INFLAMMATORY DISORDERS OF THE SKIN AND SUBCUTIS:
A PRACTICAL AND ANALYTICAL APPROACH
Cynthia M. Magro, M.D.
Ohio State University
A.Neil Crowson, M.D.
Regional Medical Center and
University of Oklahoma
Martin C. Mihm Jr., M.D.
Massachusetts General Hospital
Harvard Medical School
The topic of inflammatory skin disease is a challenging and diverse one. We will attempt to review the
fundamentals of inflammatory skin diseases. We will consider reactions of the epidermis, dermal based
infiltrates and panniculitis.
Classification of Inflammatory Disorders of the Skin and Subcutis
Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on the slide images for a larger view of each slide.
SPONGIOTIC AND ECZEMATOUS DERMATITIS
The topic of spongiotic and eczematous dermatitis will be illustrated by 2 cases: allergic contact
dermatitis and pityriasis rosea. A discussion aregarding other forms of spongiotic dermatitis will
A forty-eight year-old woman purchased a new "anti-wrinkle" eye cream. Within forty-eight hours of
applying the cream to her eyelids, she developed redness and swelling of the skin of the eyelids. A skin
biopsy was performed.
A fifteen year-old girl developed a symmetrical macular salmon-colored eruption of papules along the
cleavage lines of the trunk and proximal extremities. Clinical examination showed several of these
lesions to have a cigarette paper-like scale. A skin biopsy was performed.
The topic of psoriasiform dermatitis will be illustrated by 2 cases: psoriasis and pityriasis rubra
pilaris. The definition of psoriasiform dermatitis is one of epidermal hyperplasia characterized by
excessive elongation and expansion of rete ridges. The pattern of rete ridge elongation may be uniform
(i.e. regular psoriasiform hyperplasia) or variable (i.e irregular psoriasiform hyperplasia). The causes
include hyperproliferative states of the epidermis such as psoriasis and pityriasis rubra pilaris,
chronic reactive eczematous reactions, and cutaneous T cell dyscrasia.
A thirty-eight year-old laboratory technologist developed asymptomatic erythematous, symmetrical plaques
on the knees and elbows. Her family history was positive for a similar condition in her mother.
Clinical examination showed rounded plaques with a silvery scale which, when lifted off, were associated
with bleeding. A skin biopsy was performed.
A sixty-five year-old man developed diffuse scaly erythema of the face, the anterior chest and the upper
back. This was associated with a scaly, orange-hued discoloration of the palms and soles. Treatment
with topical steroids was ineffectual. The rash progressed to cover most of his body, but with islands
of spared, normal skin. A skin biopsy was performed.
LYMPHOCYTIC DERMAL INFILTRATES
The next topic of consideration will be one of dermal perivascular lymphoid infiltrates. Among the
causes are lupus erythematosus, polymorphous light eruption, Jessner's lymphocytic infiltrate of skin,
erythema annulare centrifugum, Lyme disease, delayed dermal hypersensitivity reactions and
pseudolymphoma. We will illustrate this concept by presenting 2 of the prototypic causes of dermal
lymphocytic infiltration: polymorphous light eruption and Jessner's lymphocytic infiltrate of skin.
A nineteen year-old woman experienced recurrent erythematous papules on sun-exposed skin every summer.
These tended to improve in the fall with diminishing sun exposure. A skin biopsy was performed.
A forty year-old woman developed papules and reddish plaques involving the neck and upper back.
Connective tissue disease serology was negative. The lesions resolved spontaneously following a skin
PERIVASCULAR LYMPHOID INFILTRATES ACCOMPANIED BY DERMAL SCLEROSIS
Morphea, the most common of the sclerodermoid tissue reactions, can show prominent perivascular dermal
lymphoid hyperplasia and therefore we felt it was only appropriate to discuss this important entity.
A twenty-two year-old woman developed an indurated plaque on the trunk. The plaque had an ivory-colored
center and a lilac-colored border. A skin biopsy was performed.
HISTIOCYTIC DERMAL INFILTRATES WITH MINIMAL EPIDERMAL ALTERATION
A common reaction pattern in the dermis is one characterized by infiltration of the Interstitum by
histiocytes with variable necrobiotic alteration of the collagen. The two classic cutaneous disorders
associated with palisading granulomatous infiltrates are GRANULOMA ANNULARE and NECROBIOSIS LIPOIDICA.
The concept of palisading granulomatous dermatitis will be illustrated by 2 cases.
A fifty-six year-old woman developed yellow-brown atrophic, depressed
plaques involving both shins. A skin biopsy was performed.
A forty-six year-old woman developed papules on her elbows several weeks following a visit with her
nephew who had a fiery , erythematous cheek and malaise. His pediatrician subsequently diagnosed
parvovirus B19 infection ("fifth disease"). In the interim, one of the woman's papules was biopsied.
THE NEUTROPHILIC DERMATOSES
The 2 main dermatoses characterized by prominent interstitial neutrophilia are Sweet's syndrome and
pyoderma gangrenosum. Other conditions which fall into the interstitial neutrophilic dermatosis category
include rheumatoid neutrophilic dermatosis, urticarial vasculitis, and erythema elevatum diutinum.
A thirty-six year-old man with intermittent diarrhea, developed violaceus, ulcerating plaques on the
lower extremities. One of these was biopsied.
A forty-eight year-old woman developed reddish-purple plaques, several of which were studded with
pustules, involving her face and upper arms. These followed an upper respiratory tract infection for
which she did not see a doctor and for which she was not treated. She had an intermittent fever, and a
complete blood count showed neutrophilia. Her ESR was elevated. A skin biopsy was performed.
A fifteen year-old girl developed plaques over the pre-tibial surfaces following an episode of
pharyngitis. Throat swabs grew Streptococcus sp. A skin biopsy was performed.
A twenty-eight year-old man had a past history of tuberculosis in the Philippines. He developed
ulcerating plaques on the posterior calves. A skin biopsy was performed.
Connective Tissue Disease Panniculitis
A twenty-four year-old woman with a long-standing history of systemic lupus erythematosus developed
plaques involving her upper arms and thighs. A skin biopsy was performed.
Opinions stated and/or conclusions reached in this syllabus are the
of the authors and are not necessarily endorsed by the