Comparison between Clinical and Histopathological Diagnosis of Papulosquamous Dermatoses
*Sharmin L,1 Saha NK,2 Saem AM,3 Islam N,4 Begum MS5
Papulosquamous dermatoses presume considerable importance because of their frequency of occurrence. These lesions are commonly misdiagnosed because of their certain common clinical presentations. There is an overlap in histopathology and distribution of these lesions leading to difficulty in diagnosis. Combination of proper clinical observation and histopathological study gives a conclusive diagnosis. This cross sectional observational study was done to find the histopathological diagnosis of papulosquamous dermatoses and their comparison with clinical diagnosis. A total of 60 cases were studied. Lesions occurred in all age groups but were common in age group 51-60 years. Males were commonly affected (63.3%). The most frequently encountered lesion was psoriasis followed by lichen planus. This study showed a high concordance (68.3%) and low discordance (31.7%) between clinical and histopathological diagnosis. Specific histopathological diagnosis is important to distinguish these lesions as the treatment and prognosis vary significantly from other lesions with similar clinical presentations.
[Journal of Histopathology and Cytopathology, 2018 Jul; 2 (2):85-91]
Key words: Papulosquamous dermatoses, Clinical diagnosis, Histopathological diagnosis
Skin is a complex organ. As for any other organ system, diagnosis of skin disease involves history and examination. The visibility of skin allows an instant diagnosis in some cases, using a variety of visual clues such as site distribution, color, scaling and arrangement of lesions. Papulosquamous dermatoses assume considerable importance because of their frequency of occurrence.1 The papulosquamous skin disorders are a heterogeneous group of disorders comprising the largest group of diseases seen by a dermatologist. The characteristic primary lesion of these disorders is a papule, usually erythematous, that has a variable amount of scaling on the surface. Plaques or patches form through coalescence of the primary lesions.2,3 The papulosquamous disorders include psoriasis, lichen planus, parapsoriasis, pityriasis rubra pilaris, pityriasis rosea, seborrheic dermatitis, atopic dermatitis, psoriasiform eczema, dermatophytoses, allergic dermatitis, lichen nitidus, lichen striatus, lichenoid drug eruptions.2,4
- * Dr. Lyzu Sharmin, Lecturer of Pathology, Colonel Malek Medical College, Manikgonj.
- Professor Dr. Naba Kumar Saha, Professor and Head, Department of Pathology, Sylhet MAG Osmani Medical College, Sylhet.
- Dr Abu Mohammad Saem, Lecturer, Department of Pathology, Comilla Medical College, Comilla.
- Nazmul Islam, Assistant Professor, Department of Pathology, Army Medical College, Comilla.
- Mst. Shahzadi Begum, Lecturer, Department of Pathology, Sylhet MAG Osmani Medical College, Sylhet.
Few papulosquamous conditions like psoriasis mimics diverse dermatological conditions as they present with numerous clinical variants and pose to be a diagnostic dilemma for the clinician. Some conditions like lichen planus is well defined in general population, however its pathogenesis is not exactly defined. Separation of each of these becomes important because the treatment and prognosis for each tend to be disease specific.1 Histopathological study is considered to be the gold standard in the diagnosis of various skin lesions. Histopathological features are specific and characteristic for each papulosquamous skin lesion.5 Hence, combination of proper clinical observation and histopathological study can provide a conclusive diagnosis.
This cross sectional observational study was done in the department of pathology in collaboration with department of dermatology and venereology of Sylhet MAG Osmani Medical College during the period from July 2016 to June 2017 with a view to study the histopathology of papulosquamous disorders and to compare with clinical diagnosis. For this purpose, 60 cases were selected with a clinical diagnosis of papulosquamous skin disorders. Relevant clinical information of each case were noted with special emphasis on age, sex, characteristics of the lesions, drug history, family history and any systemic manifestations. The differential diagnosis was obtained from the dermatologist in skin outpatient department and verified by senior professor of department of dermatology and venereology. Incisional or punch biopsy from the lesional site was taken by the dermatologist and the specimen was preserved in 10% formalin for histopathological examination. The formalin fixed biopsy specimens were collected from the dermatology department and were taken to the pathology department for histopathological examination. Tissue sections were prepared from paraffin block and stained with hematoxylin and eosin stain. The diagnoses of papulosquamous skin lesions were done according to histopathological findings under light microscope (Model-OLYMPUS CX 23) under the supervision of professor of pathology. All histopathological reports were recorded for further analysis. Finally clinical and histopathological findings of each patient were analysed and comparison was done.
The age of the patients ranged from 7 to 90 years with a mean of 41.22 (SD +19.80) years. The highest number of patients 12 (20%) were in the age group 51-60 years and the lowest number of patient 1(1.66%) was in the age groups 71-80 and 81-90 years. Male preponderance was noted, 38 (63.3%) were males and 22 (36.7%) were females with male to female ratio of 1.72:1. Among 60 cases of papulosquamous dermatoses, 31(51.7%) were diagnosed clinically as psoriasis followed by lichen planus 17(28.3%), parapsoriasis 3(5%), pityriasis rubra pilaris 3(5%), seborrheic dermatitis 3(5%), lichen simplex chronicus 2 (3.3%) and erythema dischromicum perstans 1(1.7%).
Erythematous, scaly, plaque and papule were the commonest lesions. Most of the cases 40 (66.6%) were sporadically present all sites of the skin followed by 10 (16.6%) at both extremities, 4 (6.6%) at lower extremities and 1 (1.7%) case each at face, right ankle joint, scalp, shoulder, trunk and distal phalanges of both extremities. Out of 60 histopathologically diagnosed cases, 22 (36.7%) were diagnosed as psoriasis, 12 (20%) as lichen planus, 8 (13.3%) as chronic non specific dermatitis, 5 (8.3%) as lichen simplex chronicus, 4 (6.7%) as pityriasis rubra pilaris, 3 (5%) as parapsoriasis, 2 (3.3%) as granulomatous inflammation, 1 (1.7%) case each as erythema dischromicum perstans, prurigo simplex, discoid lupus erythematosus and seborrheic dermatitis.
Acanthosis and parakeratosis were observed in 100% cases of psoriasis. Munro microabscesses were found in 18.1% of cases and spongiform pustule of Kogoj in 9 % of cases. In lichen planus, majority of them showed wedge-shaped hypergranulosis, irregular acanthosis, vacuolar alteration of the basal layer, irregular elongation of rete ridges and band like lymphocytic infiltrate in upper dermis.
Table I: Contingency (cross) table showing the correlation between clinical and histopathological diagnosis of papulosquamous dermatoses
| Histopathological diagnosis
|Chronic non specific dermatitis||Lichen simplex chronicus
|Pityriasis rubra pilaris||Parapsoriasis
Lichen simplex chronicus
|Erythema dischromicum perstans||Prurigo simplex||Discoid lupus eythematosus||Seborrheic dermatitis||Total
|Pityriasis rubra pilaris||–||–||–||–||2||1||–||–||–||–||–||3|
|Lichen simplex chronicus||–||–||–||2||–||–||–||–||–||–||–||2|
|Erythema dischromicum perstans||–||–
In 5 cases of lichen simplex chronicus, wedge-shaped hypergranulosis, irregular elongation of rete ridges and vertically oriented collagen bundles were observed. Basket weave cornified layer and spongiosis were observed in all 3 (100%) cases of parapsoriasis. Histopathologically, parakeratosis, broad and short rete ridges and thick suprapapillary plates were found in 75% of cases and spongiosis in 25% of cases of pityriasis rubra pilaris.
Of the 60 cases, 31 were clinically suspected to be psoriasis of which 21 were confirmed histopathologically as psoriasis, 6 as chronic nonspecific dermatitis, 2 as lichen simplex chronicus, 1 as granulomatous inflammation and 1 as discoid lupus erythematosus. Out of 17 clinically suspected lichen planus, 12 were confirmed histopathologically as lichen planus,1 case each as chronic nonspecific dermatitis, lichen simplex chronicus, pityriasis rubra pilaris, prurigo simplex and psoriasis. Of the three cases of parapsoriasis suspected clinically, 2 were histopathologically confirmed as parapsoriasis and 1 as pityriasis rubra pilaris. Out of clinically diagnosed 3 cases of pityriasis rubra pilaris, 2 were histopathologically confirmed as pityriasis rubra pilaris and 1 as parapsoriasis. Among the clinically diagnosed 3 cases of seborrheic dermatitis, 1 was diagnosed histopathologically as seborrheic dermatitis, 1 as chronic nonspecific dermatitis and 1 as granulomatous inflammation. Clinically diagnosed one case of erythema dischromicum perstans and two cases of lichen simplex chronicus showed concordance with histopathological diagnosis.
Histopathologically diagnosed 8 cases of chronic nonspecific dermatitis, 1 case of discoid lupus erythematosus, 2 cases of granulomatous inflammation and 1 case of prurigo simplex showed discordance with clinical diagnosis in 100% of cases (Table Ι).
Concordance between clinical diagnosis and histopathological diagnosis was observed in 41 (68.3%) cases and discordance in 19 (31.7%) cases. Clinical diagnosis of 60 study cases of papulosquamous dermatoses had tendency to express concordance with histopathological diagnosis but was not statistically significant (p=0.791) which is shown in Table ΙΙ.
Table ΙΙ: Comparison between clinical and histopathological diagnosis of 60 study cases of papulosquamous dermatoses.
|Clinical diagnosis||Number of Cases||Histopathological diagnosis||*p|
|Pityriasis rubra pilaris||3||2(66.7%)||1(33.3%)|
|Lichen simplex chronicus||2||2(100%)||0(0%)|
|Erythema dischromicum perstans||1||1(100%)||0(0%)|
*Pearson Chi-Square test was employed to analyze the data.
Figure 1. Photomicrograph of histopathological section of psoriasis (H & E stain, high power)
Figure 2. Photomicrograph of histopathological section of lichen planus (H & E stain, high power).
Figure 3. Photomicrograph of histopathological section of pityriasis rubra pilaris (H & E stain, high power).
Histopathological study is considered to be the gold standard for the diagnosis of skin lesions. The goal of improving diagnostic accuracy is achieved by comparison of histopathological findings with clinical diagnosis.2 In this study, histopathological diagnoses of skin biopsies were compared with clinical diagnoses in all 60 cases of papulosquamous dermatoses. Age ranged from 7 to 90 years with a mean of 41.22 (SD ± 19.80) years, maximum number of cases were found in 6th and 3rd decades which are close to the findings of studies done by Chichani et al and Chavhan et al.6,7 Male preponderance was observed with male to female ratio of 1.72:1 which are similiar to findings reported by other authors.6-8
Erythematous lesions were maximum and constituted 65% of the total study cases. Reddy et al1 observed 40% erythematous lesions in their study which is less than the erythematous lesions of this study. Psoriasis (51.7%) was the commonest papulosquamous lesion in the present study followed by lichen planus (28.3%) which are consistent with the study of Chichani et al6 who observed psoriasis in 51.28% of cases followed by lichen planus in 32.05% of cases. In the study done by Reddy et al,1 out of 80 cases of papulosquamous disorders psoriasis (42.5%) was the commonest followed by lichen planus (30%).
Psoriasis showed male preponderance and highest number of patients were in the sixth decade in our series and has been described similiarly in the other literatures,6,7 who also observed male preponderance. In our study, 31 patients of psoriasis presented as erythematous sharply demarcated plaques covered with silvery scales over the extremities, back and sporadically at other sites of the skin which has concordance with the findings of other studies.2,9 Out of 22 (36.7%) cases of histopathologically diagnosed psoriasis, clinicohistopathological correlation was seen in 21 cases and 1 case was clinically diagnosed as lichen planus. Most common histopathological findings of psoriasis in all 22 (100%) cases were acanthosis and parakeratosis. Thinning of suprapapillary epidermis, regular elongation of rete ridges and diminished granular layer were observed in 77.2 % of cases. Absent granular layer was observed in 18.1 % of cases, hyperkeratosis in 9 % of cases, Munro microabscesses in 18.1% of cases and spongiform pustule of Kogoj in 9 % of cases. Perivascular dermal infiltrate was observed in 100 % of cases. Nearly similar findings have been described in other studies.1,2,7,8,10
In this study, out of 31 clinically diagnosed psoriasis, 21(67.7%) had clinicohistopathological concordance while 10 (32.3%) cases showed discordance with histopathological diagnosis. Raju et al2 observed concordance in 74% of cases and discordance in 26% of cases of psoriasis. Chichani et al6 observed 57.5% concordance in psoriasis.
We found no sex predilection in cases of lichen planus. Highest number of patients was in the second decade which has consistence with the study of Chichani et al6 who observed highest number of patients in the second decade and male to female ratio was 1: 1.08. Lichen planus presented as flat topped, violaceous papule with scaly lesions over the lower extremities and shoulder in this study, which was similiarly described by Raju et al.2 Wedge-shaped hypergranulosis, irregular acanthosis, vacuolar alteration of the basal layer and irregular elongation of rete ridges were found in all 12 cases of histologically diagnosed lichen planus, similar findings have been described by other authors1,2,7,8 with addition of hyperkeratosis, focal parakeratosis, Max Joseph space and civatte bodies. Raju et al2 found 92.9% clinicohistopathological concordance in 39 clinically diagnosed lichen planus which was maximum clinicohistopathological concordance in their study. In this study, we found 70.6% clinicohistopathological concordance in 17 clinically diagnosed lichen planus.
Among 5 cases of lichen simplex chronicus, histopathologly revealed acanthosis, parakeratosis, wedge-shaped hypergranulosis, irregular elongation of rete ridges and increased number of fibroblasts and vertically oriented collagen bundles in the upper dermis, which are nearly close to the findings of Rathod et al.9 4 cases were histologically diagnosed as pityriasis rubra pilaris with male to female ratio of 1:1 and maximum patients were in the third decade. Chichani et al6 observed highest number of patients in the second decade with male to female ratio of 2:1 which are discordant with the findings of the present study. Histopathology of pityriasis rubra pilaris revealed parakeratosis, acanthosis, broad and short rete ridges, focal hypergranulosis, thick suprapapillary plate, spongiosis and dermal infiltrate which are nearly similar to those of the reported series.8,9 66.7% clinicohistopathological concordance was observed in the diagnosis of pityriasis rubra pilaris. Hosamane et al8 observed 60% clinicohistopathological concordance in pityriasis rubra pilaris which is nearly close to the findings of our study.
Basket weave cornified layer, spongiosis, acanthosis, hypergranulosis and exocytosis were observed in parapsoriasis but elongation of rete ridges and parakeratosis were not seen in any case, which were described in the study of Rathod et al.9 Of the 3 cases of clinically diagnosed parapsoriasis, 2 (66.7%) were histopathologically confirmed and 1(33.3%) was diagnosed as pityriasis rubra pilaris. One case of clinically suspected parapsoriasis turned out to be subacute spongiotic dermatitis in the study of Hosamane et al.8
Histopathologically diagnosed 8 cases of chronic non specific dermatitis, 1 case of discoid lupus erythematosus, 2 cases of granulomatous inflammation and 1 case of prurigo simplex showed 100% discordance with clinical diagnosis. 68.3% of clinically diagnosed papulosquamous lesions were confirmed histologically while 31.7% of cases had different histological diagnosis. Raju et al2 reported 68.72% concordance and 31.28% discordance and Reddy et al1 reported 86.25% concordance and 13.75% discordance between clinical and histopathological diagnosis.
There is overlap of clinical pattern and distribution of papulosquamous skin disorders which often makes clinical diagnosis difficult. Some of the histological features overlap in lesions like pityriasis rosea, prurigo nodularis and prurigo simplex. However, some of the histopathological features are specific and characteristic for some skin lesions. Hence, combination of proper clinical observation and histopathological study gives a conclusive diagnosis. We found maximum cases were in the age group 51-60 years, with a male preponderance. The most frequently encountered lesion was psoriasis followed by lichen planus. This study showed a high concordance (68.3%) and low discordance (31.7%) between clinical and histopathological diagnosis. So knowledge of the histopathological features and a clinicohistopathological comparison is helpful for better patient care.
- Reddy BR, Krishna MN. Histopathological Spectrum of Noninfectious Erythematous, Papulosquamous lesions. Asian Pacific Journal Of Health Sciences 2014; 1(4S): 28-34.
- Raju CG, Ankur CP, Vaishali MR, Khushbu MR. Study of Clinicohistopathological Correlation of Papulosquamous Disorders at Tertiary Care Hospital. Scholars Journal of Applied Medical Sciences 2015; 3(3B): 1154-1158.
- Pandit GA, Narayankar Significance of Clinicopathological Correlation in Psoriasis. Medical Journal of Dr. D.Y. Patil University 2015; 8: 481-5.
- Sehgal VN, Dogra S, Srivastava G, Aggarwal AK. Psoriasiform Dermatoses. Indian Journal of Dermatology,Venereology and Leprology 2008; 74(2): 94-99.
- Elder DE, Elenitsas R, Murphy GF, Johnson BL, Xu X. Introduction to Dermatopathologic Diagnosis. In: Elder DE, Elenitsas R, Murphy GF, Johnson BL, Xu X, eds. Lever’s Histopathology of the Skin, 10th Philadelphia, USA: Lippincott Williams and Wilkins 2009: pp. 1-3.
- Chichani S, Negi SR, Kalla AR, Gaur S. Study of Histopathology of Pulosquamous Lesion of Skin: A Prospective and Retrospective Study. International Journal of Applied Research 2016; 2(7): 115-117.
- Chavhan SD, Mahajan SV, Vankudre AJ. A Descriptive Study on Patients of Papulosquamous Lesion at Tertiary Care Institute. MVP Journal of Medical Sciences 2014; 1(1): 30–35.
- Hosamane S, Pai M, Philipose TR, Nayarmoole U. Clinicopathological Study of Non-Infectious Erythaematous Papulosquamous Skin Diseases. Journal of Clinical and Diagnostic Research 2016;10(6): 19-22.
- Rathod NN, Panicker NK, Gore CR, Vimal SS. The Clinical and HistopathologicalCorrelation Of Psoriasiform Dermatoses. National Journal of Integrated Research inMedicine 2012; 3(3): 52-56.
- Mehta S, Singal A, Singh N, Bhattacharya A study of Clinicohistopathological Correlation in Patients of Psoriasis and Psoriasiform Dermatitis. Indian Journal of Dermatology, Venereology and Leprology 2009; 75: 100.