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SECTION 1, Chapter I: Inflammation, general
(HOME)
(RICHARD J. REED, M.D., New Orleans, LA 70125, 1 Jul 05)
The Color of Inflammation:
This collection of text and images is devoted to a conceptual presentation of models for the interpretation of inflammatory diseases of the skin. It is concerned with basic concepts. The presentation is a classic
morphologic approach; immunohistochemistry, genetics, and electron microscopy are given little attention. This approach was selected with students, residents, and fellows in mind. Pathologists with experience in
dermatopathology might find the presentation tedious and, depending on perspective, might even find it controversial. Much of the material is old and, being old, is open to criticism as simply being dated, not only
physically, but even conceptually. A good portion of the material dates from the 1960’s, the 1970’s, and the 1980’s. Many of the 35mm transparencies, which have been digitized, show signs of deterioration; many of
the digital photomicrographs are little better than the respective old transparencies (even a few lantern slides have been digitized).
The greatest handicap for a neophyte in dermatopathology is a lack of both terminology and stored virtual images; one might (must) use both in the search for an understanding of unfamiliar histologic patterns. I have
no assurance that my approach will prove of value to a student of pathology; the material, the interpretations, and the philosophical asides are representative of my approach to the histologic interpretation of
inflammatory diseases of the skin. I find more utility in my approach than in the oft emphasized “superficial and deep” approach; once a resident has characterized a pattern as one, the other, or both, he must set
the characterization aside, and then begin a search of a different nature. It is this search, of a different nature, which I hope will be promoted by a review of the material in this presentation.
I don’t expect this material to be widely distributed to, or even greatly sought after by, most residents and fellows; perhaps, the act of having prepared this material is more indicative of an attempt to find
vindication for my fading ambitions (and failing abilities) than an act by which a serious teaching aid has been structured. In any case, I would be pleased, if a resident, having availed himself of the material,
finds new insights and both a deeper understanding of, and appreciation for, the significance of patterns when viewing a histologic section of an inflammatory lesion of the skin. This is not a multi-authored effort.
No copy editor has reviewed the material. I have had more trouble with the software and digitization than with the description of the pathologic changes associated with disease. Whatever has been accomplished, a
great deal of work has been expended.
TACTICAL CONCERNS:
This site consists of 17 sections: an INTRODUCTION, a DIRECTORY (indexdir), a dummy section (SITE DIAGRAM) (indexextr), and 15 additional sections (index1-15).
In the folder on the CD, the variations of the “INDEX” items give recognition to file names; by identifying the collection of “INDEX” items on the CD, a click on a selected item (i.e., index or indexextr)
will take the reader to the respective section.
Each section consists of a variable number of chapters (i.e., pages in a web site sense, rather than the more uniform structure of paper pages). The first 13 sections, and the 15th & 16th sections all have three
tiers consisting of a single chapter on the first tier (HOME), a variable number of textual chapters on the second tier (S-C- items), and a variable number of pictorials and visual aids on a third tier (S-C-P-, or
S-C-VA- items). With the exception of Chapter14, the chapters of the second tier are of a textual nature. Those of the third tier for Sections 1-13, & 15 &16 are pictorials or visual aids. In Section 14,
there are no textual chapters; the second tier is devoted to pictorials. If this brief explanation has elicited confusion, the reader might refer to the Site Diagram (click on the respective navigation aid in the cluster of
mauve
bars either in the MASTERBORDER, or at the end of each page of each section). In the SITE DIAGRAM, I have attempted to explain the structure of this site and to relate structure to problems in navigation.
On each page (i.e., each chapter), in a MASTER BORDER to the left and at the end of each page, there are clusters of navigation bars; these bars allow the reader to go from chapter to chapter in a particular section,
or to the various sections of this site. A SECTION INDEX is available on each on the sections on the second tier. It is included in the first chapter of the second tier in Sections 2-7, 9-14, and 16, the SITE
DIAGRAM, and the DIRECTORY. The
third chapter (the second chapter on the second tier) of the first, eighth, and fifteenth sections is a SECTION INDEX. The SECTION INDEX provides a brief description of basic reaction patterns in each respective section.
By clicking on the appropriate listing in the cluster of mauve
bars in either the MASTERBORDER, or at the end of each page, the reader can navigate among the sections. SECTION INDICIES at the end of each IMAGE MAP (i.e., second chapter of most sections [first chapter of the second tiers], or third chapter of Sections 1, 8 & 15) merely provide brief descriptions of relevant material; they are not responsive to a click on the mouse. The
mauve buttons in the MASTERBORDER, or at the end of each of the pages provide access to other sections; they will be responsive to a click on the mouse.
The first chapter of each section is a home page (HOME) on which there are general comments, as well as suggestions regarding the navigation of the section (the reader is currently at HOME of
Section 1, with access to tiers 1, 2, & 3). An IMAGE MAP with a listing of illustrations and with a brief comment on the nature of the respective disorders is available for all sections (it is the first chapter on the second tier of each section [i.e., Chapter 2]). From the IMAGE MAP, a reader has access to the illustrations and respective captions, by clicking on the appropriate underlined, identifying label. The
mauve bars in the MASTERBORDER, or at the end of each page will take the reader to his selected section where other navigation bars and links in other IMAGE MAPS
will allow the reader to search out particular diseases, or review a large group of pictorials, all relevant to a particular reaction pattern of the skin.
For this section, as for Sections 1-16, the first vertically oriented cluster in the MASTERBORDER to the left is blue; it is a first level cluster providing access to
Home and all the chapters of Level 2. At Level 2, this cluster additionally provides access to pictorials at level 3. It should be noted that chapters marked with an “-X” in the blue
first cluster of the MASTERBORDER and in the beige
cluster in the MASTERBORDER of this section are parent textual chapters at level 2; they provide access to the respective parent textual chapters at level 2, and thence to the respective pictorials. A cluster of two
green bars at the end of each page of this section provides access to two web sites.
In the clusters to the left in the MASTERBORDER, the letter “S” followed by a number identifies a particular section. In turn, the letter “C” followed by a number identifies a chapter in the respective section. If
the designation in the MASTERBORDER has no other letters or numbers, and is not identified as HOME, then the chapter is at tier two and is textual, but not a parent. If letters “S” & “C” are followed by a
“P” or by “VA,” then the reader can click on the appropriate bar to navigate to the third tier; in the act, he will find access to the pictorials. Groups of pictorials are related to a particular parent chapter at
level 2. If the reader wishes to go directly to the pictorials, he should search out a box of navigation aids in which the designations include a “P” or a “VA” (i.e., aids in the beige cluster in the MASTERBORDER, and in some sections continued at the end of each page, as they are for this section). It is possible to by-pass the textual
component and go directly to the first pictorial by searching the clusters in the MASTER BORDER, or at the end of each page, to find, and then click on, the appropriate navigation bar. It should be noted that the
location of the various colored clusters of navigation aids, with the exception of the blue
cluster, is peculiar to each section; parent chapters in the clusters of navigation aids are identified by an “-X.” In the blue
cluster at Level 2, children (groups of pictorials) follow, in sequence, each parent chapter.
There is a SECTION MAP (click on first aid in beige cluster in MASTERBORDER to go to section map) at the second level of this section. A click on a selected bar in the
mauve
cluster at the end of each page of this section takes the reader to his selected section. Having arrived at the appropriate section, the navigation bars, in either the MASTERBORDER (as seen in the border to the left), or at the end of each page, will allow the reader to move about the selected section.
Please note that you will not have arrived at the end of any page (chapter) until you have at least reached the end of the downward travel of your cursor. At the end of each page of all the sections, there should be
three additional navigational bars. One (NEXT) allows the reader, if at either level 2 or level 3, to move in a spatial sequence, along the horizontal axis of the active tier, to the next page at that level; at
level 3, this migration is useful only in regard to pages that are the children of a single parent textual page at level 2; to access other pictorials, use MASTERBORDER aids to the left. The UP button takes a
reader, who is at the pictorial level, to the relevant parent textual page at level 2 or, if the reader is at level 2, a click on this aid will take the reader HOME.
The third aid takes the reader back to the previous page (BACK button); movement is spatial along the horizontal axis of the tier. Two additional bars forming a green
cluster are available at the end of the page. One of these aids takes the reader to Bill Weems’ web site. The other takes the reader to my web site (REED PATCH 3) which mostly is devoted to melanocytic lesions. The reader’s “back” button of his browser also has utility in moving about the sections; it has relevance for temporal sequences.
The final chapter at level (tier) 2 of each section, is an offering of SELECED READINGS (click to go to this chapter). This is a rather scanty, hodge podge of material, mostly relevant to some of the material in the texual and pictorial chapters of a respective section.
I have attempted to present the photomicrographs in a favorable fashion, but some are old; the colors are altered. Some of the faults reflect my inexperience. The reader might attempt to accommodate the condition of
some of the photomicrographs by adjusting the brightness and contrast of his monitor.
General Comments (Inflammation)
Inflammatory diseases of the skin are divisible into categories in which the correlations between clinical and histologic features are remarkable. The perspectives for the study of skin diseases are constantly
changing in response to an accumulation of new data; they change as new procedures for the study of disease are introduced. Perspectives are also influenced by personalities. In the face of all the new techniques
and information, a histologic study of diseases of the skin - the classic approach - still retains relevancy and, for many lesions, even primacy.
Herein, an approach to the study and classification of inflammatory diseases of the skin is presented. The approach is not that of evaluations of the distribution of infiltrates of lymphoid cells in the dermis
(i.e., “superficial and deep”); it is something more than pattern analysis at low magnifications. The approach is one of identifying basic parcels in general reaction patterns and, then, comparing the parcels with
those from other related disorders, or even with those from disorders which apparently are foreign to one another.
The material and the approach are old; this lack of freshness is apparent in the quality of many of the illustrations. This approach, in which skin diseases are examined by first identifying real images, and then defining parcels of virtual images, obscures the boundaries among some of the categories. For example, infectious disorders will be found in the chapter on infectious diseases, but some aspects will also be found in the chapter on granulomatous diseases.
In the current approach to terminology, temporality is seldom emphasized. What might once have been characterized as acute dermatitis currently is likely to be found in the category of neutrophilic dermatitis (I am
reminded of an old Emeritus Professor who was signing-out the daily load of skin biopsies at Charity Hospital. At that time, the reports at Charity Hospital consisted of only a diagnosis; a description was not
allowed. His diagnosis for one case was “dermatitis.” The resident asked him if he would prefer “chronic dermatits” as his diagnosis. His response was: “No, I would not want to be that specific.”
At one time, the plasma cell might have been cited as a marker for chronicity. Currently, it is identified as a secretory cell with a specific role in immunity.
The histiocyte at one time was likely to be viewed as a marker for a resolving inflammatory process with the cell having a role in the removal of tissue debris. The role remains the same for certain histiocytes (the identifying marker being KP-1 [CD-68]); other dendritic cells with different markers have been credited with a role in the modulation of relationships between cells and their stroma, or as having a role in providing receptor sites for the presentation of antigens; the distinctions, that are championed by a new generation of pathologists, may not be as rigid as students of the markers would have us believe.
The basement membrane of histologists was defined as a membranous boundary at the interface between the domains of cells of divergent lineage. It has become a complicated zone of unique structure with unique
components. The molecular basis of all the new discoveries must be acknowledged and promoted but, in practice, much of the basis for an understanding of dermatopathology remains at the level of the light microscope.
The material in each section is structured in “chapters;” the reader is advised to think of the units as seen in the SITE DIAGRAM as separate chapters. The INDEX MAP of this section (chapter 2, tier II) provides information regarding the basic reaction patterns which are discussed in other chapters.
The sections include:
1.) the colors, and the cells of inflammation; 2.) spongiotic and psoriasiform disorders;
3.) the lichenoid disorders with a lichen planus-like reaction as the defining image; 4.) the cell-rich lichenoid lymphocytic vasculitic reactions, including erythema multiforme-like disorders, and some of the pityriasic disorders(erythema multiforme-like and pityriasic); 5.) the cell-poor lichenoid lymphocytic vasculitic reactions, including lupus erythematosus and dermatomyositis (LE-like lichenoid reaction); 6.) the vesiculo-bullous disorders; 7.) additional vesiculo-bullous disorders; 8.) the vasculitides; 9.) the collagenoses, including some examples of elastoses and mucinoses; 10.) the panniculitides; 11.) infectious disorders; 12.) granulomas; 13.) borderline disorders 1; 14.) limited clinical iconography; and 15.) borderline disorders 2.
This limited presentation is not structured to provide a thorough coverage of the entire spectrum of cutaneous inflammatory diseases. Instead, emphasis is placed on basic building blocks with which the student might
begin to dissect from histologic patterns. These building blocks become the foundation for distinctive parcels of virtual images. He then might restructure the building blocks in a manner which might allow for the
assignment of a problematic disease process to a recognized category, even if he is unable to provide a specific diagnosis. This approach might provide a student with a greater understanding of what pathologists do
(and in the act provide some appreciation for the many pitfalls in the practice of pathology). The student is directed to a standard textbook for a more complete discussion of each general category and for more
detailed coverage of clinical and histologic features, immunohistochemical findings, and electron microscopic correlations.
In this section, a copy of the Site Diagram is available in the SECTION MAP (beige
cluster in the MASTERBORDER to the left - the SECTION MAP follows the IMAGE MAP as the next page [Chapter 3 or 2nd page of the second tier]). A more (too?) detailed discussion of the structure of the site and the manner in which structure relates to problems in navigation, is available in the section, Site Diagram (see last button in the mauve cluster below).
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