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Clinico-pathological study of non-neoplastic skin disorders

Jyoti Singh Rajput¹, Kishor Singh², Surendra Singh³, Amarjeet Singh^4*

¹Resident, Department of Pathology, Lala Lajpat Rai Medical College, Meerut, Uttar Pradesh, INDIA.

²Professor and HOD, ⁴Resident, Department of Dermatology, Venereology and Leprosy, NIMS Medical College, Jaipur-Delhi Highway, Jaipur-303121, Rajasthan, INDIA.

³Associate Professor, Department of Pathology, Heart and General Hospital, Jaipur-303121, Rajasthan, INDIA.

Email: jyotisnmc@gmail.com, kishorsingh487@gmail.com, shekhawat.1@email.com, amarjeetverma.av@gmail.com

Research Article

 

Abstract               Introduction: A large number of Skin conditions that might present to a dermatologist ranging from acute to chronic,as well as cosmetic problem in daily practice. Many of these diseases can be quickly diagnosed. However some patients need detailed and time consuming investigation to confirm the clinical diagnosis. Skin biopsy probably is the most important ancillary aid to confirm clinical diagnosis. Prevalence of skin diseases varies from country to country and various regions within the same country. The skin lesions among the patients can be classified into various categories according to the morphology of lesion and can be confirmed by skin biopsy. Objective: To study the clinic-pathological pattern of various nonneoplastic lesions of skin and find out the agreement between clinical diagnosis and histopathological examination. Methods: A total of 60 cases of non-neoplastic skin lesions were enrolled for the study. Clinical diagnosis was correlated by histopathological examination with H & E stain. Special stains were used as an when required. Results: Maximum number of cases showed infectious diseases consisting 23(38.33%) cases of all non-neoplastic skin biopsies followed by non-infectious erythematous, papular and squamous diseases consisting of 15(25%) cases, connective tissue diseases and biopsies having non-specific histology constituted 7 cases each (11.67%). Among non-infectious group, there were 4 (6.66%) cases of vesiculobullous and vesiculopustular diseases, and had 2 cases (3.33%) of genodermatoses. 1 case each from the group of folliculitis and cutaneous manifestation of gastrointestinal disease were seen. Conclusion: The overall accuracy of the clinical diagnosis depends upon the clinicopathological correlation and skin biopsy is clearly a worthwhile investigative procedure. Infectious diseases comprised of overwhelming diseases of nonneoplastic disorders in our region.

Keywords: Biopsy, Histopathology, Infectious disorders, Skin lesions.

 

INTRODUCTION

Dermatology evolved as a branch of medicine during the 19^thcentury. Many skin diseases can be quickly diagnosed by their clinical features and need little or no investigations. At the other extreme some patients need detailed and time consuming investigations to confirm the diagnosis¹. There are probably at least 2000 different skin conditions that might present to the dermatologist from neonate to very old. The conditions vary enormously in severity ranging from cosmetic problems such as dry skin through a huge variety of acute and chronic diseases². The most common investigations performed in dermatology clinic other than simple blood tests and swabs, skin biopsies probably is the single most important diagnostic ancillary technique used for the management of patients with skin disorders.

Skin Biopsy

The skin biopsy technique is relatively simple, fast and done at little inconvenience to the patient and the entire spectrum of diseases process can be correlated clinically & pathologically. Biopsy submitted without a differential diagnosis is likely to be less successful in supporting a more definitive diagnosis. Histologic examination of a fully developed lesion will give more information than examination of an early or involuting lesion³.Various skin biopsy techniques are punch biopsy, shave biopsy, excision biopsy & incison biopsy.

Interpretation of Skin Biopsies⁴

If a logical approach is adopted the great majority of skin biopsies can be diagnosed specifically and remaining can be partly categorized in a particular group of disease. The interpretation of many skin biopsies requires the identification & integration of two different morphological features – the tissue reaction pattern & the pattern of inflammation. Various tissue reaction patterns are the lichenoid reaction pattern, the psoriasiform reaction pattern, the spongiotic reaction pattern, the vesiculobullous reaction pattern, Granulomatous reaction pattern (further divided into Sarcoidal, Tuberculoid, Necrobiotic, Suppurative, Foreign body granuloma) Vasculopathic reaction pattern(i.e. Neutrophilic vasculitis Granulomatous vasculitis Neutrophilic dermatoses). Various patterns of inflammation can be discerned in biopsies characterized on the basis of distribution of inflammatory cells within the skin. These are superficial perivascular inflammation, superficial & deep dermal inflammation & Panniculitis.

 

AIMS AND OBJECTIVES

1. To find out the pattern of various nonneoplastic skin biopsies submitted for histological examination.
2. To find out the agreement between clinical diagnosis and histopathological examination of the biopsy submitted.

 

MATERIALS AND METHODS

A hospital based prospective observational study were done on skin biopsies of 60 patients with non neoplastic skin lesions. Skin biopsies which did not include the full depth of dermis together with a portion of subcutaneous fat were excluded. The present study was carried out on 60 untreated cases with one or more clinical diagnosis of a non-neoplastic skin dermatoses presenting in the Department of Dermatology, of a Tertiary Care Hospital, Jaipur from Aug.2013 to July 2014 who were biopsied for histopathological confirmation of clinical diagnosis. A detailed clinical history was recorded for each patient with particular reference to age, sex, duration of symptoms, mode of onset, characteristics and anatomic distribution of the lesions and associated symptomatology and this was recorded in a proforma prepared for the purpose. Gross photographs were taken of some of the lesions and then biopsy was taken after receiving consent. The specimen was immediately put in 10% buffered formalin for fixation. A systematic analysis of the biopsy was done starting form keratin layer, epidermis, dermo-epidermal junction, the superficial and deep dermis, the fat and finally the blood vessels. Histomorphological observations were recorded and histopathological diagnosis was made wherever possible. These findings were then correlated with clinical diagnosis. Paraffin embedded tissue sections were used.

Staining Techniques

All the sections were studied after staining with Mayer’s Hematoxylin and Eosin (H&E) stain⁵. All sections of skin biopsies diagnosed clinically as leprosy were stained with modified Fite’s stain⁶ to demonstrate Mycobacterium leprae. Some of the biopsies were stained by Ziehl-Neelsen (ZN) stain⁵for Mycobacterium tuberculosis. When required the biopsies were stained for Gram’s Stain⁵ for demonstrating organisms. For demonstration of collagen, sections are stained with Van Gieson’s stain⁵.

 

OBSERVATION AND RESULTS

The following observations were made of the 60 cases studied. Histomorphological observations were recorded and histopathological diagnosis was made wherever possible. These findings were then correlated with clinical diagnosis.

 

Table 1: Distribution of cases according to age

 

Table 2: Distribution of cases according to sex

 

Table 3: Distribution of cases according to histopathological diagnosis group

 

Figure 1: Age and sex distribution

Out of sixty cases maximum number of cases were in the age group of 30-39 yrs (26.67%) closely followed by age group of 20-29yrs (23.33%) and 12 cases(20%) were in the age group 10-19 yrs. Least number of cases were from the age group of 0-9 yrs i. e. 1.67% of total cases. The youngest patient was 8 year old while the oldest patient was 68 years old (Table-1). The sex distribution pattern revealed maximum number of cases were males 38(63.33%) and females 22(36.67% cases). (Table 2).

Distribution of cases according to group of disorders

Maximum number of cases showed infectious diseases i. e. 23 cases(38.33%) of all non-neoplastic skin biopsies followed by non-infectious erythematous, papular and squamous diseases consisting of 15 cases (25%), connective tissue diseases and biopsies having non-specific histology constituted 7 cases each (11.67%). Non-infectious vesiculobullous and vesiculopustular diseases had 4 cases (6.66%) while 2 cases (3.33%) were of genodermatoses. 1 case each from the group of folliculitis and from cutaneous manifestation of gastrointestinal disease was seen (Table-3).

Clinicopathological Correlation

Out of 60 cases examined, 36 cases (60%) cases were given definite pathological diagnosis consistent with the clinical diagnosis, whereas 9 cases (15%) had a descriptive pathological diagnosis consistent with the clinical diagnosis, 8 (13.33%) cases had a definite pathological diagnosis inconsistent with clinical diagnosis while 7 cases (11.67%) had a descriptive pathological diagnosis that was inconsistent with the clinical diagnosis. Overall clinicopathological consistency occurred in 75% cases (Table-5). Most cases presented with more than 12 months duration of lesions 27 (45%) while cases with duration less than 6 months were 21 (35%) and from 6-12 months were 12 cases (20%). Cases with less than 6 months duration of lesions showed higher clinicopathological consistency as compared to cases presenting with longer duration of illness. Most cases had single clinical diagnosis 51 cases (85%) whereas 9 cases (15%) had more than one clinical diagnosis. Cases having single clinical diagnosis showed consistency in 74.50%, while cases having multiple diagnosis showed consistency in 77.78% cases. In the present series, the most common type of biopsy performed were punch biopsies in 39(65%) cases followed by excision biopsy in 18(30%) cases and least were incision biopsies 3(5%) cases .

Table 6: Distribution of cases of infectious disorders

 

Out of 23 cases of infectious cases overwhelming majority of cases constituted of leprosy comprising of 18 cases(78.26%) . 2 cases of cutaneous tuberculosis and one case each of actinomycoses, fungal infection and viral infection were observed.

 

Table 7: Distribution of cases of non-infectious erythematous, papular and squamous disorders

 

The most frequently encountered lesion among non-infectious erythematous, papular and squamous disorders was psoriasis constituting 60% of all the cases followed by lichen planus which constituted 26.66% of cases, one case each of pustular psoriasis and lichen planus hypertrophicus was also seen. Thus psoriasiform lesions formed the bulk with 66.67% of cases.

 

DISCUSSION

Skin biopsy is one of the most commonly used diagnostic tests in dermatology. To achieve accurate and rapid diagnosis, it is important to incorporate clinical knowledge of the disease. Various studies observed that clinical diagnostic accuracy rates of dermatologists were significantly higher than those of physicians in other disciplines. Skin diseases in general population in various studies varies from 6.3% to 11.16%. The pattern of skin diseases in India is influenced by the developing economy, level of literacy, social backwardness, varied climate, industrialization, access to primary health care, and different religious, ritual and cultural factors. The present study was prospective study carried out on 60 untreated cases of non neoplastic skin disorders presenting in the outpatient department of a tertiary care hospital, Jaipur.    Maximum number of cases were found in the age group of 30-39 yrs i. e. 16 cases (26.67%) followed by 20-29yrs i. e. 14 cases (23.33%) and 12 (20%)  cases were in the age group of 10-19 yrs. The youngest patient in the present series was 8 year old while the oldest patient was 68 years both of them being males. Aslan⁷ et al in their study in 2010 found mean age of their patients to be 46 ± 20 yrs. In the present series there were 38 males (63.33%) and 22 females (36.67%). The male to female ratio was 1.72:1.Similarly D’Costa⁸ et al also found male preponderance in their study, they found that males constituted 57.94% while females were 42.06 % of total cases. An analysis of broad spectrum of the dermatological lesions revealed that maximum number of lesions were of infectious nature constituting 23 cases (38.33%) of all the cases followed by non-infectious papulosquamous disorders constituting 15 cases (25%). D’Costa⁸ et al also found that most number of cases in their study were of infectious nature comprising of 24.29% cases followed by papulosquamous disorders comprising of 20.56% of the total cases. The third largest group of skin disorders in the present study was of connective tissue disorders comprising of 7 cases constituting 11.67% similar to study by D’Costa⁸ et al found that connective tissue disorders along with eczematous dermatitis constituted third largest group in their study. Similar studies carried out by various authors have put the infectious disorders ranging from 23% to 64 % of skin dermatoses among Indian population. Out of 23 cases of infectious cases overwhelming majority of cases constituted of leprosy comprising of 18 cases (78.26%) . 2 cases of cutaneous tuberculosis and one case each of action mycoses, fungal infection and viral infection were observed. D’Costa⁸ et al also observed leprosy to be single largest category of all dermatoses and also single largest group among infectious disorders. This may be due to the fact that distribution of various skin disorders vary from country to country and even across different parts within the same country. The second largest group of disorders in the present study was of papulosquamous disorders constituting 25% of all the cases. Similarly D’Costa et al⁸ also found these to be commonest after infectious disorders. In contrast Bin Yap⁹ found papulosquamous disorders to constitute 7.7% of total cases. Out of the broad category of non infectious erythematous, papular and squamous disorders  majority of cases were from psoriasiform dermatitis consisting of 10 cases out of 15 cases (66.67%), rest of the cases showed lichenoid pattern. Similarly D’Costa et al⁸ also found psoriasis to be the most common group among papulosquamous disorders followed by lichenoid pattern. However in another study by the same author in 2010¹⁰ of non infectious erythematous , papular and squamous lesions of the skin they found that lichenoid lesions were commonest followed by psoriasiform lesions. Psoriasis constituted 10 cases comprising of 73.33% of papulosquamous disorders and 16.67 % of overall cases. Out of 10 cases 9 (90%) cases were of psoriasis vulgaris while one case was of pustular psoriasis. D’Costa et al⁸ found psoriasis vulgaris in 81.58% of cases in a similar study. Five cases of lichen planus were seen in the present study constituting 8.33% of the total cases, out of these 5 cases 4 were of classical lichen planus (80%) and one case was of lichen planus hypertrophicus (20%). Similarly D’Costa et al in 2010⁸ found that lichen planus was more common constituting 57.33% cases while lichen planus hypertrophicus constituted 18.67% of cases. The third largest group of skin dermatoses comprised of connective tissue disorders constituting 7 cases (11.67%) of total cases.  D’Costa et al⁸ also found this group to comprise 6.54% of total cases while Bin Yap⁴⁸ found them to constitute 6.0 % of their total cases. Out of seven cases 4 cases were of scleroderma with 3 cases of morphea (localized scleroderma) and one case of systemic sclerosis (systemic scleroderma).Three cases out of seven cases of connective tissue disorders were of discoid lupus erythematosus. 2 were males while one was female similar to study by Pandhi et al¹¹ who also found male preponderance. The next group of disorders seen was from the group of non infectious vesiculobullous and vesiculopustular disorders constituting of 4 cases (6.66%) while in the study carried out by D’Costa et al⁸ it constituted 3.72% of the total cases and Bin Yap⁹ found this group to constitute1.5% of total cases.2 cases were of pemphigus vulgaris while 2 were of subepidermal blisters with one case of pemphigoid and one of herpes gestationis. Collier and Wojnarowska¹² in1997, Salmanpour et al¹³ in 2006 and Nurul Kabir et al¹⁴ in 2008 also found pemphigus vulgaris to be the most common blistering disorder. Single case of pemphigoid lesion was also seen, clinically suspected to be of dermatitis herpetiformis. A single case of herpes gestationis was also seen in a 27 year old pregnant female clinically presenting with intense pruritic lesions over abdomen and lower extremities. The next group composed of 2 cases (3.33%) of genodermatosis out of total 60 cases similar to study by D’Costa et al⁸ who also found this group in 3.73% of cases. Out of two cases one was of ichthyosis vulgaris in 16 yr old male with lesions over abdomen and chest. One case each from broad groups of folliculitis and from cutaneous manifestations of gastrointestinal diseases were also observed. While one case of keratosis pilaris was seen in the present series similarly D’Costa et al⁸ also found a single case of keratosis pilaris in their study. Overall in 88.33% cases histopathological examination was able to give diagnosis in the present series while D’Costa et al⁸ in their study found that histopathology was able to give diagnosis in 82.33% of cases, Rajaratnam et al¹⁵ were able to give a working diagnosis in 78% of cases when detailed clinical information was available to them and Bin Yap⁹ was able to achieve overall correlation in 92% cases. Thus a high level of clinicopathological correlation can be achieved when detailed clinical examination along with clinical diagnosis is available to the pathologist.

 

CONCLUSION

The present study was conducted on skin biopsies of 60 clinically diagnosed cases of nonneoplastic skin disorder. Histological classification of these cases was done and then was correlated with the clinical classification. Middle aged adults constituted the major group of the present study with a preponderance of males. The analysis of cases revealed that maximum number of cases were from the broad group of infectious diseases followed by group of non infectious erythematous, papular and squamous disorders, followed by connective tissue disorders. Out of infectious disorders the largest numbers of cases seen were of leprosy, followed by cutaneous tuberculosis. Out of the broad group of papulosquamous disorders most cases were of psoriasis followed by lichen planus. Of the connective tissue disorders most cases were of scleroderma and rest were of lupus erythematosus. Of the 4 cases of non-infectious vesiculobullous and vesiculopustular disorders 2 cases were of intraepidermal bullae while 2 cases were of subepidermal bullae. Two cases of congenital disorders were also seen 1 each of ichthyosis vulgaris and epidermolysis bullosa. One case each of keratosis pilaris and Behcet’s disease were seen. A proportion of cases constituting 11.67% of all the cases did not show a specific histological picture to be able to classified into a disease group. In large number of cases in the present study a definite pathological diagnosis consistent with the clinical diagnosis was possible. Along with the cases where descriptive pathological diagnosis consistent with the clinical diagnosis the present study was able to achieve a good overall clinicopathological consistency. Few of the cases had definite pathological diagnosis inconsistent with the clinical diagnosis, thus overall in a large number of cases histopathology was able to give a final diagnosis and in few cases histopathology was not able to provide a diagnosis. Overall in 88.33 % cases histopathology was able to provide a final diagnosis.

Based on the results, the following conclusions can be drawn

1. Infectious diseases comprised of overwhelming diseases of nonneoplastic disorders.
2. Providing sufficient clinical descriptive knowledge increases the probability of an accurate diagnosis. The correlation between the pathologist and the dermatologist was high at 75%.

 

 

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