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Spongiotic Reaction Pattern …and review Nathan C. Walk, M.D. Spongiotic reaction pattern Spongiosis = Intercellular edema ?Mechanism unclear Elongation of bridges Æ vesiculation, bullae Fluid comes from dermis Important points: Nonspecific “Histologic hallmark of eczema is spongiosis” Spectrum Acute – subacute - chronic Spongiotic reaction pattern 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 Variants – 4 of them (per Weedon) Neutrophilic Eosinophilic p Miliarial Follicular Neutrophilic Pustular psoriasis Reiter’s syndrome y IgA pemphigus Herpetiform pemphigus Infantile acropustulosis AGEP P l Palmoplantar l pustulosis l i Dermatophytoses Pustular contact dermatitis Miliarial Intraepidermal edema centered on the acrosyringium Miliaria crystallina - @ stratum corneum Miliaria rubra Miliaria p profunda – DE jjunction Follicular Marked spongiosis @ Infundibulum Infundibulofolliculitis (Disseminate and recurrent infundibulofolliculitis) Atopic dermatitis (follicular lesions) Eosinophilic folliculitis Case 29 Stasis dermatitis 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 Focal p parakeratosis and serum scale crust Mild spongiosis ?Spongiotic vesiculation…think superimposed contact dermatitis **Dermal changes 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 Case 25 Eosinophilic spongiosis Correlate with clinical – Allergic contact dermatitis Differential of eosinophilic spongiotic dermatitis Bullous pemphigoid - early Urticarial stage C precede Can d the h di diagnosis i b by many years **Prominent dermal eosinophilic infiltrate Remember dermal inflammation important when characterizing vesiculobullous lesions lesions, not the junk in the blister. blister Pemphigus p g – earlyy Acantholysis Transitional forms between eosinophilic spongiosis and the usual histological findings of pemphigus Differential of eosinophilic spongiotic dermatitis Allergic contact dermatitis 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) Prominent exocytosis of eosinophils Intraepidermal p vesicle formation with eosinophils p Other entities that may show eosinophilic spongiotic i i d dermatitis ii 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 ? Allergic contact – spongiotic c/w photoallergic versus Irritant contact – spongiotic p g c/w phototoxic With higher concentrations of irritant, get more characteristic pattern of: Ballooning keratinocytes in the upper epidermis Variable necrosis…may become confluent + PMNs Allergic contact Spongiotic vesicles at different horizontal and vertical levels Exocytosis of eosinophils Case 28 Diagnosis: Spongiotic dermatitis with intraepidermal vesicle formation, formation consistent with eczema Dyshidrotic eczema = P Pompholyx h l Age of onset: < 40 years Precipitating factors 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 M=F ½ have atopic background Pruritus Pain in fissures f Secondary infection Distribution: hands ((80%)) and feet Lateral aspects of fingers, palms, palms soles Dorsa of fingers Histology Eczema = spongiosis With intraepidermal vesicle formation Lymphocytes both inside the vesicles and in upper dermis Case 27 Histological g features of pityriasis p y rosea Epidermal p changes: g Undulating pattern Focal, mounding parakeratosis Spongiosis + Lymphocyte exocytosis – forming vesicles resembling small Pautrier microabscesses +/-- dyskeratotic cells +/ Dermal changes Red cell extravasation Edema Melanin incontinence Mild to moderate lymphohistiocytic infiltrate Pityriasis Rosea – A Acute exanthematous h eruption i 1)) Distinctive morphology p gy A single lesion first One or two weeks later, later a generalized secondary eruption develops in a “Christmas tree” distribution 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 Case 26 Seborrheic dermatitis Histology: Acute lesions Subacute lesions 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 Psoriasiform hyperplasia Less appreciable spongiosis Presence of scales crusts in a folliculocentric distribution Unknowns
