Table Of ContentPRACTICAL
Dermatopathology
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S E C O N D E D I T I O N
PR ACTI CAL
Dermatopathology
Ronald P Rapini MD
Josey Professor and Chairman
Department of Dermatology
Professor of Pathology
University of Texas Medical School
and MD Anderson Cancer Center
Houston, TX, USA
Edinburgh, London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto 2012
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Notices
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they
should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are
advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise,
or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
The Publisher
Rapini, Ronald P.
Practical dermatopathology. – 2nd ed.
1. Skin – Diseases – Diagnosis.
I. Title
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Contents
Preface vii
Acknowledgements viii
Dedication ix
1 Clinical and Pathologic Findings with Differential Diagnostic Lists 1
2 Eczematous and Papulosquamous Diseases 45
3 Reactive Erythemas 61
4 Vasculitis and Other Purpuric Diseases 73
5 Intraepidermal Vesicular and Pustular Diseases 87
6 Subepidermal Vesicular Diseases 93
7 Non-infectious Granulomas 101
8 Deposition and Metabolic Diseases 119
9 Alterations of Connective Tissue 139
10 Adnexal Inflammatory Diseases 151
11 Some Genodermatoses 159
12 Bacterial Diseases 167
13 Fungal Diseases 187
14 Viral, Rickettsial, and Chlamydial Diseases 207
15 Parasitic Diseases 219
16 Panniculitis 231
17 Other Non-neoplastic Diseases 239
18 Epithelial Neoplasms 253
19 Cysts 277
20 Melanocytic Neoplasms 285
21 Sebaceous Neoplasms 307
22 Follicular Neoplasms 311
23 Sweat Gland Neoplasms 321
24 Myeloproliferative Disorders 331
25 Vascular Proliferations and Neoplasms 353
26 Neural Neoplasms 367
27 Fibrohistiocytic Proliferations and Neoplasms 379
28 Metastatic Neoplasms to Skin 397
29 Miscellaneous Remnants and Neoplasms 405
30 Special Stains 417
References and Further Reading 427
Index 431
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Preface
The first edition of this book was a complete overhaul of a organized by their clinical morphology instead of by histol-
similar book I co-authored in 1988, published as Atlas of Der- ogy. They would prefer to have chapters on lichenoid,
matopathology. A practical approach to skin biopsies is pre- perivascular, and spongiotic dermatitis instead. But they can
sented to supplement existing textbooks of dermatopathology. find that kind of thinking in Sections 1.72, 1.109, and 1.132.
I hope that the lists of differential diagnoses for clinical and There is no perfect way to organize diseases in this kind of
pathologic changes found in Chapter 1 will serve as a starting text, and this book reflects the perspective of an author who
point in the evaluation of a skin biopsy. The first edition was is both a clinician and a histopathologist. Organization strictly
compact enough for residents to carry around, and even by etiology or clinical features provides the reader with no
experienced dermatopathologists sometimes kept a copy starting point in evaluating a biopsy with a specific patho-
near the microscope for a quick list of differential diagnoses. logic change. Textbooks organized by pathologic changes
Since many have complained about a very worn-out copy of often end up discussing a given disease in multiple frag-
the first edition, we have embarked upon a second edition, mented locations throughout the book, because most inflam-
deciding to keep the size compact. Adding clinical photo- matory diseases present with variable histologic patterns.
graphs would have made the book too thick, so we are pro- I must alert the reader to additional pitfalls in the use of
viding these along with additional histologic photographs on this book. In my efforts to publish “classic” examples of each
a website instead. I have listed the important clinical and disease, the reader may be confused when examining a lesion
histologic features and variations for both common and showing only some of the typical features. There is no sub-
unusual diseases, italicizing the most characteristic features. stitute for experience in dealing with all of the numerous
I have tried to distill the most important facts into this text. variations that may occur (experientia docet). Uncommon
To be concise, I have omitted discussion of normal skin histol- presentations of common diseases are common. There is not
ogy, electron microscopy, hair, nails, oral mucosa, disease enough space to publish both low- and high-power photomi-
pathogenesis, and treatment. Of course, knowledge of the crographs of all conditions; otherwise, several expensive
pathogenesis is critical in understanding skin disease, and volumes would be needed to adequately cover the gamut of
detailed correlation between the clinical and pathologic fea- skin diseases. This is not meant to minimize the importance
tures is very important in making a specific diagnosis. The of scanning microscopy. Skin lesions evolve through time,
reader can readily find this information in some of the major and it has not been possible for any author to illustrate the
textbooks listed at the end of this book, most of which give incipient or non-diagnostic stages of all of these skin diseases
many references. I have not given extensive references in a single volume. The reader should realize that the lists
because of space considerations, and because most physicians found in Chapter 1 and elsewhere in the book purposely do
now have ready access to computerized literature searching not include every possibility, although they are reasonably
for contemporary references. Essentially this is a book that complete. My bias toward being a “lumper” may be apparent,
aids in making a diagnosis. Making a correct diagnosis is of so that many conditions considered by “splitters” to be sepa-
utmost importance, because the treatment can then be found rate entities are often grouped together as “Variations” under
in a variety of sources. The physician without a specific diag- some other heading. I appreciated comments from readers of
nosis is doomed to treat patients by trial and error. inevitable errors or omissions found in the first edition, and
The book has been organized so that one can quickly I solicit additional feedback on this newest version.
look up a disease or a pathologic feature and immediately
find the important criteria and a differential diagnosis. Pure Ronald P Rapini, MD
pathologists will complain that rashes in Chapters 2 and 3 are 2012
Acknowledgements
Richard Zuehlke MD organized some of the ideas used in I thank many other faculty, colleagues (and residents and
Chapter 1, which were presented in his Syllabus of Dermato- students!) who have taught me over the years. Special thanks
logic Histopathology, the fourth edition of which was pub- to recent dermatopathology fellows Darren Whittemore DO,
lished by Westwood Pharmaceuticals in 1982. That guide Valencia Thomas MD, Kimara Whisenant MD, and Scott Bangert
updated lists of differentials prepared by Victor I Spear MD MD for help with some of the new second edition photos.
in 1962 at University of Michigan, crediting the 1954 book I cannot list all of those individuals who have shared their
Systematized Histopathology by Drs Walter R Nickel and James cases or provided slides for my teaching collection. They are
H Lockwood. Loren Golitz MD provided me with valuable too numerous to mention individually.
fellowship training in dermatopathology and served as a role
model educator and collector of slides for teaching purposes. Ronald P Rapini, MD
Dedication
To Mary Jo, my love, who tolerates (most of the time) the
competing affection I feel for academic work.
To Joann and Vince Rapini, my parents, who laid the foun-
dation for my life.
To Brianna and Sarina, my children, in whom I hope to
have instilled the drive to do something meaningful while
being considerate of others.
