Dermatological disorders are very common in all parts of the country but the spectrum may vary from region to region.[1] The skin diseases are more common in developing countries, which could benefit from public health care centres.
A total of 120 cases with various skin lesions, presenting to our dermatological outpatient department during April 2013 to April 2014 were included in the study. The study was carried out in rural back ground tertiary care centre of Northern India. Histopathological analysis of the skin biopsy samples was carried out and slides were stained with routine (Hematoxylin and eosin) and special stains used whenever required (Ziehl-Neelsen Staining, periodic acidic-Schiff etc.).
Out of 120 cases, 35 cases were of granulomatous lesions, 25 cases were of non-specific dermatitis, 20 cases of psoriasiform dermatitis, 8 cases of spongiotic dermatitis, 6 cases of tumour and cyst in epidermis, 5 cases of vesicobullous diseases, 2 cases of pigmentary disorder and 2 cases of connective tissue disorder. 17 cases were observed with interface dermatitis.
The incidence of skin lesions was observed more frequently in adult males. Leprosy is still the most common granulomatous dermatitis.
Various lesions affecting skin range from non-specific dermatosis and inflammatory diseases to neoplastic changes. Skin diseases are influenced by many factors like literacy, hygiene methods, environmental factors, racial and social customs.[2] Clinico-pathological analysis plays an important role in the diagnosis and further management of several skin disorders. Skin biopsy forms the basis of differential diagnosis in clinically similar dermatosis, thereby yielding important information to the dermatologist and pathologist. After performing clinical evaluation and excision of lesions, histopathological confirmation of diagnosis is the bedrock in guiding the further treatment. Though histopathology was an excellent diagnostic tool in routine dermatological practice, studies relating to clinical and pathological correlation are few.[3-7] papulonodular lesions are commonly seen in dermatological illnesses. Various infectious diseases, benign and malignant tumors are also manifested as papulo-nodular lesions. Histopathology made the diagnosis easier; but it is still a challenging job. So, clinical correlation is also important. Leprosy is found as granulomatous lesion, on histopathology. It is caused by Mycobacterium leprae and it predominantly affects peripheral nerves. Clinically the lesions may appear as macular, papular, nodular or diffused infiltrative type. Histopathologically it shows extensive cellular infiltrate with flattened epidermis and narrow grenz zone. Macrophages may be packed with lepra bacilli or foamy macrophages with degenerated bacilli.[8] The objective of our study is to evaluate the diagnosis histopathologically and correlate clinically.
The study aims to evaluate the incidence of different types of skin diseases and to evaluate the consistency between clinical and histopathological diagnosis of skin diseases.
Total of 120 cases with various skin lesion, presenting to dermatology outpatient department of BPSGMC, Khanpur Kalan, during the study period of one year (from April 2013 to April 2014) were included in the study. Approval from IEC was taken before commencing the study. Clinical history and family history were taken. As acne in teenagers and pyoderma in children are common skin problem, that were diagnosed clinically but no histopathology was done for that, so excluded from the study. A detailed history of the patients was taken and physical examination findings were recorded. Any patient with skin lesions not responding to conservative treatment for more than a period of 15 days were included in the study. Written informed consent of all the patients was taken. A fresh lesion i e a papule, vesicle or bullae with no sign of secondary infection was selected for skin biopsy, punch or excision biopsy was done to obtain tissues for histopathological examination. Skin biopsy sample was collected in 10% formalin vial and sent for histopathological examination to the pathologist. Sections were routinely stained with hematoxylin and eosin stain and special stains were used as and when required.
Patients were selected with following inclusion criteria.
Any patient with skin lesion, not responding to conservative treatment, all age and sex groups and who gave consent for the study.
Patient who refused to be included in the study.
Sexually transmitted infections, pyoderma and acne also excluded from study, because no histopathology was done for that.
Patient’s history such as age, sex and other relevant clinical details such as site of lesion and characters were noted.
All tissue specimens were subjected to gross examination. Slides were stained with routine hematoxylin & eosin and special stains such as Ziehl-Neelsen stain, periodic acid-Schiff, Alcian blue, fite Faraco and Congo red for myeloid etc.
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| Less than 10 | 9 | 5 | 4 |
| 11-20 | 25 | 13 | 12 |
| 21-30 | 35 | 20 | 15 |
| 31- 40 | 12 | 7 | 5 |
| 41 – 50 | 13 | 7 | 6 |
| 51 – 60 | 10 | 6 | 4 |
| More then 60 | 16 | 9 | 7 |
| total | 120 | 67 | 53 |
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| Non specific dermatitis | 25 | 20.8 |
| Psoriasiform dermatitis | 20 | 16.6 |
| Interface Dermatitis with lichenoid interface lesion | 9 | 7.5 |
| Interface Dermatitis with vacuolar interface lesion | 8 | 6.6 |
| Spongiotic Dermatitis | 8 | 6.6 |
| Granulomatous Lesions | 35 | 29.16 |
| Vesicobullous Lesions | 5 | 4.16 |
| Connective Tissue Diseases | 2 | 1.6 |
| Pigmentary Disorder | 2 | 1.6 |
| Benign Tumors | 3 | 2.5 |
| Malignant Tumors | 2 | 1.6 |
| Vasculitis | 1 | 0.8 |
| Total | 120 | 100 |
A total number of 120 cases were studied during the study period. Maximum numbers of biopsies sent were in the age group of 21 – 30 years and least number was in the group of 0 – 10 years. (Table 1)
Out of the 120 patients, 67 patients (55.8%) were male and 53(44.2%) cases were females. The histopathological diagnosis distribution is presented in Table- 2.
Majority of the patients observed were of granulomatous lesion 35 (29.16%) followed by non-specific dermatitis 25 cases (20.8%). Vacuolar interface dermatitis was observed in 8(6.6%) cases (erythema multiforme-2, photodermitis-2, Lichen sclerosus et atrophicus-1, Lupus erythematous-1 and pigmented dermatitis -2). Lichenoid eruptions were seen in 9(7.5%) cases which included 4 cases of Lichen planus, 2 cases each of Pityriasis lichenoides chronica and post inflammatory hyperpigmentation and one case of Lichen nitidus. Granulomatous lesions were observed in 35 cases. In this group lupus vulgaris was commonest type of granulomatous lesion, observed in 10 cases, more common in males (6 cases). Tuberculous verrucous cutis was observed in one male patient. One patient of post kalazar dermal lechmaniasis was diagnosed histopathologically because of presence of LD bodies, although clinically it showed resemblance to lupus vulgaris. Tubercular leprosy was observed in 7 cases, more common in male patient (5 cases) followed by borderline tuberculoid and borderline lepromatous leprosy in 4, 2 cases respectively. Lepromatous leprosy was observed in 6 cases. Histoid and indeterminate leprosy were observed in 2 cases each. Malignant tumors (basal cell carcinoma) were observed in 2 cases. Benign tumors were observed in 3 cases, in which one case of trichoepithelioma and 2 cases were of seborrheic keratosis.
This study has documented the clinico histopathological correlation of skin lesions at our rural back ground tertiary care centre of north India. It showed the high presence of granulomatous lesion (29.16%). The sex distribution pattern revealed that most of the patients were male (55.5%). The age pattern revealed that the maximum biopsies sent were in the range of 21 to 30 years (Table-1). The granulomatous lesions were the most frequently seen followed by non specific dermatitis. The correlation of clinical and histological diagnosis is very important before reaching the final diagnosis. Psoriasiform dermatitis was observed in 20 (16.6%s cases), it revealed hyperkeratosis and elongation of the epidermal rete-ridges. Interphase dermatitis with lichenoid eruption was observed in 7.5% cases. Granulomatous lesions were observed in 35 (29.16% cases) which is in accordance with study done by Mohan et al.[9] Leprosy was observed in 23 patients with male predominance which is in concordance with the study of Gill et al. [10]
Papulonodular lesions of skin were diagnosed well clinically and better correlated with histopathological examination. Clinically, most of infections were diagnosed and confirmed by histopathology and correlation was 100%. In leprosy, clinico-pathological correlation was 98% and in cutaneous tuberculosis, actinomycosis and vesicobullous disorders the clinico-pathological correlation was 100% on histopathological examination.
Rook A, Savin JA, Wilkinson DS. The Prevalence, incidence and ecology of diseases of skin. In: Rook A, Wilkinson DS, Edling FJ, editors, Textbook of dermatology, Oxford university Ress: Mumbai 1987, 39-53.
Sarkar SK, Islam AKMS, Sen KG, Ahmed ARS. Pattern of skin diseases in patients attending OPD of Dermatology Department at Faridpur Medical college hospital, Bangladesh. Faridpur Med Coll. J. 5(1), 2010, 14-16.
Aggrawal D, Singh K et al. histopathological review of dermatological disorders with a keynote to granulomatous lesion: a retrospective study. Int J Sci Stud 3(9), 2015, 66-9.
Uz Zafar MN, Sadiq S, Arif Memon M. Morphological study of different granulomatous lesion of skin. J Pak Assoc. Dermatol 18, 2008, 21-8.
Gulia SP, Wadhai SA, Lavanya M. et al. histopathological pattern of skin disease in a teaching hospital, Puducherry. Int J Recent Trend Sci Technol 11, 2014, 45-50.
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Patil R, Mekdani M, Gunjalia A, Gandhi K, Patel H. Retrospective study of papulonodular skin lesions and their clinopathological correlation. Int J Med Sci Public Health. 4, 2015, 612-6.
Lever WF, Lever GS. Histopathology of skin, Philadelphia, PA:Lipincott. 9, 2005.
Mohan H, Bal A, Dhami GP. Non infectious granulomatous dermatitis. A Clinico pathological study. J Cutan Patho. 33, 2006, 767-71.