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Spongiotic Reaction
Pattern
…and review
Nathan C. Walk, M.D.
Spongiotic reaction pattern
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Spongiosis = Intercellular
edema
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?Mechanism unclear
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Elongation of bridges Æ
vesiculation, bullae
Fluid comes from dermis
Important points:
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Nonspecific
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“Histologic hallmark of
eczema is spongiosis”
Spectrum
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Acute – subacute - chronic
Spongiotic reaction pattern
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Irritant contact dermatitis
All i contact ddermatitis
Allergic
ii
Protein contact dermatitis
Nummular dermatitis
Seborrheic dermatitis
Atopic dermatitis
Pompholyx
Stasis
Autoeczematization
A toeczematization
Pityriasis rosea
Spongiotic drug rxn
Chronic superficial dermatitis
Light reactions
Dermatophytoses
Arthropod bites
Others
Others….
Spongiotic reaction pattern
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Variants – 4 of them (per Weedon)
Neutrophilic
„ Eosinophilic
p
„ Miliarial
„ Follicular
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Neutrophilic
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Pustular psoriasis
Reiter’s syndrome
y
IgA pemphigus
Herpetiform pemphigus
Infantile acropustulosis
AGEP
P l
Palmoplantar
l
pustulosis
l i
Dermatophytoses
Pustular contact dermatitis
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Miliarial
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Intraepidermal edema centered on the acrosyringium
Miliaria crystallina - @ stratum corneum
„ Miliaria rubra
„ Miliaria p
profunda – DE jjunction
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Follicular
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Marked spongiosis @ Infundibulum
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Infundibulofolliculitis
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(Disseminate and recurrent infundibulofolliculitis)
Atopic dermatitis (follicular lesions)
„ Eosinophilic folliculitis
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Case 29
Stasis dermatitis
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Common disorder of middle
middle-aged and older individuals
Impaired venous drainage
Si
Sites:
L
Lower legs
l andd ankles
kl
Early stages - Edema
Later - Dryy and scalyy or crusted
and weeping areas may develop
Discoloration and ulceration
common
Histological features of Stasis Dermatitis
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Focal p
parakeratosis and serum scale crust
Mild spongiosis
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?Spongiotic vesiculation…think superimposed contact dermatitis
**Dermal changes
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Proliferation of small blood vessels with RBC extravasation
Variable dermal fibrosis
Abundant hemosiderin present throughout the dermis
Thick walled veins in deep dermis or subcutis
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Case 25
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Eosinophilic spongiosis
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Correlate with clinical –
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Allergic contact dermatitis
Differential of eosinophilic spongiotic
dermatitis
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Bullous pemphigoid - early
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Urticarial stage
C precede
Can
d the
h di
diagnosis
i b
by many years
**Prominent dermal eosinophilic infiltrate
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Remember dermal inflammation important when characterizing
vesiculobullous lesions
lesions, not the junk in the blister.
blister
Pemphigus
p g – earlyy
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Acantholysis
Transitional forms between eosinophilic spongiosis and the usual
histological findings of pemphigus
Differential of eosinophilic
spongiotic dermatitis
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Allergic contact dermatitis
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Marked lower epidermal spongiosis in early stage
Spongiotic vesicles at all levels of epidermis in later stage
Exocytosis of lymphocytes and eosinophils
Mixed dermal inflammatory infiltrate
** uncommon pattern
Incontinentia pigmentosus (first stage)
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Prominent exocytosis of eosinophils
Intraepidermal
p
vesicle formation with eosinophils
p
Other entities that may show eosinophilic
spongiotic
i i d
dermatitis
ii
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Pemphigus
p g vegetans
g
Herpes gestations
Idiopathic
p
eosinophilic
p
spongiosis
p g
Eosinophilic, polymorphic, and pruritic eruption
Atopic dermatitis
**Arthropod bites
Eosinophilic folliculitis (Ofuji’s disease)
Drug reaction
“Id” reactions
Contact dermatitides…often lumped together
hi l i ll – differences?
histologically
diff
?
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Allergic contact – spongiotic
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c/w photoallergic
versus
„ Irritant contact – spongiotic
p g
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c/w phototoxic
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With higher concentrations of irritant, get more characteristic pattern of:
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Ballooning keratinocytes in the upper epidermis
Variable necrosis…may become confluent
+ PMNs
Allergic contact
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Spongiotic vesicles at different horizontal and vertical levels
Exocytosis of eosinophils
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Case 28
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Diagnosis:
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Spongiotic dermatitis with intraepidermal vesicle
formation,
formation consistent with eczema
Dyshidrotic eczema =
P
Pompholyx
h l
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Age of onset: < 40 years
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Precipitating factors
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Confluent tapioca
tapioca--like vesicles and
crusted erosions on the dorsum of
fingers
E
Emotional
i l stress
Hot, humid weather
Duration - several weeks
Symptoms
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M=F
½ have atopic background
Pruritus
Pain in fissures
f
Secondary infection
Distribution: hands ((80%))
and feet
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Lateral aspects of fingers,
palms,
palms soles
Dorsa of fingers
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Histology
Eczema = spongiosis
„ With intraepidermal vesicle formation
„ Lymphocytes both inside the vesicles and in upper
dermis
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Case 27
Histological
g
features of pityriasis
p y
rosea
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Epidermal
p
changes:
g
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Undulating pattern
Focal, mounding parakeratosis
Spongiosis + Lymphocyte exocytosis – forming vesicles
resembling small Pautrier microabscesses
+/-- dyskeratotic cells
+/
Dermal changes
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Red cell extravasation
Edema
Melanin incontinence
Mild to moderate lymphohistiocytic infiltrate
Pityriasis Rosea –
A
Acute
exanthematous
h
eruption
i
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1)) Distinctive morphology
p
gy
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A single lesion first
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One or two weeks later,
later a
generalized secondary eruption
develops in a “Christmas tree”
distribution
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Herald patch (80%)
Exanthem – oval, fine scaling papules and
plaques following the lines of cleavage
2) SelfSelf-limiting course, remits in
6 weeks without any therapy
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Case 26
Seborrheic dermatitis
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Histology:
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Acute lesions
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Subacute lesions
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Mild spongiosis with mild exocytosis of lymphocytes, overlying scale
crust,, centered on a follicle
Mildly edematous papillary dermis
Mild SPLI (superficial perivascular lymphocytic infiltrate)
++ irregular acanthosis
Chronic lesions
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Psoriasiform hyperplasia
Less appreciable spongiosis
Presence of scales crusts in a folliculocentric distribution
Unknowns