American Journal of Dermatopathology:
Letters to the Editor
Histologic Assessment of Perilesional Skin in Vesiculobullous Diseases: Giving Its Due
Tirumalae, Rajalakshmi MD, DNB; Yeliur, Inchara K. MD, DNB
Department of Pathology, St. John's Medical College, Bangalore, India
The authors have no funding or conflicts of interest to disclose.
To the Editor:
Direct immunofluorescence of perilesional uninvolved skin (PS) is performed in most vesiculobullous dermatoses (VBL). Although immunopathologic and ultrastructural changes are described in PS, there is no data on histopathologic changes.1–3 The few studies available affirm the absence of changes on morphology.1,2
We studied hematoxylin and eosin–stained frozen sections of perilesional skin biopsies from 36 VBL, the majority of which were pemphigus (19) and bullous pemphigoid (9). In cases of pemphigus, we observed incipient acantholysis (18) (Fig. 1A), clefts between strata basale and spinosum (18) (Fig. 1B), adnexal involvement (9) (Fig. 1C), and suprabasal vesicles (5) (Fig. 1D). PS in pemphigoid showed spongiosis (4) (Fig. 2A), sub/intraepidermal clefts (4), eosinophils in the papillary dermis (3) (Fig. 2D), and frank subepidermal vesicles (4) (Fig. 2C). Eosinophils sticking to the basement membrane were noted in 2 cases of pemphigoid (Fig. 2B). Dermal melanophages were noted in most sections of both pemphigus and pemphigoid. We had 2 cases of bullous vasculitis that showed spongiotic vesicles and leukocytoclastic vasculitis. Freezing artifacts were noted in some cases but did not hamper interpretation. The only confounding factor among these was the nuclear/cytoplasmic vacuolization (Fig. 1B) that was difficult to tell apart from early suprabasal clefting. The presence of acantholysis came to rescue in such instances. We also examined frozen sections from 12 samples sent for vasculitis as a control group. None of the above changes were seen in these biopsies, except for focal nuclear and cytoplasmic vacuoles.
Significant morphologic changes are seen in perilesional skin of VBL, which are representative of the etiology and not due to freezing artifact. Credence to this observation comes from another study, which concluded that the number of mononuclear inflammatory cells was greater in perilesional than in clinically uninvolved pemphigus skin.4 The proportions of CD4+, CD8+, and Langerhans cells were also higher.4
It is particularly useful to study the morphologic features when a biopsy of lesional skin is not done simultaneously or is inconclusive. It is also potentially useful in identifying sample mix-ups and errors. Hence, we conclude that a detailed histologic evaluation of perilesional skin is pertinent in bullous lesions.
1. Grando SA, Terman AK, Stupina AS, et al.. Ultrastructural study of clinically uninvolved skin of patients with pemphigus vulgaris. Clin Exp Dermatol. 1991;16:359–363.
2. Grando SA, Glukhen'kii BT, Stupina AS, et al.. The ultrastructural changes in the clinically unaffected skin of patients with pemphigus vulgaris. Vestn Dermatol Venerol. 1990;8:11–34.
3. Hietanen J, Salo OP, Kanerva L, et al.. Ultrastructure of uninvolved oral mucosa in pemphigus patients. Acta Derm Venereol. 1983;63:491–494.
4. Mashkilleyson N, Konttinen YT, Visa K. Local involvement of antigen-presenting cells and activated T cells in perilesional and clinically uninvolved skin in pemphigus vulgaris. Acta Derm Venereol. 1989;69:424–428.
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