e-ISSN: 0975-1556, p-ISSN:2820-2643
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International Journal of Pharmaceutical and Clinical Research 2023; 15(5); 2109-2117
Original Research Article
Study of Clinicopathological Concordance in the Diagnosis of
Papulosquamous Lesions in a Teritiary Care Hospital,
Hyderabad
Radha M1, Keerthana Muppidi2, Pooja Shivkumar3, Divya L4
1
Associate Professor, Department of Pathology, Mamata Academy of Medical Sciences,
Hyderabad
2
Assistant Professor, Department of Pathology, Mamata Academy of Medical Sciences,
Hyderabad
3
Resident, Department of Pathology, Bidar Institute of Medical Sciences
4
Associate Professor, Department of Dermatology, Venerology & Leprosy, Mamata
Academy of Medical Sciences, Hyderabad
Received: 23-03-2023 / Revised: 21-04-2023 / Accepted: 26-05-2023
Corresponding author: Dr. Divya L
Conflict of interest: Nil
Abstract
Background: Papulosquamous disorders, characterised by scaly papules and plaques are one
of the most common skin dermatoses seen by dermatologists. Some of the examples of
papulosquamous skin disorders include lichen planus, psoriasis, pityriasis rosea, pityriasis
rubra pilaris, parapsorias etc. Due to clinical and morphological overlap, it is sometimes
difficult to make a straight forward clinical diagnosis without histological confirmation. Some
of the histopathological features are specific and characteristic for each entity. Hence,
combination of proper clinical observation and histopathological study will give a conclusive
diagnosis.
Aims and Objectives: The present study aims to analyse various histopathological patterns of
papulosquamous lesions of the skin based on the tissue reaction pattern and assess the
concordance of provisional clinical diagnosis and histopathological diagnosis.
Materials And Methods: This is a hospital based retrospective study of 2 year duration from
2021-2022, at Department of pathology. Descriptive data on clinical history and
histopathological examination of all the cases of papulosquamous lesions of skin was collected
and results were drawn on various parameters using statistical analysis tools.
Results: Out of total 90 cases of clinically suspicious papulosquamous disorders, only 74 cases
confirmed as various papulosquamous disorders histopathologically with a positive correlation
of 82.2 % and negative correlation of 17.7%. Majority (23 cases) were in the age group of 31
to 40 years. There was slight male preponderance with male: female ratio being 1.14:1.The
commonest diagnosis was Lichen planus and its variants (23 cases), followed by Psoriasis and
its variants (19 cases), eczema (17 cases),pityriasis rosea (5 cases), Lichen nitidus (3cases),
Lichenoid dermatitis (3 cases), Parapsoriasis (2 cases), 1 case each of pityriasis rubra pilaris
and chronic cutaneous lupus.
Conclusion: The present study is designed to know the correlation between the clinical patterns
of various papulosquamous disorders and their histopathological diagnosis .There are many
studies done on clinical correlation with histopathological diagnosis but still the positive
correlation is not reaching up to 100%, some studies have negative correlation of around 40%.
Therefore, more studies are required in this field to appropriately diagnose and manage the
Radha M et al. International Journal of Pharmaceutical and Clinical Research
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papulosquamous disorders in order to reduce the disease burden and as a key to better patient
care.
Keywords: Papulosquamous disorders, clinical data, Clinico-histopathological correlation.
This is an Open Access article that uses a funding model which does not charge readers or their institutions for access and distributed under
the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0) and the Budapest Open Access Initiative
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original work is properly credited.
Introduction
Papulosquamous skin disorders are a kept in 10% formalin for 24hrs for fixation.
heterogeneous group of disorders that After fixation, the specimens were
comprise the commonest group of diseases processed in an automatic tissue processor.
seen by dermatologists. The characteristic After processing, the paraffin blocks were
primary lesion of papulosquamous skin made and cut on a rotary microtome into
disorder usually includes papules and 5micron thick sections. Sections were
plaques with various amount of scaling on stained with hematoxylin and eosin and
the surface. [1] were examined by conventional light
Because all papulosquamous disorders are microscopy. Detailed microscopic
characterized by scaling papules, clinical examination was undertaken for
confusion may result during their diagnosis. histopathological diagnosis of
The skin has a limited number of reaction papulosquamous disorders of the skin.
patterns with which it can respond to Data generated were input into IBM-SPSS
various pathological stimuli: clinically statistics for Windows version 23 for
different lesions may show similar analysis. Statistical tools such as frequency,
histological patterns. Therefore, to obtain percentages and correlation values were
the precise diagnosis, skin biopsy should be used to assess the degree of relationship
accompanied by all clinical details [2] between clinical observations and
Clinical features when considered alone histological confirmation of the disease.
may not be reliable, as they vary with both Results
disease duration and treatment. In these The current study was carried out in the
circumstances an attempt at clinic- Department of Pathology at a tertiary care
histopathological correlation should serve centre, from January 2021 to December
as an ideal approach. [3] 2022. Out of 5559 histopathological
Materials and Methods specimens, 168 (3%) were skin biopsies
The present study is a 2 year retrospective and 90 (1.6% ) were papulosquamous
study, conducted in Department of disorders of the skin. Papulosquamous
Pathology, tertiary care centre, Hyderabad. disorders of the skin constituted 53.57% of
Detailed clinical history, thorough physical the total number of skin biopsies at our
examination of patients presenting with institute.
papulosquamous lesions were carried out as A total of 90 cases were studied. Majority
per the proforma. Informed consent was (23 cases) were in the age group of 31 to 40
taken before biopsy. Before proceeding for years. Youngest is 3 year old female
the biopsy, xylocaine sensitivity test was diagnosed with Pityriasis rosea and oldest
done. Local anaesthesia was given by being 80 year old female patient diagnosed
infiltration of 2% lignocaine solution with to have Irritant contact dermatitis.
adrenaline under the lesion. Punch biopsy Distribution of cases among different age
was done to obtain an adequate amount of groups is shown in Table 1.
tissue for diagnosis. Biopsy specimen was
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Table 1: Distribution of cases among different age groups.
Age No. of Cases (Percentage)
0-10 4((4.4%)
11-20 13(14.4%)
21-30 19(21.1%)
31-40 23(25.5%)
41-50 16(17.7%)
51-60 7(7.7%)
61-70 5(5.5%)
71-80 3(3.3%)
Majority were males (53.3%) with male to female ratio being 1.14:1 which is shown in Fig 1.
SEX DISTRIBUTION
MALES FEMALES
Figure 1: Sex distribution of cases.
When it comes to site of occurrence of lesions, maximum number (43.3%) of cases were seen
on the extremities. Table 2 shows the distribution of cases based on the site of occurence. Scaly
plaque was the commonest presentation clinically.
Table 2: Distribution of cases based on the site of occurence.
SITE No. of Cases ( Percentage)
Head and neck 20(22.2%)
Trunk 9(10%)
Extremities 39(43.3%)
Entire body 13(14.4%)
Trunk +extremities 9(10%)
In our study of 90 cases of papulosquamous cases) were Lichen planus and its variants
disorders of skin which were diagnosed followed by Psoriasis and its variants(19
clinically, only 74 were confirmed as cases). The other diagnosis were Pityriasis
various papulosquamous disorders rosea, Eczema, Pityriasis Rubra pilaris,
histopathologically. 16 cases were not Lichenoid dermatitis and chronic cutaneous
correlating with the clinical diagnosis. lupus. The distribution of various
Among 74 histopathologically proven cases papulosquamous disorders is shown in
of papulosquamous disorders, majority(23 Table 3 and Figure 2.
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Table 3: Distribution of cases based on the Histopathological diagnosis
S.N. Diagnosis Variants No. of Cases Percentage(%)
1. Lichen planus Lichen planus pigmentosus 12 16.2
(23 cases) Hypertrophic lichen planus 04 5.4
Classical lichen planus 03 4
Lichen plano pilaris 03 4
Erosive lichen planus 01 1.3
2. Psoriasis (19 cases) Plaque Psoriasis 10 13.5
Palmoplantar Psoriasis 04 5.4
Inverse Psoriasis 02 2.7
Nail Psoriasis 01 1.3
Guttate Psoriasis 01 1.3
Verrucous Psoriasis 01 1.3
3. Eczema (17) Prurigo nodularis 04 5.4
Lichen simplex chronicus 04 5.4
Contact dermatitis 04 5.4
Seborrheic dermatitis 01 1.3
Chronic Lichenified eczema 03 4
Hyperkeratotic eczema 01 1.3
4. Pityriasis rosea 05 6.7
5. Lichen nitidus 03 4
6. Lichenoid Lichenoid dermatitis 02 2.7
dermatitis( 3 cases) Lichenoid drug eruption 01 1.3
7. Parapsoriasis 02 2.7
8. Pityriasis Rubra 01 1.3
pilaris
9. Chronic cutaneous 01 1.3
lupus
Total 74 100%
Figure 2: Pie chart showing histopathologically diagnosed cases of papulosquamous
disorders.
On histopathological examination of 23 were of lichen planus pigmentosus that
cases of lichen planus, 12 (52.1%) cases showed features of pigment incontinence
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along with classical lichenoid dermatitis, 4 follicles along with changes of classical
cases of Hypertrophic lichen planus variant lichen planus. One case of Erosive lichen
that revealed marked acanthosis and planus wherein saw tooth appearance of
hyperkeratosis as compared to classical epidermal hyperplasia along with wedge
lichen planus. Only 3 cases of Classical shaped hypergranulosis was seen. Figure 3:
lichen planus were seen.3 cases were of shows gross and microscopic pictures of
lichen planopilaris which showed follicular lichen planus.
plugging and dense infiltration around
Among 19 cases of psoriasis, majority i.e., parakeratosis, elongated rete ridges and
10 cases(52.6%) were Plaque psoriasis, lymphocytic infiltration in upper dermis
followed by 4 cases of palmoplantar were seen in all cases. Variants like Palmo-
psoriasis, 2 cases of Inverse psoriasis and plantar, Inverse plaque, Nail psoriasis and
one case each of nail psoariasis, guttate Guttate were classified according to the
psoriasis and verrucous psoriasis. clinical description of lesions. Verrucous
psoriasis was characterized by extensive
Histopathological examination of 10 cases
of psoriasis vulgaris revealed that hyperkeratosis.
A B
Figure 4: Psoriasis A: Clinical picture of Psoriasis showing multiple sharply demarcated,
erythematous plaques with silvery scales on the back. B. Photomicrograph of Plaque Psoriasis
showing acanthosis, elongated rete ridges, suprapapillary thinning, alternate hyper and
hypogranulosis, dilated dermal capillaris, and lymphocytic infiltration in papillary dermis. (40X ,
H&E).
Out of 74 cases of papulosquamous disorders, 17(22.9 %) cases were of eczema(Fig 5). Among
eczema cases, 4 cases each of Lichen simplex chronicus, Prurigo nodularis, Contact dermatitis
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were noted followed by 3 cases of Chronic lichenified eczema and 1 case each of Seborrheic
dermatitis and Hyperkeratotic eczema.
A B
B
Figure 5 : Prurigo Nodularis: A: Clinically presented as multiple chronic, excoriated and
thickened nodules. B: Microscopy show Hyperkeratosis, Irregular acanthosis and vertical
orientation of collagen fibres. (40X, H&E).
Out of 74 cases of papulosquamous inflammatory infiltrate in papillary and
disorders of the skin, 5 (6.7%) cases were reticular dermis, RBCs in papillary dermis
of Pityriasis rosea. Histopathological and dilated superficial plexus of blood
examination of Pityriasis rosea revealed vessels. One of the two cases showed
following epidermal changes: focal edema in papillary collagen, melanin in
parakeratosis, spongiosis, hyperkeratosis, upper dermis and eosinophils in dermal
acanthosis, exocytosis and hydropic infiltrate.
degeneration. One of the two cases showed Two (3.33%) cases of Pityriasis rubra
parakeratotic mound, basket weave pilaris.(Fig 6) were noted out of 74 cases of
hyperkeratosis, decreased granular layer,
papulosquamous disorders of the skin.
and erythrocytes in exudate. Dermal
changes seen in both the cases were
A B
Figure 6: Pityriasis rubra pilaris-A- multiple well demarcated scaly plaques with
characteristic reddish orange hue over the back. B. Microscopic picture showing
acanthosis and follicular plugging.
Our present study concluded with 82.2% of correlation between the clinical and
positive correlation and 17.7 % of negative histopathological diagnosis. This infers that
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histopathology plays a pivotal role in the patients by giving accurate diagnosis.
differentiating various papulosuamous Table 4 shows correlation of clinical and
disorders and helps in the management of histopathological diagnosis.
Table 4: Correlation of Clinical diagnosis with Histopathological diagnosis.
Correlation Positive Negative Total
Number of cases 74 16 90
Percentage (%) 82.2% 17.7% 100%
Discussion Lichen planus and psoriasis. Since skin is
Out of 90 cases of clinical diagnosis of exposed to many chemicals in industries,
papulosquamous disorders, 74 cases we found many eczema cases in our study.
confirmed histopathologically as Similarly Awake et al [15] also found that
papulosquamous disorders. Rest 16 cases Eczema is the second common diagnosis in
were not correlating with the clinical his study next to psoriasis. But in contrast
many other studies by Kedarisetty et al [4]
diagnosis.
and Gandhi J et al [16] showed that eczema
The majority of the cases in the present is less commonly found in their studies.
study were in the age group of 31-40 years
of age, accounting for 25.5% of cases. This There was discordance in 16 (17.7%) cases
observation is in concordance with the between clinical diagnosis and
study done by Kedarisetti.V.et al [4], histopathological confirmation. These
Ramesh et al [5] and Pandit et al [6]. But comprise 7 cases of lichen planus which
the last 2 studies were done only on were opined as chronic nonspecific
dermatitis and inconclusive cases. Also 2
psoriasis.
cases of clinically diagnosed as psoriasis
Males are affected more than the females in but histologically diagnosed as chronic
our study with the male: female ratio being non-specific dermatitis and inconclusive
1.14:1. Similar findings were seen in cases. This is similar to studies that have
studies done by Raju G et al [7], Ramesh et shown that there could be discordance
al [5] and Narayankar et al [8]. Only Study between clinical manifestations and
by Barman DD et al [9] showed female histological studies. Ukonu et al [13],
preponderance. Reddy et al [17], Younas et al [18] and
In the present study extremities were Bhargava et al [19] showed similar
commonly affected (43.3% of cases) which correlation values with positive correlation
is in concordance with many studies done of 76.5%, 86.25%, 76.30% and 58%
by Hosamane et al [10], Karumbaiah et al respectively which is similar to our study
[11] and Patel et al [12]. where positive correlation is 82.2%.Other
studies that are done by Barman D et al [9]
Among 74 cases of histopathologically and D costa et al [2] showed higher positive
correlated cases, the majority of the cases correlation of 92.3% and 97.52%
were diagnosed as Lichen planus and its respectively.
variants (31.08%) followed by Psoriasis
and its variants( 25.6% ). Similar findings Conclusion
were seen in studies done by Ukonu et al The present study is designed to study the
[13],Barman DD et al [9], Raju G et al [7] correlation between the clinical patterns of
and Chavhan et al [14]. various papulosquamous disorders and
Our study which was conducted in a tertiary their histopathological diagnosis, gender
centre situated in an industrial area showed and age distribution, clinical subtypes and
a quite a good number of cases of Eczema features of individual diseases. Lichen
and its various forms(22.9 % cases) next to planus was the most common
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papulosquamous disorder reported 7. Chaudhary RG, Chauhan AP, Makwana
followed by psoriasis and eczema cases. VR, Modi KR. Study of Clinico-
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