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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 1904 - 14 Sept - Dr Arti Bakshi Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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43/F, papular keratotic rash, initially appeared on ankle and legs, spread to arms, thigh and neck

Edited by Admin_Dermpath


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Saman Fatah

Posted

Predominantly compact brightly eosinophilic orthokeratosis (with a possible foci of parakeratosis at right edge) overlying a discrete area of atrophic epidermis with complete effacement of rete ridges. A band-like lichenoid infiltrate + some activated looking irregular lymphocytes immediately beneath it. Papillomatous spires especially more noticeable on the left side of the image.

To me, this looks like a Flegel's disease (Hyperkeratosis Lenticularis Perstans), aware it is a rare disease. Kyrle's disease can share some features with this condition as well but less likely in the current case.

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Alternating hyper and orthokeratosis, alternating acanthosis and atrophy of stratum malpighi along with dense band of dermal lymphocytic infiltrate and vacuolar changes in basal cells suggest keratosis lichenoids chronica. Can't rule out Flegel's though.

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Raul Perret

Posted (edited)

When I first saw the images I thought of keratosis lichenoides chronica. However, I did not consider Flegel's (have seen only one case before in Richard Carr's amazing collection) so agree, should add Dr. Fatah's great diagnosis as a differential

Edited by Raul Perret

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vincenzo polizzi

Posted

I didn’t know too much about this disease, but thank s to all of you I’m learning something and as far as I can understand agree with Fatah. Great case. 

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Dr. Richard Carr

Posted

Thanks Raul (is your memory photographic?). My pretty simultaneous "spots" were same as yours. Hope it is KLC then I can ask Arti for some copy sections as I don't have a case in the collection.

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Saman Fatah

Posted

Dear All:

It is very interesting to hear Dermatopathologists like Dermatologists relies heavily on visual memories of slides or patterns to reach a possible diagnosis/diagnoses, which will be refined and expanded continually with experience.

KLC remains a challenging and enigmatic disorder, thanks for teaching me Nekham can have similar histology features.

We will wait for Arti for her final thoughts/feedback as CPC is crucial including family history.

For those keen on learning more on Flegel's, this link is a valuable reference written 30 years ago describing various stages of histology depending on the age of lesion.

https://www.ncbi.nlm.nih.gov/pubmed/2439113

 

 

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Arti Bakshi

Posted

Great discussion and well done to Saman for the diagnosis and her educative comments.  

This is Flegel's disease...my very first and only case!...The only other case I have seen was in Richard's collection too.

This patient had typical clinical lesions. No family history that I am aware of. There was no linear/reticulate pattern (seen with clinical lesions of KLC)  nor was there any facial seborrhoeic dermatitis.

The histology fits very well with Flegel's. The discrete and well demarcated area of hyperkeratosis overlying an attenuated epithelium is a characteristic feature. Image 4 shows the sharp border between compact hyperkeratosis and the adjacent normal keratin layer. The band like dermal infiltrate completes the picture.

Sorry, Richard, your wait for a case of KLC continues....

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