S6C24P18-1: Along the floor of the defect in this lesion of cicatricial pemphigoid, there is a change in the character of the fibrous tissue above the row of blue arrows. Above the arrows, the tissue is loose; there is a greater number of fibroblasts per unit area. The loose fibrous tissue is young, granulation tissue in the process of organization.

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S6C24P18-2: This is a lesion of cicatricial pemphigoid late in its life history. The lesion can be recognized as “old” by the vertical dimensions of the abnormal fibrous tissue in the domain of what would normally be a papillary dermis (above line outlined by blue arrows). The uniform density of this fibrous tissue also can be cited as evidence of chronicity. The fibrous tissue is richly vascularized; perivascular infiltrates of lymphoid cells are mild. These markers for fixity of the reaction and for chronicity should be evaluated separately from the markers above the level of the fibrous tissue, namely those associated with a well-developed, subepidermal bulla. The  well-formed sub-epidermal bulla is a marker for continued damage to cohesive structures at the dermal-epidermal interface; acute damage (activity) continues in the face of all the markers for chronicity. It is possible to categorize the process as one in which a localized area of skin has become a “dump” into which harmful antibodies are sequestered from out of the blood. The blue arrows define the boundary between portion of the reticular dermis that is uninvolved and the organized granulation tissue.

S6C24P18-3: The floor of this chronically active bulla of cicatricial pemphigoid is composed of organizing granulation tissue. This tissue forms, in part, as an organization of condensed fibrin along the floor of a subepidermal defect and, in part, as repair in areas of partially digested fibrous tissue of the papillary dermis and the dermal papillae. Some of the dilated, angulated vessels in the fibrous tissue are dilated lymphatics. The plane along the floor of the bulla is relatively straight; the slight undulations along the surface of the floor probably are markers for papillae that have lost their structural identity in an area of scarring.

S6C24P18-4: In this lesion, the interface between relatively normal reticular dermis and abnormal fibrous tissue is identified by a row of blue arrows. Above the arrows, there is a wide zone in which collagen bundles are closely aggregated and parallel to the surface of the skin. The green arrows define a second boundary; The zone above the green arrows mostly represents a new domain, incorporating, but extending beyond, the domain of what was once the papillary dermis. The intermediate zone of fibrosis is altered reticular dermis (PAS stain).

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