|Year : 2015 | Volume
| Issue : 4 | Page : 481-485
Significance of clinicopathological correlation in psoriasis
Gopal Ambadasrao Pandit, Shilpa Laxmikant Narayankar
Department of Pathology, Dr. VMGMC, Solapur, Maharashtra, India
|Date of Web Publication||14-Jul-2015|
Shilpa Laxmikant Narayankar
A1/84/2, Sector-21, Vashi, Navi Mumbai - 400 705, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Psoriasis affects about 1.5% to 3% of world's population. Other papulosquamous dermatoses are Pityriasis rosea, Lichen planus, Seborrheic dermatitis, Pityriasis rubra pilaris and Parapsoriasis. Drug eruptions, tinea corporis, and secondary syphilis may also have papulosquamous morphology. Because all papulosquamous disorders are characterized by scaling papules, clinical confusion may result during their diagnosis. Separation of each of these becomes important because the treatment and prognosis for each tends to be disease-specific. Aim: To study the pattern of clinical and histopathological features of psoriasis of the skin with clinicopathological correlation. Material and methods: The present study of 42 cases of psoriasis of the skin was carried out in the Department of Pathology of a tertiary care centre from December 2009 to October 2011. In this study, the patients which were clinically diagnosed as psoriasis of skin, before starting the treatment and attending the outdoor skin department were selected. Histopathological findings were interpreted in light of clinical details. Results: Out of 42 cases of psoriasis 24 (57.14%) were males, 18 (42.86%) were females with male to female ratio of 1.33:1. Mean age was 34.45 years. Maximum number of cases 22 (52.38%) were encountered in 3rd and 4th decade of life. Histopathological findings: parakeratosis, acanthosis, suprapapillary thinning, Munro microabscesses and hypogranulosis were noted in most of the cases. Conclusion: Histopathology serves as a diagnostic tool and rules out other lesions which mimic psoriasis. The most accurate diagnosis is the one that most closely correlates with clinical outcome and helps to direct the most appropriate clinical intervention.
Keywords: Correlation, clinicopathological, psoriasis
|How to cite this article:|
Pandit GA, Narayankar SL. Significance of clinicopathological correlation in psoriasis. Med J DY Patil Univ 2015;8:481-5
| Introduction|| |
Psoriasis (Greek. Psora, the itch)  is a common, chronic, relapsing, papulosquamous dermatitis, characterized by an epidermis covered by silvery scales.  Papulosquamous dermatitis comprises a group of dermatoses that have distinct morphologic features. The characteristic primary lesion of these disorders is a papule, usually erythematous, that has a variable amount of scaling on the surface. Plaques or patches form through coalescence of the primary lesions.  Psoriasis affects about 1.5-3% of world's population. , Other papulosquamous dermatoses are pityriasis rosea, Lichen planus, Seborrheic dermatitis, Pityriasis rubra pilaris and parapsoriasis. Drug eruptions, tinea corporis, and secondary syphilis may also have papulosquamous morphology. 
Because all papulosquamous disorders are characterized by scaling papules, clinical confusion may result during their diagnosis. Separation of each of these becomes important because the treatment and prognosis for each tend to be disease-specific.  The skin has a limited number of reaction patterns with which it can respond to various pathological stimuli: Clinically different lesions may show similar histological patterns. Therefore, to obtain the precise diagnosis of the skin biopsy, it should be accompanied by all clinical details. 
Thus, this study is carried out to study the pattern of clinical and histopathological features of psoriasis of the skin with clinicopathological correlation.
| Materials and Methods|| |
This study of 42 cases of psoriasis of the skin was carried out in the Department of Pathology of a tertiary care center from December 2009 to October 2011. In this study, the patients, which were clinically diagnosed as psoriasis of the skin, before starting the treatment and attending the outdoor skin department were selected. Diagnoses of all clinical cases were given by two dermatologists. Detailed clinical history, thorough physical examination and thorough examination of lesions of each and every case were carried out as per the proforma. Informed consent was obtained before biopsy. Before preceding the biopsy, xylocaine sensitivity test was done by injecting 0.5 ml of xylocaine subcutaneously. The lesion was selected for biopsy, and the skin surface was cleaned with a spirit swab. Local anesthesia was best obtained by infiltration of 2% lignocaine solution with adrenaline under the lesion. Scalpel biopsy was done to obtain an adequate amount of tissue for diagnosis of the most skin lesions. Biopsy specimen was kept in 10% formalin for 24 h for fixation. After fixation, the specimens were processed in an automatic tissue processor. After processing, the paraffin blocks were made and cut on a rotary microtome into 5 microns thick sections. Sections were stained with H and E and were examined by conventional light microscopy. Detailed microscopic examination was undertaken for histopathological diagnosis of psoriasis of the skin. Histopathological findings were interpreted in light of clinical details by two pathologists.
| Results|| |
Clinical features of histologically diagnosed cases of psoriasis of the skin
Of 42 cases of psoriasis 24 (57.14%) were males, 18 (42.86%) were females with male to female ratio of 1.33:1. Mean age was 34.45 years. Maximum number of cases 22 (52.38%) were encountered in 3 rd and 4 th decade of life.
Scaly plaque 39 (92.85%) was the most common clinical presentation. Plaques were erythematous and covered with silvery scales. Limbs 35 (83.33%) were the most frequent site of involvement, followed by the trunk 20 (47.61%), scalp 17 (40.47%), face 10 (23.80%) and neck 2 (4.76%). Itching, Auspitz's sign, Koebner phenomenon and family history were noted in 35 (83.33%), 27 (64.28%), 5 (11.90%) and 3 (7.14%) cases respectively.
Histopathological findings of psoriasis of the skin are shown in [Figure 1] [Figure 2] [Figure 3] [Figure 4] and [Table 1].
|Figure 1: Psoriasis vulgaris showing multiple erythematous scaly plaques with silvery white scales on the trunk|
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|Figure 2: Photomicrograph of psoriasis vulgaris showing acanthosis, parakeratosis, elongated rete ridges, suprapapillary thickening, Munro microabscesses, hypogranulosis, dilated dermal capillaris, and lymphocytic infiltration in papillary dermis. (H and E, ×100)|
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|Figure 3: Photomicrograph of psoriasis vulgaris showing mounds of parakeratosis with Munro microabscesses, acanthosis, suprapapillary thickening, hypogranulosis, spongiosis, dilated dermal capillaris, and lymphocytic infiltration in papillary dermis. (H and E, ×100)|
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|Figure 4: Photomicrograph of Psoriasis vulgaris showing kogoj pustules, acanthosis, hypogranulosis, and spongiosis (H and E, ×100)|
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Out of 42 histologically diagnosed cases of psoriasis, 40 (95.24%) cases had a clinical diagnosis of psoriasis whereas rest of the 2 (4.76%) cases had a clinical diagnosis of tuberculous verrucosa cutis [Table 2]. Thus, histopathology gave diagnosis in 4.76% of the cases.
| Discussion|| |
Psoriasis has many different clinical variants and can resemble other skin diseases such as secondary syphilis, dyshidrotic eczema, seborrheic dermatitis, pityriasis rosea, psoriasiform drug rash, and parapsoriasis. Besides, the same patient can present at different times with a different clinical presentation or variant. ,, The recurrent nature and prognosis of psoriasis differs from that of psoriasiform dermatitis, thus further highlighting the importance of reaching the correct diagnosis. 
In psoriasis, Khandpur et al.  reported majority of the cases (66.8%) in the age group of 21-50 years. Henseler and Christophers  identified two ages of onset: Type I occurring at or before the age of 40 years in approximately 75% of the patients; and type II presenting after the age of 40 years. Gudjonsson and Elder  stated that type I psoriasis is HLA-associated while type II lacks human leukocyte antigen (HLA) association. Fry  also mentioned that two-thirds of cases occurred before the age of 30 years, and 22% cases were in the age range of 30-50 years. Neimann et al.  also postulated that psoriasis has a bimodal peak of activity, type I is said to occur before the age of 40 and accounts for 75% of all cases and results in more severe form whereas type II occurs in patients after 40 years of age. We noted 73.80% (31) patients presented below the age of 40 years, which is in accordance with Henseler and Christophers 11] and Neimann et al. 
Dogra and Yadav  stated that psoriasis is twice more common in males compared to females. However, Fry  and Gudjonsson and Elder  stated that psoriasis affects males and females equally. In our study, male preponderance was noted in psoriasis that is in accordance with Rakhesh et al.  and Khandpur et al.  Meier and Seth  also stated that the most common morphologic presentation of psoriasis is that of the plaque type characterized by well-defined raised erythematous papules and plaques with silvery coarse scales. We noted similar findings in the present study. In psoriasis we found limbs as the most frequent site of involvement, is in accordance with Meier and Seth  and Sinniah et al. 
Indian studies reported lower familial incidence of the disease.  According to Gudjonsson and Elder,  younger age of onset and positive family history has been associated with more widespread and recurrent disease.
Maize et al.  stated that the silvery scale of psoriasis correlates histologically with the confluent parakeratosis in the cornified layer. The elevation of the plaques is due primarily to the elongation of the rete ridges and the reciprocal hypertrophy of the dermal papillae, although the interstitial edema associated with the dermal inflammatory response may contribute to the elevation. The beefy red color of the lesions is produced by the reactive hyperemia and vasodilation of the vessels of the superficial plexus. Comparison of histological features of psoriasis is shown in [Table 3].
Various histopathological studies of psoriasis like Lal et al.,  Gordon and Johnson  and Mehta et al.  also noted parakeratosis, acanthosis, suprapapillary thinning, Munro microabscesses and hypogranulosis in most of the cases. The present study also noted similar histological findings in the majority of the cases of psoriasis. Mehta et al.  stated that, suprapapillary thinning and the absence of granular cell layer could be added to the list of essential histopathological criteria for psoriasis, in addition to Munro microabscess and Kogoj's abscess.
| Comparison of clinical diagnosis with histological diagnosis in psoriasis|| |
In the present study, 42 cases were histologically psoriasis in which 40 (95.24%) had a clinical diagnosis of psoriasis while 2 (4.76%) cases had a clinical diagnosis of tuberculous verrucosa cutis. Mehta et al.  reported 58 histologically diagnosed cases of psoriasis in which 42 (72.41%) had a clinical diagnosis of psoriasis while 16 (27.58%) were other lesions clinically. He also stated that the term psoriasiform implies that the lesion either clinically or histologically mimics psoriasis. This group includes psoriasis, seborrheic dermatitis, parapsoriasis, pityriasis rosea and pityriasis rubra pilaris, allergic dermatitis, atopic dermatitis, nummular dermatitis, lichen simplex chronicus, pityriasis rosea, dermatophytosis, and mycosis fungoides. 
Altman and Kamino  also stated that the clinical presentation of psoriasis is varied, hence many times the definitive diagnosis depends on the histological examination. David Elder has considered histopathology as a "gold standard" for the diagnosis of most dermatological conditions including psoriasis. In clinical practice, diagnostic dilemma and exclusion of life-threatening malignancies constitute the most common reasons for seeking histopathological evaluation. Clinical features, when considered alone, may not be reliable, as they vary with both disease duration and treatment.  On the contrary, histological material constitutes definite evidence, which can be preserved and will continue to be available for future review, if necessary. However, at times, histopathology cannot resolve the issue and the picture are more typically 'compatible with' rather than 'diagnostic of' a clinical diagnosis. This situation precludes effective clinical decision making and management of the patient. In these circumstances, an attempt at clinicohistopathological correlation should serve as an ideal approach. 
| Conclusion|| |
Psoriasis has varied clinical presentations. Besides, the same patient may present with different types of lesions. Psoriasis of the skin must be differentiated from other lesions which mimic them, like infectious diseases (tinea, syphilis, tuberculous verrucosa cutis, dermatophytosis), allergic disorders (nummular dermatitis, contact dermatitis, eczemas) and tumors (mycosis fungoides, papulonodular lesions of Kaposi's sacrcoma). Thus, histopathology serves as a diagnostic tool and rules out other lesions that mimic psoriasis. The most accurate diagnosis is the one that most closely correlates with clinical outcome and helps to direct the most appropriate clinical intervention.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]