Quiz 19: What is your diagnosis?

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Diagnosis: Quiz 19

Quiz 19

Answer:  Psoriasis, erythrodermic

Criteria for diagnosis histopathologically:  An acanthotic epidermis that is covered in part by staggered mounds of parakeratosis housing numerous neutrophils and elongated dermal papillae containing dilated tortuous capillaries and lymphocytes around venules of the superficial plexus sum up to the diagnosis of psoriasis.

Differential diagnosis histopathologically: There is none.

Criteria for diagnosis clinically: A diffuse erythema covered by coarse scales that have a raised edge is the presentation of psoriasis at the erythrodermic stage. Gross examination of the nails and joints can help to come to a correct diagnosis when changes of psoriatic onychopathy and or psoriatic arthritis are present.

Differential diagnosis clinically: Other diseases can clinically present as erythroderma, including mycosis fungoides, pityriasis rubra pilaris, drug eruptions, atopic dermatitis, and allergic contact dermatitis. Therefore, a skin biopsy is necessary to come to the correct diagnosis.

Clinico-pathologic correlation:  The erythema is related, in large measure, to dilation of venules and capillaries in the upper part of the dermis. The scale-crust is a manifestation of the zones of hyper- and parakeratosis that contain many neutrophils.

Options for therapy predicated on knowledge of histopathologic findings:  There are different treatment options for erythrodermic psoriasis. The severity of disease, the course (acute onset or chronic disease), and the presence of comorbidities have to be taken into consideration when choosing a particular therapy. Cyclosporine and infliximab seem to have the most rapid onset of action. Alternatively, acitretin and methotrexate can be used, but these drugs work more slowly and might be only effective in combination with other therapies.

1) Erythroderma is one of the various clinical expressions of psoriasis. Histopathologically the typical changes of fully developed psoriasis are present: dilated tortuous capillaries in thin dermal papillae, edema of the papillary dermis, a thinned granular zone, epidermal pallor, psoriasiform hyperplasia, an increased number of mitotic figures in the suprabasal layer of the epidermis, and a sparse lymphocytic inflammatory infiltrate in the upper part of the dermis.

2) In erythrodermic psoriasis the proliferation of keratinocytes is dramatically increased, and this severely affects their differentiation, leading to a near absence of a cornified layer and to the presence of viable keratinocytes instead of corneocytes.

3) The near absence of scale in an otherwise typical lesion of psoriasis is a clue to erythrodermic psoriasis. The absence of mounds of parakeratotic cells might be due to exfoliation or to an artefact caused by fixation of specimens with formalin.

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