The fundamental

histologic changes in
skin diseases
Dr. Mahmud Ghaznawie, PhD.

Lesion and eruption

(rash)

Lesion: describes an area of

disease - usually small

Eruption (or rash): describes

more widespread skin involvement,
normally composed of several
lesions which may be the primary
pathology or due to secondary
factors (scratching, infection, etc.).

Primary
lesions

Macule
Papule
Nodule
Vesicle
Bulla

Primary lesions are

the first to appear
and are due to the
disease or abnormal
state.

Pustule
Cyst
Plaque
Wheal

Secondary
lesions

Result from the natural

evolution of primary lesions
(eroded area left by
bursting vesicle) or from
the patient's manipulation
of the primary lesion
(scratching).

Scale
Ulcer
Crust
Erosion
Excoriatio
n

Lichenification
Atrophy
Scar

Macule

Macule: flat, nonpalpable circumscribed area

of change in the skin. Macules are < 1-2 cm in
size.
Macules may be the result of

(A) hyperpigmentation (e.g. brown as in

lentigos),
(B) depigmentation (e.g. vitiligo),
(C) vascular dilation (e.g. erythema)

Macules blanch upon pressure (diascopy) are

due to inflammatory vasodilation.

Papule

Papule: small solid elevation of skin

generally < 5 mm in diameter.
Flat-topped, as in lichen planus
Dome shaped, as in xanthomas
Spicular, ifrelated to hair follicles.

Papules may result from

(A) dermal metabolic deposits,

(B) localized dermal cellular infiltrates,
(C) localized hyperplasia of dermal or
epidermal cellular elements.

Lichen planus

Band like lymphocytic infiltration = interface dermatitis

Nodule

Nodule: palpable, solid, round, or ellipsoidal

lesion.
Its depth of involvement differentiate
it from a papule
Usually larger than papules: > 5 mm
Can involve any layer of the skin:
epidermal, dermal, and
subcutaneous.
Can be edematous or solid

Vesicle & Bulla

Vesicle (blister): elevated lesion that is < 5 mm

in diameter containing serous (clear) fluid.

Vesicle walls can be so thin that the contained

serum, lymph, blood, or extracellular fluid is easily
seen. Fluid can be accumulated within or below the
epidermis.

Bulla: A vesicle with a diameter > 5 mm.

(A) subcorneal vesicle - fluid just below
stratum corneum,
(B) spongiotic vesicles - intercellular edema.

Vesicles & Bulla

Mechanisms of blister

(A) Acantholytic vesicles - cleavage within

epidermis due to intercellular attachment loss

(B) Balloon degeneration of epidermal cells in

certain viral infections leads to vesicles.

(C) Intercellular edema (spongiosis)

(D) Subepidermal vesicles due to changes in

dermal-epidermal junction

 Acantholysis

Acantholytic vesicles - cleavage within

epidermis due to intercellular attachment
loss

Cell Balooning

Balloon degeneration of epidermal cells in certain

viral infections leads to vesicles, e.g. Herpes Zoster

Spongiosis
intercellular edema

Subepidermal blister

Pustule

Pustule: superficial, elevated lesion that

contains pus (pus in a blister).
Pustules may vary in size and shape.
The color may appear white, yellow,
or greenish-yellow depending on the
color of the pus.
Pus is composed of leukocytes with or
without cellular debris. It may also
contain bacteria or may be sterile.

Cyst

Cyst: an epithelial lined cavity containing liquid or

semisolid material (fluid, cells, and cell products).
A spherical or oval papule or nodule may be a cyst if,
when palpated, is resilient (feels like an eyeball).
Most common are
(A) Epidermal cysts, lined by squamous epithelium
and produce keratinous material.
(B) Pilar cysts, lined by multilayered epithelium
which does not mature through the granular layer.
Bluish, resilient cyst filled with mucous material adnexal tumor (cystic hidradenoma).

Plaque

Plaque: palpable, plateau-like

elevation of skin, usually more than
2 cm in diameter and rarely more
than 5 mm in height. Often formed
by a convergence of papules, as in
psoriasis.
1. Plaques occupy a relatively large
surface area in comparison with its
height above the skin.
2. Well-defined, reddish, scaling
plaques.

Wheal = urtica

Wheal: transitory, compressible papule

or plaque of dermal edema.
The borders of a wheal are sharp, but
not stable (can move from involved to
adjacent uninvolved areas over hours).
The epidermis is not affected.
Wheals can be pale red or white (esp. in
the center) if edema is sufficient to
compress superficial vessels.
A wheal may be large coalescing
plaques as in this allergic reaction.

Scale /
squama

Scale: accumulation or abnormal shedding of

horny layer keratin (stratum corneum) in
perceptible flakes.
May be primary or secondary.
Scales usually indicate inflammatory
change and thickening of the epidermis.
They may be fine, as in pityriasis; white and
silvery, as in psoriasis; or large and fishlike, as in ichtyosis.

Parakeratotic scale (with retained nuclei) can be

seen in psoriasiform epidermal hyperplasia.

Ulcer = ulcus

Ulcer: circumscribed area of skin

loss extending through the
epidermis and at least part of the
dermis (papillary).
Basically, it's a "hole in the skin".
Usually result from the impairment
of vascular/nutrient supply to the
skin.

Crusta = crust

Crust: dried serum, blood, or pus

on the surface of skin.
May be thin, delicate, and friable
or thick and adherent.
Crusts are
1.

yellow, if from serum;

green or yellow-green if
from pus; or
brown or dark red if
formed from blood.

Erosion

Erosion: moist, circumscribed, usually

depressed lesion due to loss of all or
part of the epidermis
Often results from eruptions of
vesicles and bullae. Seen in infection
from herpes viruses and in pemphigus,
and toxic epidermal necrolysis (TEN).

Excoriation: linear or punctate

superficial excavations of epidermis
caused by scratching, rubbing, or
picking.

Lichenification

Lichenification: chronic thickening of

the skin along with increased skin
markings. Results from scratching or
rubbing

Note the increased skin markings

Atrophy

Atrophy: paper-thin, wrinkled skin with

easily visible vessels.
Results from loss of epidermis, dermis or
both.
Seen in aged, some burns, and long-term
use of highly potent topical steroids.
Dermal atrophy manifests as a
depression in the skin.
Dermal and epidermal atrophy: loss of
normal skin texture, thinning and
wrinkling.

Scar

Scar: replacement of normal tissue by

fibrous connective tissue at eh site of injury
to the dermis.
Scars may be hypertrophic, atrophic,
sclerotic (hard due to collagen
proliferation).
Reflects pattern of healing in the affected
area.
(A) Hypertrophic or (B) Atrophic scar.

Patterns of tissue
reaction

Interface dermatitis
Lichenoid reaction
Basal cell degeneration
Psoriasiform hyperplasia
Vesicobullous reaction
Spongiotic reaction
Granulomatous reaction
Vasculitic
Non-specific reaction due to infection

Reaksi lichenoid

Band like lymphocytic infiltration = interface dermatitis

Basal cell
degeneration

Lupus erythematosus showing basal cell

degeneration, hyperkeratosis, keratotic
pug, pigmentary incontinence

Vesicobullous

Pemphigus vulgaris
showing suprabasal
acantholysis

Bullous pemphigoid

Pemfigoid
bulosa

Dermatitis
herpetiformis

Epidermolisis
bullosa

Granulomatous Reaction

Leprosy

Fungal infection

Scabies