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Dermpath Review
Accessory Tragus Small hairs at periphery, polypoid. Digital Fibrokeratoma Acral skin, fibroblastic (like DF) thick collagen Supernumerary Nipple Enlarged pilosebaceous unit with smooth muscle around it, dark staining ducts around that, trichrome stain would highlight the muscle. Epidermolytic Hyperkeratosis Dissolution of keratinocytes, stippled keratohyalin granules (similar to wart) except there is dropout of nuclei (empty vacuoles) unlike warts which retain nuclei. Verruca Plana Increased keratohyalin granules (owls eyes clear cells with nucleus with empty shell around nucleus. No substance around nucleus (empty) unlike Pagets. Bowens Disease Clear cells, disorganization, empty cytoplasm, hyperchromatism Tinea Versicolor No inflammation or spongiosis (unlike dermatophyte), easily seen organisms on regular H&E. Acanthosis Nigricans Papillomatosis (dermis in epidermis) no inflammation, occasionally may see spores (no hyphae). Pemphigoid May be cell poor with festooning like PCT. Cell Poor Subepidermal Blister Differential: Pemphigoid sprinkling of eos>neuts EBA-sprinkling of neuts>eos PCT (no neuts/eos, few lymphs, rarely see true vessel thickening. Erythema Multiforme Normal stratum corneum (if there is parakeratosis=PLEVA), Necrotic keratinocytes, chewing up of basement membrane (necrosis at different levels of epidermis, not just at DE jxn) If only at DE jxn=lichenoid. Graft vs Host Disease Looks like very subtle EM. Few scattered necrotic keratinocytes (still retains pyknotic nuclei red cell with black nucleus). Necrotic cells go down adnexal structures more commonly. Coma blister Intra or subepidermal blister or erosion. Key is necrotic sweat glands. Incontinentia Pigmenti Eosinophilic spongiosis with necrotic keratinocytes, may have pigment incontinence in later lesions. Acute Fixed Drug Rxn Orthokeratosis, necrotic keratinocytes (just like EM) but there will be scattered eosinophils and neuts in the dermis (not seen in EM). Pigment incontinence.

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Eosinophilic Abscess Differential (filled with eos) Pemphigus vegetans Erythema neonatorum toxicum Eosinophilic Spongiosis Differential Contact dermatitis Arthropod bites Pemphigus Pemphigoid Incontinentia pigmenti TEN Orthokeratosis, confluent epithelial necrosis, paucicellular, whole epidermis looks red (also seen with secondary burn) Dermatitis Herpetiformis Subepidermal blister with neutrophils laterally see neuts in dermal papilla. Little dermal edema (sweets syndrome has lots of edema, more neutrophilic debris) Bullous LE, linear IgA, and DH can look identical. Dariers Disease Corp ronds=big swollen cell with a halo in the upper spinous zone or granular layer (key). Usually dry keratotic papule (little serum). Usually suprabasilar split. Dariers vs Grovers grovers has spongiosis, dariers does not. Corp Ronds Differential Dariers Grovers Warty dyskeratosis Herpes Simples Steel grey cells with dark rim around nucleus, multinucleated cells. Herpes can just effect the hair follicle and have a normal epidermis (necrotic follicular epithelium herpes). Warty dyskeratoma Cup shaped, corp ronds, acantholytic cells, may be cyst with warty cup shape off of hair follicle. Pemphigus Vulgaris Tombstones, no corp ronds, goes down the hair follicle, has acantholytic cells. Hailey-Hailey No corp ronds. Acantholytic cells, Has serum (important). Serous crust, cells fall apart (dilapidated brick wall) Pemphigous erythematosus Subcorneal acantholytic process that is pauci neutrophilis (bullous impetigo is more abscess like loaded with neuts). Base of blister, look for acantholytic cells poking up into blister space because roof may be gone. Bullous Impetigo Subcorneal neutophilic process, more abscess like. Still has cells poking up into blister space. Erythema Annulare Centrifugum Tight perivascular cuffing, do not even see the vessel due to all the infiltrate. Superficial and Deep infiltrate. Focal parakeratosis, extravasated RBCs. Secondary Syphilis Usually lichenoid process, always look for plasma cells eccentric nucleus.

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Superficial and Deep Lymphocytic infiltrate differential EAC Lupus Jessners should have hairs PMLE papillary dermal edema CLL monotonous small cells Lues Plasma cell differential Acne keloidalis Hidradentitis supprativa Dissecting cellulitis Oral mucosa syphilis Lichen Simplex Chronicus Hyperkeratosis, alternating parakeratosis with lengthening of papilla and vertical fibrosis Hypertrophic Lichen Planus Dense lichenoid infiltrate with elongated papilla, rounded rete (not as saw-toothed), melanophages. Psoriasis Epidermis in not reliable, look in the spinous zone, stratum corneum. Absent or diminished granular layer multilayer stratum corneum (wafer like scale), +/-neuts in stratum corneum, +/- parakaratosis, palor to the upper spinous layer. PRP Paratkeratosis into the follicular ostia (no neuts), elongated platelike scale, vertical hyperkeratosis in follicle going above the rest of the stratum corneum. May have hypergranulosis (as opposed to psoriasis). Alternating ortho/parakeratosis (horizontal and vertical). Glucagonoma sandwich effect or artificial look - Distinct line of ballooning superficial keratinoctyes or pallor, then thick compact zone of parakeratosis. Well dermarcated transition thick parakeratosis or ballooned cells, stuck in normal looking epidermis. Pityriasis Rosea Discrete parakeratotic mounds lymphocytic perivascular infiltrate, mild spongiosis, extravasated RBCs. Guttate psoriasis May have granular layer, spongiosis, mounds of parakeratosis. In scale, will have neutrophils/serum (key) not seen in PR. PLEVA Obscured junction, a lot of infiltrate, parakeratotic scale multilayered, not mound like. Necrotic keratinocytes at different levels of epidermis. May have a lymphocytic vasculitis. May be wedge shaped. May have RBC extravasation. Lymphomatoid Papulosis Should have large atypical lymphs. Never see eos/neuts in PLEVA, but may be seen in LyP. Spongiform Pustule Differential (lots of neuts in small compartments, groups of 4-5. Pustular psoriasis Reiters Dz Geographic Tongue Candida

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Lichen Planopilaris Hypergranulosis of hair follicle, dense infiltrate of follicle. May or may not have activity between follicles, if so it will be confluent and look like regular LP. In lupus, the infiltrate is not as lichenoid or dense, typically nothing going on between hair follicles. If there is activity with Lupus, it will be patchy between follicles. Alopecia Areata Swarm of bees around hair bulb at dermal sub-Q junction (key). Lichenoid Drug Reaction The difference between lichen planus and a lichenoid reaction is that there is parakeratosis in a lichenoid reaction and none in lichen planus. Also may see eosinophils with parakeratosis in lichenoid drug. (lichenoid + plasma cells = syphilis). Porokeratosis Superficial porokeratosis may have lichenoid infiltrate. Must look carefully for coronoid lamella in lichenoid processes. Typically thinned epidermis. Lichen Planus Lichenoid infiltrate with plasma cells look to see if the biopsy is from the mouth, dont assume its syphilis. The mouth normally has plasma cells. Lichen Nitidus Small dome shaped, collaretting at border. Lymphocytes and histiocytes (key) +/- giant cells. Lichenoid keratoses Parakeratosis, lichen infiltrate, look for a remnant of an SK or look at the basal layer may see hyperpigmentation like a lentigo. Lichen Striatus Lichenoid, may be spongiotic. Vacuolpathy. Nonspecific, BUT only disease that has a lichenoid infiltrate, empty dermis, and then a dense infiltrate around the sweat glands. Halo Nevus Lichenoid infiltrate, but very deep (compact infiltrate all the way across biopsy). Curved surface (bump like process). May see few melanocytes or pigment because it is obscured. Melanin does not drop from lower epidermis deeper into dermis, if you see pigment down deeper into dermis, it is either melanocytes or hemosiderin. May be helpful to confirm melanocytes deeper in the dermis. Leukocytoclastic Vasculitis May obscure vessels. If vessel wall blends with the surrounding collagen indicates fibrin in the walls. (sweets rarely has fibrin in vessel walls and the neuts are diffuse, not angiocentric). Nuclear debris. LCV may rarely have thrombosis as secondary effect. Atrophie Blanche (livido vasculitis) Segmental hyalinizing vasculitis. No PMNs unless there is ulceration minimal inflammation. Thicker red vessel wall which is distinct from collagen. Similar vascular change seen in EPP (identical histology). Lumen are primarily patent. Cryoglobulinemia Intravascular thrombosis pink thrombin in vessel lumen.

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Intravascular Thrombosis Differential Cryoglobulinemia DIC Purpura Fulminans Heparin/coumadin necrosis Lupus Anticoagulant (antiphospholipid) Prot C/S deficiency Paroxysmal Nocturnal Hematuria Pigmented Purpuric Dermatoses Perivascular lichenoid process lymphs bridging vessels (interconnection of lymphocytic infiltrate from vessels). Brownish-orange pigment not near the DE Jxn (hemosiderin). No acute inflammatory cells (eos/neuts). No vasculitis (no fibrin). Extravasated RBCs, focal parakeratosis (not seen in LP). Granuloma Faciale Grenz zone. On the face. Small aggregates of numerous cell types (lymhs, histiocytes, neuts, eos, plasma cells). +/- vasculitis. Grenz Zone Differential Granuloma Faciale Lepromatous leprosy AMML (acute myelomonocytic Leukemia) Eosinophils with hair follicles (eos on face) differential Granuloma faciale Angiolymphoid hyperplasia with eosinophilia Follicular mucinosis Contact dermatitis Arthropod bite Sweets Syndrome Diffuse neutrophils (not angiocentric), lots of nuclear debris, marked papillary dermal edema. May have RBCs. No vasculitis. Papillary Dermal Edema Differential Sweets PMLE sup and deep perivascular infiltrate Dermal EM superficial perivascular infiltrate Pernio Arthropod bites PMLE Superficial and deep perivascular lymphocytic infiltrate, marked papillary dermal edema. Pernio Acral skin. Interface change at DEJ, diffuse superficial and deep infiltrate (also around sweat glands) much more diffuse than lupus. Vacuolopathy. Papillary dermal edema. May have lymphocytic vasculitis with fibrin/thrombus. Trichotillomania (traction alopecia) Melanin casts in follicle clumps of melanin. Catagen hairs are seen (mimics outer root sheath, pale epithelium)

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Alopecia Areata Peribulbar Inflammation at the dermal subQ junction , swarm of bees (lymphocytes) around hair bulb. May have catagen hairs and miniaturized follicles. Acne Keloidalis (hidradenitis supprativa, dissecting cellulitis) Acute pustular folliculitis. Surrounding stroma has lymphoplasmacytic (not seen in regular folliculitis) infiltrate and cicatricial fibrosis. Chronic abnormally dilated hair follicle, fewer neuts. Still has lymphoplamacytic cells and cicatricial fibrosis. Hidradenitis supprativa Also get secondary sweat gland involvement, otherwise same as above. Pseudopelade Perifollicular mucinous sheath around follicle, fibrous vertical tracts where hairs used to be. Very little inflammation. Scabies Only insect that is in the stratum corneum. Demodex may be seen there (esp in hair follicle), but scabies are much larger. Will have eos/lymphs in dermis. Cutaneous larva migrans is in the epidermis. Radiation Dermatitis Pale, amorphous hylanized collagen deep and diffuse throughout dermis. Overall pallor to collagen. Radiation fibroblast difficult to find, blue-silver fibers. Telangiectasias in the upper dermis. No infiltrate. (collagen is much paler than in morphea that had red healthy collagen.) Lichen sclerosus et atrophicus Band-like lichenoid infiltrate deeper in dermis below pale zone of dermis, may have thinned epidermis. Early lesions are edematous. Late lesions are sclerotic. Alopecia Mucinosis Mucin is in follicle milky blue look to mucin. Eos/lymphs around follicles in stroma. Balloon Cell Nevus Foamy cytoplasm, Difficult to differentiate from xanthoma look for nesting cells, melanocytes in basal layer, pigment within cells in papillary dermis. Balloon cells may go into epidermis and group together. Rectangular biopsy differential Pretibial myxedema Scleredema Morphea NLD Pretibial Myxedema Separated collagen fibers throughout the entire dermis, faint blue coloration. Rectangular biopsy. No increase in fibroblasts, normal number of nuclei. Scleredema Reticular dermis collagen looks separated more than usual, need a mucin stain to confirm (colloidal iron, alcean blue). No increased fibroblasts, fenestrated collagen. Myxoid cyst Pseudocyst, not a true cyst with lining. Acral (key), myxoid stroma. Milky blue fluid with fibroblasts. Same histo as focal cutaneous mucinosis.

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Mucocele IN mouth (no granular layer). Find salivary glands. Get very small histiocytes with foamy cells mucophage. May look like suepidermal blister look for salivary glands. High propensity to rupture, may have a lot of inflammatory cells. Focal Cutaneous Mucinosis Almost identical to myxoid cyst have bump in dermis. Not acral (key). Localized mucinous deposit in dermis. Scleromyxedema (papular mucinosis)(lichen myxedematosus) Increased fibroblasts with pale staining surrounding collagen. Slight bluish nature to collagen due to mucin only mucinous process with increased fibroblasts. Fibroblasts are not histiocytic. Main Diff Dx GA. Granuloma Annulare Foci of pallisading granulomas with normal collagen in between the granulomas. NLD affects the entire dermis. GA always see palisading histiocytes in zones of necrobiosis. In NLD may have large zones of necrobiosis without palisading histiocytes. Giant cells seen in both. Plasma cells in NLD, not in GA. GA-may see mucin in granulomas not seen in NLD. NLD Rectangular biopsy, bright red collagen. Zones of inflammation, the entire collagen is affected, there are no normal areas in between. End stage NLD might look like morphea but you never see giant cells/histiocytes with morphea. May see plasma cells deeper in NLD. Eruptive Xanthoma Only xanthoma where lipid may be in the stroma all others have only foamy histiocytes. Lipid containing histiocytes dissecting between collagen. Pools of lipid (may look like necrobiosis in GA) look for bubbly cytoplasm in histiocyte. Should be obvious foam cell dont try to overread GA cells. Not every cell will have foam in it. GA interstitial Small zones of histiocytes dissecting through collagen. Histiocytes look like Idaho potatoes round nucleus. Fibroblasts are more stellate. Deep GA need to see the dermis ant other findings of superficial GA to differentiate from rheumatoid nodule. May see nuclear debris. Rheumatoid nodule Large zones of altered collagen with tight pallisaded fringe. Does not affect the dermis much deeper. Erythema nodosum Characterized by widened septa and giant cells in septum (key). May have a little to a lot of lobular inflammation, may have eos/neuts, no vasculitis, no necrosis. Alpha 1 antitrypsin Does involve the dermis. Dense neuts that affect septa and push into dermis. With time, fibrosis of septa. Pancreatic Fat Necrosis Triad: 1. lipocytes with pinkish surrounding material. 2. Surrounded by blue calcium material 3. Surrounded by neutrophils. Fuzzy pink lipocytes, blue calcium material, neuts. Subcutaneous Fat Necrosis of Newborn Radiating crystals in lipocytes and macrophages. (Sclerotic collagen in sclerema neonatorum). Sclerosing lipogranuloma (paraffinoma) Swiss cheese look. Very red sclerosed collagen. May see foamy paraffin. Big holes with sclerotic material.

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Sclerosing panniculitis (lipodermatosclerosis) May have stasis changes. Cystic degeneration of fat thickened collagen. In between lipocytes, see foamy cells (lipophages). Lipomembranous change frothy lining to the degenerated cystic areas (fuzzy red lining). Erythema Induratum Liquefying necrosis, marked neutrophilic infiltrate. May look like infectious process. Vasculitis - Fibrin in walls. Only panniculitis with necrosis. (cryptococcus may look similar). PAN Acute inflammatory cells, fibrin in wall (vasculitis of large vessel), NO necrosis. Little inflammation in fat lobules (inflammation doesnt extend far from vessels), may have thrombosis of vessels. Lupus Profundus May have DE jxn involvement, not usually however. Lymphoid aggregates (may have plasma cells) combined with pink degenerative change to fat (waxy pink look). Infiltrate may mimic lyphoid follicles. Perforating folliculitis (Kyrles) Epidermis clawed around basophilic debris with orange change to elastic fibers. Large keratin plug. Bluish junk extruded through epidermis, claw around blue stuff. EPS Small keratin plug, basophilic junk, altered thin orange fibers elastic fibers at base of debris. Reactive Perforating Collagenosis Larger opening than above (volcano like). Acanthosis on both sides of opening, no clawing. Looks like open ulcer but has basophilic debris with altered bands of eosinophilic collagen fibers in base of debris. PXE Pink squiggles visible on H&E in dermis. Very characteristic. May have calcified areas that can mimic calcinosis cutis. Monotonous Cell Differential Mastocytosis Glomus tumor Poroma Mastocytosis On low power can look like congenital dermal nevus thick on top and then splays down through collagen down low. Sheets of mast cells (granular cytoplasm with very monotonous cells, usually very round). Edema, +/- eosinophils. Mycosis Fungoides Patch/plaque stage see minimal lymphocytic atypia. Minimal spongiosis, lymphocytes are larger but not bizarre. Lymphocytes prominent at basal layer often with surrounding vacuoles (halos around lymphocytes) key to diagnosis. Melanocytes do not have such a black nucleus as the MF lymphocytes. Lymphocytic infiltrate does not obscure the DEJ. Histiocytosis X Most have unique edematous zone in upper dermis with distinct cells floating in this zone. Large cells with kidney bean nucleus (may be convoluted) with lots of cytoplasm. May have epidermotropism. Lichenoid infiltrate. Lymphomatoid Papulosis Wedge shaped infiltrate with lichenoid pattern at DE jxn, obscures DEJ.. May have extravasated RBCs. May look like PLEVA. Has large atypical lymphocytes dark staining nuclei. CD 30+ lymphoma looks identical just not wedge shaped more diffuse. LYP vs PLEVA look for eos/neuts which are seen in LyP.

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Merkel Cell Tumor Very blue on low power, clustered (cluster of grapes). Pale blue on high power (lymphomas look darker). Mitoses are dark blue. Reactive Lymphoid Hyperplasia (pseudolymphoma) Classic presentation is formation of germinal centers pale center with darker outer zones (indicated benign process). May have nodules of lymphocytes more top heavy (suggests benign process). Polymorphous infiltrate (lymphs, eos, plasma cells, etc) suggests benign process. Nuclear debris within germinal centers are called tingable bodies. Leukemia Cutis Grenz zone. Dissecting of slightly enlarged cells through the collagen. Sheetlike formation through dermis splay out at bottom. May have Indian filing but will primarily see individual floating cells. Horizontal cellular strands in reticular pattern between collagen bundles. Lymphoma Cutis May appear to have grenz zone, but there will still be a few cells floating up into the zone. 1. Large cell type complete filling of dermis, very bizarre cells. 2. bottom heavy infiltrate large nodules but NOT germinal centers. Monotonous cells in nodules, cells not as bizarre. Deep aggregates. JXG Lots of touton giant cells (multinucleated giant cells surrounded by foam, 1 touton cell does not equal JXG). If all cells are lipidized, more likely xanthoma. Some giant cells lipidized with other histiocytes = xanthogranuloma. Xanthelasma Atrophic epidermis with miniaturized hair follicles (tells you its around the eyes). Collections of foamy cells (usually nodules). Reticulohistiocytic Granuloma Lots of large red giant cells without foamy cytoplasm (have ground glass cytoplasm) look in upper dermis for cells not as obscured by inflammation. Macular Amyloid Pigment incontinence. Pink/orange globules in papillary dermis. Crystal violet stain. Nodular Amyloid Pink amorphous material in nodules, more of it than above. Colloid milium Looks very similar to nodular amyloid. May see clefts in colloid millium. Lichen Amyloid NOT lichenoid. Lichenified acanthosis, hyperkeratosis, fibrosis. Still have waxy material. LSC + amyloid = lichen amyloid. Bullous amyloid Cell poor subepidermal blister. Look for pigment incontinence and amyloid in papilla. Discoid Lupus Erythematosis (chronic lupus) Patchy vacuolopathy of the basal layer. Perifollicular infiltrate. Superficial and deep infiltrate with follicular plugging. +/- thickened BM. Jessners Lupus without interface change. Superficial and deep infiltrate of hair bearing areas. Mucin.

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Acute-Subacute Lupus Patchy vacuolopathy of basal layer. Sparse sup and deep infiltrate. No adnexal involvement or pyknotic nuclei as seen in GVH. May have more pigment incontinence. Mucin in dermis and subQ fat. Scleroderma Red collagen, lymphs/plasma cells may be there. Rectangular biopsy. NO telangiectasias (as seen in radiation). bound down appendages. Scleredema Looks like normal collagen. Reticular collagen is separated more than normal. Mucin stain should be done. Fenestration of collagen. Ochronosis Brown orange dermal deposits, very characteristic. Gout Amorphous material with milky appearance, very thin crystals in milky area (crystals are whitish to pale pink). Surrounded by mononuclear cells. Calcinosis cutis Big clumps of calcium r/o PXE. Calciphylaxis Calcium in vessels and fat. Ossified Pilomatricoma Has calcium and ossified areas, look carefully for ghost cells. Osteoma Cutis Only bony spicules no ghost cells. Amalgam tattoo Oral mucosa (mouth has pale staining epithelial cells). Wisp like black granules. Very thin and hard to see. Freeze artifact Epidermal/dermal vacuoles looks very bubbly. Tons of vacuoles. Gel Foam Purple angulated material Electrodesiccation Artifact Epithelial cells will look like fibroblasts spindling of cells. Sick look to collagen. Stringy spindled elongated epithelial cells. Dermatofibroma Nodule composed of spindle cells and haphazard oval cells, may be storiform pattern. Key is to look at periphery of lesion will see collagen trapping (small red globules of collagen). Haphazard pattern. +/- induction of epidermis (acanthosis, pilosebaceous units). Cicatrix (scar) Spindle cells in parallel horizontal fashion. May have vertical arranged vessels (not consistent). Wavy elongated fibroblasts. +/- flattened rete.

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Infantile Digital Fibroma Acral, scarlike fibroblasts (not arranged). May be whorled elongated wavy fibroblasts. PAS+. Key is acral location and red drops (globules) in stroma fibroblast area. Vimentin +, actin +. Skin Mesenchymal Malignacies Neural none Muscle leiomyosarcoma Fibers malignant fibrous histiocytoma (AFX) -DFSP Vascular Kaposis - Angiosarcoma Fibrous Histiocytoma (cellular histiocytis DF) Cellular, not as spindled (histiocytes look like Idaho potatoes). May have multinucleated cells, foam cells. Haphazard cells, storiform/fascicular architecture. Periphery start to get spindled cells with clumps of trapped collagen. May have iron pigment. DFSP Very cellular. Engulfs and swallows fat, penetrates through fat. (deep DF no cells in center of fat lobules). Cells not malignant looking, less collagen, more cellular. Storiform pattern, radiating whorled pattern. Fibrous Papules Dome shaped (acellular DF). Collagen sweeps around hair follicle. Variable vascularity. Fibrohistiocytes, fibrous stroma. May have pigment incontinence. Onion ringing around hair follicle. AFX Multinucleated cells (large bizarre cells) that are often foamy in DERMIS (epidermis looks normal). Does not extend beyond dermis. Positive for vimentin, alpha-1 antitrypsin, antichymotrypsin. Malignant Fibrous Histiocytoma Do not see any dermis (tumor is very deep) Very bizarre large cells, sheets of histioctyes. Multinucleated bizarre giant cells. Mitoses. Giant Cell Tumor of Tendon Sheath Giant cells, osteoclastic origin. Very multinucleated Giant cells (resemble osteoclasts) purple odd shaped cells, not as malignant looking at MFH. Surrounding histiocytes. +/- Hemosiderin. No mitoses. May have foam cells. Circumscribed. Giant Cell Epulis Purple giant cell up under epidermis. Odontogenic origin. Multinucleated odd shape, in the mouth. Deep Lesion Differential MFH Giant cell tumor of tendon sheath Nodular Fasciitis Myxoid liposarcoma Hibernoma Angioleiomyoma Chondroid syringoma Neurolemoma Keloid Acellular red matrix. Thick material trapping cells in between collagen. At periphery waxy spindle cells in horizontal fashion (scar cells).

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Fasicles/bundles differential Leimyoma Hypertrophic cicatrix Kaposis Leiomyoma Red orange look. Fasicles and bundles of smooth muscle cells spindle cells on end and lengthwise, not very wavy. Cells in fasicles have blunt ended nuclei (cigar shaped). +/- perinuclear vacuoles in bundles. Intermingle with collagen bundles, not as circumscribed. Hypertrophic Cicatrix Parallel fibroblasts horizontally arranged. May also have bundles. NOT red (like leimymoa). More eel-like spindle cells. Not blunt ended. Angioleiomyoma Deep tumor with a RED color. Usually very acellular. Individual cells not very helpful. Generally well demarcated (well circumscribed). Forms whorls around blood vessels. Positive for actin, desmin, vimentin. Nodular Fasciitis Deep scar with myxoid tissue, fibroblastic look (key). Rare mitoses. Thin spindle cells (like scar). Not malignant, deep tumor. Lots of mucin. tissue culture-like cells fibroblasts in loose mucoid matrix. Myxoid Liposarcoma Deep myxoid tumor with lines in tumor (lines are linear collapsed vessels). Lipoblasts vacuolated cell with indented nucleus, lipoblasts in myxomatous loose collagenous stroma with plexiform capillary pattern. Hibernoma Deep tumor, large vacuolated cells (cells with ping pong balls in cytoplasm). Well encapsulated subcutaneous tumor. Granular cell tumor Always in dermis, pink granular cytoplasm. Big cells, large nuclei. Lots of cytoplasm. Positive for S100, nerve myelin proteins, NSE. CNH Acanthosis on either side of central erosion, central fibrosis with granulation tissue beside the fibrosis. +/cartilage. Glomus Tumor Monotonous round cells. Few layers to sheets of cells. Vascular structures surrounded by very round cells. Actin positive. Angiolymphoid Hyperplasia with eosinophilia (epithelioid hemangioma) Every vessel is individual, there is no anastomosing of vessels (unlike angiosarcomas). Low power pallor around vessels with lymphoid infiltrate around that. Each vessel is discrete. Lyphs and eos in infiltrate. May have protruberant cells into vascular lumen. In hair-bearing areas (typically face). Epithelioid changes to endothelial cells with hobnailing and subendothelial vacuoles. Intravascular Papillary Endothelial Hyperplasia (Massons Pseudoangiosarcoma) Recanalizing thrombus. Seen in angiomas/venous lakes. Endothelial cells line a huge vascular space filled with breaking up collagenous material (contains little blood vessels within the collagenous islands). Loose cells/debris in lumen of vessels (angiosarcoma this occurs around vessel wall). Get collagenous fronds in lumen. Small papillary structures lying free in lumen.

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Angiosarcoma Interconnecting vascular channels trying to simulate blood vessels Vessels are anastomosed and dissect through collagen lined by hyperchromatic atypical endothelial cells, vascular slits. Cytologic atypia of endothelial cells. Hobnail cells, promontory sign free floating cells in lumen. Kaposis Plaque spindle cell proliferation (sheets of whorled spindle cells school of fish) with areas of spindle cells sandwiching RBCs (key). Usually single layer of endothelial cells. Nodular some trapped RBCs, nodular aggregates. Often ulcerated, may have granulation tissue. Slit like spaces with single filing of RBCs. Positive for factor VIII, CD31, CD34. Pyogenic Granuloma Lobular capillary hemangioma. Small spindle cells, no trapped RBCs. Lots of small vascular channels with proliferation of delicate spindle cells surrounding well formed vascular channels. Nodular proliferation of capillaries, open lumen, collarette. Angiolipoma Look for fat cells. Limited to fat. Lot of well formed vessels surrounded by spindle cells (just like PG but in fat). Finely encapsulated adipose tissue with vessels. Stasis Dermatitis Spongiosis and scale within epidermis (dermatitis). Stasis vessels are proliferations of round vessels with plump endothelial cells in the upper dermis. Extravasated RBCs, hemosiderin. Lymphangioma Acanthosis, endothelial cells line large cystic space filled with milky substance. Sclerosing angioma (hemosiderotic DF) Hemosiderin. Very cellular. Multinucleated giant cells. At periphery, get collagen trapping. Very cellular pigmented process, periphery is key. Looks like a DF. No nesting rules out melanoma. No sandwiching of RBCs and spindle cells rules out Kaposis. Granulation Tissue Edematous tissue, engorged blood vessels, cells of all types (lymphs, neuts, plasma, eos, etc). Bacillary Angiomatosis PG without ulceration with neutrophils=BA. If there is granulation tissue and the epidermis is not ulcerated, think BA. Neurofibroma Very small cells dot-like neural cells or wavy nuclei with indistinct wavy cytoplasm. Often multiple vessels. bubble gum stroma pink, delicate (fine collagen bundles like the papillar dermis, no thick reticular dermis bundles. May have engorged vessels. Well demarcated, not encapsulated. +/- interstitial mucin. Neurilemmoma May be deep tumor. Schwann cells large, wavy. Antoni B tissue myxoid degeneration at periphery. Verocay bodies acellular pink areas lined on both sides with spindle cells picket fence lining = antoni A. Encapsulated. Palisaded encapsulated neuroma Simulate nerve trunk, clefting around outside, very well demarcated. Individual nerve fasicles with large spindle cells (schwann cells). Clefts throughout. High up on dermis. Not acral. Fasicles and bundles, no true varocay bodies. Not true capsule (or very thin fibrous capsule). Seen in MEN IIB.

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Amputation neuroma (supernumary digit) Acral, nerve fasciles spread out in haphazard way. Get clefts around fascicles. Nerve twigs spindle cells in ovoid shape high in dermis in scar tissue (dense collagen). Adenoid squamous cell carcinoma Acantholysis within tumor islands, get drop out of cells makes it look glandular, left with large cells. Atypical keratinocytes. Steatocystoma Saw tooth jagged lined cyst with pink cuticle (key). Sebaceous glands in wall.

Bronchogenic Cyst Goblet cells in lining (mucoid cytoplasm). Columnar cells that are ciliated. Columnar cells with goblet cells +/cilia = bronchogenic cyst. Branchial cleft Dense lymphoid tissue around cyst lining somewhat columnar. Can get squamous lining. Cutaneous endometriosis Deep tissue, very cellular stroma. Irregular shaped glandular structures. Lining can be variable depending on cycle flat to columnar. Often have RBCs or debris in lumen. Trichofolliculoma Central cyst or dilated follicle coming off epidermis with budded follicles coming off that. Some buds form dermal papilla. Some show pale outer root sheath buds. Trichoepithelioma Interlacing reticulated pattern of basiloid epithelial cells surrounded by dense fibrotic stroma. All islands look identical to each other (Pac-man islands, recapitulates the hair bulb). NO RETRACTION. Horn cyst. May see hair bulbs. Trichoblastoma more solid, less reticulated. Same family. Morpheic BCC Islands are hyperchromatic linear piercing cells, breaking away from each other. As they go down deeper into dermis, islands become more cord-like and thinner (one layer thick). +/- stomal retraction. Hyperchromasia. May even have horn cysts. No syringomatous (ductal) component. May have calcium. +/- mucin. Trichilemmoma Outer root sheath tumor. Pale staining cells from epidermis, lobulated connects to epidermis. Palisaded cells at periphery with pink cuticle (mimics vitreous sheath). May have hyperkeratosis (wart like). Microcystic Adnexal Carcinoma Follicular and syringoid elements. Cells look benign, growth pattern is invasive however. Top part looks like syringoma. Solid balls of cells, horn cysts, glandular elements. Further down, islands get more linear, penetrating. Lower part looks like morpheic BCC (not as hyperchromatic though). Desmoplastic trichoepithelioma At the base, growth pattern stops abruptly (not infiltrative at base). Horn cysts +/- calcium. Basiloid epithelial cells in cord-like fashion. Can have ductal areas (syrinoma like areas). Fibrotic stroma. May get fibrotic rim around each island. Morpheic BCC never get syringoma like areas.

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Proliferating Trichilemmal cyst No connection to epidermis. Wall of cyst is disorganized. Pale staining cells mimic outer root sheath. No granular layer. Some areas look like pilar cyst. Always rounded, lobulated islands. Large amorphous areas of keratin, may have calcium. May have disorganized cells and mimic SCC. Pilomatricoma Ghost cells, calcium, multinucleated giant cells. Clear Cell Acanthoma Elevated, flat top. Regular epidermal hyperplasia. Very pale staining, always see neutrophils/nuclear debris in epithelium. Well demarcated pale cells from regular epidermal cells in the basal area. Trichilemmoma more vertical growth pattern. Verrucous Carcinoma Very large. No cytologic atypia. Wart gone bad. Irritated Seborrheic Keratosis (inverted follicular keratosis) Noninfiltrating base, stops abruptly. Numerous whorled keratinocytes. No atypia. Classic squamous eddies. Clonal SK Clones of epidermal cells, no atypia. Look different than regular epidermal cells. Bland cells, may be more spindly. Nested clones. Bowens Full thickness atypia. Hyperchromatosis, completely disorganized. Nevus Sebaceus Marked acanthosis. Abnormal pilosebaceous units coming off epidermis or in epidermis. Miniaturized sebaceous glands. Basaloid island trichoblastic areas, SCAP areas. +/- apocrine glands. +/- other sebaceous glands. Prominent eccrine glands. (epidermal hyperplasia with immature sebaceous glands). Sebaceous Adenoma Lobular rounded growth pattern with smooth bulbous bottom, not infiltrative. Admixture of sebocytes and germinative epitheloid cells. (no such thing as sebaceous epithelioma). +/- mitoses. Sebaceoma (sebaceous epithelioma) More haphazard arrangement not as defined base. +/- mitoses. Basaloid cells >50% of cell mixture. BCC with sebaceous differentiation Other areas classic BCC, but get areas of sebaceous cells. Sebaceous Carcinoma Sebocytes admixed with atypical squamous cells. Mitoses. Hyperchromasia. Hidrocystoma Apocrine or eccrine lining. Eccrine poroma Monotonous cells. Fibrovascular to fibroedematous stroma. Small monotonous round poroid cells, transition from epithelial cells to poroid cells. Rare ducts. Intraepithelial variant=hidrocanthoma simplex. Dermal Duct tumor Intradermal poroma. Monotonous cells, few ducts. (hidradenomas not as monotonous, cystic degeneration, clear cells).

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Cylindroma Blue lobules, multiple islands, hyaline cuticle. Hyaline droplets in islands. Spiradenoma Never see hyaline cuticle, rare hyaline deposits. Few islands. Stromal islands in basaloid tumors (blood vessels/stroma-looks like dermis). Syringoma Horn cysts, solid islands rounded epithelial cells. Eccrine glands, comma shaped. sperm in the derm Hidradenoma papilliferum Interlacing apocrine tubules compressed on top of each other. Fibrotic stroma. Nodule with interlacing elongated tubules, decapitation secretion. Well demarcated. Intradermal, no connection to epidermis. Chondroid syringomas (mixed tumor) Epithelial + mesenchymal component. Deep tumor usually dont see epidermis or dermis in biopsy. Fibromucinous stroma always present. +/- chondroid areas. 2 presentations: 1. varying size ducts syringoid ducts and elongated ducts in fibromucinous stoma +/- cartilaginous area. 2. small syringomatous ducts only, fibromucinous stroma +/- cartilaginous area. Basophilic mucoid pseudocartilagenous component plus epithelial eccrine ductal component. Eccrine mucinous carcinoma Significant pools of mucin with epithelial cells floating in mucin. Cells not very atypical. Metastatic Renal Cell CA Large dermal nodules with clear cells. On higher power, lots of blood vessels and cytologic atypia. Mitoses. Hyperchromatism. Blood vessels + low grade atypia. Nodular Hidradenoma (Clear Cell Hidradenoma) Some fusiform cells, some cuboidal. No mitoses. Clear cells. May have cystic degeneration (solid cystic hidradenoma). Not as monotonous as poroidal cells. Occasional sclerotic stroma, may have ducts. Syringocystadenoma papilliferum Form true vili. Plasma cells in stroma. Apocrine secretion at periphery. Connects to epidermis (hidradenoma papilliforum not true vili stacked glands). Metastatic Breast CA Very deep, cytologic atypia, glandular structures, hyperchromatic piercing single file cells (Indian filing). May have larger islands. Spitz nevus Symmetrical melanocytic lesion near DEJ vertical nests of spindle cells, little involvement of epidermis. May rarely have cells migrating into epidermis. Clefted artifact. May have rare mitoses in superficial dermis only. Deep mitoses generally mean malignant. Splaying out of collagen down deep, somewhat wedge shaped. Less cellular deeper in dermis. Epithelioid deeper. Mostly nests in epidermis (single cells in epidermis predominate over nests in melanoma). May have lots of pigment. Kamino bodies red globules. Dont worry as much about cytology, hard to tell. Superficial spreading melanoma More single cells in epidermis, nests also, atypical cells. Mitoses deep. No maturation big cells at base. Asymmetry. Cellular. Dermal spitz Still clefting, spindle cells, nests are deeper. Splay collagen. Matures as it deepens, cells get smaller.

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Pagets Disease Clear cells in epidermis, but cytoplasm has mucoid substance. No melanin. Fuzziness to cells. Bluish tinge around nucleus, larger than melanocytes. Bubbly nature. Atypical cells above basal layer never see that with melanoma (always involves basal layer in melanoma). May nest. Lentigo maligna melanoma Typically spindled cells, go down hair follicles. Less likely to have upward migration into epidermis. Basal layer only involved which tracts down hair follicles. Pigmented spindle cell nevus (of Reed) Symmetrical. Pigmented spindle nests arranged vertically. Several spindle cells migrating above nests. Pigmented parakeratosis. Cleft artifact. Recurrent Nevus Epidermal component can look like melanoma. Look for scar. Upper part looks like lentigo maligna typically. Proliferation of single celled melanocytes along basal layer, may look atypical. May see dermal nevus cells under scar. Congenital nevus Larger, splay out collagen as they go deeper, around adnexals follicles, glands, smooth muscle. Doesnt fill collagen, more cellular toward top. Nevus of ito (dermal melanocytosis nevus of ota, Mongolian spot) Proliferation of pigmented spindle cells, not very dense. Very scattered pigmented cells throughout dermis. Much less cellular than blue nevus. Brown granules. Elongated bipolar melanocytes scattered in collagen. Lead tattoo Black deposits. Inert, does not initiate inflammatory response. Clumps of pigment (may get tattoo granuloma if allergic to dye of tattoo). Cellular blue nevus Lots of pigment deep, more cellularity as you get deeper. Spindle cells, pigmentation. In pigmented area cells look more like histiocytes. Thickened collagen, spindled pigment cells upper portion. More pigmented areas deep cells look more histiocytic. May even nest down deep. Not mitoses. Not atypical. Nodular melanoma May be symmetrical. Very cellular, space occupying lesion see little dermis. Cytologically atypical. Nests mitoses, hyperchromasia. Tuberculoid leprosy See granulomas (nodules of epithelial cell histiocytes with indistinct cell membrane one mass of cells). Sarcoid granulomas in leprosy with perineural involvement. Granulomas are often more linear than in sarcoid (because they follow vessel/nerve). Look deeper in dermis find nerve twig (little spindle cells with delicate stroma). Sarcoidal granulomas differential Sarcoid Tuberculoid leprosy TB (lupus vulgaris) Foreign body (zirconium, selenium, etc) Crohns Melkersons Rosenthal Chromoblastomycosis Borderline leprosy Cells become paler, less pink.

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Sarcoid Round granulomas. May have a little inflammation, but still naked tubercles. For TB, lots of lymphs. Granulomatous rosacea Caseous necrosis, dense granulomatous infiltrate. Hair bearing area (face). Giant cells. May be smaller granulomas. Usually single focus, looks like TB granuloma. Suture granuloma Tiny black dots in fasicles. Yellowish on low power. Keratin Granuloma Granulomas, giant cells, clefts with pink material inside, giant cells surrounding this. Lepromatous leprosy Grenz zone + sheets of epithelioid histiocytes indistinct margins, cant see cell membranes. Nonfoamy. Pale staining. Orf Ballooned keratinoctyes. Acral. Usually up into stratum corneum and upper epidermis. NO multinucleated giant cells, just ballooning degeneration. Leishmaniasis Lymphohistiocytic, usually not granulomas. Dense infiltrate. Dot like organisms. One feature (histoplasmosis has tiny halos around organisms not seen in leishmaniasis, only difference). Organisms in giant cells, histiocytes, or stroma. Cryptococcus Gelatinous matrix white area around organism. Larger than histoplasmosis. Vacuolated areas with spores free in tissue little inflammation. Blastomycosis Psuedoepitheliomatous hyperplasia. Broad based budding, double capsule on organism. Abscess. Giant cells. Coccidiomycosis Pseudoepithelial hyperplasia, abscess. Large. Grey-silver round spores inside organism (spores inside a spore). (rhinosporidium looks similar but 20xs larger). Grey organism, little round halos inside. Paracoccidiomycosis Mariners wheel Chromomycosis Dematiaceus (brown) fungi. Sarcoidal granulomas. 5 round copper pennies. Botryomycosis Sulfure granules. Dark blue illicit large inflammatory response. Sulfur granules made up of organisms usually staph when dark blue. Purplish red granules cant tell organism. Purple granules with clubs off edge=actinomyces. Tinea Nigra Brown hyphae in stratum corneum, acral. Talo noir Orange material in stratum corneum.