basement membrane constituents: blisters can be classified into those that develop LD
within the lamina lucida (LL) and those that arise below the lamina densa (LD). (AF,
anchoring fibrils; AP, anchoring plaque; CM, cell membrane.) Dermis Fig. 4.3
Split skin immunofluorescence.

In this chapter, only those conditions in which subepidermal blister forma-

­electron microscopy or immunofluorescence) (Figs 4.4, 4.5), the technique
tion represents an inherited or autoimmune primary event are considered.
enables precise localization of a circulating basement membrane zone anti-
Other conditions, which may be associated with subepidermal blistering, are
body to either the floor or the roof of the artificial blister cavity. In bullous
dealt with in more appropriate chapters.
pemphigoid, pemphigoid gestationis, and the majority of cases of mucous
membrane pemphigoid, linear immunofluorescence is found along the roof of
Split skin immunofluorescence the artificial blister whereas in diseases characterized by a sublamina densa
split (e.g., epidermolysis bullosa acquisita, antilaminin mucous membrane
This technique represents a modification of indirect immunofluorescence ­pemphigoid, anti-p105 pemphigoid, anti-p200 pemphigoid, and bullous der-
(IMF) where normal skin is split through the lamina lucida of the basement matosis of bullous lupus erythematosus), the immunofluorescent signal is
membrane region to produce an artificial blister cavity (with the lamina densa found along the floor of the blister (see references 3 and 4 for a review)
lining the floor) for use as substrate. Artificial separation can be achieved by (Fig. 4.6). In some diseases, positive immunofluorescence may be found on
the suction technique (in vivo) or by immersion of normal skin in 1 M NaCl either the roof or the floor or even at both sites simultaneously (e.g., ­linear IgA
for 48 hours at 4°C (Fig. 4.3). In general, the latter technique is preferred.2 As disease and some variants of mucous membrane pemphigoid). Such variable
such a split is invariably through the lamina lucida region ­(confirmed by labeling reflects the antigen heterogeneity in a number of bullous dermatoses.


Fig. 4.4
(A, B) Split skin immunofluorescence: the split is through the lamina lucida, the lamina densa lining the floor of the artificial blister cavity.
Epidermolysis bullosa 101

Fig. 4.5 Fig. 4.7

Split skin immunofluorescence: type IV collagen lines the floor of the split skin Paraffin-embedded immunoperoxidase antigen mapping: in bullous pemphigoid,
artificial blister which therefore forms within the lamina lucida. By courtesy of B. type IV collagen is present along the floor of the blister.
Bhogal, FIMLS, Institute of Dermatology, London, UK.

Fig. 4.6
Split skin immunofluorescence: (left) linear IgG at the basement membrane;
(middle) in epidermolysis bullosa acquisita (EBA), the antibody binds to the floor of
the blister cavity; (right) in bullous pemphigoid (BP), the antibody binds to the roof
of the blister. By courtesy of B. Bhogal, FIMLS, Institute of Dermatology, London, Fig. 4.8
UK. Paraffin-embedded immunoperoxidase antigen mapping: in epidermolysis bullosa
acquisita, type IV collagen is present along the roof of the blister cavity.

Immunoperoxidase antigen mapping Epidermolysis bullosa

As an alternative to split skin immunofluorescence, paraffin-embedded Epidermolysis bullosa (EB) refers to a heterogeneous group of diseases in
sections of lesional skin have been proposed in a direct immunoperoxidase which the skin and sometimes the mucous membranes blister easily in
antigen mapping technique to identify the level of the epidermodermal response to mild trauma, hence the alternative title ‘mechanobullous derma-
separation.5–8This procedure localizes known basement membrane region tosis’, which has sometimes been applied.1 All are rare conditions; the estimated
constituents such as keratins 5/14, laminin, and type IV collagen to the roof incidence for the group as a whole is in the order of 1:20 000. Apart from the
or floor of the blister cavity. The site of blister formation can therefore be acquired autoimmune variant (epidermolysis bullosa acquisita), they are all
characterized as intrabasal, within the lamina lucida or deep to the lamina autosomal inherited disorders.
densa. For example, in epidermolysis bullosa simplex variants, all of these EB was initially described as a defined entity in 1886.2 This group of con-
immunoreactants are present along the floor of the blister cavity. In bullous ditions has been classified in several ways over the years. The three major
pemphigoid, keratin is present along the roof of the blister while laminin and types were defined in a groundbreaking electron microscopy study in 1962.3
type IV collagen are found along the floor (Fig. 4.7). In dystrophic epidermolysis In 1988, the contemporary classification and subtyping of the major variants
bullosa, epidermolysis bullosa acquisita, and bullous systemic lupus commenced with the first consensus meeting of the Steering Committee of
erythematosus, all three immunoreactants are present in the roof of the blister the National EB Registry (established in 1986) held in conjunction with the
(Fig. 4.8). However, in many hereditary and acquired blistering diseases American Academy of Dermatology.4,5 At that time, 23 seemingly clinically
the relevant antibodies against the target antigens do not work well in distinct variants were recognized (Table 4.1).5 In the following decade, a
paraffin-embedded material and false-positive and false-negative results are second consensus conference was held.6 As a result of the considerably
common, making this method unreliable for use in routine diagnosis. For increased number of cases available for study, a much greater degree of clinical
example, antigen mapping of the group of hereditary subepidermal blistering overlap between the various subtypes was recognized. For this reason and
diseases is done exclusively on frozen sections with excellent results. because of a much better understanding of the molecular basis for many of
102 Inherited and autoimmune subepidermal blistering diseases

Table 4.1 Table 4.2

First consensus conference (1988): classification of subepidermal blisters Second consensus conference (1999): classification of epidermolysis bullosa
EB simplex
Major EB Protein/gene
Localized Major EB type subtype systems involved
EB simplex of hands and feet (Weber-Cockayne variant)
EBS (‘epidermolytic EBS-WC K5, K14
EB simplex with anodontia/hypodontia (Kallin syndrome)
EB’) EBS-K K5, K14
Generalized EBS-DM K5, K14
EB simplex, Koebner variant EBS-MD Plectin
EB simplex herpetiformis (Dowling-Meara variant)
Junctional EB JEB-H Laminin-5*
EB simplex with mottled or reticulate hyperpigmentation with or without
HEB-nH Laminin-5; type XVII collagen
punctate keratoderma
EB simplex superficialis JEB-PA† α6β4 integrin‡
EB simplex, Ogna variant DEB (‘dermolytic EB’) DDEB Type VII collagen
Autosomal recessive EB simplex (letalis) with or without neuromuscular RDEB-HS Type VII collagen
disease RDEB-nHS Type VII collagen
EB simplex, Mendes da Costa variant
Reproduced with permission from Fine, J.D. et al (1991) Pediatrician, 18, Reproduced from Fine et al (2000) J Am Acad Dermatol, 42, 1051–1066 from American
175–187. Academy of Dermatology.
DDEB, dominant dystrophic EB; DEB, dystrophic EB; RDEB, recessive DDEB, dominant dystrophic EB; EBS-DM, EBS Dowling-Meara; EBS-K, EBS, Koebner;
EBS-MD, EBS with muscular dystrophy; EBS-WC, EBS, Weber-Cockayne; JEB-H,
dystrophic EB.
junctional EB, Herlitz; JEB-nH, junctional EB, non-Herlitz; JEB-PA, junctional EB with
Junctional EB pyloric atresia; RDEB-HS, recessive dystrophic EB, Hallopeau-Siemens; RDEB-nHS,
Localized recessive dystrophic EB, non-Hallopeau-Siemens.
*Laminim-5 is a macromolecule composed of three distinct (α3, β3, γ2) laminin chains;
Junctional EB, inversa
mutations in any of the encoding genes result in a junctional EB phenotype.
Junctional EB, acral/minimus †Some cases of EB associated with pyloric atresia may have intraepidermal cleavage
Junctional EB, progressiva variant or both intralamina lucida and intraepidermal clefts.
Generalized ‡α β integrin is a heterodimeric protein; mutations in either gene have been
6 4

Junctional EB, gravis variant (Herlitz variant) associated with the JEB-PA syndrome.
Junctional EB, mitis variant (non-Herlitz variant; EB atrophicans
generalisata mitis; generalized atrophic benign EB)
Cicatricial junctional EB
Dystrophic EB
In 1999, a fourth category – hemidesmosomal EB (where the level of split
Localized is within the hemidesmosome) – was added.10 This provisional category has
RDEB, inversa now been removed and Kindler syndrome now constitutes a fourth major cat-
DDEB, minimus egory. The most recent classification, which takes into account the current
DDEB, pretibial
precise molecular data which is now known for virtually all of the subtypes
RDEB, centripetalis
of this disease, is particularly valuable when considering the pathological
basis of EB and forms the basis for this account. There have been some
Autosomal dominant forms of DEB changes in nomenclature based on an attempt to produce names that are
DDEB, Pasini variant
more accurately descriptive of the diseases and concordant with current
DDEB, Cockayne-Touraine variant transient bullous dermolysis
of the newborn
molecular classification of this disease.
Autosomal recessive forms of DEB Mutations of sundry types in a variety of genes encoding plakophilin-1
RDEB, gravis (Hallopeau-Siemens variant) (PKP1), desmoplakin (DSP), keratins 5 and 14 (KRT5, KRT14), plectin
RDEB, mitis (PLEC1), BP180, α6 and β4 integrin subunits (ITGA6, ITGB4), laminin-5
(now termed laminin-332 and encoded by LAMA3, LAMB3, LAMC2), types
XVII and VII collagen (COL17A1, COL7A1) and kindling-1 (KIND1) cur-
rently account for the different subtypes of EB (a more detailed account of
the variants of EB, a considerably simplified classification system was rec- these basement membrane proteins is given in Chapter 1).10–12
ommended at that time (Table 4.2).7,8 Most recently, at the Third International Molecular studies including Western blot and ­immunoprecipitation,
Consensus Meeting on Diagnosis and Classification of EB, the classification ­however, are not always available for every case of EB, particularly at
scheme was further revised and this current proposed scheme forms the ­presentation, and therefore initially at least the patient may well be
framework for the discussion in this chapter (Tables 4.3, 4.4).9 Research ­provisionally subclassified on the basis of:
over the past two decades has generated a wealth of literature ­specifically • clinical variation,
addressing the molecular basis of the various subtypes of EB. As a result, it • presence or absence of extracutaneous manifestations,
is now possible to subgroup EB on the basis of the level of ­separation within • mode of inheritance,
the ­basement membrane region as well as on specific molecular findings. • immunoepitope mapping and/or electron microscopy.
Though molecular classification now drives our understanding of this dis- Clinical evaluation of a patient with suspected EB should include the age
ease group, knowledge of the traditional clinical subtypes can be helpful in of onset and nature and distribution of the cutaneous lesions and whether or
explaining the disease course to patients, despite the often overlapping not scarring and contractures are present. In addition, the family pedigree
­spectrum of manifestations. should be studied and the patient investigated for the presence or absence of
Traditionally, EB has been classified into three major groups based on extracutaneous involvement (eyes, oropharynx, larynx, gastrointestinal and
­clinical differences, antigen mapping, and electron microscopic observations: genitourinary tracts, and musculoskeletal system) and other specific lesions
• simplex (epidermolytic; in which the level of split is within the basal (including enamel hypoplasia, anodontia or hypodontia, pyloric atresia, and
keratinocyte), muscular dystrophy) that might point towards a particular variant.4,5
• junctional (lucidolytic; where the level of split is within the lamina Four major subtypes of EB are now recognized: simplex, junctional,
lucida), ­dystrophic and Kindler Syndrome: 4–7,9
• dystrophic (dermolytic; where the level of split is deep to the lamina • EB simplex (historically also known as the epidermolytic variant) is
densa). characterized by the level of separation within the epidermis, usually as a
Epidermolysis bullosa 103

Table 4.3
Third consensus conference (2007): classification of epidermolysis bullosa

Major EB type Major EB subtype Protein involved

EBS Suprabasal
Lethal acantholytic EB Desmoplakin
Plakophilin deficiency Plakophilin-1
EBS superficialis (EBSS) ?
EBS, localized (EBS-loc)+ K5, K14
EBS, Dowling-Meara (EBS-DM) K5, K14
EBS, other generalized (EBS, gen-nonDM; EBS, gen-nDM)^ K5, K14
EBS with mottled pigmentation (EBS-MP) K5
EBS with muscular dystrophy (EBS-MD) Plectin
EBS with pyloric atresia (EBS-PA) Plectin, α6β4 integrin‡
EBS, autosomal recessive (EBS-AR) K14
EBS, Ogna (EBS-Og) Plectin
EBS, migratory circinate (EBS-migr) K5
Junctional EB JEB, Herlitz (JEB-H) Laminin-332 (laminin-5)*
JEB, other (JEB-O)
JEB, non-Herlitz, generalized (JEB-nH gen)$ Laminin-332; type XVII collagen (BP180)
JEB, non-Herlitz, localized (JEB-nH loc) Type XVII collagen
JEB with pyloric atresia (JEB-PA)† α6β4 integrin‡
JEB, inversa (JEB-I) Laminin-332
JEB, late onset (JEB-lo)# ?
LOC syndrome (laryngo-onycho-cutaneous syndrome) Laminin-332 α3 chain
DEB (‘dermolytic EB’) Dominant dystrophic EB (DDEB)
DDEB, generalized (DDEB-gen) Type VII collagen
DDEB, acral (DDEB-ac) Type VII collagen
DDEB, pretibial (DDEB-Pt) Type VII collagen
DDEB, pruriginosa (DDEB-Pr) Type VII collagen
DDEB, bullous dermolysis of the newborn (DDEB-BDN) Type VII collagen
Recessive dystrophic EB (RDEB)
RDEB, severe generalized (RDEB-sev gen)@ Type VII collagen
RDEB, generalized other (RDEB-O) Type VII collagen
RDEB, inversa (RDEB-I) Type VII collagen
RDEB, pretibial (RDEB-Pt) Type VII collagen
RDEB, pruriginosa (RDEB-Pr) Type VII collagen
RDEB, centripetalis (RDEB-Ce) Type VII collagen
RDEB, bullous dermolysis of the newborn (RDEB-BDN) Type VII collagen
Kindler syndrome Kindlin-1

Adapted from Fine et al (2008) J Am Acad Dermatol, 58, 931–50 from American Academy of Dermatology.
Rare variants are italicized.
+Previously termed EBS, Weber-Cockayne
^Includes cases previously termed EBS-Koebner
‡α β integrin is a heterodimeric protein; mutations in either gene have been associated with both EBS-PA and JEBS-PA. Some cases of EB associated with pyloric atresia may have
6 4
intraepidermal cleavage or both intralamina lucida and intraepidermal clefts.
*Laminin-332 (laminin-5 is a macromolecule composed of three distinct (α3, β3, γ2) laminin chains; mutations in any of the encoding genes result in a junctional EB phenotype.
$Previously termed generalized atrophic benign EB (GABEB).

#Previously termed EB progressiva.

@Previously termed RDEB, Hallopeau-Siemens.

Dominant dystrophic EB; EBS-DM, EBS Dowling-Meara; EBS-K, EBS, Koebner; EBS-MD, EBS with muscular dystrophy; EBS-WC, EBS, Weber–Cockayne; JEB-H, junctional EB, Herlitz;
JEB-nH, junctional EB, non-Herlitz; JEB-PA, junctional EB with pyloric atresia; RDEB-HS, recessive dystrophic EB, Hallopeau-Siemens; RDEB-nHS, recessive dystrophic EB, ­
†Some cases of EB associated with pyloric atresia may have intraepidermal cleavage or both intralamina lucida and intraepidermal clefts.

‡α β integrin is a heterodimeric protein; mutations in either gene have been associated with the JEB-PA syndrome.
6 4

consequence of cytolysis. Traditionally, all variants have been associated distinguished by the split through the hemidesmosome. The group
with mutations in the genes encoding keratin 5 or 14.8,9 However, the included EB with late-onset muscular dystrophy (previously included in
most current classification scheme divides this group into suprabasal and the simplex group), some examples of generalized atrophic benign EB
basal forms, and now certain rare variants are known to be associated (others associated with laminin-332 mutations are included within the
with mutations in the genes encoding desmoplakin, plakophilin-1, junctional group) and EB with pyloric atresia (previously included in the
plectin, and α6 and β4 integrin subunits.9 junctional group).10,14–16 These three variants of EB develop as a
• Epidermolysis bullosa with late-onset muscular dystrophy, which had consequence of mutations of genes encoding the hemidesmosomal
traditionally been included in the simplex category, is now known to proteins plectin, BP180, and the α6 and β4 integrin subunits
result from a mutation in the plectin gene and was included in the respectively.10 In the newest classification scheme, these are now
provisional hemidesmosomal group of EB as delineated by Pulkkinen and included in the suprabasal and basal types of EB simplex (Table 4.4).
Uitto in the 1999 classification scheme.10,13 Hemidesmosomal EB was The hemidesmosomal group designation is no longer used as the
104 Inherited and autoimmune subepidermal blistering diseases

Table 4.4 a recently described inherited disease known as ectodermal dysplasia-skin

Simplified classification of epidermolysis bullosa fragility syndrome. Plakophilin-1 (PKP1) deficiency is an autosomal recessive
disease that is associated with skin fragility and an inflammatory response
Subtype Mutation
resulting in erosions, scale-crust, and progressive palmoplantar keratoderma.
Simplex Suprabasal Plakophilin-1; desmoplakin Ectodermal effects such as sparse hair and anhidrosis and astigmatism are
Basal Keratin 5 or 14; plectin; α6β4 integrin also noted.20 While initially described in a single child, approximately ten
Junctional Herlitz Laminin-332 (laminin-5) cases with mutations in this gene have now been described.20,21
Non-Herlitz Laminin-332; type XVII collagen;
α6β4 integrin Epidermolysis bullosa simplex superficialis
This rare form of EB transmitted in an autosomal dominant fashion was first
Dystrophic Dominant Type VII collagen
described in 1989. It specifically differs from the other simplex variants by
Recessive Type VII collagen
the site of epidermal cleavage: variable subcorneal split between the stratum
Kindler syndrome Kindlin-1 corneum and granular cell layer or sometimes within the stratum spinosum
rather than intrabasal.22 Patients present at birth or within the first 2 years of
life with erosions and crusts sparing the palms and soles. Atrophic scarring,
nail dystrophy, and milia are additional common features; oral and ocular
consensus conference considered its application to be less useful than the epithelia can be affected.23 As well as the cutaneous manifestations, anemia
current scheme. The main reason for this decision is that it is a somewhat and gastrointestinal lesions affect a minority of patients. Some cases are asso-
artificial category. It separated non-Herlitz junctional EB into two ciated with mutations causing structural dysfunction of type VII collagen.23
categories namely, junctional EB and hemidesmosomal EB, based only on The condition may be clinically confused with peeling skin syndrome but in
the presence of mutations in the genes encoding either laminin-332 or the latter there are no blisters and peeling is continous and spontaneous.
type XVII collagen, respectively. Both conditions have very similar
clinical features and cannot be separated on clinical grounds, making this
Basal EBS
distinction confusing for clinicians, patients, and their parents. Thus all
the diseases in the hemidesmosomal category are now reclassified into Nine subtypes of basal EBS are currently recognized, five of which are very
either the junctional or simplex types of EB. rare.
• Junctional EB is characterized by the development of cleavage within the EB simplex, localized (Weber-Cockayne; EB simplex of the
lamina lucida. It results from mutations in one of the three genes hands and feet)
encoding the hetrotrimeric subunits of laminin-332 (laminin-5), α6 and β4 This is the most common form of epidermolysis bullosa and has an ­autosomal
integrin subunits, and type XVII collagen.17 As mentioned above, some of dominant mode of inheritance.4 5 Lesions are limited to the palms and soles
these cases were deamed in the provisional hemidesmosomal category in and are usually detected in infancy or the first few years of life (Fig. 4.9).
the previous classification scheme (e.g., α6 or β4 integrin subunits with EB Occasionally, in patients with mild involvement, blisters and erosions may
with pyloric atresia). not develop until childhood or even early adulthood in association with
• Dystrophic EB (also known as the dermolytic variant) is defined by a strenuous activity. The lesions, which sometimes heal with atrophic scarring,
split developing immediately below the lamina densa in the region of the show seasonal variation, often occurring only in the summer months.
anchoring fibrils. This type is composed of genetically dominant and Hyperhidrosis may sometimes be present. Milia, atrophic scarring, and nail
recessive subtypes invariably due to type VII collagen gene mutations.18,19 dystrophy are uncommon features.5,7 The teeth are uninvolved and there is no
evidence of any systemic involvement, except perhaps for oral erosions, which
Clinical features may affect an appreciable number of patients in infancy.7 Ocular lesions are
not a feature. Repeated episodes of secondary infection may occur in some
EB simplex (EBS)
patients. Postinflammatory hyper- and hypopigmentation may sometimes
Two major types of EB simplex (with 12 subtypes) are now recognized: be a cosmetic problem.8
• suprabasal,
• basal. EBS, Dowling-Meara (EBS herpetiformis)
This variant, which is the second commonest form of EB simplex, shows clin-
Suprabasal EBS ical features resembling dermatitis herpetiformis and has an autosomal domi-
Three suprabasal subtypes are recognized; all of them are rare variants. nant mode of inheritance (Fig. 4.10).7,24–27 Herpetiform grouping of blisters is
characteristic. Lesions are usually present at birth and have a distribution
Lethal acantholytic EB sometimes mimicking severe dystrophic or junctional disease.7 Some patients
Lethal acantholytic EB has been described in two cases with severely defective die in early infancy due to infection, fluid loss or electrolyte imbalance.1 Milia
skin and mucosal epithelia.19 The disease was lethal in the neonatal period formation is common, but atrophy and scarring are rare.7 Distal flexural
due to epidermolysis that was first noted during parturition leading to uncon- contractures are occasionally present.25 Nail dystrophy is often found and
trollable loss of fluid from the skin. Additional defects included universal palmoplantar keratoderma is characteristic. Anodontia and hypodontia have
alopecia and complete shedding of nails and the presence of neonatal teeth. also been described. Normalization during episodes of high fever is a typical
Histology revealed clefting of the suprabasal layer producing a tombstone-type finding but seasonal variation is not a feature.26 Blistering significantly
appearance reminiscent of pemphigus vulgaris. Molecular investigation improves with advancing years.27 Mutations in keratins 5 and 14 underlie this
revealed that the patient had inherited two different nonfunctional copies of disease.28–31 Death as a result of complications of the disease is rare and gener-
the gene encoding desmoplakin (DSP, a desmosomal protein that links the ally occurs by age 1 as a result of sepsis or respiratory failure.32
transmembrane cadherins to the various proteins of the cytoplasmic interme-
diate filaments), one from each parent, indicating that the disease is autosomal EBS, other generalized (includes Koebner variant)
recessive. The mutations both lead to truncation of the desmoplakin protein This group has an autosomal dominant mode of inheritance and includes pri-
and an inability to act as a linker. Additional cases will be necessary to further marily those cases previously termed Koebner-type and all other generalized
define this syndrome. subtypes of EBS.5 In the Koebner variant, blisters are present at birth or
shortly thereafter and, although the entire body may be affected, lesions are
Plakophilin deficiency (ectodermal dysplasia-skin fragility syndrome, particularly severe on the extremities, where the dorsal surfaces tend to be
McGrath syndrome) involved (Fig. 4.11).5 The blisters usually heal without scarring or atrophy
Plakophilin is a required component of desmosomes and an important pro- and milia are very uncommon.5 The eruption often worsens in the summer
tein in ectodermal development. The rare deficiencies in this protein result in months. The nails are rarely dystrophic and teeth abnormalities are typically
Epidermolysis bullosa 105


Fig. 4.9
EB simplex (Weber-Cockayne): typical lesions affecting (A) the fingers and (B) the toes. The pale color of the latter is due to the marked thickness of the roof of the blister.
By courtesy of the Institute of Dermatology, London, UK.

Fig. 4.11
EB simplex (Koebner):
intact blisters are present
in the axilla and on the
chest. By courtesy of
M.J. Tidman, MD, Guy's
Hospital, London, UK.
Fig. 4.10
EB bullosa simplex:
Dowling-Meara variant involvement.36–38 Blisters and erosions present at birth or soon ­thereafter and
showing characteristic are usually generalized. Patients may also suffer from atrophic ­scarring, milia,
grouping of blisters and
nail dystrophy or anonychia, alopecia, and oral lesions36,37 Severe mucose
erosions. By courtesy
of R.A.J. Eady, MD,
membrane involvement is rare.39 The mortality of this variant is high.6
Institute of Dermatology, Mutations in plectin are associated with these forms of the disease.40–42 Plectin
London, UK. is a large (greater than 500 kD) intermediate filament binding protein that pro-
vides mechanical rigidity to cells by acting as crosslinking adaptor to the
cytoskeleton.43 The PLEC1 gene bears a domain structure similar to BPAG1,
indicating they belong to a common family and may have similar functions.
absent. Although oral lesions may be present in infancy, systemic involvement
A lethal variant of EBS with mutations in plectin at the level of the plakin
is not a feature of this variant.
domain may occur exceptionally and it is associated with aplasia cutis of the
EBS with mottled pigmentation limbs and developmental impairment.42
This autosomal dominant variant was originally described in six members of
EBS with pyloric atresia
a single kindred.33 The cutaneous lesions are similar to the Dowling-Meara
This category was placed in the provisional hemidesmosomal category in the
variant with the addition of mottled or reticulate pigmentation, particularly
prior edition of this book. Cases with pyloric atresia are currently considered
affecting the neck and trunk. Atrophic scarring, milia, and nail dystrophy are
in two groups: EBS discussed here, and another category in junctional EB dis-
uncommon. Punctate keratoderma affecting the palms and warty hyperkera-
cussed below. This is a rare variant of epidermolysis bullosa in which affected
totic lesions involving the hands, elbows, and knees may be additional fea-
infants are at risk of ureterovesical junction obstruction with fibrosis involv-
tures.33–35 Dental caries is also sometimes present and intraoral lesions are
ing the entire urinary tract and aplasia cutis congenita in addition to pyloric
occasionally seen.
atresia (Figs 4.12, 4.13).44–47 Polyhydramnios is also seen. The pyloric atresia
EBS with muscular dystrophy (pseudojunctional EB) may be due to a diaphragm or stenosis (Fig. 4.14). The mortality rate of this
This is an autosomal recessive variant in which patients concomitantly develop variant is very high, up to 78% of affected infants succumbing.46 It appears to
muscular dystrophy or exceptionally myasthenia gravis and even cardiac be the most lethal form in the EBS category. Mutations in both plectin and
106 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.12
EB with pyloric atresia:
stillborn infant with
widespread blistering.
By courtesy of M.J.
Tidman, MD, Institute of
Dermatology, London, UK.

Fig. 4.14
(A, B) EB with pyloric atresia: pyloric canal is obliterated by fibrous connective tissue.

EBS, Ogna
This form is autosomal dominant and presents at birth. It primarily involves
acral sites, but can become widespread. Blistering is prominent and ony-
chogryphosis is common. A tendency to bruise has been described.9,52 Lack of
muscular involvement distinguishes this form of disease from EBS with mus-
cular dystrophy described above; the mutation genotype may be predictive of
disease expression.42,53
Fig. 4.13 Mutations in plectin underlie this syndrome.39,52
EB with pyloric atresia: in addition to blistering there is also deep ulceration.
By courtesy of M.J. Tidman, MD, Institute of Dermatology, London, UK. EBS, migratory circinate
This generalized form of EBS presents at birth with an autosomal dominant
inheritance pattern. Blistering is very prominent and associated with a migra-
tory circinate erythema and postinflammatory hyperpigmentation.9 Mutations
α6β4 integrin subunits (junctional EB) have been described.48 Since both α6β4 in keratin 5 have been described, but none is currently reported in keratin
integrin and plectin are expressed in villous trophoblast from the first trimes- 14.39,54,55
ter of pregnancy this feature has been used successfully for the prenatal diag-
nosis of this group of conditions.49 Hemidesmosomal EB
This group previously included three variants:
EBS, autosomal recessive • patients with generalized atrophic benign EB (GABEB) (others were
Autosomal recessive EBS is generalized with onset at birth. Blistering is prom- included in the junctional group; see below),
inent with mild atrophic scarring. Ichthyotic plaques and focal palmoplantar • EB with late-onset muscular dystrophy (formerly included in the simplex
keratoderma are sometimes encountered. Nails may be dystrophic or absent. group),
Anemia, growth retardation, dental caries, and constipation can be complica- • EB with pyloric atresia (formerly included in the junctional category).
tions.9 Mutations in keratin 14 underlie this disease; keratin 5 mutations have This subtype is of historical interest only as it no longer exists in the most
not been described.50,51 current classification scheme.
Epidermolysis bullosa 107

Junctional epidermolysis bullosa

Two major subtypes of this variant are recognized: junctional EB-Herlitz and
junctional EB-non-Herlitz (Other). This later group encompasses both local-
ized and generalized forms, cases with pyloric atresia, and three additional very
rare variants under the newly revised classification scheme.9 Junctional EB with
pyloric atresia was classified in the hemidesmosomal group in the prior classi-
fication scheme. All have an autosomal recessive mode of inheritance.

Junctional EB, Herlitz (Herlitz, gravis variant of junctional

EB, EB hereditaria letalis, EB atrophicans generalisata
Within this generalized variant, no additional subtypes are recognized. Blisters
and erosions are present at birth accompanied by scarring and atrophy
(Fig. 4.15).56–58 Milia may be a feature.7 Healing with the formation of
­exuberant, vegetative or tumorous granulation tissue is a pathognomonic
­feature (Fig. 4.16).5 This is found particularly around the mouth, sides of the
neck, trunk, and about the nails.4 The nails may be dystrophic or absent and
scarring alopecia is sometimes evident.5 Severe oral involvement (including
­scarring and microstomia) is usually present and pitted dystrophic enamel is Fig. 4.16
characteristic (Fig. 4.17). Dental caries are frequently severe. Other ­features Junctional EB (Herlitz): infant showing granulation tissue at the edge of a healing
may include musculoskeletal deformities, gastrointestinal lesions, laryngotra- blister. By courtesy of the Institute of Dermatology, London, UK.
cheal stenosis, and genitourinary and ocular involvement. Esophageal involve-
ment may result in stenosis. Perforation with resultant infection is an
important cause of death. Severe growth retardation and anemia are usually ­ yperpigmentation and hypopigmentation are characteristic.63 Skin lesions
evident. Infantile mortality is high (42.2%).7 Mutations in one of the three may be exacerbated during summer. Milia are variably present. Exuberant
subunits of ­laminin-332 underlie this syndrome.59–61 ­granulation tissue is less common than in the Herlitz variant. Other features
include dystrophic or absent nails (Fig. 4.18), oral erosions with mild scar-
Junctional EB, Other ring, pitted dystrophic enamel, and severe dental caries. Ocular lesions include
The category contains six subtypes, two common and four rare. recurrent corneal erosion, blistering, and corneal scarring.64 Follicular atro-
phy with resultant alopecia involving the scalp, axillary, and pubic hair in
JEB, non-Herlitz, generalized (generalized non-Herlitz junctional EB, addition to sparse eyelashes and eyebrows is common (Fig. 4.19).63 Large or
EB atrophicans generalisata mitis, generalized atrophic benign EB multiple melanocytic nevi have also been described as part of the phenotype58
(GABEB), hemidesmosomal EB, junctional EB mitis) but this is not currently believed to be a specific feature.5 Contractures do not
This somewhat milder form, in which the cutaneous features are similar to develop. Systemic involvement is usually limited to mild laryngeal and/or
the gravis form, includes some patients with laminin-332 gene mutations and esophageal lesions.4 Growth may be retarded and anemia is present in some
others with mutations in type XVII collagen previously classified in the hemi- patients. Infantile mortality is high (up to 44.7%).7,32
desmosomal group.9,62 Systemic involvement is typically mild or absent.63–66
Patients present at birth with extensive blistering and erosions accompanied JEB, non-Herlitz, localized
by mild scarring and widespread cigarette paper-like atrophy. Variable This milder and localized form of JEB is associated with mutations in type
XVII collagen rather than laminin-332.67,68 Genotypic correlations and immu-
nofluorescence antigen mapping may allow distinction of this form from the
more several generalized form.68
JEB with pyloric atresia
All EB with pyloric atresia was previously placed in the now defunct hemides-
mosomal category. These cases are now divided into two categories within
EBS and JEB. While both plectin and α6β4 integrin subunit mutations have
been noted in EBS with pyloric atresia, only the latter is believed associated
with JEB with pyloric stenosis.69–71 The clinical features are similar, with gen-
eralized blisters present from birth associated with atrophic scarring, dystro-
phic or absent nails, and milia on occasion. Large areas of aplasia cutis have
been described.67 This disease is usually fatal at an early age.

JEB inversa
Lesions, which are present at birth or develop in early infancy, are initially gen-
eralized, but later are predominantly localized to inverse (flexural) sites includ-
ing the axillae and groin.5 Blisters and erosions are accompanied by atrophic
scarring and nails may be dystrophic or absent. Other features that are some-
times evident include mouth erosions, maldeveloped teeth with enamel hyp-
oplasia, and occasional gastrointestinal lesions, particularly affecting the
esophagus and anus. Mutations in the subunits of laminin-332 are noted.9,58
Fig. 4.15
Junctional EB (Herlitz):
JEB-late onset (progressiva)
newly born infant with
blistering and nail
In this variant, lesions do not present until late childhood, and consist of
involvement. By courtesy blisters and erosions affecting the hands, elbows, knees, and feet.5 Nails
of J. McGrath, MD, may be dystrophic or absent and enamel hypoplasia is characteristic. Mouth
Institute of Dermatology, erosions may be evident. Mild finger contractures are sometimes a compli-
London, UK. cation.3,5 The mutation underlying this form of the disease is unclear.9
108 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.17 Fig. 4.19

Junctional EB (Herlitz): note the scarring with microstomia and severe dental involvement. Generalized atrophic benign EB: note the sparsely distributed eyebrows and eye
By courtesy of J. McGrath, MD, St John's Dermatology Centre, London, UK. lashes. By courtesy of the Institute of Dermatology, London, UK.

Dominant dystrophic EB
Five subtypes are recognized; four of these are rare.
Dominant dystrophic EB, generalized
Autosomal dominant EB, generalized includes both the Cockayne-Touraine
and Pasini variants. This is because the two conditions are characterized by
identical type VII gene mutations and the albopapuloid lesions (white perifol-
licular papules and plaques) have been found to be an inconsistent finding
(Fig. 4.20).6,7 Generalized blisters are seen at birth (Fig. 4.21a).4,8 Alopecia
may be present and milia, atrophic scarring, and dystrophic or absent nails
are typical features (Fig. 4.21b). Oral involvement may be mild or absent.
Enamel hypoplasia is sometimes evident. Gastrointestinal and genitourinary
tract involvement is seen in a minority of patients. There is a slightly increased
risk of basal cell carcinoma and melanoma.75

Dominant dystrophic EB, acral

In this mild autosomal dominant localized variant, lesions present at birth or
in early childhood, particularly in an acral distribution. Blisters and erosions
in the absence of other significant lesions except for atrophic scarring, milia,
Fig. 4.18
Generalized atrophic benign EB: there is scarring and complete absence of nails.
By courtesy of the Institute of Dermatology, London, UK.

Laryngo-onycho-cutaneous (LOC) syndrome

A mutation in the gene encoding the laminin-332 α3 chain resulting in an
unusual N-terminal deletion underlies this syndrome.72 It was first described
by Shabbir and colleagues in 22 patients of Punjabi extraction and about 10
additional cases have been described.73,74 So far, this autosomal recessive con-
dition has not been described outside of this population. It can occur in a
nonconsanguineous context. It consists of epithelial defects resulting in cuta-
neous erosions, nail dystrophy, and chronic conjunctival and laryngeal granu-
lation tissue. Symblepharon and blindness are serious complications. Airway
obstruction and infection can also be problematic. The degree of skin fragility
is less than that seen in other variants of JEB. Under the new classification
system, based on molecular and clinical similarities to JEB, this syndrome has
been added as a rare variant.9,59

Dystrophic EB
Two major subtypes – dominant dystrophic EB and recessive dystrophic EB Fig. 4.20
(Hallopeau-Siemens) – are recognized and these are categorized into three Dystrophic EB: albopapuloid lesions on the lumbosacral area. These are an
major subtypes (one dominant and two recessive) and nine rare dominant or inconstant finding in dystrophic EB. The lesions are not preceded by blistering and
recessive groups. All subtypes are associated with mutations in the gene probably represent connective tissue nevi. By courtesy of M.J. Tidman, MD, Guy's
encoding type VII collagen. 9 Hospital, London, UK.
Epidermolysis bullosa 109

Fig. 4.21
Dominant dystrophic EB
(Cockayne-Touraine): (A)
truncal involvement is present
in addition to the more typical
limb lesions; (B) hemorrhagic
blisters, scarring, milia and
nail dystrophy. By courtesy of
A B the Institute of Dermatology,
London, UK.

and nail dystrophy may cease altogether after childhood.1 Extracutaneous

manifestations have not been recorded.
Dominant dystrophic EB, pretibial
This is a mild, localized, and typically symmetrical autosomal dominant form.
An autosomal recessive variant has recently been described (see below).76 The
onset is often delayed, patients usually presenting in early ­childhood.77 Blisters
and erosions accompanied by atrophic scarring and milia are ­particularly
seen on the pretibial region and dorsal aspects of the feet (Figs 4.22, 4.23).
The scarring may have a violaceous appearance reminiscent of hypertrophic
lichen planus.76 Lesions are also sometimes seen on the forearms and trunk.76
Pruritus and nail dystrophy are common. There are no teeth or hair
Dominant dystrophic EB, pruriginosa
This variant, which presents in childhood, includes dominant and ­recessive
variants (see below).78 Patients present with highly pruritic, violaceous

Fig. 4.23
Dystrophic EB–pretibial: close-up view. By courtesy of the Institute of Dermatology,
London, UK.

­ odular prurigo-like nodules developing against a background of blisters,

milia, nail dystrophy, and albopapuloid lesions.
Dominant dystrophic EB, bullous epidermolysis of the newborn
This exceptionally rare, self-limiting condition presents in the newborn with
blisters that usually resolve within the first 2 years and heal with mild atro-
phy, milia, and scarring.79,80 Most cases have been inherited as an autosomal
dominant, although recessive variants have also been documented.6

Recessive Dystrophic EB
This category is composed of seven subtypes, of which five are rare.

Recessive dystrophic EB, severe generalized (Hallopeau-Siemens;

polydysplastic EB; EB gravis)
This autosomal recessive variant is a much more serious form than its auto-
somal dominant counterpart.4,8 Blisters and erosions are present at birth and,
atrophy, scarring, anemia, and growth retardation are consistently present
(Figs 4.24, 4.25). Nikolsky's sign is positive. Destructive involvement of the
distal peripheries results in contractures and severe deformities including the
characteristic ‘mitten lesions’ (pseudosyndactyly) of the hands and feet (Figs
4.26–4.28).81 If the latter is left untreated, there may eventually be resorption
Fig. 4.22 of the underlying bones (autoamputation). Nail dystrophy and milia are
Dystrophic EB–pretibial: extensive erosions with scarring are localized to the front marked, and scarring alopecia is common (Fig 4.29). Oral involvement is
of both shins. By courtesy of the Institute of Dermatology, London, UK. severe, with blisters, erosions, and scarring. Excessive caries are usual.
110 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.24
Recessive dystrophic EB (Hallopeau-Siemens): extensive blistering present at birth.
The disease process has involved the nails and those of the first two toes are
absent. By courtesy of R.A. Marsden, MD, St George's Hospital, London, UK.

Fig. 4.27
(A, B) Recessive dystrophic EB (Hallopeau-Siemens): in addition to the gross mitten
deformity, there is very severe scarring and scaling. (A) By courtesy of R.A.J.
Eady, MD, and B. Mayou, MD, St Thomas' Hospital, London; (B) by courtesy of the
Institute of Dermatology, London, UK.
Fig. 4.25
Recessive dystrophic EB (Hallopeau-Siemens): note the scarring and extensive
erosions. By courtesy of the Institute of Dermatology, London, UK.

Fig. 4.26
Recessive dystrophic EB (Hallopeau-Siemens): weblike folds enveloping the toes Fig. 4.28
have resulted in a clublike appearance. By courtesy of R.A. Marsden, MD, St George's Recessive dystrophic EB (Hallopeau-Siemens): there is gross deformity of the knees.
Hospital, London, UK. By courtesy of J. McGrath, MD, Institute of Dermatology, London, UK.
Epidermolysis bullosa 111

Fig. 4.30
Recessive dystrophic EB:
extensive esophageal
involvement with
complete separation of
Fig. 4.29 the mucosa has resulted
Recessive dystrophic EB in this dramatic, but
(Hallopeau-Siemens): note fortunately very rare,
the conspicuous milia. manifestation. By courtesy
By courtesy of the of R.A. Marsden, MD,
Institute of Dermatology, St George's Hospital,
London, UK. London, UK.

Gastrointestinal and renal complications are common.82,83 There is often con-

junctival involvement with keratitis and scarring, and lesions of the mucous
membranes result in difficulty in opening the mouth, dysphagia, and esopha-
geal stricture formation, with some infants eventually succumbing to terminal
respiratory infections (Fig. 4.30).84 Anal and genitourinary involvement may
also be present. Squamous cell carcinoma is a common complication of the
cutaneous scarring (occurring in 39.6% of cases) and is a significant cause of
mortality (Figs 4.31–4.33).85,86 Tumors are frequently multiple, have an aggres-
sive behavior, and may be associated with extensive metastatic spread.
Melanoma much less commonly develops. This variant of EB has a high mor-
tality: 38.7%.7

Recessive dystrophic EB, generalized other

This type is often referred to as non-Hallopeau-Siemens type. In contrast to
the severe generalized form, anemia and mental retardation are less common
and dental caries are not increased. In this variant the features are similar to
the Hallopeau-Siemens variant except that the extracutaneous lesions and
complications (e.g., anemia, mental retardation, and dental caries) are less
severe and the risk of developing cutaneous squamous cell carcinoma is
diminished (14.3%).4,8 The mortality for this variant of EB is 10.0%.87
Genotypic differences in mutational types and sites in the gene encoding type Fig. 4.31
VII collagen likely underlie differences in the phenotypic expression of this Recessive dystrophic EB (Hallopeau-Siemens): in this patient numerous large
disease.88 keratoses are evident. Many of these progress to squamous cell carcinoma. Courtesy
of R.A.J. Eady, MD, and B. Mayou, MD, St Thomas' Hospital, London, UK.
Recessive dystrophic EB, inversa
In this autosomal recessive form, lesions are present at birth and consist of
blisters, erosions, milia, and atrophic scarring, found particularly about the
flexural sites, including the inguinal regions, axillae, neck, and the lower Recessive dystrophic EB, centripetalis
back.89,90 Nail dystrophy is usually evident and sometimes scarring alopecia is This autosomal recessive localized form has been described in a single
seen. Severe oral and esophageal involvement (erosions and scarring) is patient. Presentation was at birth with widespread blisters. In adulthood,
characteristic.91 however, the distribution became acral. The blisters, milia, and severe scar-
ring with atrophy then showed a characteristic centripetal spread. Nail dys-
Recessive dystrophic EB, pretibial trophy and/or absence were also present. Despite the severe scarring,
The pattern of involvement is similar to the dominant form (see above), but contractures and deformities were not features.92 There were no extracuta-
can be more severe. neous manifestations.

Recessive dystrophic EB, pruriginosa Recessive dystrophic EB, bullous dermolysis of the newborn
The pattern of involvement is similar to the dominant form (see above), but The pattern of involvement is similar to the dominant form (see above), but
can be more severe. can be more severe.
112 Inherited and autoimmune subepidermal blistering diseases

Pathogenesis and histological features

The investigation of a patient with suspected EB should ideally include immu-
nofluorescence antigen mapping, ultrastructural, and molecular genetic
­studies. In general, routine histopathology often contributes little, other than
to confirm the presence of a subepidermal blister.
Immunofluorescent antigen mapping of basement membrane determinants
is a method of identification of the plane of cleavage in the various types of
EB that can sometimes avoid the need for ultrastructural studies.100,101
Essentially, the location of three antigens – type IV collagen, laminin-332,
and bullous pemphigoid antigen-1 – is determined by standard indirect immu-
nofluorescence of lesional (either naturally occurring or mechanically induced)
• In simplex variants, all three antigens are found along the floor of the blister.
• In junctional lesions, bullous pemphigoid antigen-1 is identified mainly in
the roof of the blister, whereas laminin-332 and type IV collagen are
present along the floor.
• In dystrophic EB, the plane of cleavage is below the lamina densa and
therefore all three basement membrane antigens are present in the roof of
Fig. 4.32 the blister.
Recessive dystrophic EB (Hallopeau-Siemens): in addition to severe scarring The immunofluorescent investigation of skin samples for a wide range of
accompanied by autoamputation of the fingertips, there is a large ulcerated squamous recognized basement membrane constituents known to be absent or
cell carcinoma. Courtesy of R.A.J. Eady, MD, and B. Mayou, MD, St Thomas' Hospital, ­diminished in the various subtypes of epidermolysis bullosa has proved to be
London, UK. particularly valuable, and has also been shown to be of use in antenatal
(16–18 weeks' gestation) diagnosis.102–104
The monoclonal antibody KF-1, which localizes to the lamina densa, shows
an absence of labeling in nonlesional skin from patients with the severe
recessive dystrophic form of EB, whereas in the dominant variant it is
The monoclonal antibodies AF1 and AF2, which recognize antigens in and
immediately below the lamina densa (probably constituents of anchoring fibrils),
show an absence of immunolabeling in both normal and lesional skin from the
recessive dystrophic form, but appear normal in dominant dystrophic EB.107
LH7:2 is a monoclonal antibody directed against the NC-1 globular
domain of type VII collagen, which binds to the lamina densa and attached
anchoring fibrils.108,109 Labeling is absent or markedly reduced in the severe
recessive dystrophic form, patchily reduced in mild or localized recessive dys-
trophic variants, and normal in the dominant dystrophic variant.110,111
Immunolabeling with the monoclonal antibody GB3, which recognizes
laminin-332 (nicein/kalinin/epligrin), is reduced or absent in the junctional
(Herlitz) form of EB. It may be normal, reduced or absent in the non-Herlitz
junctional variants.112,113 Laminin-332 is a major constituent of the anchoring
filaments, which stretch from the hemidesmosomes to the lamina densa.
Two further antibodies, 19-DEJ-1 and AA3, characteristically fail to label
Fig. 4.33 the basement membrane zone in all patients with junctional epidermolysis
Recessive dystrophic EB (Hallopeau-Siemens): in this patient there is a massive bullosa and are therefore of additional diagnostic value.114 19-DEJ-1, which
squamous carcinoma, which has destroyed much of the knee. Courtesy of R.A.J. recognizes uncein, has been recommended as the most reliable antibody for
Eady, MD, and B. Mayou, MD, St Thomas' Hospital, London, UK. evaluation and diagnosis of the major junctional variants.115,116
Bullous pemphigoid 180-kD antigen is demonstrably diminished or absent
as determined by immunofluorescence in many patients with generalized
Kindler syndrome atrophic benign EB.117
Kindler syndrome has been added to the EB classification scheme due to simi-
larities to EB, and the hope that patients with this disease may benefit from the EB simplex
greater molecular and pathogenetic understanding of EB as a whole. It does In EB simplex variants, blisters develop as a consequence of basal cell ­cytolysis
not readily fit into any of the EB types as the level of blistering separation can (Fig. 4.34). The plane of cleavage lies deep to the nuclei of the keratinocytes
be intraepidermal, junctional or below the lamina densa. This disease is caused such that wispy remnants of basal cell cytoplasm may be identified along the
by a mutation in the KIND1 gene that encodes the protein kindlin-1, a component floor of the blister cavity, which is therefore intraepidermal in location
of contact foci in basal keratinocytes.93,94 First described in 1954, more than (Figs 4.35, 4.36).118 In older lesions the blister often appears to be subepidermal
50 cases are now published in the literature.95,96 Significant heterogeneity is due to continued lytic changes of the residual keratinocyte cytoplasm
noted, but this rare autosomal recessive disease is associated with skin fragility (Fig. 4.37). By direct immunoperoxidase antigen mapping on paraffin-embedded
similar to other forms of EB associated with the symptoms of poikiloderma sections, keratin, laminin, and type IV collagen staining may be identified along
and photosensitivity not seen in other forms of EB. Trauma-induced blistering the floor of the blister, confirming its intraepidermal location (Fig. 4.38).
and photosensitivity often improve with age. Squamous cell carcinoma and Ultrastructural studies have shown that the earliest change is loss of keratin
transitional cell carcinoma of the bladder have been described.97 filaments (tonofilaments).118,119 As a consequence, there is structural instabil-
All types of hereditary epidermolysis bullosa (simplex, junctional, and ity and fragility of the keratinocytes. Keratin clumps similar to those described
­dystrophic) may rarely present with large nevi that often simulate melanoma on in the Dowling-Meara variant (see below) have been a rare finding in EB simplex
clinical grounds. Histology, however, shows no evidence of mali­gnancy.98,99 Koebner.120 Loss of keratin filaments is subsequently followed by dissolution
Epidermolysis bullosa 113

Fig. 4.34
EB simplex: the earliest histological feature in the development of a blister is Fig. 4.37
marked vacuolation of the basal keratinocytes, so-called cytolysis. EB simplex: old lesion; the features are those of a cell-free subepidermal blister and
are not specific.

Fig. 4.35
EB simplex: established lesion showing ‘subepidermal’ vesiculation.
Fig. 4.38
EB simplex: paraffin
displays type IV collagen
along the floor of the
blister cavity (same case
as Fig. 4.37).

of the other keratinocyte cytoplasmic constituents. Suprabasal desmosomes

appear unaffected. The lamina densa and anchoring fibrils are normal. While
the hemidesmosomes generally appear normal, reduplication and increased
electron density have been described in a recent case report.121
The Dowling-Meara variant (including the subset with mottled pigmenta-
tion) is characterized by 1–5-μm homogenous intracytoplasmic clumps of
keratin filaments in addition to cytolysis (Fig. 4.39).122 These are present in
the basal keratinocytes and extend into the overlying prickle cell layer. They
may also be identified in the follicular outer root sheaths, dermal eccrine
sweat ducts, and sebaceous glands. The clumps are composed of keratins
5 (type II) and 14 (type I).122 In addition to intraepidermal vesiculation,
Fig. 4.36 ­intrakeratinocyte cleavage may also be found in the follicular infundibula.
EB simplex: basal keratinocyte cytoplasmic remnants are visible along the floor of The other skin appendage structures are not affected. The dermis may contain
the blister cavity. an infiltrate of lymphocytes and eosinophils.
114 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.39
EB simplex (Dowling-Meara): (A) electron micrograph
showing intrakeratinocyte splitting; (B) close-up view of
A B tonofilament clumps. By courtesy of J.A. McGrath, MD, and
R.A.J. Eady, MD, Institute of Dermatology, London, UK.

The keratoderma shows hyperkeratosis and acanthosis. Clumps of keratin clusters on chromosomes 12 and 17.126–130 The gene for keratin 5 is carried on
may also be evident. chromosome 12q and that for keratin 14 is located on 17q. Truncated mutant
Ultrastructurally, the level of cleavage is low within the basal keratinocytes, just human keratin 14 gene induces the EB phenotype when introduced into trans-
above the level of the hemidesmosomes (Figs 4.40, 4.41). In ­addition to cytolysis, genic mice and similarly causes an identical keratin abnormality when
however, acantholysis may also sometimes be evident. The keratin filament expressed in ­transfected human keratinocytes.131,132 Specific missense muta-
abnormalities include irregular whorled bundles in addition to homogeneous tions or ­deletions have now been identified in patients with Dowling-Meara
clumps. They are present in normal skin in addition to lesional material (K5 and K14), localized (K5 and14), other generalized (K5 and14) subtypes,
(Fig. 4.42).122,123 Desmosomes may appear diminished in number in the keratinocytes and the the rare EB simplex subtypes with mottled pigmentation (K5), autosomal
showing tonofilament clumps. Basement membrane zone constituents are normal. recessive (K14), and migratory circinate (K5).133–138 The highly conserved end
In EB simplex superficialis the plane of cleavage is in the upper epidermis domains of the keratin rod are particularly susceptible to significant mutation
just beneath the stratum corneum.22 Additional clefts may also be evident in with resultant instability of the filament assembly and consequent fragility of
the lower third of the epidermis. basal keratinocytes following mild trauma.124
It is now apparent that the majority of EB simplex develop as a direct Plectin, which localizes to the inner plaque of the hemidesmosome, is a
­consequence of keratin gene mutation, but mutations in desmoplakin, member of the plakin family and in concert with BP230 is believed to be of
­plakophilin, plectin, and α6β4 integrin subunits are seen in some of the rare importance in keratin filament anchorage.10,14 Recently, mutation of the gene
subtypes (see Table 4.2).124,125 Following the initial discovery of keratin PLEC1 encoding this protein has been described in patients with the muscular
­filament clumps in Dowling-Meara EB and their subsequent identification as dystrophy-associated, pyloric atresia, and Ogna subtypes.39 Plectin is associ-
keratins 5 and 14, it was shown that keratinocyte cultures from patients with ated with the Z-lines in the desmin cytoskeleton and this explains its
this disease exhibited an identical morphological abnormality.120 Genetic importance in myocyte adhesion and their role in the pathogenesis of EBS
linkage studies showed that EB simplex was associated with keratin gene with muscular dystrophy.139 Mutations in the genes encoding desmoplakin
and plakophilin-1, respectively, are associated with lethal acantholyic EB and
­plakophilin deficiency.19,20
EB (both the simplex and junctional forms) associated with pyloric atresia
results from α6β4 integrin missense mutations resulting in premature termina-
tion codons with synthesis of defective or nonfunctional α6 or β4 subunits.140–142
As a result, hemidesmosomes are hypoplastic or reduced in number.10 Mutations
in the gene encoding plectin are also noted in the simplex form.48,143
Exceptionally, amlyoid has been described in the Weber-Cockayne type of
EB.144 Dyskeratosis has been reported as a histologic feature in Dowling-Meara
EB but not in other variants, including Koebner EB or Weber Cockayne EB.145
The sample in this study, however, was small and further investigation is
required to confirm the specificity of this finding.
Fig. 4.40
EB simplex (Koebner): the
M blister cavity forms within Junctional EB
the basal keratinocyte.
Note the cytoplasmic Junctional EB variants are also characterized by subepidermal ­blistering, usually
remnants along the unaccompanied by any substantial inflammatory cell infiltrate (Fig. 4.43).146
floor of the blister. Ultrastructurally, the site of cleavage is through the lamina lucida (Fig. 4.44). The
(M, melanosome.) hemidesmosomes may appear malformed, be ­diminished in number or
Epidermolysis bullosa 115

Fig. 4.41 Fig. 4.43

EB simplex (Koebner): this high-power view shows the floor of the blister cavity. Junctional EB: subepidermal cell-free blister.
Note the lamina densa (arrowed), hemidesmosomes (arrowheads) and basal
keratinocyte cytoplasm. (A, blister; B, cytoplasm; C, dermis.)

Fig. 4.42 Fig. 4.44

Epidermolysis bullosa simplex (Dowling-Meara): numerous tonofilament clumps are Junctional EB: lesional skin showing separation within the lamina lucida of the
present in the adjacent clinically normal skin (arrowed). By courtesy of J.A. McGrath, dermoepidermal junction. By courtesy of R.A.J. Eady, MD, Institute of Dermatology,
MD, Institute of Dermatology, London, UK. and M.J. Tidman, MD, Guy's Hospital, London, UK.

absent.147–150 Hemidesmosome alterations as detected by electron microscopy, Junctional EB, non-Herlitz (generalized and localized) is most commonly
however, are heterogeneous. In a morphometric study of numbers of hemidesmo- a result of BP180 mutations (BPAG2/type XVII collagen).161–163 Nonsense
somes per unit length of basement membrane, one of five patients with the Herlitz mutations or insertions/deletions with resultant premature termination
variant and two of three patients with non-Herlitz variants had normal results.151 codons result in absence of type XVII collagen. This is a transmembrane col-
The same authors recorded an association between junctional EB and a reduction lagen that is thought to contribute to the anchoring filaments via its carboxy-terminal
in the numbers of hemidesmosomes with associated sub-basal plates. segment.10 The amino-terminal globular domain resides within the cytoplasm
Junctional EB is characterized by mutations in the genes that encode the of the basal keratinocyte localizing to the outer plaque of the hemidesmo-
α3, β3 or γ2 chains of laminin-332 (laminin-5).152–158 Mutations resulting in some. Less often, laminin-332 mutations are responsible for this clinical
premature termination codons in the laminin-332 genes are present, for phenotype.
example, in all cases of the Herlitz lethal variant.7,10 Nonsense mutations,
out-of-frame deletions or insertions and splicing errors affect both alleles, Dystrophic EB
resulting in reduced synthesis and defective assembly of trimeric laminin-5 In the dystrophic variants the histological features are those of subepidermal
molecules.10 The majority of mutations have affected the LAMB3 gene vesiculation or blister formation in the absence of any significant inflamma-
although LAMA3 and LAMC2 gene abnormalities have also been docu- tory content (Fig. 4.45). The clinical subtypes show no particular distinguishing
mented. Non-Herlitz junctional EB variants, including some cases of general- features. The adjacent dermis is often markedly scarred due to previous epi-
ized atrophic benign EB, are associated with milder missense mutations or sodes of blistering.
deletions in the laminin-332 genes.152,159,160 Laminin-332 is located within The squamous carcinoma that develops in association with recessive dys-
anchoring filaments and in the lamina densa. The abnormal laminin-332 trophic EB is very often well differentiated (Fig. 4.46) and occasionally its
results in defective anchoring filaments with resultant instability at the base- appearance suggests a verrucous variant. Whether this latter form has the
ment membrane region. good prognosis usually evident with verrucous carcinoma is uncertain.
116 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.45 Fig. 4.47

Dystrophic EB (Hallopeau-Siemens): in addition to obvious subepidermal blistering Dystrophic EB (Hallopeau-Siemens): lesional skin demonstrates cleavage
there is dermal scarring and chronic inflammation. immediately beneath the lamina densa of the dermoepidermal junction (arrowed).
By courtesy of R.A.J. Eady, MD, Institute of Dermatology, and M.J. Tidman, MD,
Guy's Hospital, London, UK.

Ultrastructurally, the site of cleavage is immediately below the lamina

densa (Fig. 4.47).164,165 In the autosomal dominant and some localized
recessive groups, anchoring fibrils are decreased in number, but may
appear ­morphologically normal, whereas in the generalized recessive
­variants (and occasionally in severe dominant cases), the fibrils are very
sparse or more often absent.166–168 Frequently, thin wispy filaments imme-
diately adjacent to the lamina densa are all that are visible. In a recent
morphometric study of basement membrane in various dystrophic forms,
using nonblistered skin, anchoring fibrils were completely absent in gen-
eralized recessive dystrophic EB. Reduced numbers of morphologically
normal anchoring fibrils were found in localized recessive and dominant
dystrophic variants.169 Type VII collagen expression in dystrophic EB,
however, as determined by LH7:2 immunolabeling, is not an all-or-none
phenomenon. Even in the recessive variant, some positive staining of thin,
­ill-formed filamentous structures may be seen immediately below the lam-
ina densa. Collagenolysis in the superficial dermis may also be seen in the
A more severe variants.
In transient bullous dermolysis of the newborn, in addition to reduced
numbers of anchoring fibrils, intracytoplasmic inclusions are seen in the basal
keratinocytes. These have a stellate appearance and represent retained type
VII and type IV collagen.170–172
Dystrophic EB variants are all caused by mutations in the type VII collagen
gene COL7A1.173–175 Over 100 distinct mutations have been identified.10 The
Hallopeau-Siemens severe recessive variant is characterized by nonsense
mutations, insertions, deletions or splicing errors, which cause premature ter-
mination codons affecting both alleles, resulting in very low levels of mRNA
and virtual absence of type VII collagen synthesis.10,172,173 Premature termina-
tion codon, missense, deletion, and substitution mutations have been identi-
fied in a number of the less severe dystrophic variants.7 Dominant dystrophic
EB is caused by a glycine substitution mutation resulting in a less severe vari-
ant in which type VII collagen, although defective, is still produced and
anchoring filaments are present albeit in reduced numbers.176,177 Transient
bullous dermolysis of the newborn also results from a mutation in
B Milia, which are most commonly seen in dystrophic EB, are small cysts within
the upper dermis, consisting of a mass of keratinized squames surrounded by a
Fig. 4.46 wall of squamous epithelium, thereby representing miniepidermoid cysts. They
(A, B) Dystrophic EB (Hallopeau-Siemens): biopsy from the forearm of a 30-year-old are not specific to epidermolysis bullosa, being found in a variety of conditions
patient showing a cell-free subepidermal blister. In addition, a well-differentiated associated with damage to the cutaneous adnexal structures (e.g., severe burns
squamous cell carcinoma extends into the subcutaneous fat. and porphyria cutanea tarda) and other blistering disorders.
Bullous pemphigoid 117

Differential diagnosis (Fig. 4.51). Often they contain clear or bloodstained fluid. Any area of the
body may be affected, but the blisters are most commonly located about the
With the appropriate clinical information the histological diagnosis of EB
lower abdomen, the inner aspect of the thighs and on the flexural surfaces of
should not pose any problems. With the exception, however, of the
the forearms, the axillae, and groin (Fig. 4.52).14 Grouping of lesions as seen
Dowling-Meara variant, it is not usually possible to predict which subtype
the patient suffers from although, in specimens from early lesions, it is in dermatitis herpetiformis is not usually a feature and symmetry is character-
sometimes possible to identify the simplex variants of the basis of cytolysis. istically absent. A ‘cluster of jewels’ appearance of new blisters arising at the
Cell-free subepidermal blisters, however, may be seen in a variety of conditions edge of resolving lesions as seen in linear IgA disease may, however, ­occasionally
be a feature of bullous pemphigoid (Fig. 4.53).15 The lesions are often pruritic
including autolysis, EB acquisita, cell-free pemphigoid, suction blisters,
and a burning sensation is sometimes a feature. Nikolsky's sign is usually
bullous cutaneous amyloidosis, bullous lichen sclerosus, porphyria cutanea
negative. In contrast to mucous membrane pemphigoid, generalized bullous
tarda, and pseudoporphyria.
pemphigoid is not associated with scarring.
Because the genetic defects for so many of the EB subtypes are now known,
Reported mucosal involvement (frequently as ulcers) is highly variable,
prenanatal testing is possible.178 It is hoped that understanding of the molecu-
lar pathobiology of this disease may eventually lead to successful gene ther- ranging from 8% to 58%.16–18 In a series of 115 patients, 24% had oral
involvement and 7% had genital lesions.18 Lesions are found most often on
apy as was recently described for a patient with junctional EB using
the palate, the cheeks, lips, and tongue (Fig. 4.54). Other sites less commonly
transplanted epidermal stem cells genetically modified to express wildtype
involved include mucosae of the nose, pharynx, conjunctiva and, rarely, the
urethra and vulva (see below) (Fig. 4.55).17 In contrast to mucous membrane
pemphigoid, mucosal involvement in generalized bullous pemphigoid is not
associated with scarring.
Bullous pemphigoid
Clinical features
Bullous pemphigoid is not a single disease entity. Rather, there are many sub-
types, which have been classified into primary cutaneous and mucosal vari-
ants and into generalized and localized forms (Fig. 4.48).1–4 Bullous
pemphigoid (BP) is the most frequently encountered autoimmune bullous
dermatosis with an annual incidence of 6.6 new cases per one million of the

Generalized cutaneous pemphigoid

Any age group may be affected, but the generalized variant demonstrates
a predilection for the later years of life, showing a maximum incidence in
the seventh decade and over. Rarely, however, children and even infants
may be affected.7,8 The disease is associated with a worldwide distribu-
tion and shows no racial propensity. There are no significant human leu-
kocyte antigen (HLA) associations and the sex incidence is approximately
Prodromal events are numerous and include erythematous, urticarial and,
rarely, eczematous phases.9,10 Erythroderma, either preceding the bullous Fig. 4.49
phase or occurring simultaneously, is a very rare manifestation (erythroder- Erythrodermic BP: blistering has developed against a background of generalized
mic pemphigoid).11,12 Similarly, patients may present with a history of gener- erythroderma. By courtesy of the Institute of Dermatology, London, UK.
alized pruritus in the absence of visible skin lesions (pruritic pemphigoid). In
such circumstances, immunofluorescence investigations are essential to estab-
lish the correct diagnosis.13
The characteristic lesions of established disease are tense and often intact
blisters arising on normal or erythematous skin (Figs 4.49, 4.50). They may
measure up to several centimeters in diameter and are typically dome-shaped

Widespread Vegetans


Widespread Mucous Membrane

Desquamative Gingivitis
Fig. 4.50
Fig. 4.48 BP: early tense blister arising on an erythematous base. By courtesy of the Institute
Bullous pemphigoid: classification. of Dermatology, London, UK.
118 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.51 Fig. 4.53

BP: tense, dome-shaped blisters. The flexures are typically affected. By courtesy of BP: new blisters arising at the edge of a healing lesion (‘cluster of jewels’ sign). Although
the Institute of Dermatology, London, UK. typically seen in childhood linear IgA disease, this is sometimes a feature of bullous
pemphigoid. By courtesy of R.A. Marsden, MD, St George's Hospital, London, UK.

Fig. 4.54
Fig. 4.52 BP: oral erosions are an occasional finding. Intact blisters are rare. By courtesy of
BP: widespread, fluid- R.A. Marsden, MD, St George's Hospital, London, UK.
filled, hemorrhagic blisters
on the arms and legs
of an elderly female. By
courtesy of the late M.
Beare, MD, Royal Victoria
Hospital, Belfast, N.

Although bullous pemphigoid has been reported in association with a

variety of internal malignancies, this may just be coincidental, merely reflect-
ing the age incidence of these two diseases.19 In a series of almost 500 patients
from Sweden, no increased incidence of cancer was observed.20 Other stud-
ies, however, have shown that there may be a positive correlation between
internal malignancy and seronegative bullous pemphigoid patients.21
Generalized bullous pemphigoid is a serious condition with a significant
mortality ranging from 10% to 20%.1 Since the advent of steroid therapy and
immunosuppressive agents, patients are more at risk of developing severe iat-
rogenic disorders than of dying from their disease.22 Morbidity from this dis-
ease may be related more to the age and general state of health of the patient
than to the severity of blistering.23 Although mortality from the disease is low, Fig. 4.55
there has been a reported increase in mortality in the last 20 years of the BP: conjunctival injection is present. By courtesy of R.A. Marsden, MD, St George's
twentieth century.24 Hospital, London, UK.
Bullous pemphigoid 119

Fig. 4.56 Fig. 4.57

Bullous pemphigoid: occasionally erythematous urticarial lesions may be the Bullous pemphigoid: close up view. By courtesy of R.A. Marsden, MD, St George's
presenting feature. Blisters may not evolve until several weeks later. By courtesy of Hospital, London, UK.
R.A. Marsden, MD, St George's Hospital, London, UK.

Clinical variants of generalized pemphigoid Dyshidrosiform pemphigoid is a rare variant of pemphigoid in which
Urticarial bullous pemphigoid presents with large persistent erythematous patients develop 1–2-mm, tense ‘sago-grain-like’ vesicles on the palms and
plaques, which sometimes display an annular or gyrate peripheral component soles resembling dyshidrosiform dermatitis (pompholyx).44–50 Lesions may be
(Fig. 4 56, 4.57).1 Rarely, small vesicles are also to be found. localized, or precede or occur simultaneously with generalized disease.
Vesicular pemphigoid is a rare clinical variant in which the cutaneous Overlap with pemphigoid nodularis has been described.51
manifestations show a striking overlap with dermatitis herpetiformis.25–28 Childhood pemphigoid exhibits lesions that are similar to their adult coun-
Patients present with numerous small tense vesicles that may be symmetrical, terparts, but there is some tendency for lesions to be localized around the
intensely pruritic, and therefore associated with conspicuous excoriation. face, lower trunk, thighs, and genitalia, reminiscent of linear IgA disease in
Polymorphic pemphigoid is a somewhat confusing entity, which is similar childhood (Fig. 4.60).7,8,52–61 Similarly, a ‘cluster of jewels’ ­appearance is
to vesicular pemphigoid, but probably shows overlap with linear IgA sometimes evident.7 Palmar, plantar, and oral lesions are often present and
disease.29–31 may be the sole site of involvement in infants (Fig. 4.61). The mucous mem-
Patients present with burning and itching lesions predominantly affecting branes may be affected but scarring is absent. A number of children with pri-
the extensor aspects of the limbs, back, and buttocks. Symmetry, grouping, mary localized penile and vulval lesions have also been described (Fig.
and a polymorphic clinical appearance of papules, vesicles, and variably sized 4.62).47,48,59,62,63 This is of particular clinical importance since it may be mis-
bullae emphasize a similarity to dermatitis herpetiformis. It has been sug- taken for evidence of sexual abuse. Childhood pemphigoid has a good prog-
gested that polymorphic pemphigoid is not an entity sui generis, but repre- nosis and, as in adults, is usually self-limiting. Although the etiology is
sents a potpouri of conditions including vesicular pemphigoid, linear IgA generally unknown, in some infant cases there appears to be a relationship to
disease, and mixed subepidermal bullous disease in which patients show both prior vaccination or immunization.59,64 Differences between childhood and
linear IgG and linear IgA or dermal papillary granular IgA on direct infant cases have been described, but the importance of further subdividing
immunofluorescence.30 this group is unclear.64
Pemphigoid vegetans is an exceedingly rare vegetative intertriginous vari-
ant that may be associated with chronic inflammatory bowel disease.32–39
Fewer than 10 cases have been documented. Patients present with vegetative, Localized cutaneous pemphigoid
crusted, purulent, and sometimes eroded lesions in the groin, axillae, neck, Although classical bullous pemphigoid not uncommonly presents initially as
hands, eyelids, inframammary, and perioral regions (Fig. 4.58). Vesicles and localized lesions that after a few months become generalized, occasional
bullae may also be evident. Scarring has been described.39 The etiology of the patients present with localized blisters that do not subsequently disseminate
vegetative lesions is unknown. (localized bullous pemphigoid).65 Traditionally, this group has been ­subdivided
Seborrheic pemphigoid is a variant in which the clinical features are sug- into two variants:
gestive of pemphigus erythematosus.31 • Brunsting-Perry pemphigoid predominantly affects the head and neck
Pemphigoid nodularis represents the extremely rare association of lesions and is associated with scarring.66
of bullous pemphigoid with intensely pruritic papules and nodules of nodular • Localized cutaneous nonscarring bullous pemphigoid (Eberhartinger and
prurigo predominantly affecting the trunk and extremities (Fig. 4.59).40–42 Niebauer variant)67 predominantly affects the lower legs (in particular the
The association of pemphigoid nodularis with immune dysregulation, poly- pretibial region) of females.
endocrinopathy, enteropathy, and X-linked (IPEX) syndrome is the subject of The former variant is considered in the section on mucous membrane
a single case report.43 pemphigoid. Although the latter nonscarring cutaneous form particularly
Exceptionally, patients may show immunofluorescent evidence of bullous affects the lower legs (Fig. 4.63), it may also present at a variety of other sites
pemphigoid in the absence of clinical blistering.42 The cause of this unusual including forearms and hands, breasts, chest, buttocks, and umbilicus. Lesions
phenomenon is unknown although in some patients at least, chronic scratch- in localized bullous pemphigoid may be related to trauma.67 This variant
ing probably damages the basement membrane region with exposure of shows a peak incidence in the sixth decade. As with generalized bullous pem-
bullous pemphigoid antigens. There is a female predilection (2:1).42 The age phigoid, patients present with tense, sometimes hemorrhagic, bullae that arise
range of this variant extends from 24 to 80 years but, as with classical bullous on normal or erythematous-appearing skin. Localized cutaneous nonscarring
pemphigoid, the majority of patients are elderly. bullous pemphigoid is generally associated with a good prognosis.67
120 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.58
(A, B) Pemphigoid vegetans:
presentation as verrucous
lesions in the flexures
may result in considerable
diagnostic difficulties. By
courtesy of R.K. Winkelmann,
A B MD, The Mayo Clinic,
Scottsdale, Arizona, USA.

Fig. 4.60
Childhood BP: very rarely
this disease affects young
Fig. 4.59 children and infants.
Pemphigoid nodularis: in There is a widespread
addition to bullous lesions, distribution of bullae,
this patient also developed which characteristically
these pruritic nodules. arise on an erythematous
By courtesy of H. Shimizu, base. By courtesy of
MD, Keio University R.A. Marsden, MD,
School of Medicine, Tokyo, St George's Hospital,
Japan. London, UK.

Rare patients present with localized bullous pemphigoid at the site of manifestation of lichen planus, mucosal pemphigoid, and pemphigus.41 The
trauma without much evidence of disease elsewhere.68 diagnosis of localized oral pemphigoid depends upon the presence of a linear
band of immunoreactants at the epithelial basement membrane region on
Mucosal pemphigoid/desquamative gingivitis direct immunofluorescence.69 Clinical features include erythema, edema, erosions,
Localized oral pemphigoid is a recently described variant of desquamative gin- and ulcers.72 The oral lesions are nonscarring. Bullous pemphigoid-associated
givitis.69–71 The latter, of multifactorial etiology by definition, affects the mar- desquamative gingivitis may remain confined to the gingiva (the localized oral
ginal and attached gingivae. It shows a female predominance (9:1) and presents pemphigoid type), but approximately an equal proportion of patients goes on
most frequently in the middle aged. Desquamative gingivitis may also be a to develop full-blown cutaneous pemphigoid (Fig. 4.64).69
Bullous pemphigoid 121

Fig. 4.63
Localized pemphigoid,
nonscarring variant:
lesions are found
particularly on the lower
Fig. 4.61 legs of females. The
Childhood BP: plantar involvement is sometimes the only site of disease. By courtesy prognosis is usually good,
of M. Liang, MD, The Children's Hospital, Boston, USA. but occasionally the
condition can become
generalized. By courtesy
of R.A. Marsden, MD,
St George's Hospital,
London, UK.

Fig. 4.62
Childhood BP: note the perineal scarring and isolated blister. By courtesy of M. Liang,
MD, The Children's Hospital, Boston, USA.

Pathogenesis and histological features Fig. 4.64

The histological features of bullous pemphigoid depend to some extent upon Desquamative gingivitis: note the intense gingival erythema and retraction. Such
the age of the lesion biopsied. Early erythematous and urticarial lesions most features may also be seen in mucous membrane pemphigoid and pemphigus. By
often show upper dermal edema associated with a perivascular lymphohistio- courtesy of P. Morgan, FRCPath, London, UK.
cytic infiltrate accompanied by usually conspicuous eosinophils (Figs 4.65
and 4.66). Eosinophilic spongiosis is sometimes evident and occasionally, if
eosinophils are present in sufficient numbers, flame figures may be a feature. severe edema. An infiltrate of eosinophils and mononuclears surrounds the
Mild interface changes characterized by basal cell hydropic degeneration can blood vessels and extends between the adjacent collagen bundles.
be seen in early or prodromal lesions. Leukocytoclasis is not seen and features of vasculitis are absent. The adjacent
If the biopsy is taken from an established blister, the changes are most papillary dermis is often edematous and, very occasionally, eosinophil
often those of an inflammatory (cell-rich) variant.73 The blister, which is sub- microabscesses are a feature (Fig. 4.70). Exceptionally rarely, neutrophil
epidermal, is typically unilocular and covered by attenuated epithelium (Fig. microabscesses may be seen (see vesicular pemphigoid), raising diagnostic
4.67). In early lesions the roof epidermis may appear unaffected or show confusion with dermatitis herpetiformis. Eosinophilic spongiosis is also some-
occasional to even confluent necrotic basal keratinocytes. The blister contents times evident in the adjacent epidermis (Fig. 4.71).74
include coagulated serum, fibrin strands, and large numbers of inflammatory Cell-poor (noninflammatory) features are occasionally seen if biopsies are
cells including conspicuous eosinophils (Fig. 4.68). Variable numbers of neu- taken from lesions arising on noninflamed skin (Fig. 4.72). Because inflam-
trophils may be present. matory cells are sparse or, exceptionally, even absent in such cases, there may
A typical finding in bullous pemphigoid is retention of the dermal papil- be considerable problems with the differential diagnosis, particularly if ade-
lary outline (festooning) which project like sentries into the vesicle cavity quate clinical information and immunofluorescence findings are not
(Fig. 4.69). The underlying dermis is inflamed and usually shows widespread available.
122 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.65 Fig. 4.68

Prebullous pemphigoid: there is upper dermal edema and a perivascular lymphohis­ BP: the blister cavity contains large numbers of eosinophils.
tiocytic infiltrate with conspicuous eosinophils.

Fig. 4.69
BP: preservation of the dermal papillary outline (festooning) is a characteristic
Fig. 4.66 feature.
Prebullous pemphigoid: there are numerous eosinophils.

Fig. 4.67 Fig. 4.70

BP: an established lesion showing a subepidermal tense, dome-shaped blister BP: the presence of eosinophil microabscesses in the dermal papillae is a useful
containing edema fluid, fibrin, and inflammatory cells. although rare diagnostic marker.
Bullous pemphigoid 123

Fig. 4.71
BP: eosinophilic
spongiosis is sometimes
seen in the epidermis
adjacent to the blister.

Fig. 4.73
Vesicular pemphigoid: (A) low-power view showing a multilocular blister; (B) the
blister contains a neutrophil-rich infiltrate.

Localized nonscarring (pretibial) bullous pemphigoid usually shows the his-

tology of cell-rich bullous pemphigoid. Localized oral pemphigoid is typified by
a subepithelial vesicle (when present) and cannot be distinguished histologically
from oral involvement in mucous membrane pemphigoid (see below).
Ultrastructurally, in early lesions of bullous pemphigoid, the dermoepider-
mal cleavage is seen to have developed between the plasma membrane of the
Fig. 4.72 basal keratinocyte and the lamina densa, through the lamina lucida.75 The
Cell-poor pemphigoid: this is a very uncommon variant and is most often seen if a lamina densa is therefore located along the floor of the blister
very early lesion is sampled. The blister contains only a little edema fluid and there (Figs 4.77, 4.78). Degenerative changes in the basal cells, including villous
is a light chronic inflammatory cell infiltrate in the superficial dermis.
­process formation, mitochondrial swelling, and cytoplasmic vacuolization,
are frequently found. Hemidesmosomes may appear reduced in number or
may even be absent.76 Intercellular edema between adjacent basal cells is a
Vesicular/polymorphic pemphigoid is characterized by subepidermal vesi- common finding.77 If specimens from established inflammatory lesions are
cles with features suggesting either bullous pemphigoid or dermatitis herpeti- examined, the lamina densa is sometimes fragmented or entirely absent.48
formis or both (Fig. 4.73). Neutrophil dermal papillary microabscesses, Bullous pemphigoid is characterized by a linear antibasement membrane
which are often regarded as pathognomonic of dermatitis herpetiformis, may zone antibody using the indirect immunofluorescent technique.78 Although
be seen in this variant (Fig. 4.74). IgG is invariably present (and most commonly of the IgG4 subclass), other
Pemphigoid vegetans is characterized by acanthosis, often with pseudoepi- immunoglobulins, including IgE, may be represented.79 Such antibodies are
theliomatous hyperplasia, papillary dermal edema with subepidermal clefting present in around 75–80% of patients.80–83 Sensitivity can, however, be
or frank vesicle formation and an inflammatory cell infiltrate of eosinophils, increased to 90% if split skin is used as substrate.18 Although the antibody
mononuclears, and occasional neutrophils. titer does not correlate with disease activity or severity, more recently it has
Pemphigoid nodularis exhibits pruriginous lesions which are characterized been shown that serum antibodies to the NC16A domain of BP180 (a subunit
by hyperkeratosis and acanthosis, and which may amount to pseudoepithe- of the bullous pemphigoid antigen) do correlate with disease activity (see
liomatous hyperplasia and dermal fibrosis (Fig. 4.75). In the dermis, a below).84,85
perivascular infiltrate of lymphocytes and eosinophils is present. The blisters Split skin indirect studies are essential in the investigation of a patient in
show typical features of bullous pemphigoid (Fig. 4.76). whom a linear IgG antibasement membrane antibody has been detected.86–88
124 Inherited and autoimmune subepidermal blistering diseases


Fig. 4.74
Vesicular pemphigoid: (A) neutrophil microabscesses in the adjacent dermal papillae heighten the resemblance to dermatitis herpetiformis. It would be impossible to establish
the diagnosis of bullous pemphigoid without appropriate immuno-fluorescent findings; (B) preservation of the dermal papillae may be a clue to the correct diagnosis of

Fig. 4.75
Pemphigoid nodularis: this is a biopsy of a pruritic nodule showing hyperkeratosis,
irregular acanthosis, dermal chronic inflammation, and scarring.
Fig. 4.77
BP: electron micrograph showing the lamina densa lying along the floor of the
blister cavity.

Fig. 4.76
Pemphigoid nodularis: this subepidermal blister comes from the same patient as
shown in Figure 4.75. Pemphigoid nodularis is of particular importance because Fig. 4.78
the nodular lesions may precede clinical evidence of blistering. BP: high-power view of the lamina densa.
Bullous pemphigoid 125

Such antibodies are also characteristic of mucous membrane pemphigoid, her-

pes (pemphigoid) gestationis, inflammatory epidermolysis bullosa, and bullous
systemic lupus erythematosus. The antibodies in pemphigoid variants (with the
exception of the anti-p105 and anti-p200 variants discussed below) bind to the
epidermal side of 1 M NaCl-split skin whereas those of inflammatory epider-
molysis bullosa and bullous systemic lupus erythematosus bind to the floor.
In those patients in whom indirect fluorescent studies are not available,
similar information may sometimes be obtained through the localization of
lamina densa constituents such as type IV collagen or laminin-1 using
­paraffin-embedded direct immunoperoxidase techniques. In pemphigoid, the
staining is found along the floor of the blister, whereas in inflammatory
­epidermolysis bullosa and bullous systemic lupus erythematosus it is located
along the roof (see Figs 4.7 and 4.8).
Bullous pemphigoid antibodies are capable of complement fixation in as
many as 75% of patients.89,90 Most of complement fixation in bullous pem-
phigoid antibody resides in the IgG4 subclass.91
Linear in vivo-bound immunoglobulin at the epidermodermal interface on
direct immunofluorescence is present in 90% or more of patients (Fig.
4.79).18,92 Complement (C3) is also usually present and is sometimes the sole
immunoreactant (Fig. 4.80).93 Other immunoglobulin subclasses including Fig. 4.80
BP: direct immunofluorescence showing C3 deposition (left), no staining is
IgM, IgA, and IgE may be detected occasionally.83,89,94 In addition to C3, the
seen in the negative control (right). By courtesy of B. Boghal, FIMLS, Institute of
other components of the classical complement pathway, in particular C5b-9 Dermatology, London, UK.
(the membrane attack complex) and members of the alternative complement
pathway, including properdin, factor B and B-1H-globulin, may also be iden-
tified.83,95 There is therefore evidence that both the classical and alternate rescent test for bullous pemphigoid antibody, while others may be positive for
complement pathways are involved in the pathogenesis of bullous pemphig- in vivo-bound complement, but negative on indirect examination.66,67,99 One
oid.96 The classical complement pathway, however, predominates. A recent series has shown that almost 70% of patients with localized pemphigoid have
mouse model underscores the necessity of an intact innate immune system, as circulating IgG antibodies in their sera and the presence of these can be rele-
depletion of complement or neutrophils or blockage of mast cell activation vant for serum-based testing, as discussed below.67,100 A caveat is that in one
prevents blister formation.97 study, antibodies were also detected in more than half of normal subjects who
The immunofluorescence findings in erythematous, pruritic, urticarial, did not subsequently develop the disease.101,102 This finding is further dis-
and eczematous prodromal lesions and childhood, dyshidrosiform, vesicular, cussed below.
nodular, and vegetans variants are similar to those seen in the conventional By direct immunoelectron microscopy, the immunoreactants (IgG and C3)
generalized disease.25–28,32–49,98,99 In polymorphic pemphigoid either linear IgG are seen to be located within the hemidesmosomal plaque and upper lamina
or IgA deposits may be identified along the basement membrane region.29–31 lucida (Fig. 4.81).103–107 Indirect immunoelectron microscopic ­studies show
The serum may contain either IgG or IgA antibodies.30 that the bullous pemphigoid antigen is most often detected ­intracellularly in
Immunofluorescence findings in localized cutaneous disease are variable. the region of the cytoplasmic face of the hemidesmosome (Fig. 4.82).104,108–110
In some reports, patients show positive direct immunofluorescence for IgG The immunoelectron microscopic observations in childhood bullous pem-
and C3 at the epidermodermal junction and a positive indirect immunofluo- phigoid, vesicular pemphigoid, polymorphic pemphigoid, pemphigoid nodu-
laris, pemphigoid vegetans, and localized pemphigoid are identical to those of
classic bullous pemphigoid.111,112
Two principal bullous pemphigoid antigens are recognized by Western
blot and immunoprecipitation studies: one is 230 kD (BPAG1) and the other
is approximately 180 kD (BPAG2) (Fig. 4.83).113–119 These represent products
of distinct genes.120–123
BP230 maps to the short arm of chromosome 6, locus 6p11-12.121 It
belongs to the plakin family and shows homology with plectin and the
­desmogleins.122 It is wholly intracellular and localizes to the hemidesmosome.
BP230 is not involved in the early stages of the pathogenesis of blistering but
is of importance as a secondary event; antibodies against this antigen are not
required for blister formation in most cases.124–126
BP180 (collagen type XVII) is the major pathogenic antigen in bullous
pemphigoid. The BPAG2 (COLI7A1) maps to the long arm of chromosome
10, locus 10q24.3.121 It is a transmembrane adhesion molecule comprising an
­intracytoplasmic N-terminal fragment, a transmembrane region, and a col-
lagenous ­extracellular C-terminal ectodomain.127 The latter constitutes part
of the anchoring ­filament and distally merges with the lamina densa. The
antibodies directed against BP180 in bullous pemphigoid most commonly
react with a short extracellular noncollagenous locus – NC16A (regions
MCW0-MCW3) – located within the upper lamina lucida proximal to the
collagenous segment (Fig. 4.84).127–130 It now appears that antibodies specific
Fig. 4.79
to this area are ­generally required for blister formation and, while antibodies
BP: direct
immunofluorescence of
may also target BP180 non-NC16A domains, these latter antibodies do not
perilesional skin showing appear to be pathogenic in most cases.124–26 This finding reconciles the fact
intense linear basement that antibodies to both BP180 and BP230 can be seen in a significant portion
membrane zone staining of the population without blister formation as these are not against the criti-
(IgG). cal NC16A region of BP180.84
126 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.81 Fig. 4.83

BP: direct immunoperoxidase reaction using frozen tissue substrate showing BP: Western blot
electron-dense deposits in the lamina lucida. demonstrating the two
quite separate bullous
pemphigoid antigens.
By courtesy of M.M.
Black, MD, Institute of
Dermatology, London, UK.

More recently, two patients with a nonscarring, bullous pemphigoid-like

illness characterized by neutrophil-rich subepidermal blisters resembling
­dermatitis herpetiformis and antibodies to a unique 105-kD protein – ­so-called
anti-p105 pemphigoid – have been documented.141–143 This antigen localizes
to the dermal side of split skin on indirect immunofluorescence. Its precise
nature has not yet been determined.
Anti-p200 pemphigoid is characterized by antibodies to a lower lamina
lucida basement membrane antigen.144–146 Patients generally present with a

Basal keratinocyte

HD plaque

NH2 Globular cytoplasmic domain

Fig. 4.82
BP: immunogold electron microscopic preparation. Note that the immunoreactant
to BP180 and BP230 is particularly located on the hemidesmosomes (open arrows). Transmembranous domain Cell membrane
However, deposits are also present within the lamina lucida, black arrows. (BC,
basal cell; DER, dermis.) By courtesy of H. Shimizu, MD, Keio University School of
Medicine, Tokyo, Japan.

Lamina lucida Rod-like interrupted

Between 50% and 90% of patients with generalized bullous pemphigoid collagenous domain
have antibodies that react with BP230 and 35–50% have antibodies that
react with BP180 that are readily detected by immunoblotting.131 However,
the sera in 100% of patients react with BP180 NC16A domain recombinant
protein.131 This latter finding underscores the usefulness of recent testing for
anti-NC16A domain antibodies from peripheral blood to distinguish bullous
pemphigoid from other disorders.100,132–134 COL1
Flexible ‘tail’
Circulating antibodies against BP180 or BP230 have also been defined in
Lamina densa COOH
many of the other less common variants of bullous pemphigoid, including
localized and vesicular forms, pemphigoid vegetans, erythrodermic pemphig-
oid, and pemphigoid nodularis.131,135–139
In childhood pemphigoid, the antibodies also react against the same anti- Fig. 4.84
A schematic representation of the BP180 molecule showing the globular
gens.140 In addition, rarely there may also be antibodies that react with the
intracellular NH2 domain, the membrane proximal NC16A domain and the flexible
linear IgA 120-kD antigen.140 The BP180 antigen is most often ­targeted, and rod-like interrupted collagenous structure of the extracellular domain. (HD,
immunoblot analyses have shown that the antibodies react ­specifically with hemidesmosome). Collagen XVII/BP180: a collagenous transmembrane protein
the NC16A domain as in adult patients. In some children at least, the IgG and component of the dermoepidermal anchoring complex. (Powell AM, ­
subclasses differ from adult disease, consisting of all IgG subclasses or IgG2 Sakuma-Oyama Y, Oyama N, Black MM. Department of Immunodermatology,
in isolation.18 IgE antibodies are not a feature of c­ hildhood disease. St John's Institute of Dermatology, St Thomas' Hospital, London, UK.)
Pemphigoid gestationis 127

nonscarring bullous pemphigoid-like illness although linear IgA disease-like Successful differentiation depends upon careful clinicopathologic correlation
and dermatitis herpetiformis-like variants have also been reported.144 The dis- and immunofluorescent studies or, more recently, serum-based immunologic
ease has also been described in association with psoriasis.145 With split skin (ELISA) testing. Split skin indirect immunofluorescence or lamina densa anti-
indirect IMF, the antibodies bind to the floor of the blister cavity.144 With gen mapping by type IV collagen or laminin-1 direct immunoperoxidase is
indirect immunoelectron microscopy, the antibodies bind to the lower lamina essential to determine the level of the split. Although electron microscopy,
lucida.147,148 The identity of the 200-kD antigen has yet to be determined but immunoelectron microscopy, and immunoprecipitation or Western blotting
it is neither laminin nor type VII collagen.148 provide definitive information, such techniques are not necessary in the
Anti-p450 pemphigoid has been documented in a single patient. The anti- majority of cases.
gen, which has been localized to the basal keratinocyte, belongs to the plectin The cell-poor variant of bullous pemphigoid has a very wide range of ­differential
family.149 Its precise nature has yet to be determined. diagnoses including epidermolysis bullosa (congenital and acquired), porphyria
Exceptionally, bullous pemphigoid may be associated with antiplectin cutanea tarda, bullous amyloidosis, bullosa diabeticorum, and autolysis.
Bullous pemphigoid has been described following PUVA therapy for myco-
sis fungoides. More recently, a case arising in the setting of radiation therapy Pemphigoid gestationis
has also been noted, perhaps suggesting a role for tissue damage in the patho-
Pruritus is a very common symptom in pregnancy, occurring in up to 18% of
genesis of this disease.151
gravid females.1–4 When it occurs in the absence of significant cutaneous stig-
A mechanism for blister development in bullous pemphigoid has been pro-
mata it is known as pruritus gravidarum. This may occasionally be associated
posed by Jordon et al.80,152 and is outlined as follows. Following antibody–
with a cholestatic pathogenesis. The specific pregnancy eruptions have long
antigen interaction and complement fixation, various chemotactic agents
been a source of considerable confusion and controversy in the literature,
including C3a and C4a are produced.153 Mast cells degranulate under the
largely due to a diverse range of terminologies and classifications. Recently,
influence of the latter or IgE, and release ECF-A, NMW-NCF, ESM, hista-
Holmes has attempted to clarify the situation with the introduction of a new
mine, and enzymes.154 Eosinophils and neutrophils, so recruited, bind (possi-
and much simplified classification and others have proposed similar schemes.2,5
bly via C3b receptors) to the basement membrane region. By direct cytotoxic
Therefore the specific dermatoses of pregnancy may be divided into:
action (eosinophils are capable of antibody-dependent cellular cytotoxicity)
• polymorphic eruption of pregnancy, where the predominant lesions are
or via released proteases, particularly elastase, damage at the basement mem-
urticarial; in the United States, the term pruritic urticarial papules and
brane region results in the development of a vesicle. Lymphocytes elaborate
plaques of pregnancy (PUPPP) has achieved greater popularity;
histamine-releasing factor (HRF), which increases mast cell degranulation
• pregnancy prurigo in which the lesions consist of itchy papules;
and perpetuates the process. A broad range of cytokines are involved in this
• pemphigoid (herpes) gestationis, an autoimmune dermatosis belonging to
inflammatory reaction including interleukin (IL)-1, IL-4-IL-8, IL-10-IL-13,
the bullous pemphigoid group of diseases.
IL-15 and interferon gamma (IFN-γ).155 As yet, their relative importance and
Pemphigoid gestationis is a bullous dermatosis of pregnancy and the puer-
time sequences are unknown.
perium. It may be exacerbated by the use of oral contraceptives and rarely
Bullous pemphigoid is therefore a true autoimmune disease in which
complicates hydatidiform mole and gestational (but not nongestational) cho-
­antigen–antibody reaction and complement fixation results in a character-
riocarcinoma. The current evidence implicates an autoimmune-mediated
istic and reproducible train of events, which is inevitably accompanied by
pathogenesis in which hormonal influences play a significant role.6,7
the development of subepidermal blister formation. The etiology or
­initiator (other than those associated with drugs or PUVA therapy, which Clinical features
are the ­minority) is unknown. The question as to why self-tolerance breaks
down with the ­formation of symptomatic autoantibodies in patients with The term herpes (gestationis) is neither appropriate nor satisfactory. It is not
this d
­ isease is an important question for further investigation. of viral etiology, nor has it anything to do with creeping (Gr. herpes, to creep).
It was originally so named because of the tendency of the disease to show
‘progressive involvement by peripheral extension’.3 Because of its intimate
Differential diagnosis relationship to bullous pemphigoid, the designation pemphigoid gestationis is
The inflammatory cell-rich variant of bullous pemphigoid must be distin- preferred. As the major larger series have consisted of patients derived from a
guished from other subepidermal blistering dermatoses in which a heavy variety of sources, estimates of incidence have been very variable, ­ranging
inflammatory cell component is a typical finding. These include dermatitis from 1:3000 to 1:50 000 pregnancies.4,8–10 The more recent figures where
herpetiformis, linear IgA disease, inflammatory epidermolysis bullosa cases have had immunofluorescent confirmation would suggest that the latter
acquisita, and bullous systemic lupus erythematosus (see Table 4.5). figure is the most accurate.3

Table 4.5
Differential diagnosis of cell-rich pemphigoid


DIMF Linear IgG, C3 Linear IgG, C3 Linear IgG, C3 Linear IgA Granular IgA
IIMF IgG antibodies 75–80% IgG antibodies 25–50% IgG antibodies 60% IgA antibodies 30% Antitransglutaminase antibodies
Split skin IMF Roof Floor Floor Roof or floor or both N/A
Type IV collagen Floor Roof Roof Roof or floor N/A
EM: site of split LL Sub-LD Sub-LD LL, sub-LD or both Papillary dermis
Western blot BP180 kD 290 kD 290 kD BP180 kD Antigen uncertain
BP230 kD (type VII collagen) (type VII collagen) BP230 kD
200/280 kD
285 kD
250 kD
290 kD
BP, bullous pemphigoid; BSLE, bullous systemic lupus erythematosus; DH, dermatitis herpetiformis; DIMF, direct immunofluorescence; EBA, epidermolysis bullosa acquisita; EM,
electron microscopy; IIMF, indirect immunofluorescence; IMF, immunofluorescence; LAD, linear IgA disease; LL, lamina lucida; sub-LD, sub-lamina densa.
128 Inherited and autoimmune subepidermal blistering diseases

Pemphigoid gestationis may present in the first or any subsequent preg-

nancy.3 It may first also rarely present in the postpartum period. In one series,
30% of patients were primigravidae.9 In addition to developing in pregnant
or postpartum patients, pemphigoid gestationis has rarely been described fol-
lowing a hydatidiform mole and gestational choriocarcinoma.11,12 It has not,
however, been reported in nongestational variants such as those occurring in
Fig. 4.86
the ovary, mediastinum, and testis, or complicating malignant teratoma. Pemphigoid gestationis:
Pemphigoid gestationis is predominantly a disease of white females, being the blisters are tense and
exceedingly rare in blacks.13,14 Presentation is usually in the second or third dome-shaped.
trimester, most often developing in the sixth or seventh month, but the range By courtesy of R.C.
is variable from 2 months to 4 days postpartum.10,15 Although the disease Holmes, MD, Warneford
may rarely completely remit before delivery, most patients (up to 75%) Hospital, Oxford, UK.
develop an exacerbation, which is frequently severe, in the immediate puerpe-
rium when progesterone levels have fallen.15,16 Exceptionally, the infant may
contain clear fluid, but at times the fluid may become hemorrhagic (Fig.
show transient urticated erythema and blistering.4
4.86). They typically heal without scarring.
Pemphigoid gestationis usually complicates subsequent pregnancies, fre-
The umbilicus is frequently the site of initial involvement; spread to the
quently presenting earlier on and with more severe symptomatology.10
trunk and extremities then follows (Figs 4.87, 4.88).3 Surprisingly, lesions on
Sometimes, however, it may skip intervening pregnancies.3 This may be
the face and mucous membranes are distinctly uncommon. Eventually palmar
related to a change in paternity, or else due to compatibility at the HLA-D
and plantar manifestations may appear. Other than pruritus, symptoms are
usually mild, with stinging, burning, and pain being relatively infrequent.10
Pemphigoid gestationis may develop into a very protracted ‘postpartum’
illness associated with considerable morbidity and lasting up to 12 years.17,18
In the majority of patients, however, the disease resolves by about 6 months
postpartum.4 The disease may first present following a change in sexual part-
ner.3,19 Alternatively, recurrent disease may persist even when there has been
a change of sexual partner.7 This obviously calls into question the role of spe-
cific paternal antigens.
Exacerbation following the use of the oral contraceptive is a common
complication,10,20–23 affecting 20–50% of patients.3 Estrogens in particular
have been implicated.22 The condition may also relapse during menstruation
for some weeks or months postpartum and the return of symptoms (pruritus)
has also been noted to coincide with ovulation (again suggesting an estrogen
influence), although this is rare.3,10,22
Evidence has been published relating the duration of symptoms postpar-
tum to the practice of breast-feeding. Bullous lesions lasted only 5 weeks in
those who breast-fed compared to 24 weeks in those who bottle-fed. Although
hormonal factors must be implicated, the precise pathogenetic implications
underlying this observation are not fully understood.22
Pemphigoid gestationis is associated with intense pruritus, which may be
present for days or weeks before the onset of typical cutaneous manifesta-
tions.1 The dermatosis is characteristically polymorphous, consisting of ery-
thematous or urticarial papules and plaques, some with a polycyclic ­pattern,
and later vesicles and bullae develop at the periphery of spreading erythema-
tous plaques (Fig. 4.85).3,10,24 When fully evolved, the blisters are tense and

Fig. 4.87
Fig. 4.85 Pemphigoid gestationis: slightly raised erythematous lesions with a propensity to
Pemphigoid gestationis: prebullous phase showing erythema and small papules. cluster on the abdomen. By courtesy of R.C. Holmes, MD, Warneford Hospital,
By courtesy of the Institute of Dermatology, London, UK. Oxford, UK.
Pemphigoid gestationis 129

Fig. 4.89
Pemphigoid gestationis: early erythematous lesion showing marked edema of the
Fig. 4.88 papillary dermis and conspicuous eosinophils.
Pemphigoid gestationis: umbilical involvement is a common mode of presentation.
By courtesy of the Institute of Dermatology, London, UK.

Occasionally, the presence of target or iris lesions may mimic erythema mul-
tiforme.25 Less commonly, features may initially suggest classical bullous
pemphigoid.25 Very occasionally, there is clinical overlap with dermatitis
Pemphigoid gestationis is not associated with pre-eclamptic toxemia and
there is no related maternal mortality.
Pemphigoid gestationis is accompanied by a significant increased risk of
developing Graves' disease and an increased risk of autoantibodies.26
The literature concerning the incidence and nature of fetal morbidity and
mortality is a source of some confusion. Kolodney therefore considered that
there was no evidence of an increased incidence of stillbirths or abortions;
however, his report predates the immunofluorescence era.5 An investigation
by Lawley et al.20 of a large series of cases where immunofluorescent confir-
mation was available, suggested that there was an increased risk of fetal mor-
bidity and mortality. More recently, evidence has been presented that patients
with pemphigoid gestationis are liable to deliver low weight and small-for-
dates infants, prematurely.27 In contrast, however, Shornick et al. failed to
show any evidence of significant fetal complications.7 It has been shown that Fig. 4.90
the onset of the disease in the first and second trimester and the presence of Pemphigoid gestationis: early erythematous lesion showing eosinophilic
blisters is associated with higher morbidity including premature birth and spongiosis.
low birth weight children.28 Morbidity, however, still remains low. The anti-
body can cross the placenta and, in approximately 5% of cases, this may be
associated with a mild and transient vesiculobullous eruption.29–32

Pathogenesis and histological features

The histopathologic features seen in biopsies from patients with pemphigoid
gestationis are variable, depending upon whether early erythematous lesions,
urticarial papular lesions, or fully established vesicles and bullae are
In early lesions, the major pathological features are seen in the superficial
dermis where there is a perivascular inflammatory cell infiltrate consisting of
lymphocytes, histiocytes, and typically very large numbers of eosinophils.
This is associated with edema of the papillary dermis, which when marked
may result in a ‘teardrop’ appearance (Fig. 4.89).33 Sometimes there is accom-
panying spongiosis and this may be associated with large numbers of eosino-
phils (eosinophilic spongiosis, Fig. 4.90). Occasionally the infiltrate of
lymphocytes, histiocytes, and eosinophils is present in a linear distribution
along the dermoepidermal junction.3
Vacuolar degeneration of the basal keratinocytes, sometimes accompa-
nied by individual cell necrosis, may be a feature of the early lesions, but is
often more evident in the fully established vesicular or bullous stage.33 In the
latter, the blister is subepidermal in location and frequently contains large Fig. 4.91
numbers of eosinophils (Figs 4.91, 4.92).33 The underlying and adjacent Pemphigoid gestationis: established subepidermal blister.
130 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.92 Fig. 4.93

Pemphigoid gestationis: the blister cavity contains a heavy eosinophil infiltrate. Pemphigoid gestationis: indirect complement immunofluorescence showing linear
deposition of IgG.

dermis is edematous and contains a predominantly perivascular lympho/his- same NC16A domain as described in bullous pemphigoid.55–62
tiocytic infiltrate with large numbers of eosinophils. Leukocytoclasis and This can be detected in serum using the same test employed for bullous
eosinophil dermal papillary microabscesses are only rarely identified.33,34 ­pemphigoid.60–62 Antibodies that recognize the 230-kD bullous ­pemphigoid
Ultrastructural studies show that the cleavage plane lies within the lamina antigen are present in 10–26% of cases.56,57 Experimental models indicate that
lucida.33,35 antibodies against the NC16A domain of BP180 are the ­pathogenic antibodies
Direct immunofluorescence of perilesional skin in pemphigoid gestationis in pemphigus gestationis just as they are for bullous pemphigoid 7,62
shows a linear basement membrane zone deposition of C3 in all patients.3,36–41 Patients with pemphigoid gestationis have an increased incidence of HLA-
About 30–50% of cases also have an IgG band (less frequently IgM or IgA).36 B8 (43–79%), HLA-DR3 (61–80%) and HLA-DR4 (52–53%). The paired
They are present in nonlesional (perilesional) as well as in lesional skin.36 haplotypes HLA-DR3 and -DR4 are present in 54% of patients compared
Recently, it has been suggested that demonstration of linear C3d deposition with 3% in the general population.1,3,22,63,64 The phenotype, however, does not
at the dermoepidermal junction may be a useful tool in the diagnosis of the appear to correlate with the clinical features of pemphigoid gestationis.3,65
disease.42 The authors of this study used immunohistochemistry in paraffin- Patients with pemphigoid gestationis also have a high incidence (100%) of
embedded, formalin-fixed material with good results. Complement pathway anti-HLA cytotoxic antibodies, particularly directed against the paternal
components including properdin and properdin factor-B may also be identi- ­antigens.36,63–66 These are, however, found in 25% of normal multiparous
fied.1 IgG and complement can often be detected along the amniotic basement women and therefore their possible role in the pathogenesis of pemphigoid
membrane region using direct immunofluorescence.38,43,44 Pemphigoid gesta- gestationis is uncertain.26
tionis antigen has been detected in the placenta from early in the second The pathogenesis of pemphigoid gestationis relates to antibody-associated
­trimester onwards.45 The antibody may also be found in the skin of infants of complement fixation with the production of leukocyte chemotactic factors,
affected mothers.29 Interestingly, serologic evidence of pemphigoid gestationis mast cell degranulation, and associated dermoepidermal separation.36
without manifestation of the disease may be seen, An exceptional case of neo- The presence of pemphigoid gestationis antigen in both skin and amnion
natal pemphigus in a child whose mother had clinical and serologic evidence raises the possibility that an initial antiplacental antibody cross-reacts with
of pemphigus vulgaris but only serologic evidence of pemphigoid gestationis skin, giving rise to the clinical features of pemphigoid gestationis.29 Support
has been described.46 for this theory has been the discovery that the HLA antigens -DP and -DR are
Circulating complement-fixing (via the classical pathway) IgG antibodies consistently expressed in the placentas of patients with this condition.64,67 The
(pemphigoid (herpes) gestationis (HG) factor) can be detected in 50–75% of main antigen present in both the skin and placenta seems to be collagen type
cases by indirect complement immunofluorescence (Fig. 4.93).20,36,47–51 The so- XVII and this, associated with genetic predisposition and specific HLA
called HG factor is nothing more than a low titer IgG complement-fixing ­genotype, appears to trigger the disease.68
antibasement membrane antibody.36 The antibody can be of any IgG subclass;
IgG1 and IgG4 have been reported as predominent.38,51 If monoclonal antibod-
ies directed against IgG are used, 100% of patients can be shown to possess Differential diagnosis
circulating HG factor.38 Approximately 25% of patients have ­antibasement The differential diagnosis includes epidermolysis bullosa acquisita, dermatitis
membrane zone antibodies detectable by conventional ­techniques.51 These bind herpetiformis, linear IgA disease, and bullous systemic lupus erythematosus (see
to the roof of 1 M NaCl-split skin.36 The antibody also reacts with amnion and Table 4.4). Pemphigoid gestationis must also be distinguished from pruritic urti-
chorion basement membrane.42,44 The autoantibodies in the disease are directed carial papules and plaques of pregnancy (PUPPP) and pregnancy prurigo.
against collagen XVII which is the BP ­180-kD protein (BPAG2). The latter PUPPP is predominantly a disorder of first pregnancies. Lesions particu-
plays a major role in cell adhesion and signaling. It has been demonstrated that larly develop around abdominal striae, and periumbilical sparing is a charac-
collagen XVII is present in the epithelial cells of the amniotic membrane and in teristic feature (Fig. 4.94). Eosinophilic spongiosis and subepidermal
syncitial and cytotrophoblastic cells.52 Although the exact pathogenetic mecha- blistering may be seen in established lesions and therefore, in the absence of
nism of the disease is still unknown (see below), the presence of collagen XVII clinical details and immunofluorescence findings, distinction from pemphig-
in these tissues seems to play a major role in the mechanism of the disease. oid gestationis may be impossible.
With immunoelectron microscopy the immunoreactants are deposited Pregnancy prurigo, which typically develops in the third trimester, ­presents
within the upper lamina lucida where they are most probably associated with with pruritic papules and nodules (Fig. 4.95). Blisters are not a feature.
the sub-basal dense plate.53,54 In pemphigoid gestationis the antibody recog- Histologically, the changes are those of a low-grade, non-specific spongiotic
nizes BPAG2 (collagen type XVII) on Western ­immunoblot and localizes to the dermatitis.
Lichen planus pemphigoides 131

Fig. 4.94
Pruritic papules and plaques of pregnancy: note the erythematous papules
particularly related to the abdominal striae, and characteristic umbilical sparing. Fig. 4.96
By courtesy of R.C. Holmes, MD, Warneford Hospital, Oxford, UK. Lichen planus pemphigoides: typical lichenoid papules are present on the anterior
aspect of the wrist. By courtesy of M.M. Black, MD, Institute of Dermatology,
London, UK.

Fig. 4.95
Pregnancy prurigo: there are erythematous papules and excoriations. Blisters are
not a feature of this condition. By courtesy of R.A. Marsden, MD, St George's
Hospital, London, UK.
Fig. 4.97
Lichen planus pemphigoides: note the blisters and erosions arising on an erythematous
base. Atypical target lesions are present. By courtesy of M.M. Black, MD, Institute of
Lichen planus pemphigoides Dermatology, London, UK.

Clinical features
Lichen planus (lichen ruber) pemphigoides (Kaposi) must be distinguished Pathogenesis and histological features
from the vesicles occasionally seen in lichen planus as a consequence of severe The lichenoid lesions show the typical histopathological and immunofluores-
hydropic degeneration (lichen planus vesiculosis).1,2 Rarely, lichen planus is cent changes of lichen planus, but the bullae have features more suggestive of
associated with a generally benign, bullous pemphigoid-like disease: lichen bullous pemphigoid (Fig. 4.99). A variety of findings have been described.
planus pemphigoides. This represents a heterogeneous condition characterized Early erythematous lesions show intense dermal edema with a dense
by basement membrane antibodies directed towards a number of antigens. ­perivascular and interstitial eosinophil infiltrate; eosinophilic spongiosis may
Clinically, the pemphigoid-like lesions are usually preceded by typical also sometimes be evident. Established blisters are subepidermal and both
lichen planus although rarely the blisters may develop first (Fig. 4.96). The inflammatory (cell-rich) and cell-poor variants have been documented (Figs
bullae, which are most numerous on the extremities, may arise on normal 4.100, 4.101).5 Eosinophils are variably present but often may be numerous.
skin, in areas of erythema or on lichenoid papules (Figs 4.97 and 4.98). Immunofluorescent examination of biopsies from peribullous skin reveals
In some patients the blisters are generalized. Exceptionally, the blisters are linear deposition of IgG and complement.10–13 The serum contains an IgG
localized with typical lichen planus-like lesions elsewhere. A case with single antibasement membrane antibody in up to 50–60% of patients. With NaCl-split
blisters on the soles has been described.3 They are tense, dome-shaped and skin, the antibody generally labels the roof of the blister cavity. Ultrastructural
hemorrhagic or contain clear fluid. Evolution to pemphigoid nodularis-like investigations have shown that the level of separation is ­usually through the
lesions has been described.4 Lichen planus pemphigoides more commonly lamina lucida. By immunoelectron microscopy, the immunoreactants ­typically
affects males and presents most often in the fourth and fifth decades.5,6 localize to the hemidesmosome and lamina lucida.5,13,14 Mucous membrane
Exceptionally, however, cases have been documented in childhood.7–9 All pemphigoid and epidermolysis bullosa acquisita ­(EBA)-like variants have,
races may be affected. however, also been documented.15
132 Inherited and autoimmune subepidermal blistering diseases

Fig. 4.98
Lichen planus pemphigoides: note the intact dome-shaped tense blister. By courtesy
of M.M. Black, MD, Institute of Dermatology, London, UK.

Fig. 4.100
Lichen planus
pemphigoides: there is a
subepidermal blister.

Fig. 4.99
Lichen planus
pemphigoides: the
lichenoid papules show
typical features of lichen

A number of antigens have been recognized in lichen planus pemphigoides Fig. 4.101
including BP180, BP230, and an as yet uncharacterized 200-kD protein of Lichen planus
keratinocyte derivation.1,15–23 The segment of the NC16A domain recognized pemphigoides: the blister
in lichen planus pemphigoides differs from BP, localizing to MCW-4 (the contains eosinophils.
more C-terminal end of the domain) as opposed to MCW-0 to MCW-3.24,25
Type VII collagen has also been implicated in the EBA-like variant although
the immunoblot was negative.15 planus pemphigoides might be associated with internal malignancy but the
Although the pathogenesis of lichen planus pemphigoides has not been diagnosis lacked substantiation by immunofluorescence studies.36 Two addi-
fully unraveled, it is likely that the basement membrane zone damage associ- tional cases involving a patient with multiple keratoacanthomas and colonic
ated with lichen planus results in antigen exposure with subsequent autoanti- adenocarcinoma indicating a Torre-Muir-like syndrome and association with
body production and resultant bullous disease. So far, it is uncertain why only retroperitoneal Castleman disease have been noted more recently.37,38
a small percentage of patients with lichen planus are affected. The pathogen-
esis in those patients in whom the blisters develop first is unknown although a Differential diagnosis
different antigen may be involved. Exceptionally, cases have been documented Lichen planus pemphigoides differs from typical bullous pemphigoid clini-
as an adverse drug reaction (e.g., to angiotensin-converting enzyme inhibitors, cally by its earlier age of presentation and predilection for the lower limbs. In
complicating PUVA therapy, or in a patient taking paracetamol, ibuprofen, those cases associated with antibodies to BP180, epitope mapping may make
and having narrowband UVB).26–35 There has been a suggestion that lichen the distinction.
Mucous membrane pemphigoid (cicatricial pemphigoid) 133

Mucous membrane pemphigoid (cicatricial

Mucous membrane pemphigoid represents a spectrum of diseases (e.g., ocular
pemphigoid, oral pemphigoid, benign mucous membrane pemphigoid) which
affect the mucosa and skin.1–4 With the advent of molecular studies identifying
the antigens involved, it is becoming clear that there are a number of ­relatively
well-defined clinicopathological variants that arise as a consequence of auto-
immune diseases directed against a number of different basement ­membrane
antigens. Although multiple systems are often affected, there is increasing
­evidence that pure ocular and oral variants may also be encountered.1,2

Clinical features
Mucous membrane pemphigoid is a rare blistering disorder in which mucosal
lesions predominate and in which scarring is a characteristic feature (although
not generally in the oral lesions).1,2,5 It is often associated with severe morbid-
ity, largely due to the effects of the scarring. As ocular and oral lesions pre-
dominate, many patients come to the attention primarily of the dental and
Fig. 4.103
oral surgeons or ophthalmologists rather than dermatologists.
Mucous membrane pemphigoid: in addition to erosions, intact blisters are evident.
The incidence is estimated as being between 1:12 000 and 1:20 000 of the By courtesy of P. Morgan, FRCPath, London, UK.
population per year.2 It is associated with a female preponderance (2:1) and it
not uncommonly presents in the seventh decade. Very rare instances of child-
hood involvement have been reported.3,6–10 Mucous membrane pemphigoid is
a chronic disease and is rarely self-limiting. It shows no racial or geographic Ocular lesions, which occur in approximately 64% of patients, are a
predilection. source of considerable morbidity.17–19 The eye (in particular th