The fundamental

histologic changes in
skin diseases
Dr. Mahmud Ghaznawie, PhD.
Anatomi Kulit
e = epidermis
d = dermis
s = sebaceous
gland
g = eccrine gland
sc = corneal layer
m = melanocyte
mc = mast cell
v = vessel
Lc = Langerhans
cell
h = hair
Skin Tumors
Nevus pigmentosus
intradermalis
Nevus cells
grow
diffusely into
the deep
dermis
 Nevus pigmentosus

Junctional nevus Intradermal nevus cell

Displastic nevus

Lamellar Fibroplasia Atypical Nevus cell

Displastic
nevus
Irregular
border
Varied
coloration
Diameter
> 5 mm
Progression of nevus to melanoma
Melanoma
maligna
Warna

bervariasi
Ukuran
besar
Tepi
ireguler
Tumbuh
noduler
Perubahan
rasa
Perdarahan
Melanoma maligna
Melanoma maligna
Perhatika
n ukuran,
bentuk,
inti sel,
dan
nukleolus
Keratosis
seboroik
Lesi
berpigmen,
batas tegas,
permukaan
kasar, bisa
multipel dan
bergabung
Keratosis
Keratoakantoma
Keratoakantoma

Perhatika
n ciri sel
yang
glassy
 Multipel
silindroma
Siringoma
Bentuk kecebong
 Trikoepiteliom
a

Struktur hair bulb primitif

Diferensiasi ke arah folikel rambut
 Aktinik keratosis

Normal
Displasia

Hiperkeratos
is
Karsinoma in situ
Karsinoma sel
skuamous
Karsinoma

sel
skuamous
Karsinoma sel
basal
Karsinoma sel
basal
Histiositosis-X
Mikosis
fungoide
s
Mikosis fungoides
INFLAMATORY SKIN
LESIONS
Lesion and eruption
(rash)
Lesion: describes an area of
disease - usually small

Eruption (or rash): describes

more widespread skin involvement,
normally composed of several
lesions which may be the primary
pathology or due to secondary
factors (scratching, infection, etc.).
 Primary lesions are
Primary the first to appear
lesions and are due to the
disease or abnormal
state.

Macule Pustule
Papule Cyst
Nodule Plaque
Vesicle
Wheal
Bulla
 Result from the natural
Secondary evolution of primary lesions
lesions (eroded area left by
bursting vesicle) or from
the patient's manipulation
of the primary lesion
(scratching).

Scale Lichenificatio
Ulcer n
Crust Atrophy
Erosion Scar
Excoriation
Macule

Macule: flat, nonpalpable circumscribed area of

change in the skin. Macules are < 1-2 cm in
size.
1. Macules may be the result of
(A) hyperpigmentation (e.g. brown as in lentigos),
(B) depigmentation (e.g. vitiligo),
(C) vascular dilation (e.g. erythema)

2. Multiple well-defined macules of various

shapes and sizes. In this case, the macules
blanch upon pressure
(diascopy) and thus are due to inflammatory
vasodilation.
Papule
Papule: small solid elevation of skin
generally < 5 mm in diameter. The majority
of the papule elevation projects above the
plane of the surrounding skin. Papules may
be flat-topped, as in lichen planus; or dome
shaped, as in xanthomas; or spicular,
ifrelated to hair follicles.
 1. Papules may result from
(A) dermal metabolic deposits,
(B) localized dermal cellular infiltrates,
(C) localized hyperplasia of dermal or
epidermal cellular elements.
2. Two firm dome-shaped papules -
dermal melanocytic nevi.
3. Multiple well-defined and coalescing
papules - lichen planus.
Nodule

Nodule: palpable, solid, round, or ellipsoidal

lesion. Its depth of involvement and/or
palpability differentiate it from a papule
rather than its diameter (although nodules
are usually larger than papules: > 5 mm
diameter). Nodules can involve any layer of
the skin and can be edematous or solid.
Based on the anatomical component(s)
involved, there are five types of nodules:
epidermal, epidermal-dermal, dermal,
dermal-subdermal, and subcutaneous.
 1. Nodule can be located in
(A) the dermis and subcutaneous layer or in
(B) the epidermis.

2. Firm well-defined nodule with a smooth and

glistening surface through which dilated capillaries
(telangiectasia) can be seen; there is central
crusting due to tissue breakdown and thus
ulceration - nodular basal cell carcinoma

3. Multiple nodules varying in size - melanoma

metastases
Vesicle & Bulla
Vesicle (blister): circumscribed, elevated lesion
that is < 5 mm in diameter containing serous (clear)
fluid.

A vesicle/bulla is the technical term for blisters.

Vesicle walls can be so thin that the contained
serum, lymph, blood, or extracellular fluid is easily
seen. Fluid can be accumulated within or below the
epidermis.

Bulla: A vesicle with a diameter > 5 mm.

(A) subcorneal vesicle - fluid just below stratum corneum,

(B) spongiotic vesicles - intercellular edema.
Vesicle &
Bulla
Mechanisms of blister
(A) Acantholytic vesicles - cleavage within
epidermis due to intercellular attachment loss

(B) Balloon degeneration of epidermal cells in

certain viral infections leads to vesicles.

(C) Intercellular edema

(D) Subepidermal vesicles due to changes in

dermal-epidermal junction
 Acantholysis

Acantholytic vesicles - cleavage within

epidermis due to intercellular attachment
loss
Cell Balooning

Balloon degeneration of epidermal cells in certain

viral infections leads to vesicles, e.g. Herpes Zoster
Spongiosis
intercellular edema
Subepidermal blister
Pustule

Pustule: superficial, elevated lesion that

contains pus (pus in a blister). Pustules may
vary in size and shape. The color may appear
white, yellow, or greenish-yellow depending on
the color of the pus. Pus is composed of
leukocytes with or without cellular debris. It may
also contain bacteria or may be sterile.

1. A pustule is basically a papule containing pus.

2. Superficial, subcorneal pustules - pustular

psoriasis.
Cyst

Cyst: an epithelial lined cavity containing liquid

or semisolid material (fluid, cells, and cell
products). A spherical or oval papule or nodule
may be a cyst if, when palpated, is resilient
(feels like an eyeball).
Most common are
(A) epidermal cysts, lined by squamous epithelium
and produce keratinous material.
(B) Pilar cysts, lined by multilayered epithelium which
does not mature through the granular layer.

Bluish, resilient cyst filled with mucous material

- adnexal tumor (cystic hidradenoma).
Plague
Plaque: palpable, plateau-like
elevation of skin, usually more than 2
cm in diameter and rarely more than
5 mm in height. Often formed by a
convergence of papules, as in
psoriasis.

1. Plaques occupy a relatively large

surface area in comparison with its
height above the skin.

2. Well-defined, reddish, scaling

plaques.
Wheal = urtica
Wheal: transitory, compressible papule or
plaque of dermal edema.
Wheal is usually rounded or flat-toped,
and evanescent, disappearing within
hours.
The borders are sharp, but not stable and
can move from involved to adjacent
uninvolved areas over hours. The
epidermis is not affected. Wheals can be
pale red or white (especially in the center)
if edema is sufficient to compress
superficial vessels. Wheals are a common
allergic reaction.
2. A wheal may be large coalescing
plaques as in this allergic reaction.
Scale /
squama

Scale: accumulation or abnormal shedding

of horny layer keratin (stratum corneum) in
perceptible flakes. The change may be
primary or secondary. Scales usually
indicate inflammatory change and
thickening of the epidermis. The may be
fine, as in pityriasis; white and silvery, as in
psoriasis; or large and fish-like, as in
ichtyosis.

Parakeratotic scale (with retained nuclei) can be

seen in psoriasiform epidermal hyperplasia.
Actinic keratoses is a densely adherent scale with
gritty feel due to a localized increase in stratum
corneum.
Ulcer = ulcus
Ulcer: circumscribed area of skin
loss extending through the
epidermis and at least part of the
dermis (papillary).

1. Basically, it's a "hole in the skin".

Ulcers usually result from the
impairment of vascular and nutrient
supply to the skin.

2. Gigantic ulcer, red granulating

base with punched out borders.
Crusta = crust
Crust: dried serum, blood, or pus on
the surface of skin.
1. May be thin, delicate, and friable
or thick and adherent. Crusts are
yellow, if from serum; green or
1.
yellow-green if from pus; or brown or
dark red if formed from blood.
Characteristic of pyogenic infections.

2. Crusts that occur as honey-

coloured, delicate, glistening
particulates are typical of - Impetigo.
Erosion
Erosion: moist, circumscribed,
usually depressed lesion due to loss
of all or part of the epidermis
1. Often results from eruptions of vesicles
and bullae. Seen in infection from
herpes viruses and in pemphigus.
2. Toxic epidermal necrosis causes
erosion.

Excoriation: linear or punctate

superficial excavations of epidermis
caused by scratching, rubbing, or
picking.
Lichenification
Lichenification: chronic thickening of
the skin along with increased skin
markings. Results from scratching or
rubbing

Note the increased skin markings

Atrophy
Atrophy: paper-thin, wrinkled skin with easily visible
vessels. Results from loss of epidermis, dermis or
both. Seen in aged, some burns, and long-term use of
highly potent topical corticosteroids.

Dermal atrophy manifests as a depression in the skin.

Epidermal atrophy manifests as thin almost transparent
skin; may not retain normal skin lines.

Dermal and epidermal atrophy. There is loss of normal

skin texture, thinning and wrinkling.
Scar
Scar: replacement of normal tissue by
fibrous connective tissue at eh site of
injury to the dermis. Scars may be
hypertrophic, atrophic, sclerotic or hard
due to collagen proliferation. Reflects
pattern of healing in the affected area.

(A) Hypertrophic or (B) Atrophic scar.

Vesicobullou
s

Pemphigus vulgaris
showing suprabasal
acantholysis
 Bullous pemphigoid

Pemfigoid
bulosa
Dermatitis
herpetiformis
Epidermolisis
bullosa
Granulomatous Reaction

Leprosy
Fungal infection
Scabies