Case Number : Case 2639 - 18 August 2020 Posted By: Uma Sundram

epidermal necrosis in superficial portions with pallor and dermal perivascular lymphocytes

could be necrolytic erythema

49 minutes ago, Krishnakumar subramanian said:

epidermal necrosis in superficial portions with pallor and dermal perivascular lymphocytes

could be necrolytic erythema

Necrolytic erythema could be a good differential.

This is an erythema multiforme-like single lesion (single area if I’m not mistaken ). ?FDE( but I don’t see any eosinophils nor melanophages). 

Difficult...

I see a fairly tight perivascular lymphocytic infiltrate in the upper and mid-dermis.  At one end of the biopsy (Fig 3) there is parakeratosis with a disturbance of the cytology of the lower epidermis similar to a solar keratosis, but probably secondary to the inflammation.  In the centre there is vaculoar change with some colloid bodies and necrosis of the upper epidermis.  I don't see any dyskeratotic cells.

Although the overall appearance is suggestive of necrolytic migratory erythema, this would be an unlikely diagnosis at this age.  More plausible would be erythema multiforme.  I would also consider the possibility of nutritional deficiency possibly complicating liver disease or HIV.

Apart from EM, FDE and nutritional,  I would add D/D of Pityriasis lichenoides in view of parakeratotic mounds underneath basket weave stratum corneum, interface pathology and EM like necrosis. 

The clinical points to a solitary lesion mostly, so early FDE is my first thought.. it needs CPC

A solitary lesion. Fixed drug eruption is a good thought; this is what we suggested and fit with the clinical. We also thought about irritant contact dermatitis. The patient is otherwise healthy.