Case Number : Case 2996 - 30 December 2021 Posted By: Saleem Taibjee

lymphocytic vasculitis

some sort of dermatological purpura

To me there appears to be some vascular proliferation with plump endothelial cells and lymphoid infiltrate. Makes me think of Acral pseudolymphomatous angiokeratoma, which was originally described in children (APACHE) but there have been reports in adults. 

A regressive lesion. But canestrated ortokeratosis should be in keeping with some benign or recent lesion. No parakeratosis typical of a chronic process. 

12 hours ago, vincenzo said:

A regressive lesion. But canestrated ortokeratosis should be in keeping with some benign or recent lesion. No parakeratosis typical of a chronic process. 

Yes. May be some regressed lesion

Meenakshi's suggestion is plausible and will need some IHC for confirmation. 

Another possibility is a regressing lesion of lymphomatoid papulosis type E which is usually paucilesional.

Will be interesting to see the findings of IHC.

Happy New Year!

This is a common scenario. Yes, the pattern of superficial dermal fibrosis, vascular proliferation and chronic inflammation is very suggestive of a regressed / previously treated lesion, and this possibility should be raised in the report. In such cases it can be important to remind the clinician that the biopsy may not be fully representative i.e. that if the biopsy has been taken from a much larger lesion, to consider further biopsy.

In the absence of significant alteration of the keratin layer or frank lichenoid damage, the most common scenario seems to be a regressed superficial BCC.

In this instance the punch biopsy was processed on end with 3 initial levels by the laboratory. In this situation I have a very low threshold for requesting additional levels because I see many examples where a clearer diagnosis manifests with deeper levels and presumably the biopsy was not adequately 'cut-in' on the initial sections. Lo-and-behold, the deeper levels did reveal superficial BCC in this case (see images below). When the biopsy is bisected from the outset, the initial sections tend to be more reliably fully representative. Even in that situation I might still consider requesting additional levels. But I would certainly encourage bisecting of punch biopsy specimens from the outset whenever possible.

BW
Saleem