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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 2727 - 18 December 2020 Posted By: Dr. Richard Carr

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M70. Right forehead (2017). ?BCC. Further specimen left forehead (2020)


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Krishnakumar subramanian

Posted

epidermis shows parakeratosis with inflammatory cells, there is spongiosis and some sort of acantholysis in epidermis. the dermis shows evidence of actinic damage. There is acantholysis in the follicular epithelium

acantholytic disorder

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Richard Logan

Posted

What an interesting series of slides - they could be used to illustrate a significant number of dermatopathological phenomena!

Starting from the outside there is neutrophilic inflammatory debris in the parakeratotic stratum corneum with foci of fine stippled material which is probably secondary bacterial debris.  The epidermis shows both suprabasal acantholysis and spongiosis.  The acantholysis also involves the follicular epithelium.  There is a degree of sebaceous hyperplasia and marked solar elastosis.  The associated inflammatory infiltrate includes conspicuous plasma cells (image 5) which I think are a sign of secondary infection rather than syphilis, for which the clinical story doesn't fit.

I agree with Krishnakumar Subramanian that this is primarily an acantholytic disorder. Because of the follicular involvement I would go for pemphigus, more likely vulgaris than foliaceous.

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Dr. Richard Carr

Posted

The 2017 specimen was reported as an actinic keratosis. The patient had biopsies from further lesions from the left and right forehead ?BCC: Images from a further lesion on the left forehead above.

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Richard Logan

Posted

That's interesting.  the 2020 images show more extensive acantholysis than in 2017, with more prominent eosinophils in the infiltrate.  I agree with Vincenzo that this could be drug-induced pemphigus.

This begs the question concerning the 2017 biopsy.  Was this an early manifestation of pemphigus?  There was acantholysis in the follicular epithelium.  I find it hard to square that with a diagnosis of solar keratosis - you would imagine that the deeper follicular epithelium would not have been exposed to sufficient UV to induce dysplasia - a corollary of the theory of Freudenthal's funnel.

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Dr. Richard Carr

Posted

The case was a referral and the patient was known to have a history of ?pemphigus foliaceus / pemphigus vulgaris dating from 2009. But obviously the clinical colleagues neglected to mention this in 2017 specimen. I thought this was a nice case of impetiginised pemphigus, no dysplasia. The clue in 2017 being the follicular acantholysis which is more striking in the 2020 lesion. Eosinophils can be quite variable in pemphigus in my experience and are rather inconspicuous in 2017.

Thanks Richard for drawing my attention to Freudenthal's funnel. As you know I believe while AK is a marker for SCC most derive from the follicular stems cells which can sit exceedingly high in the skin. It's quite common, on the head and neck skin, to find highly miniaturised vellus follicles with even the deepest hair bulb part completely surrounded by solar elastosis. 

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