Septal Panniculitis

Disease Erythema nodosum (EN)

Erythema nodosum migrans subacute nodular migratory pann. chronic erythema nodosum Morphea Profunda Panniculitis of morphea/scleroderma 1-Antitrypsin deficiency pann. (septal or mixed)

Histopathology
Septal Prototype Miescher's septal micro-granulomas (M) Greater Septal Thickening Prominent Granulomata Septal Lymphoplasmacytic infiltrate Septal Neutrophils splayed b/t collagen in reticular dermis

Site Pretibial LE, UE, face

Unilateral LE Proximal UEs, trunk Butt, Flanks Upper Thighs

Age / Gender 20-30 F 3x>M Adults 20-60 M=F Adults M=F

Clinical Pathophysiology - Treatment Bruise-like; Fever, arthritis, malaise TH1 idiopathic >infxn (Strep) > sarcoid, IBD, OCPs, coccidio Tx: bed rest, salicylates or NSAID, SSKI
Nodules migrate or undergo centrifugal spread w/ central clearing Idiopathic (occ. Strep or Thyroid disease); Chronic course. Tx: SSKI (clears in weeks) Dermal & subcut. Sclerosis; Heal w/ hyperpigmentation & atrophy; No systemic sx Ulceration & oily discharge (like pancreatic pann); Tx: Doxy or Dapsone; EtOH PiMM (nl); PiMZ (heterozygote w/ moderate dz); PiZZ (homozygous, severe dz) Associated w/ emphysema, hepatitis, cirrhosis, vasculitis, angioedema, psoriasis.

Lobular & Mixed

Disease Nodular Vasculitis Erythema Induratum (Tb) Bazins disease (if + vasculitis) Pancreatic Panniculitis Pancreatic fat necrosis Histopathology
Extensive LOBULAR Panniculitis w/ Vasculitis of MEDIUM SIZED VESSELS MIXED w/ saponification basophilic deposits Ghost lipocytes (anucleate) Early Necrosis LOBULAR CLEFTS in lipocytes No inflammation LOBULAR CLEFTS in lipocytes & giant cells LOBULAR Starburst pattern clefts in lipocytes & giant cells LOBULAR, Hyalin necrosis Lymphoplasmacytic infiltrate Lobular or mixed Lymphoplasmacytic infiltrate MIXED ID foreign material is best (polarization may help) Central nidus of inflammation MIXED Lipomembranous changes (thick membranes cysts) MIXED Neuts, hemorrhage & necrosis Special Stains may help LOBULAR Cytophagocytosis by benign histiocytes (Ms).

Site Posterior Calves

Distal LE > Abdomen

Age / Gender 30-40 F>M

Clinical Pathophysiology - Treatment Tender nodules ulceration & drainage Slowly healing lipoatrophic scars Erythema Induratum assoc. w/ tuberculosis; Others: Nocardia, drugs (PTU)
Subcutaneous nodules pain; migrate; oily discharge Pancreatic Acinar Cell carcinoma (#1) > pancreatitis, other panc. Ca. enzymes (LIPASE has clearest relationship), trypsin, amylase; Octreotide to panc enzymes; Schmids triad: nodular lesions, polyarthritis, eosinophilia (poor prognosis) Skin is cold, rigid, board-like (sparing of palms, soles, genitals) Associate w/ serious illness (75% of cases fatal, usually septicemia) Kid fat has saturated FAs (melting pt), so crystal more likely to deposit. Type A (microsize) crystals are (but found in normal infants <6mos) Hypercalcemia, thrombocytopenia > gest. DM, Rh mismatch, meconium Type B (larger) crystals arranged in rosettes elicits granulomatous response Good progrnosis. Rare complication of systemic high dose Rapid Corticosteroid Withdrawl Type B (larger) crystals arranged in rosettes elicits granulomatous response Tender nodules 33% have DLE; 10% have SLE; Rare; Indurated painful plaques with ulceration & lipoatrophy Tx dermatomyositis: prednisone, MTX, azathioprine, cyclosporine A, IVIG

mid age, elderly premature 1st week of life Newborn Infants 20-60

Sclerema neonatorum Subcutaneous fat necrosis of the newborn Post-steroid panniculitis Lupus Panniculitis Lupus Profundus Subcutaneous LE Dermatomyositis Panniculitis Traumatic Panniculitis Cold panniculitis Sclerosing lipogranuloma Injectable (Texiers disease) Blunt trauma Lipodermatosclerosis Sclerosing Panniculitis Hypodermitis sclerodermiformis Infectious Panniculitis Cytophagic Histiocytic Pann. Panniculitis-like subcutaneous lymphoma w/ cytophagocytosis

Buttocks & Thighs Proximal Extremity Cheeks, arms, trunk Shawl, cheeks Butt, abdomen, thighs, arms

Cold panniculitis - erythematous, firm nodules @ cheeks and chin (infants & young women equestrians) Sclerosing lipogranuloma - granulomatous nodules 2 self-inject oily materials (genitalia of young males) Injectable (Texiers disease) - sclerotic lesions w/ lilac borders @ buttocks & thighs 2 vit. K injections (with distribution of 'cowboy gunbelt and holster'. Blunt trauma - granuloma w/ foreign body present (esp breasts, LEs, hands & arms) Distal malleolar LEs Old fatties F>M Clinical: venous stasis heals with atrophy & sclerosis Tx: stanozolol, compression. Oxandrolone, U/S, pentoxifylline, phlebectomy. Clinical: lfluctuant nodules that ulcerate and drain Pathogens: bacteria, mycobacteria, fungi (dermatophytes, atypicals, Candida). Tx: Abx; Surgery for grain-forming bacteria/fungi (mycetoma, botryomycosis) Clinical: Subcutan nodules, fever, HSM, pancytopenia, liver failure, DIC, bleeds. Assn: Lymphoma (esp subcutaneous panniculitis-like T-cell lymphoma) Also consider malignant subcutaneous infiltrates (T-cell lymphoma)

People with T-cell lymphoma