Abstract
Introduction:
Spongiosis is defined as intercellular edema and vesicles in the epidermis. Histopathology is the gold standard for the diagnosis of spongiotic disorders. Clinical diagnosis of eczema is sometimes unclear and confused with other dermatoses; histopathology often shows spongiotic tissue reaction patterns; such conditions are called spongiotic disorders. It is challenging for a dermatologist to make the correct diagnosis noninvasively with a dermoscope and thus we have taken up the study to correlate the dermoscopic and histopathological findings in spongiotic disorders to set dermoscopic criteria for the diagnosis.
Objective:
To study the dermoscopic features of spongiotic disorders and correlate clinical, dermoscopic, and histopathological findings.
Materials and Methods:
Two hundred fifty two patients, with history and clinical presentation suggesting eczema were enrolled. They were classified as Acute (<6 weeks), Subacute (6 weeks to 3 months), and Chronic (>3 months) eczemas based on duration. Dermoscopy and skin biopsy were performed on representative lesions. Data were compiled and statistically analyzed using frequency distribution and Chi-square test.
Results:
We correlated the diagnosis based on acute, subacute, and chronic with three modalities, clinical examination, dermoscopy, and histopathology. On clinical examination, acute (27.4%), subacute (42.9%), and chronic (29.7%) dermatitis. On dermoscopy, acute (28.5%), subacute (40.4%), and chronic (31.1%) dermatitis. On histopathology, acute (29.5%), subacute (44.2%), and chronic (26.3%) spongiosis. A positive correlation of 99%, 96.2%, and 95% was observed on dermoscopy and histopathology, in acute, subacute, and chronic eczemas, respectively. Dermoscopy of acute eczemas showed linear vessels (100%) and red background (100%). White-Clods (98.9%) and excoriation marks (70.1%). Dermoscopy of subacute eczemas showed white scales (99.1%), irregular pigment network (98.3%), vascular changes with irregular dots (97.4%), a brown-white background (93.1%), and black/brown/grey dots (91.4%). Dermoscopy of chronic eczema showed brown-white background (100%), irregular pigment network (100%), and black/brown/grey blotches (100%).
Conclusion:
Definitive dermoscopic patterns are observed consistently with spongiotic diseases and these can be used additionally to set dermoscopic criteria and confirm the diagnosis. Also, dermoscopic findings are well correlated with the already established histopathological features.
KEY WORDS: Dermoscopy, eczemas, skin diseases, spongiosis, spongiotic disorders
Introduction
Clinical diagnosis of eczema is commonly confused with psoriasiform and lichenoid dermatoses and histopathology is the gold standard to confirm the diagnosis. Clinically, we classify eczemas as acute (<6 weeks), subacute (6 weeks to 3 months), and chronic (>3 months) based on the duration and clinical morphology of lesions.[1,2] It is challenging for a dermatologist to make the correct diagnosis noninvasively with a dermoscope in a short duration.[3] Dermoscopy is a noninvasive skin imaging technique performed using a handheld device that permits the visualization of surface as well as subsurface structures in the form of colors, and patterns in skin lesions, often imperceptible to the naked eye. Some dermoscopic patterns are observed consistently with certain diseases, which make it a useful aid for differential diagnosis, prognostic evaluation, and monitoring of the treatment response.[4,5] Thus, this in-office procedure may eventually obviate the need for skin biopsy for diagnosis and follow-up in a few of the dermatoses.[6,7] However, dermoscopic findings need to be correlated with the clinical and histopathological characteristics of lesions to validate it as a competitive method or alternative to biopsy and establish it as a link between microscopic and macroscopic features.[8,9,10] There are no studies available on the dermoscopic and histopathological correlation of spongiotic disorder, especially those describing the stage-wise evolution of these diseases. Hence, this study aims to establish the differentiating dermoscopic patterns for various spongiotic disorders and correlate them with corresponding clinical and histopathological characteristics.[8]
Objective
To study the dermoscopic features of spongiotic disorders and to correlate clinical, dermoscopic, and histopathological findings.
Materials and Methods
This was a hospital-based cross-sectional observational study that comprised 252 patients with histopathological diagnoses of spongiotic disorders, attending the outpatient clinic of the Department of Dermatology in a tertiary care hospital in Maharashtra. The sample size was calculated with calculation by prevalence’ which showed n = 196. After obtaining clearance and approval from the Institutional Ethics Committee, patients clinically diagnosed with dermatitis and histopathologically as spongiotic disorders were included in the study [Table 1a] after written informed consent. A detailed history of patients was taken. Demographic data in terms of age, gender, and clinical variables such as site and duration of the lesions were documented. Patients with active infections, coagulation disorders, and sensitivity to anesthetic agents were excluded. Based on the duration, they were classified into acute (<6 weeks), subacute (6 weeks to 3 months), and chronic (>3 months). Lesions with intense erythematous plaques with edema, erosion, and oozing were selected as acute dermatitis, and lesions having mild erythema with crust and peripheral hyperpigmentation were considered as subacute dermatitis. The lesions presenting with lichenification were categorized as chronic dermatitis.[11,12]
Table 1a.
Cases included in the study
| Serial number | Diseases |
|---|---|
| 1. | Atopic dermatitis |
| 2. | Seborrheic dermatitis |
| 3. | Pityriasis rosea |
| 4. | Polymorphic light eruption |
| 5. | Phytophotodermatitis |
| 6. | Nummular dermatitis |
| 7. | Prurigo nodularis |
| 8. | Lichen simplex chronicus |
A dermoscopic examination was performed on the ‘target’ lesions with a handheld Heine delta 20 dermoscopy with 10× magnifications, attached to a mobile attachment to capture images. Both polarized and nonpolarized modes were used with ultrasound gel as an interface medium. This was followed by a punch biopsy of 4 mm from the ‘target’ lesion for histopathological correlation. Clinical and histopathological photographs were taken. Patients diagnosed clinically with eczema but failed to show spongiotic reaction patterns on histopathology were also excluded from the study. Data were entered in a Microsoft Excel sheet, 2010. Categorical variables were expressed in frequency and percentages. The association between the final diagnosis of spongiotic disorders and other study parameters was carried out by performing Chi-square test. P < .05 was considered statistically significant. We also did a frequency distribution for other parameters where we could not apply Chi-square test. These findings were used to set criteria to diagnose various spongiotic disorders and to categorize the patients as acute, subacute, and chronic based on dermoscopic examination [Table 2b]. The terminology used to describe the dermoscopic findings is adopted from the International Dermoscopy Society consensus.[8]
Table 2a.
Dermoscopic and histopathological presentation of acute, subacute, and chronic spongiotic disorders
| Chronicity | Dermoscopy | Histopathology |
|---|---|---|
| Acute | -Irregular pigment | -Microvesicles |
| - Linear vessels | - Irregular psoriasiform hyperplasia | |
| - Pink-red background | - Dilated nontortuous vessels | |
| - White clods | - Infundibular spongiosis -Eosinophils in superficial perivascular infiltrate | |
| - Excoriation marks | - Papillary dermal edema | |
| - Vascular changes with irregular dots | - Exocytosis | |
| -Yellow-orange clods (in few) | ||
| Subacute | -White scales or peripherally attached scales | -Parakeratosis |
| - Irregular pigment network | - Infundibular spongiosis | |
| - Brown-white background | - Dilated nontortous vessels | |
| - Black/brown/grey dots | - Papillary dermal edema | |
| -Vascular changes with irregular dots | In few cases, | |
| -Superficial and deep perivascular lymphohistiocytic infiltrate | ||
| - Exocytosis | ||
| - Hyperkeratosis | ||
| - Extravasation of erythrocytes | ||
| Chronic | -Brown-white background | -Spongiosis with hyperkeratosis and focal parakeratosis, |
| - Irregular pigment network | - Acanthosis, | |
| - Black/brown/grey blotches | - Hypergranulosis | |
| -White dots, clods, blotches | - Dilated nontortuous vessels, lympho-histiocytic infiltrate | |
| - Subepidermal fibrinoid degeneration | ||
| - Papillary dermal fibroplasia | ||
| - Dilated and plugged follicles | ||
| -Infundibular spongiosis |
Table 2b.
Dermoscopic and histopathological correlation of various spongiotic disorders
| Diagnosis | Dermoscopic features | Histopathology features |
|---|---|---|
| Atopic dermatitis | Hypopigmented zones [Figure 1a] Brown dots [Figure 1a] Crown of branched vessels with central hypopigmentation [Figure 1b] Dotted vessels seen too in some cases. Yellow orange clods [Figure 1c] Brown rim around clods [Figure 1c] | Spongiosis with intercellular edema in the Stratum Spinosum [Figure 1d] Areas of pigment clumps in stratum corneum. Hemosiderin. Dilatation of dermal vessels [Figure 1d] RBCs extravasation, hemosiderin and plasma globules [Figure 1d] Denuded epidermis. |
| Seborrheic Dermatitis | Hypopigmented zones [Figure 2a] Disturbed pigment network [Figure 2b] Diffuse pink background [Figure 2b] Yellow scales Grouped linear vessels | Spongiosis [Figure 2d] Psoriasiform hyperplasia of the epidermis [Figure 2c] Dilatation of capillaries with inflammatory infiltrate. Exudate with plasma. Dilated capillaries |
| Pityriasis Rosea | Hypopigmented zones Decreased pigment network [Figure 3a] Collarette scale [Figure 3b] Brown dots [Figure 3a] | Spongiosis with intercellular edema Pigment dilution [Figure 3c] Hyperkeratosis and parakeratosis [Figure 3d] Extravasated RBCs, collection of dried plasma and melanin in stratum corneum. |
| Polymorphic Light Eruption | Zone of crusting [Figure 4a] Brown dots [Figure 4b] | Collection of plasma and neutrophilic debris above the stratum corneum [Figure 4c] Extravasated RBCs, collection of dried plasma and melanin in stratum corneum [Figure 4c and d] |
| Phytophoto Dermatitis | Yellow-orange clod [Figure 5a] Bluish background [Figure 5b] Hypopigmented halos [Figure 5a] Brown dots [Figure 5b] | Plasma exudate [Figure 5c] Melanin incontinence Acanthosis and pigment clumping [Figure 5d] Follicular plugging [Figure 5d] |
| Nummular Dermatitis | Yellow-orange clods [Figure 6a and b] Crusting and red dots [Figure 6a and b] Scales [Figure 6a and b] | Plasma globules, RBCs [Figure 6b] Plasma, neutrophilic debris, and RBCs [Figure 6c] Parakeratosis [Figure 6d] |
| Prurigo nodularis | Star burst pattern [Figure 7a] White clods [Figure 7a] Brown dots [Figure 7a] | Irregular pigment distribution and acanthosis [Figure 7b] Spongiosis and intercellular edema [Figure 7b] Melanin in stratum corneum |
| Lichen simplex chronicus | Fine scaling [Figure 8a] Increased pigment network [Figure 8a] | Hyperkeratosis and parakeratosis [Figure 8b] Melanin in stratum corneum [Figure 8b] |
Results
In the present study, an age-wise distribution of all dermatitis revealed that the maximum occurrence was in the age group of 31-40 years (24.1%) and the least below 10 years of age (3.4%).
A gender-wise distribution in eczemas was studied that showed that were noticed more among men (52.9%) as compared to women (47.1%).
Acute dermatitis
In the present study, the most common acute dermatitis observed was atopic dermatitis (34.5%) followed by seborrheic dermatitis (22.4%).
Most common changes observed on dermoscopy were linear vessels (100%), pink and red background (100%), white clods (98.9%), and excoriation marks (70.1%). Vascular changes with irregular dots, yellow-orange clods, and irregular pigment were observed in 65.5% of patients. Figures 1a to 1f show dermoscopic and histopathological findings of atopic dermatitis. The most common histopathological findings observed during this study were microvesicles, irregular psoriasiform hyperplasia, dilated nontortuous vessels, infundibular spongiosis, eosinophils in superficial perivascular infiltrate, papillary dermal edema, and exocytosis in all 74 patients.
Figure 1.
Dermoscopy and histopathology of atopic dermatitis (a) White areas and brown dots (b) A white area surrounded by linear branching vessels (c) Reddish-yellow areas (yellow clod sign), brown pigment, and dotted vessels (d) Histopathology shows vascular changes with extravasation of RBCs (hematoxylin and eosin stain, 40×)
Figure 2.
Dermoscopy and histopathology of seborrheic dermatitis (a) White areas and distorted pigment network (b) Short linear vessels (c) Histopathology shows vascular and inflammatory changes (hematoxylin and eosin stain, 10×) (d) Histopathology shows epidermal changes (spongiosis) (hematoxylin and eosin stain, 40×)
Figure 3.
Dermoscopy and histopathology of pityriasis rosea (a) dark brown globule, white areas with brown background (b) Collarette scale (c) Histopathology shows intraepidermal changes (hematoxylin and eosin stain, 40×) (d) Histopathology shows changes in stratum corneum (hematoxylin and eosin stain, 40×)
Figure 4.
Dermoscopy and histopathology of polymorphic light eruption (a) Reddish-brown globules, brown dots, white areas, slight scales are noted (b) Brown dots with white scales (c) Histopathology shows epidermal changes (hematoxylin and eosin stain, 40×) (d) Histopathology shows intraepidermal changes (hematoxylin and eosin stain, 40×)
Figure 5.
Dermoscopy and histopathology of phytophotodermatitis. (a) Brown areas, perifollicular white halo, distorted pigment network, brown background (b) Yellow clod sign, distorted pigment network, white areas, (c and d) Histopathology shows epidermal changes (hematoxylin and eosin stain, 40×)
Figure 6.
Dermoscopy and histopathology of nummular dermatitis. (a) Clustered arrangement of red globules and white scales on a brownish yellow background (b) Red dots, yellow globules, and white scales (c) Histopathology shows inflammatory changes (hematoxylin and eosin stain, 40×) (d) Histopathology shows parakeratosis with plasma in the stratum corneum (hematoxylin and eosin stain, 40×)
Figure 7.
Dermoscopy and histopathology of prurigo nodularis. (a) White areas with red dots and structures with white scales. Brownish striations at the periphery (star burst pattern) (b) Histopathology shows epidermal changes (hematoxylin and eosin stain, 10×)
Figure 8.
Dermoscopy and histopathology of lichen simplex chronicus. (a) White areas, distorted pigment network, greyish brown background (b) Histopathology shows epidermal changes (hematoxylin and eosin stain, 10×)
Subacute dermatitis
The most common subacute condition in the present study was seborrheic dermatitis (28.40%) followed by nummular dermatitis (23.30%) and pityriasis rosea (20.70%).
The most common findings on dermoscopy in subacute dermatitis were white scales (99.1%), irregular pigment network (98.3%) followed by vascular changes with irregular dots (97.4%), brown-white background (93.1%), black/brown/grey dots (91.4%), and peripherally attached scales (80.2%). Other least common changes were pinkish white background (59.5%) followed by linear vessels (56%) and yellow-orange clods (44%).
The most common parameters for diagnosis of subacute spongiosis on histopathology were parakeratosis (100%), infundibular spongiosis (100%), dilated nontortous vessels (100%), and papillary dermal edema (100%). Other parameters were superficial and deep perivascular lymphohistiocytic infiltrate (93.1%), exocytosis (80.2%), hyperkeratosis (52.6%), and extravasation of erythrocytes (51.7%).
Chronic dermatitis
The most common chronic conditions observed clinically were prurigo nodularis (28.6%) followed by phytophotodermatitis (24.5%) [Figure 9] and lichen simplex chronicus (20.40%).
Figure 9.
Clinical photographs of phytophotodermatitis
The most common dermoscopic features were brown-white background (100%), irregular pigment network (100%), and black/brown/grey blotches (100%). Other changes were black/brown/grey dots (71.4%), black/brown/grey clods (71.4%), white dots (63.3%), white clods (51%), white blotches (51%), and white scales (40.8%).
Histopathologically, chronic dermatitis showed acanthosis, spongiosis with hyperkeratosis and focal parakeratosis, dilated nontortuous vessels, and lymphohistiocytic infiltrate in all the cases. Other findings were hypergranulosis (85.7%), subepidermal fibrinoid degeneration (85.7%), papillary dermal fibroplasia (85.7%), dilated and plugged follicles (42.9%), and infundibular spongiosis (41.4%).
In the present study, we correlated the diagnosis based on acute, subacute, and chronic with three modalities viz. clinical examination, dermoscopy, and histopathology as shown in Table 1b.
Table 1b.
Correlation between acute, subacute, and chronic dermatitis diagnosed with clinical, dermoscopic, and histopathology
| Acute Percentage (n) | Chronic Percentage (n) | Subacute Percentage (n) | |
|---|---|---|---|
| Clinically | 27.40% (69) | 29.70% (75) | 42.90% (108) |
| Dermoscopy | 28.50% (72) | 27.80% (70) | 43.70% (110) |
| Histopathology | 29.50% (74) | 26.30% (67) | 44.20% (111) |
A positive correlation of 99%, 96.2%, and 95% was noted between dermoscopy and histopathology for acute, subacute, and chronic dermatitis, respectively [Table 2a]. It was noted that the dermoscopic features in the various stages of all the spongiotic disorders were well correlated with the histopathological findings in all patients irrespective of the other variables like age, gender, and site of involvement as shown in Table 2.
Discussion
This study offers a unique perspective on diagnosis, using an efficient, safe, rapid, and noninvasive diagnostic tool that correlates well with the already studied clinicohistological features. The results in the present study would facilitate to propose dermoscopic criteria in spongiotic dermatoses. M Corazza et al. studied dermoscopy of patch test reactions of allergic versus irritant contact dermatitis. In allergic contact dermatitis, intense erythema appeared dermoscopically as pinkish red background and vesiculation as whitish circular elements, varying in size and number, either sharp or slightly blurred, similar to soap bubbles. Vesicles were present either isolated inside the lesion or distributed in clusters or both and less commonly had follicular distribution. Other features noted on dermoscopy were orange-yellowish patchy areas and crusts, dense vessels with varied shapes, mainly dotted, and some linear and pustules.[13] In the present study, the authors observed dull translucent whitish areas which were a sign of acute vesiculation along with pinkish red background as a common finding in acute dermatitis. This was followed by microulcerations, vascular changes were seen as linear vessels with irregular dots, yellow-orange clods, and irregular pigment were observed, which showed similarity with the above study.
A study was conducted by KS Suh et al. to investigate characteristic dermoscopic findings of nummular eczema and showed shiny yellow clods, scales, and irregularly distributed brownish red globules.[14] We compared it to the findings of subacute dermatitis in our study which showed white scales, irregular pigment network, brown-white background, black/brown/grey dots, and yellow clods followed by vascular changes like irregular red dots. These findings showed great similarity to the above study.
E Errichetti et al. did a study on 14 patients with histopathologically proven prurigo nodularis. He suggested that the detection of a “white starburst pattern” surrounding brown-reddish/brown-yellowish crust(s), erosion(s), and/or hyperkeratosis/scales is a useful clue to support the clinical diagnosis of prurigo nodularis, distinguishing it from the other main differential diagnoses.[15]
In our study, the most common changes seen on dermoscopy included brown-white background (100%), irregular pigment network (100%), and black/brown/grey blotches (100%). Other common changes were black/brown/grey dots (71.4%), black/brown/grey clods (71.4%), white dots (63.3%), white clods (51%), white blotches (51%), and white scales (40.8%).
In eczema, histopathology shows spongiosis and microvesiculation in the epidermis; this leads to pigment dilution of the epidermis. These changes result in white areas on dermoscopy. The white blotches that we see are due to spongiosis and intercellular edema which distort pigment network. Spongiotic intercellular edema tends to block light from reaching the rete ridges, melanin is visualized leading to hypopigmentation and a disturbed pigment network.
In cases of acute dermatitis, the epidermis is highly spongiotic with microvesiculation throughout the epidermis, which results in white clods (areas) on a pinkish background. Extensive microvesiculation produces pigment dilution which allows the visibility of dilated capillaries in the dermis resulting in a pinkish background. In the case of chronic dermatitis, acanthosis causing the widening of rete ridges is found. This, respectively, imparts a white-color and a hyperpigmented circle. Acanthosis is a mass of keratinocytes (white) and elongated rete ridges having melanin (black) resulting in white areas with the pigmented area at the periphery in dermoscopy.
Scaling correlates to parakeratosis and hyperkeratosis. Yellow-orange clods correlate to plasma, exudate, and neutrophilic debris on histopathology.
Our study undoubtedly establishes dermoscopic findings for various spongiotic disorders which correlate well with histopathological changes. Thorough knowledge of the dermoscopic patterns is essential to use this in-office handy technique efficiently and once mastered can obviate the need for skin biopsy for diagnosis and follow-up in the future. Dermoscopy can be used as a complementary tool and in some cases as an alternative to biopsy. In our study, various dermoscopic findings are consistent for various spongiotic disorders and these can be used to set criteria for the dermoscopic diagnosis of the same. It could also help to avoid invasive procedures like biopsy in pediatric and geriatric age groups.
This study has its limitations, being a single-centered, cross-sectional study with a limited sample size for individual disorders.
Conclusions
Dermoscopic findings of spongiotic diseases are well correlated with the already established histopathological features except vascular changes. Definitive dermoscopic patterns are observed consistently with spongiotic diseases and these can be used additionally to confirm the diagnosis and categorize patients as acute, subacute, and chronic. Hence, dermoscopy can be a useful bedside tool to differentiate various spongiotic dermatoses[16] and also from other nonspongiotic diseases where the dermoscopic features are well established. Also, dermoscopic differentiation points for spongiotic diseases can be used to set dermoscopic criteria for the diagnosis and thus help obviate the need for biopsy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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