Rete ridges = epidermal projections that extend downward

between dermal papillae

Dermal papillae = dermal projections that extend upward
between epidermal rete ridges
Parakeratosis = retention of nuclei in stratum corneum keratinocytes,
suggests rapid turnover/movement to surface preventing
normal maturation with loss of nuclei
Orthokeratosis = anuclear stratum corneum layer (the normal
basket weave), compact orthokeratosis = flattened
corneal layer
Hyperkeratosis = thickened stratum corneum
Spongiosis = intercellular edema (hallmark of all eczematous
dermatitides)
Acantholysis = loss of keratinocyte cohesion (only in
epidermis)
Acanthosis = thickening of the spinous layer of the epidermis
Psoriasiform hyperplasia = uniform/regular rete ridge elongation
(versus irregular epidermal hyperplasia in lichen simplex
chronicus)
Papillomatosis = outward growth of epidermis with associated
elongation of dermal papillae
Pagetoid spread = individual upward cell spread of malignant
cells in the epidermis (can be “buckshot” scatter)
Epidermotropism = presence of atypical lymphocytes in the
epidermis, specifically refers to the migration of T lymphocytes
in mycosis fungoides
Granuloma = collection of histiocytes, with or without giant
cells
Suppurative = many neutrophils (pus), often infectious
Pseudoepitheliomatous (or pseudocarcinomatous) hyperplasia
= irregular downward proliferation of epidermis into
dermis
– This mimics the pattern seen in SCC
– Can see in mycobacterial infections, deep fungal infections,
pyoderma gangrenosum, pyoderma vegetans,

borders of ulcers, prurigo, granular cell tumor,

bromoderma
Interface = dermal-epidermal junction (DEJ) or basement
membrane zone (BMZ); interface dermatitis includes
lichenoid and vaculolar
Lichenoid inflammation = band-like inflammation at the interface
which may obscure the dermal-epidermal junction
Vacuolar alteration = damage to basal keratinocytes with formation
of vacuoles
Pigment incontinence = melanin deposits in dermal melanophages
secondary to inflammation
Necrobiosis = altered/degenerated collagen
Civatte bodies/colloid bodies = apoptotic or dyskeratotic
keratinocytes
Russell bodies = large eosinophilic homogeneous
immunoglobulin- containing inclusions (think: pregnant
plasma cells)

A Few Quick Tips

Bluish color = think mucin or elastosis
Purple color = think calcium
Frozen section = allows for slide preparation in 15 min. Poorer
quality, but in acute situations (TEN) and Mohs surgery
(for SCC, BCC), the quality is sufficient. Difficult to identify
melanocytes on frozen sections (but can be done with
Melan-A).

Approaching Histopathologic Description

1. Get oriented: Look at the slide so you don’t miss a piece!
Where are the epidermis and dermis? If it’s broken into
pieces, might be fragments of tissue from curettage.
2. Type of biopsy = shave or punch?
3. Location – use site clues:

Thick stratum corneum/presence of stratum

lucidum = likely acral (Thick stratum corneum can also
just be from LSC)
– Many hair follicles = likely scalp or face
– Many sebaceous glands = face
– No stratum corneum or granular layer (more specific),
large and pale keratinocytes (filled with glycogen),
many plasma cells could indicate mucosa
– Thin skin with multiple vellus hairs could mean eyelid
– Solar elastosis could mean older person in sun- exposed area.
– Otherwise guess “trunk or proximal extremities” –
that’s most of them!

4. Describe the epidermis: stratum corneum with normal basket

weave?
5. Describe the dermis – look for common structures: hair
follicles, sebaceous glands, eccrine glands, blood vessels
6. Describe the panniculus (subcutaneous fat)
7. Do you think this is infl ammatory or neoplastic (Remember,
neoplasms can be infl amed)? Do you think this is primarily
an epidermal or dermal process, or both? What’s the reaction
pattern (e.g., superfi cial and deep perivascular)? What
kind of cells are in the infi ltrate: neutrophils (multi-lobed),
histiocytes (large cells with grainy cytoplasm), eosinophils
(pink granules), plasma cells (eccentric nucleus with “clock
face” chromatin and perinuclear clearing), mast cells (“fried
eggs”), or lymphocytes (the default small blue cell)?
8. Describe anything that looks unusual, with specifi cs as you
know them.
9. Use the shape of the biopsy to give you clues about the
clinical appearance: e.g., Was it a papule? Was it umbilicated?
Secondary changes?
1.3.4 Immunofluorescence Findings
DIF = direct immunofluorescence; an antibody directly
detects presence of a pathologic antibody in the skin

IIF = indirect immunofluorescence; serum is introduced to a

substrate (e.g., monkey esophagus) in order to detect circulating
pathologic antibodies
Salt-split skin = with NaCl, DIF is cleaved at lamina
lucida (of dermal-epidermal junction) – Allows separation
of roof/floor fluorescence – e.g., BP (roof) vs.
EBA (floor)
– Precise type of basement membrane immunofluorescence
pattern in a DIF may demonstrate a n-serrated
pattern similar to salt-split roof fluorescence (bullous
pemphigoid or linear IgA), or a u-serrated pattern similar
to salt-split floor fluorescence (EBA or bullous
lupus erythematosis)
Biopsy for DIF of blistering disease: Most advise sampling
perilesional skin. In perilesional skin, the anatomy will still
be intact for identifying what structures are bound by
antibodies.

Morphologic Reaction Patterns

– The point is to organize dermatologic entities into as few
general categories as possible to make them easier to
understand and memorize.
– Many dermatologic diseases will not fit into this classification,
but this is helpful for inflammatory diseases.
The five basic inflammatory reaction patterns as taught by
Dr. Michael Fisher:
1. PAPULOSQUAMOUS = red and scaly, papular
2. ECZEMATOUS =
(a) Acute (edematous, vesicular)
(b) Subacute (red, scaly)
(c) Chronic (lichenifi ed)
3. VESICULOBULLOUS = vesicles/bullae/pustules

4. VASCULAR = deeper, red/purple color, minimal epidermal/

surface change
5. DERMAL = deeper (can get fi ngers around, but not
under), minimal epidermal/surface change; if cannot get
fi ngers around, suggests subcutaneous
Note
1. Papulosquamous and subacute eczematous are both red
and scaly, hard to distinguish (Some of your most common
ddx will be this; for instance, tinea, psoriasis, and eczema
can be hard to tell apart sometimes, which is why in this
ddx, we usually perform a KOH at the bedside or a PAS
stain for formalin fi xed sections of tissue)
2. Acute eczematous and vesiculobullous both have vesicles,
hard to distinguish.
3. Papulosquamous, eczematous, and vesiculobullous are the
reaction patterns primarily confi ned to the epidermis
4. Vascular and dermal have overlap as vessels are in the dermis;
ephemeral entities are more likely to be vascular.
5. Subcutaneous entities can be grouped under dermal, but
will feel “deeper,” i.e., can’t even get your fi ngers around it,
let alone under it (like in panniculitis)