Dermatology - Appearances in Various Diseases

Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 338
Appearances indermatopathology: Thediagnostic

and thedeceptive
BhushanMadke,BhavanaDoshi,UdayKhopkar
1
,AtulDongre
1
ABSTRACT
Dermatopathology involves study of the microscopic morphology of skin sections. It mirrors
pathophysiologic changes occurring at the microscopic level in the skin and its appendages.
Sometimes, we come across certain morphologic features that bear a close resemblance to
our physical world. These close resemblances are referred to as appearances in parlance
to dermatopathology. Sometimes, these appearances are unique to a certain skin disorder
and thus help us to clinch to a defnitive diagnosis (e.g., tadpole appearance in syringoma).
However, frequently, these appearances are encountered in many other skin conditions
and can be therefore be misleading. In this paper, we attempt to enlist such appearances
commonly found in the dermatopathologic literature and also enumerate their differential
diagnoses.
Key words: Appearances, dermatopathology, skin disorders, tumors
Department of Dermatology,
Topiwala National Medical
College and B.Y.L. Nair
Hospital,
1
Seth GS Medical
College and KEM Hospital,
Mumbai, India
Address for correspondence:
Dr. Uday Khopkar
OPD 117, 2
nd
Floor, OPD
Building, Seth GS Medical
College and K.E.M Hospital,
Parel, Mumbai - 400 012,
India.
E-mail: drkhopkar@gmail.com
INTRODUCTION
Dermatopathologic descriptions of various cutaneous
tumors and disorders are frequently referred to by
their characteristic appearances. While labeling the
appearance of a condition like dilapidated brick
wall or jigsaw puzzle may not always help in the
understanding of pathogenesis, it makes recall easier.
It is from this point of view that we set upon to enlist
the various labeled appearances in dermatopathology.
A thorough literature search was performed in Medline
with the keywords dermatopathologic appearances,
histopathological appearances, Portable document
format (pdf) version of Rooks Textbook of Dermatology
8
th
edition and Fitzpatrick Dermatology in General
Medicine 7
th
edition was screened with the search word
appearance. A similar search was carried out in the
html file of Levers Histopathology of Skin 9
th
edition.
All relevant searches were noted and a literature
review was performed for each of the appearance.
No attempt has been made by the authors to make this
paper comprehensive to include every uncommon
appearance. However, we have tried our best to
compile all the possible appearances seen on
histopathology on the basis of the available literature
and with relevance to Indian dermatology. For ease of
referencing, they have been placed in an alphabetical
order. At places, we have tried to demonstrate the
similarity between histopathological features and the
physical world around us.
ANTLER LIKE/STAG HORN APPEARANCE
Literally, antler means deciduous horn of a member
of the deer family. Dowling Degos disease (DDD)
is an autosomal-dominant disorder characterized
by spotted and reticulate pigmentation of the
flexures. Histopathology of the lesional skin shows
delicate digitate downgrowth of the epidermis layer
with melanocytic hyperplasia at the tip giving the
resemblance to antler-like pattern
[1]
[Figure 1]. However,
a similar appearance may be seen in Habers syndrome,
Galli Galli disease (acanthoeytic variant of Dowling
Dego disease) and pigmented actinic keratosis.
[2]
How to cite this article: Madke B, Doshi B, Khopkar U, Dongre A. Appearances in dermatopathology: The diagnostic and the deceptive.
Indian J Dermatol Venereol Leprol 2013;79:338-48.
Received: June, 2012. Accepted: September, 2012. Source of Support: Nil. Confict of Interest: None declared.
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Madke, et al. Appearances in dermatopathology
339 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3
BOX SHAPED/SQUARED OFF APPEARANCE
Biopsy from the indurative stage of morphea (localized
scleroderma) is squared off at the edges, giving the
appearance of box-shaped (or boxed dermis appearance)
biopsy under scanner view
[3]
[Figure 2]. This boxing of the
dermis probably happens due to the marked sclerosis of
collagen throughout the reticular dermis and extending
to the septa of subcutaneous fat. Morphea-lichen
sclerosus overlap and scleredema can also similarly
show squared off edges of biopsy specimen.
BUSY DERMIS APPEARANCE
It is a descriptive term for changes seen on scanning
magnification, and is due to inflammatory infiltrate
present in the interstitial dermis rather than around
the superficial and deep perivascular location. It
can be considered as a separate pattern seen in
inflammatory or infiltrative dermatoses. Depending
on the nature of infiltrate present in the dermis:
(i) histiocytes-granuloma annulare, histiocytoma,
interstitial granulomatous dermatitis of connective
tissue diseases, interstitial granulomatous dermatitis
with cutaneous cords and (ii) neutrophils-vasculitis,
resolving folliculitis and Sweets syndrome. The
busy dermis appearance can also be seen in the early
stage of Kaposi's sarcoma, desmoplastic melanoma,
leukemia cutis, interstitial granulomatous drug
reaction, mastocytosis and subtle breast carcinoma
metastasis
[4]
[Figure 3].
CAMEL FOOT APPEARANCE
It is a descriptive terminology for epidermal
hyperplasia (regular acanthosis) seen in histopathology
of plaque-type psoriasis. Normally, only 10% of the
basal cells are in the proliferative phase, whereas
in psoriasis about 90% of the basal cells are in the
replicative phase. As a result, to accommodate the
increasing population of basal cells, rete pegs take a
plunge in the dermis in the form of regular elongation
of rete ridges, giving the camel foot appearance to
dermal rete ridges
[5]
[Figure 4].
CANNON BALL APPEARANCE
Classically seen in acquired tufted angioma
(angioblastoma), a subtype of lobular capillary
hemangioma (LCH) that shows clusters of angiomatous
tufts and lobules scattered in the dermis in a cannon
ball pattern.
[6,7]
However, similar tufts of thick-walled
capillaries are frequently seen in pseudo-Kaposis
sarcoma or angiodermatitis of Mali.
Figure 1: Rete ridges showing antler-like downgrowth with
pigmentation at the tip in a case of Dowling Degos disease
(H and E, 40)
Figure 2: Biopsy from an indurated plaque showing boxed off
appearance at the edges (H and E, 40)
Figure 3: Hematoxylin and eosin section showing subtle interstitial
infltrate giving the whole specimen a busy dermis appearance
(H and E, 100)
Figure 4: Regular acanthosis with rete peg elongation giving rete
ridges a camel foot appearance (H and E, 100)
CHICKEN WIRE/FISH NET PATTERN
It is a descriptive terminology seen on direct
immunofluorescence study of pemphigus vulgaris,
where intercellular deposition of IgG and C3 between
epidermal cells give a chicken wire or fish net
appearance
[8]
[Figure 5]. Myxoid liposarcoma is a
low-grade tumor composed of hypocellular bland
fusiform to ovoid cells in a myxoid stroma with
a prominent plexiform capillary network and
scattered signet-ring lipoblasts. Myxoid liposarcoma
shows prominent branching pattern of capillaries
throughout the tumor in a so-called chicken-wire
pattern.
[9]
CHURCH SPIRE APPEARANCE
Described in the histopathology of hyperkeratotic
seborrheic keratosis and acrokeratosis
verruciformis of Hopf (an allelic disorder to Dariers
disease). Both these entities show a distinctive
pattern of epidermal features with hyperkeratosis,
hypergranulosis and acanthosis together with
papillomatosis. These epidermal changes frequently
lead to numerous digitate upward extensions of
epidermis-lined papillae, giving the appearance of
church spires.
[10,11]
Other conditions where church
spire appearance can be seen are verruca vulgaris,
epidermodysplasia verruciformis, verruca plana,
actinic keratosis, arsenic keratosis, tar keratosis,
acanthosis nigricans, epidermal nevus, confluent
and reticulate papillomatosis of Gougerot-Carteaud,
hyperkeratosis lenticularis and verrucous
carcinoma
[12]
[Figure 6].
CLAW CLUTCHING BALL APPEARANCE
The histological appearance of lichen nitidus is
commonly referred to as ball and claw configuration
for the infiltrate and epidermis, respectively. The ball
is comprised of well-circumscribed granulomatous
infiltrate composed of lymphocytes, epithelioid cells
and occasional Langhans giant cells that are clutched by
surrounding hyperplastic rete ridges, giving the overall
claw clutching ball appearance
[13]
[Figure 7]. Similar
resemblance can be seen in histology of early lesions
of juvenile xanthogranuloma (JXG) and lichenoid
eruptive histiocytoma. Occasionally, micropapular
lichen planus and tuberculoid leprosy may show such
appearance, although with shorter claws.
CLOCK FACE/CART WHEEL APPEARANCE
Plasma cell has a characteristic cart-wheel appearance
owing to its typical nuclear configuration. The plasma
cell is round or oval, with an eccentrically placed
nucleus and chromatin arranged in a pyramidal block
against the nuclear membrane, giving the characteristic
cart wheel appearance.
[14]
COAT SLEEVE APPEARANCE
Historically, coat sleeve appearance was described in
the histopathology of primary and secondary lesions
of syphilis, where the inflammatory infiltrate of
lymphocytes and plasma cells are located in a perivascular
coat sleeve-like pattern.
[15]
A similar picture can also be
seen in the histology of erythema annulare centrifugum,
where dermal perivascular infiltrate of lymphocytes
is arranged in a coat sleeve pattern.
[16]
Several other
Figure 5: Direct immunofuorescence studies showing intercellular
deposition of immune complexes giving a chicken wire/fsh net
look (100)
Figure 6: Biopsy from a seborrheic keratosis showing
hyperkeratosis along with papillomatosis resembling the
epidermal changes as church spire (H and E, 40)
Figure 7: Histology of lichen nitidus showing well-defined
granuloma enclosed by rete pegs giving the appearance of claw
clutching a ball on scanning magnifcation (H and E, 40)
inflammatory diseases with lymphoplasmocytic
infiltrate may show perivascular coat sleeve pattern.
However, the thickened endothelial lining contributes to
the coat sleeve appearance in syphilis.
CRIBRIFORM APPEARANCE
Literally, cribriform means a structure having
resemblance to a sieve akin to cribriform plate of
the ethmoid bone through which pass the fibers of
the olfactory nerve. Trichoepithelioma is a benign
neoplasm showing mostly follicular germinative
differentiation.
[17]
Five different histopathologic
patterns have been described columnar (desmoplastic
trichoepithelioma), retiform, racemiform,
adamantenoid and cribriform (trichoepithelioma).
Histology of trichoepithelioma of the cribriform pattern
shows presence of horn cysts of varying sizes and
basaloid epithelial cribriform nests and a few elongated
strands embedded in a fibroblastic stroma [Figure 8].
Papillary mesenchymal bodies formed by stromal
fibroblastic aggregation are seen typically adjacent to
epithelial islands. However, cribriform pattern may
also be seen with basal cell carcinoma, glomus tumor
and several other benign and malignant neoplasms.
DILAPIDATED BRICK WALL APPEARANCE
It is a well known appearance in dermatopathology.
It is classically seen in Hailey-Hailey disease, which
shows prominent suprabasal clefting and extensive
loss of intercellular bridges (acantholysis) with
partial coherence of cells between keratinocytes,
giving the whole epidermis a dilapidated brick wall
appearance.
[18]
It has also been described in cases of
bullous Dariers disease and Hailey-Hailey variant of
Grover disease
[19,20]
[Figure 9].
FESTOONED PAPILLAE APPEARANCE (SEE
UNDECORATED TOMB STONING)
Classically described in the histopathology of
porphyria cutanea tarda, wherein a biopsy from
a fresh blister shows a subepidermal bulla with
minimal dermal inflammatory infiltrate and
dermal papillae protruding upward into the blister
cavity (festooning) and hence the name festooned
papillae appearance
[21]
[Figure 10].
FLAME-THROWER-LIKE APPEARANCE
It is a histopathological description of the vertical
section of telogen hair shaft. Telogen club hairs have a
non-pigmented bulb with an irregular shaggy border.
The presence of bright red trichilemmal keratin
bordering the club hair results in a flame-thrower
like appearance in vertical hematoxylin and eosin
sections
[22]
[Figure 11].
Fi gure 8: Hemat oxyl i n and eosi n- st ai ned sect i on of
trichoepithelioma showing epithelial islands in a cribriform
pattern (H and E, 100)
Figure 9: Biopsy from a representative lesion of Hailey-Hailey
disease showing partial acantholytic dyskeratosis giving the
whole epidermis a dilapidated brick wall resemblance (H and
E, 100)
Figure 10: Biopsy from a blister in a case of porphyria showing
subepidermal blister along with festooning of dermal papillae (100)
Figure 11: Vertical section from scalp biopsy showing telogen
hair lined with eosinophilic trichilemmal keratin giving fame
thrower appearance (H and E, 200)
FRIED EGG APPEARANCE
Mast cells are found in small numbers (up to 10 mast cells
per 40X field) in a perivascular location in the dermis and
larger number in some neoplasms (e.g., neurofibroma)
and certain forms of mastocytosis. These cells are
commonly oval with a centrally located dark round
nucleus, giving a fried egg appearance
[23]
[Figure 12].
HOBNAIL (MATCHSTICK) APPEARANCE
Retiform hemangioendothelioma is a rare variant of
low-grade angiosarcoma characterized by indolent
clinical behavior. Histologically, it bears a close
resemblance to the architecture of rete testis on
scanning magnification. The tumor is composed
of elongated, arborizing blood vessels lined by
monomorphic bland endothelial cells with prominent
apical nuclei and scanty cytoplasm. These endothelial
cells have been described to have a match stick or
hobnail appearance.
[24,25]
Similar is the appearance of
endothelial cells lining the vessels of angiolymphoid
hyperplasia.
[26]
JIGSAW PUZZLE APPEARANCE
Cylindroma is a benign tumor of hair follicle origin.
The tumor is composed of irregularly shaped islands of
basaloid cells arranged in a mosaic-like mass molding
together in a jigsaw puzzle pattern
[27]
[Figure 13].
A rim of densely eosinophilic, Periodic acid
Schiff-positive basement membrane-like material
commonly envelops the individual nests. A similar
jigsaw puzzle appearance of tumorous mass was also
reported in eccrine spiradenomas.
[28]
MARINERS PILOT WHEEL APPEARANCE
It is description of the tissue phase of
paracoccidioidomycosis (also known as Brazilian
blastomycosis, South American blastomycosis,
Lutz-Splendore-de Almeida disease) caused by
the thermally dimorphic fungus Paracoccidioides
brasiliensis. In biopsy specimens, the tissue phase
of the fungus is seen as multiple buds surrounding
the whole surface of the mother yeast cell. This
configuration is described as Mariners pilot wheel
or Mickey mouse appearance
[29]
[Figure 14].
MORULA-LIKE APPEARANCE
Protothecosis is a rare infection caused by members
of the genus Prototheca, an achlorophyllic alga.
Olecranon bursitis and localized cutaneous
infections are the most common presentation seen
in immunocompetent patients.
[30]
Prototheca species
divide by symmetrical endosporulation. Lactophenol
cotton blue or calcofluor white mount of culture reveals
the morula-like appearance of sporangia containing
multiple endospores; however, the endospores are less
as compared with that seen in rhinosporidiosis and
coccidioidomycosis.
[31]
ONION SKIN APPEARANCE
Pacinian corpuscle is a specialized type of touch
receptor present in the deeper layers of the skin.
Each corpuscle is composed of the end of a sensory
nerve fiber with layers of connective tissue wrapped
Figure 12: Histology of mastocytosis showing numerous mast
cells having centrally located nuclei (H and E, 200)
Figure 13: Histological section of cylindroma showing numerous
tumor islands molded into each other giving a jigsaw puzzle
appearance (H and E, 100)
Figure 14: Gomori methenamine silver stain showing the tissue
phase of paracoccidioidomycosis resembling the so-called
Mariners pilot wheel appearance (1000)
around it, resembling onion skin appearance.
[32-34]

Mycobacterial infiltration of the nerve in cases of
borderline and polar lepromatous leprosy leads to
proliferation of perineurium of the nerve bundles
leading to onion peel appearance
[35]
[Figure 15].
Eosinophilic angiocentric fibrosis (mucosal variant
of granuloma faciale) and chronic fibrosing vasculitis
could lead to a similar onion skin appearance due to
extensive fibrosis of blood vessels.
[36]
OWLS EYE APPEARANCE
Histopathology of verruca plana shows, in addition to
hyperkeratosis and acanthosis, diffuse vacuolization
of cells in the upper spinous and granular layer.
The nuclei of the vacuolated cells lie at the centers
of the cells with empty shells around the nucleus.
This appearance of vacuolated cells is referred to as
Owl eye appearance
[37]
[Figure 16]. These vacuolated
cells should be differentiated from Paget cells. Similar
owls eye appearance of Reed Sternberg cell (cells
having either multinucleated or bilobed nucleus) is
considered pathognomonic for classical Hodgkins
lymphoma.
[38]
PAINT BRUSH-LIKE APPEARANCE
The name Penicillium comes from the word brush.
Penicilliosis is a systemic fungal infection caused by a
dimorphic fungus, Penicillium marneffei, common in
HIV patients whose CD4 count is less than 50/mm,
3

and was first isolated from bamboo rats in Vietnam.
[39]

Fungal culture shows greywhite colonies surrounded
by diffusible red pigment, and lactophenol cotton
blue stain preparation of the culture specimen shows
brush-like clusters of septate hyphae with terminal
conidiospores.
[40]
PALISADING APPEARANCE
Palisade means a wall or fence made from either
wooden stakes or iron plates, and is built to defend
a structure. In dermatopathology, palisading means
typical arrangement of cells of either tumorous origin
as in basal cell carcinoma,
[41]
where basal layer of
cells lies perpendicular to the basement membrane
giving a palisaded appearance or histiocytes surround
a deposit or area of collagen alteration in granuloma
annulare.
[42,43]
Benign tumors like palisaded and
encapsulated neuroma also show palisading by spindle
cells of neural origin.
[44]
Other conditions where
palisading appearance can be seen are: Palisading
neutrophilic and granulomatous dermatitis,
[45,46]

rheumatoid nodule, necrobiosis lipoidica,
[47]
syphilis
and foreign body reaction
[48]
[Figure 17].
PICKET FENCE APPEARANCE
This appearance is seen on direct
immunofluorescence (DIF) studies of dermatitis
herpetiformis. DIF of non-involved perilesional skin
shows deposit of IgA alone or in combination with
C3, which are arranged in a granular pattern at the
dermoepidermal junction. These granular deposits
may be vertically elongated, giving a picket-fence
appearance
[49]
[Figure 18].
RAVELLED WOOL APPEARANCE
Literally, ravelled means tangled mass of threads. It
is a classical histopathological description seen in
pseudoxanthoma elasticum (PXE). Biopsy from a
lesion will show small, fragmented, wavy and clumped
eosinophilic elastic fibers, giving a ravelled wool
appearance
[50]
[Figure 19]. Similar appearance of elastic
fibers can also be seen in D-penicillamine-induced
PXE and periumbilical PXE.
[51]
SAFETY PIN APPEARANCE
In granulomatous lesions of donovanosis, the bacterium
Calymmatobacterium granulomatis (C. granulomatis)
displays characteristic bipolar staining, giving a safety
pin appearance.
[52]
These bacilli are found in large
number in the cytoplasm of mononuclear cells of the
monocyte/macrophage lineage forming Donovan bodies.
SAW-TOOTH APPEARANCE
Yet another well-known histopathological finding seen
in lichen planus. Histology of lichen planus shows
irregular hyperplasia of the malpighian (spinous)
layer (irregular acanthosis) in a triangular pattern
giving a saw-tooth appearance
[53]
[Figure 20]. Similar
saw tooth appearance may be seen in some cases of
lichenoid drug eruptions and in lichen planus-like
keratoses.
SEPTATE TOMATO APPEARANCE
In Molluscum contagiosum, scanner view of
hematoxylin and eosin-stained sections shows
an epidermal invagination with several closely
spaced lobules of epidermal proliferation leading
to a septate tomato appearance. The septum of this
appearance is formed by normal dermis and not by
epidermal proliferation. In the lower epidermis, these
viral bodies appear as minute, ovoid eosinophilic
structures. At the level of granular layer, these bodies
change their staining pattern from eosinophilic to
basophilic [Figure 21].
SIEVE-LIKE APPEARANCE
Kaposi sarcoma (KS) is a low-grade malignant tumor of
vascular origin associated with human herpes simplex
virus 8 (HHV-8) infections. Biopsy from the plaque
stage of KS shows spindle cells arranged in fascicles
with slit-like dense and irregular vascular spaces,
creating a sieve-like appearance.
[54]
SPAGHETTI AND MEATBALL APPEARANCE (BANANA
AND GRAPE APPEARANCE)
Hematoxylin and eosin-stained biopsy from the
lesions of pityriasis versicolor shows slender septate
hyphae and spores resembling the sphagetti and meat
ball appearance
[55]
[Figure 22].
STORIFORM APPEARANCE
This is classically described in dermatofibrosarcoma
protuberans (DFSP), but is also seen in the frequently
seen dermatofibroma. DFSP is a rare, locally aggressive
dermal tumor composed of interwoven bundles of
spindle cells with plump nuclei arranged in a storiform
Figure 15: Histology of pacinian corpuscle showing the classical
onion peel appearance (H and E, 200)
Figure 16: Histopathology of verruca plana showing the typical
cytopathic effect on keratinocytes called as koilocytes having a
perinuclear halo referred to as owl-eye appearance (H and E,
200)
Figure 17: Specimen obtained from nodular basal cell carcinoma
showing the classical arrangement of peripheral basaloid cells in
a palisading confguration (H and E, 200)
Figure 18: Direct immunofuorescence showing deposition of IgA
along the tips of dermal papilla giving a picket fence appearance.
(100) (Photo contributed by Dr. Raghavendra Rao, Kasturba
Medical College, Manipal)
Figure 19: Biopsy from a papular lesion of pseudoxanthoma
elasticum showing fragmented and calcifed elastic fbers forming
a tangled mass resembling woolen threads, the so-called ravelled
wool appearance (H and E, 200)
Figure 20: Histology of a papule of lichen planus showing the
typical saw tooth morphology of rete ridges (H and E, 100)
or pinwheel pattern
[56]
[Figure 23]. Storiform appearance
is also seen in dermatofibroma, where histiocytes
are arranged in a storiform or whorled pattern in the
reticular dermis with evidence of entrapped collagen
bundles at its peripheral margins (c.f. DFSP). In DFSP,
the proliferation extends into the fibrous septae of
subcutaneous tissue forming pseudoseptae.
SWARM OF BEES APPEARANCE
It is a characteristic histopathological picture seen
in active alopecia areata, where the perifollicular
inflammation, in particular peribulbar infiltrates, is
composed of predominantly lymphocytes around
anagen hair follicles. This pattern of infiltrate is referred
to as swarm of bees appearance
[57]
[Figure 24]. Similar
appearance has been reported in leishmaniasis, wherein
giemsa stain of tissue material shows numerous
amastigote (20-30 in number) arranged in a swarm of
bees fashion within the cytoplasm of macrophages.
[58]
SWISS CHEESE APPEARANCE
This appearance is reported in cases of
paraffinoma (sclerosing lipogranuloma). Paraffin is
a mineral oil and is not hydrolyzed by tissue lipases
and, hence, is treated by the body as a foreign
substance. The most common site of injecting paraffin
oil is the penis and breast.
[59,60]
Biopsy obtained from
the infiltrated area shows presence of numerous ovoid
or round cavities where the paraffin resided prior to
processing, giving the Swiss cheese appearance.
TADPOLE/COMMA-SHAPED APPEARANCE
Classically seen at scanning magnification in histology
of syringoma. This benign tumor of eccrine lineage
comprises of numerous ducts lined by two rows of
epithelial cells embedded in a fibrous stroma. The
epithelial component is arranged in nests, cords
or tubules of relatively uniform size. Depending
upon the plane of section, some nests of syringoma
can assume a morphology that closely resembles a
comma or tadpole.
[61]
Similar tadpole appearance
of epitheial strands is also reported in desmoplastic
trichoepithelioma, sclerosing basal cell carcinoma and
microcystic adnexal carcinoma [Figure 25].
TELEPHONE HANDLE APPEARANCE
Another well known cellular appearance among
hematologist. The deep red nucleus of an eosinophil is
composed of two lobes connected by a band of nuclear
material, and resembles the old-fashioned telephone
receiver
[62]
[Figure 26].
TISSUE CULTURE-LIKE APPEARANCE
Nodular fasciitis is a self-limiting benign reactive
fibroblastic growth, and is often mistaken for malignant
neoplasm with its feature of rapid growth and histological
appearance. Clinically, it usually presents as a solitary,
rapidly developing, sometimes tender, subcutaneous
nodule that reaches its ultimate size of 1-5 cm. Histology
from a well-developed nodular lesion shows plump
fibroblasts growing haphazardly in a vascular, myxoid
stroma presenting a tissue culture-like appearance.
[63]
TOMB STONE APPEARANCE
Classically described in the histopathology of fresh
blister of pemphigus vulgaris or drug-induced
pemphigus. Suprabasal splitting of the epidermis
leads to blister formation, with the basal layer still
remaining adherent to the basement membrane,
and gives the resemblance to the row of the tomb
stone
[64,65]
[Figure 27]. Ackerman and colleagues have
classified tomb stoning into two broad categories:
Decorated tomb stone (discrete dermal papillae covered
by a single row of basal keratinocytes that project
into an intraepidermal blister) and undecorated tomb
stone (discrete, well-preserved dermal papillae beneath
a subepidermal blister).
[1]
Decorated tombstones have
been described apart from pemphigus in Grovers
disease, Dariers disease, Hailey-Hailey disease,
warty dyskeratoma and solar keratosis, whereas
undecorated tomb stone has been described in
suction blister, porphyria, pseudoporphyria, bullous
pemphigoid, herpes gestationis and epidermolysis
bullosa junctional and dystrophic variant.
TRILAYERED/STRIPED APPEARANCE
The histology picture of lichen sclerosus is commonly
referred to as tri-layered or striped appearance. The
established lesion of lichen sclerosis shows three
distinct zones: (i) epidermal atrophy with surface
hyperkeratosis, (ii) an underlying broad zone of
subepidermal edema in the papillary dermis and
(iii) homogenization and ground glass appearance of
collagen, which becomes more sclerotic over time.
[67]
A similar trilayered appearance can be seen in the
histology of soft chancre (chancroid) caused by
infiltrate, (ii) the mid-zone containing new blood
vessels and regenerating granulation tissue on one
hand and degenerative changes on the other and
Figure 26: Bilobed nucleus of eosinophil resembling an old
telephone receiver (H and E, 200)
Figure 27: Suprabasal acantholysis in pemphigus showing the
characteristic row of tombstone appearance (H and E, 100)
Figure 28: Haphazard orientation of keratinocytes seen in Bowens
disease commonly referred to as windblown appearance of
dysplastic cells (H and E, 100)
Figure 21: Molluscum contagiosum showing the epidermal
invagination and numerous eosinophilic viral inclusion bodies
resembling a septate tomato on scanner view (H and E, 40)
Figure 22: Numerous fungal elements of malasezzia species seen
as elongated hyphae and spores, familiarly called as spaghetti
and meat-ball appearance (200)
Figure 23: Hematoxylin and eosin-stained specimen showing
storiform/whorled appearance of dermatofbroma sarcoma
protuberans (H and E, 200)
Figure 24: Lymphocytic infiltrate around anagen follicle
resembling a swarm of bees (H and E, 200 and 100)
Figure 25: Histology of syringoma showing typical tadopole/
comma shaped epithelial tumor strand (H and E, 200)
Hemophilus ducreyi: (i) superficial zone consisting
of necrotic tissues and an acute inflammatory
(iii) the deeper zone shows a chronic inflammatory
infiltrate of plasma cells and lymphocytes.
[68]
WINDBLOWN APPEARANCE
A descriptive term for the enlarged, crowded,
haphazardly arranged neoplastic cells that show loss
of polarity, enlarged and hyperchromatic nuclei and
atypical mitoses in the epithelium of Bowens disease
and bowenoid papulosis of the genitalia. This overall
appearance in the epithelium of Bowens disease is
referred to as windblown appearance
[69,70]
[Figure 28].
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Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 338

Appearances indermatopathology: Thediagnostic

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