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The fundamental histologic

changes in skin diseases

Dr. Mahmud Ghaznawie, PhD.
Lesion and eruption (rash)

 Lesion: describes an area of disease -

usually small

 Eruption (or rash): describes more

widespread skin involvement, normally
composed of several lesions which may be
the primary pathology or due to secondary
factors (scratching, infection, etc.).
Primary Primary lesions are the
lesions first to appear and are
due to the disease or
abnormal state.

 Macule  Pustule
 Papule  Cyst
 Nodule  Plaque
 Vesicle  Wheal
 Bulla
Secondary Result from the natural
evolution of primary lesions
lesions (eroded area left by bursting
vesicle) or from the patient's
manipulation of the primary
lesion (scratching).

 Lichenification
 Scale
 Ulcer  Atrophy
 Crust  Scar
 Erosion
 Excoriation

 Macule: flat, nonpalpable circumscribed area of change

in the skin. Macules are < 1-2 cm in size.
1. Macules may be the result of
 (A) hyperpigmentation (e.g. brown as in lentigos),

 (B) depigmentation (e.g. vitiligo),

 (C) vascular dilation (e.g. erythema)

2. Multiple well-defined macules of various shapes and

sizes. In this case, the macules blanch upon pressure
(diascopy) and thus are due to inflammatory

 Papule: small solid elevation of skin generally < 5 mm in

diameter. The majority of the papule elevation projects above
the plane of the surrounding skin. Papules may be flat-topped,
as in lichen planus; or dome shaped, as in xanthomas; or
spicular, if related to hair follicles.
 1. Papules may result from
 (A) dermal metabolic deposits,
 (B) localized dermal cellular infiltrates,
 (C) localized hyperplasia of dermal or epidermal
cellular elements.
 2. Two firm dome-shaped papules - dermal
melanocytic nevi.
 3. Multiple well-defined and coalescing papules
- lichen planus.

 Nodule: palpable, solid, round, or ellipsoidal lesion. Its

depth of involvement and/or palpability differentiate it from
a papule rather than its diameter (although nodules are
usually larger than papules: > 5 mm diameter). Nodules
can involve any layer of the skin and can be edematous or
 Based on the anatomical component(s) involved, there are
five types of nodules: epidermal, epidermal-dermal,
dermal, dermal-subdermal, and subcutaneous.
 1. Nodule can be located in
 (A) the dermis and subcutaneous layer or in

 (B) the epidermis.

 2. Firm well-defined nodule with a smooth and glistening

surface through which dilated capillaries (telangiectasia)
can be seen; there is central crusting due to tissue
breakdown and thus ulceration - nodular basal cell

 3. Multiple nodules varying in size - melanoma metastases

Vesicle & Bulla

 Vesicle (blister): circumscribed, elevated lesion that is < 5

mm in diameter containing serous (clear) fluid.

 A vesicle/bulla is the technical term for blisters. Vesicle

walls can be so thin that the contained serum, lymph,
blood, or extracellular fluid is easily seen. Fluid can be
accumulated within or below the epidermis.

Bulla: A vesicle with a diameter > 5 mm.

 (A) subcorneal vesicle - fluid just below stratum corneum,

 (B) spongiotic vesicles - intercellular edema.
Vesicle & Bulla
Mechanisms of blister
 (A) Acantholytic vesicles - cleavage within epidermis due to
intercellular attachment loss

 (B) Balloon degeneration of epidermal cells in certain viral

infections leads to vesicles.

 (C) Intercellular edema

 (D) Subepidermal vesicles due to changes in dermal-epidermal

 Acantholysis

Acantholytic vesicles - cleavage within epidermis

due to intercellular attachment loss
Cell Balooning

 Balloon degeneration of epidermal cells in certain viral

infections leads to vesicles, e.g. Herpes Zoster
Spongiosis – intercellular edema
Subepidermal blister

 Pustule: superficial, elevated lesion that contains pus (pus

in a blister). Pustules may vary in size and shape. The
color may appear white, yellow, or greenish-yellow
depending on the color of the pus. Pus is composed of
leukocytes with or without cellular debris. It may also
contain bacteria or may be sterile.

1. A pustule is basically a papule containing pus.

2. Superficial, subcorneal pustules - pustular psoriasis.


 Cyst: an epithelial lined cavity containing liquid or

semisolid material (fluid, cells, and cell products). A
spherical or oval papule or nodule may be a cyst if, when
palpated, is resilient (feels like an eyeball).
Most common are
 (A) epidermal cysts, lined by squamous epithelium and
produce keratinous material.
 (B) Pilar cysts, lined by multilayered epithelium which does
not mature through the granular layer.

Bluish, resilient cyst filled with mucous material - adnexal

tumor (cystic hidradenoma).

 Plaque: palpable, plateau-like elevation of

skin, usually more than 2 cm in diameter and
rarely more than 5 mm in height. Often formed
by a convergence of papules, as in psoriasis.

1. Plaques occupy a relatively large surface

area in comparison with its height above the

2. Well-defined, reddish, scaling plaques.

Wheal = urtica

 Wheal: transitory, compressible papule or

plaque of dermal edema.
1. The papule or plaque is usually rounded or
flat-toped, and evanescent, disappearing within
hours. The borders of a wheal are sharp, but
not stable and can move from involved to
adjacent uninvolved areas over hours. The
epidermis is not affected. Wheals can be pale
red or white (especially in the center) if edema
is sufficient to compress superficial vessels.
Wheals are a common allergic reaction.
2. A wheal may be large coalescing plaques as
in this allergic reaction.
Scale /

 Scale: accumulation or abnormal shedding of horny

layer keratin (stratum corneum) in perceptible
flakes. The change may be primary or secondary.
Scales usually indicate inflammatory change and
thickening of the epidermis. The may be fine, as in
pityriasis; white and silvery, as in psoriasis; or large
and fish-like, as in ichtyosis.

 Parakeratotic scale (with retained nuclei) can be

seen in psoriasiform epidermal hyperplasia.
 Actinic keratoses is a densely adherent scale with
gritty feel due to a localized increase in stratum
Ulcer = ulcus
 Ulcer: circumscribed area of skin loss extending
through the epidermis and at least part of the
dermis (papillary).

1. Basically, it's a "hole in the skin". Ulcers

usually result from the impairment of vascular
and nutrient supply to the skin.

2. Gigantic ulcer, red granulating base with

punched out borders.
Crusta = crust

 Crust: dried serum, blood, or pus on the surface

of skin.
1. May be thin, delicate, and friable or thick and
adherent. Crusts are yellow, if from serum;
green or yellow-green if from pus; or brown or
dark red if formed from blood. Characteristic of
pyogenic infections.
2. Crusts that occur as honey-coloured, delicate,
glistening particulates are typical of - Impetigo.

 Erosion: moist, circumscribed, usually

depressed lesion due to loss of all or
part of the epidermis
1. Often results from eruptions of vesicles and
bullae. Seen in infection from herpes viruses
and in pemphigus.
2. Toxic epidermal necrosis causes erosion.

 Excoriation: linear or punctate

superficial excavations of epidermis
caused by scratching, rubbing, or

 Lichenification: chronic thickening of the skin along

with increased skin markings. Results from
scratching or rubbing

Note the increased skin markings

 Atrophy: paper-thin, wrinkled skin with easily visible
vessels. Results from loss of epidermis, dermis or both.
Seen in aged, some burns, and long-term use of highly
potent topical corticosteroids.

 Dermal atrophy manifests as a depression in the skin.

 Epidermal atrophy manifests as thin almost transparent
skin; may not retain normal skin lines.

 Dermal and epidermal atrophy. There is loss of normal

skin texture, thinning and wrinkling.

Scar: replacement of normal tissue by fibrous 

connective tissue at eh site of injury to the dermis.
Scars may be hypertrophic, atrophic, sclerotic or
hard due to collagen proliferation. Reflects pattern
of healing in the affected area.

(A) Hypertrophic or (B) Atrophic scar.

Patterns of tissue reaction

 Lichenoid reaction
 Basal cell degeneration
 Vesicobullous reaction
 Spongiotic reaction
 Granulomatous reaction
 Vasculitic
 Non-specific reaction due to infection
Reaksi lichenoid

Band like lymphocytic infiltration = interface dermatitis

Basal cell degeneration

Lupus erythematosus showing basal cell

degeneration, hyperkeratosis, keratotic pug,
pigmentary incontinence

Pemphigus vulgaris showing

suprabasal acantholysis
Bullous pemphigoid

Pemfigoid bulosa
Dermatitis herpetiformis
Epidermolisis bullosa
Granulomatous Reaction

Fungal infection