Evaluation of Histomorphological Spectrum of Skin Lesions at a Teaching Institute in Agra: A Cross-sectional Study
Correspondence Address :
Prashant Singh,
Department of Pathology, Sarjini Naidu Medical College, Agra, Uttar Pradesh, India.
E-mail: drprashant4488@gmail.com
Introduction: The skin is the largest organ system in humans. Different skin diseases consist of non specific, non infectious and infectious diseases to various neoplastic lesions. Dermatological lesions are commonly encountered in all countries and it encompasses a wide spectrum, varies from country to country and various regions within a country and influenced by sex, age and associated systemic disorders, economy, literacy, racial and social customs. The clinical presentation is restricted to only a few changes such as hyperpigmentation, hypopigmentation, macules, papules, nodules and few others. However, the spectrum of histopathology of skin disorders is varied. Accurate diagnosis of skin disorders is of utmost importance as treatment is varied for different skin disorders presenting with the similar clinical lesions.
Aim: To study histomorphological spectrum and distribution of skin lesions.
Materials and Methods: This hospital-based cross-sectional study was conducted in Department of Pathology in collaboration with Department of Skin and Venereal Diseases, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, over a period of two years from September 2019 to August 2021. The biopsy sample taken from clinically diagnosed skin lesions sent to histology laboratory in 10% formalin. Sample was fixed in 10% neutral buffered formalin over a period of 12 to 24 hours. Paraffin wax blocks were made and 3-4 micrometer sections were taken and stained with Haematoxylin and Eosin (H&E) stain and histology was studied under microscope. Special stains such as Ziehl-Neelsen (Z-N) stain and Fite stain were done, whenever required. Data was entered in Microsoft Excel excel and descriptive data was obtained.
Results: Out of total 105 cases, the maximum patients were of 21-30 years of age group 30 (28.57%) cases followed by 11-20 years of age group 25 (23.81%) cases with male and female ratio M:F=1.5:1. In this study, out of total 105 cases, the most common site involved was trunk in 42 (42%) cases followed by upper limb in 25 (23.81%) cases. The most common skin lesions were non infectious 70 (66.67%) cases, followed by infectious disease 22 (20.95) cases. In non infectious papulosquamous diseases group found 25 (23.81%) cases followed by vesiculobullous and vesiculopustular diseases group 24 (22.86%) cases. Infectious diseases were seen in 22 (20.95%) cases, out of which bacterial diseases being most common in 19 (18.10%) cases followed by parasitic infection 2 (1.90%) cases.
Conclusion: According to the findings of the present study the major cases of skin lesions requiring biopsy in developing countries is still psoriasis in non infectious papulosquamous diseases group. Tuberculosis and leprosy in infectious diseases category were being the leading cause of morbidity.
Genodermatoses, Non infectious, Papulosquamous, Pemphigus vulgaris, Tuberculosis
The skin is the largest organ of the integumentary system in human (1). Different skin diseases comprise of non specific, non infectious and infectious diseases to various types of benign and malignant tumorous (neoplastic) lesions. Dermatological lesions are commonly encountered in all countries and it encompasses a wide spectrum, varies from country to country and various regions within a country. This variation is also influenced by sex, age and associated systemic disorders, economy, literacy, racial and social customs. Its prevalence ranges from 6.3-11.16% (2). Many of the skin lesions are diagnosed clinically based on the history and examination of the lesions. However, some of them require additional simple diagnostic procedures to make final diagnosis such as potassium hydroxide preparation, Tzanck smear, examination under wood’s lamp and skin biopsy in around 1.3% of patients (2).
The histomorphology of skin disorders shows wide spectrum, however the clinical presentations are very few like hypopigmentation, hyperpigmentation, macules, papules, nodules and few others (3). Accurate diagnosis of skin disorders is of utmost importance as treatment is varied for different skin disorders presenting with the similar clinical lesions (4). Histopathological study required for definitive diagnosis and identifying causative agent with special stains wherever feasible, help clinicians to decide the appropriate management and clinical intervention (2). The present study was conducted to study histomorphological spectrum of skin lesions and to evaluate histopathological diagnosis of skin lesions in different age groups, sex and site wise distributions and to find out frequency of various dermatological disorders in the tertiary care teaching hospital in Agra.
This hospital-based cross-sectional study was conducted in Department of Pathology in collaboration with Department of Skin and Venereal diseases, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India over a period of two years from September 2019 to August 2021. Ethical clearance was obtained from Institutional Ethical Committee. (Letter No. IEC/2022/117). The study was carried out on skin biopsies of patient’s of all age group, coming to the histopathology lab and all cases coming during the study period. A total of 105 cases were selected as sample size on the basis of inclusion and exclusion criteria.
Inclusion and Exclusion criteria: All skin biopsies that showed definite signs of any specific pathology received in histopathology lab of the Department of Pathology during the study period were included. Inadequate, inconclusive and autolysed skin biopsies that did not show definite signs of any specific pathology were excluded from this study.
Study Procedure
The biopsy sample taken from clinically diagnosed skin lesions were sent immediately to histology laboratory in 10% formalin. Clinical history and relevant data were recorded. Sample was fixed in 10% neutral buffered formalin over a period of 12 to 24 hour. Paraffin wax blocks were made and 3-4 micrometer sections were taken and stained with H&E stain and histology was studied under microscope. Special stains like Z-N stain, modified Z-N Stain (Fite stain) etc were done, whenever required. Relevant demographic data was obtained from requisition form provided with the specimens.
Statistical Analysis
Data was entered in Microsoft word and descriptive data was obtained.
In this study youngest patient encountered was eight years of age and oldest patient encountered was 70 years of age. The maximum patients were of 21-30 years of age group, 30 (28.57%) cases followed by 11-20 years of age group, 25 (23.81%) cases with male and female ratio M:F=1.5:1. Most common age group affected by infectious diseases was 21-30 years accounting 7 (6.67%) cases followed by 11-20 years 6 (5.71%) cases with male predominace (M:F=1.4:1) (Table/Fig 1)a. Most common age group affected by non infectious diseases was 21-30 years accounting 22 (20.95%) cases followed by 11-20 years 16 (15.24%) cases with Male predominace (M:F=1.26:1). Most common age group affected by neoplastic diseases was 51-60 years and 11-20 accounting for 3 (3.81%) cases each followed by 31-40 years and 41-50 years 2 (1.90%) cases with male predominace (M:F=5.5:1).
In this study, out of total 105 cases, the most common site involved was trunk in 42(40.00%) cases followed by upper limb in 25 (23.81%) cases, lower limb 23 (21.90%) cases and head and neck region in 15 (14.28%) cases. In non infectious papulosquamous diseases 25 (23.81%) cases, vesiculobullous and vesiculopustular diseases 24 (22.86%) cases, pigmentary diseases 3 (2.86%) cases, benign tumour 10 (9.52%) cases, trunk being the most common site to be involved. In infectious diseases 22 (20.95%) cases, connective tissue diseases 5 (4.77%) cases, upper limb being the most common site to be involved. In non infectious Inflammatory diseases 11 (10.48%) cases, lower limb being the most common site to be involved. In malignant tumour 3 (2.86%) cases, head and neck the most common site to be involved. In genodermatoses 2 (1.90%), one case in upper limb and one case in lower limb (Table/Fig 1)b.
In this study, out of total 105 skin lesions, most common skin lesions were non infectious 70 (66.67%) cases, followed by infectious disease 22 (20.95) cases and neoplastic lesion 13 (12.38%) cases (Table/Fig 1)c.
In this study, out of 105 cases, the most common type of skin lesions were of non infectious papulosquamous diseases group 25 (23.81%) cases, in which psoriasis 11 (10.48%) cases being most common followed by vesiculobullous and vesiculopustular diseases group 24 (22.86%) cases, in which pemphigus vulgaris being most common in 6 (5.71%) cases, infectious diseases in 22 (20.95%) cases, non infectious inflammatory diseases in 11 (10.48%) cases, benign tumour in 10 (9.52%) cases, malignant tumour in 3 (2.86%) cases, pigmentary diseases in 3 (2.86%) cases, and connective tissue diseases in 5 (4.77%) cases.
In this study, out of 105 cases, infectious diseases were seen in 22 (20.95%) cases, in which bacterial diseases being most common in 19 (18.10%) cases followed by parasitic infection in 2 (1.90%) cases and viral infection in 1 (0.95%) case. In Infectious disease, most common histological diagnosis was tuberculosis and leprosy with 9 (8.57%) cases each (Table/Fig 2)a, (Table/Fig 2)b, (Table/Fig 2)c. There was only one (0.95%) case of Verruca vulgaris in viral infection. In parasitic infection with total 2 (1.90%) cases, there was single case each of crusted scabies (Table/Fig 2)d and cutaneous leishmaniasis.
In this study, 1 (5.56%) case out of nine cases of tuberculosis were found AFB positive on ZN stain and five (27.78%) cases out of nine cases of leprosy were found AFB positive on Fite stain.
In this study, out of 105 cases, non infectious inflammatory diseases were seen in 11 (10.48%) cases. In which, the most common histological diagnosis was Polymorphic light eruption 5 (4.76%) cases followed by 2 (1.90%) cases each of erythema nodosum and non caseating granulomatous lesion and 1 (0.95%) case each of granulomatous lesion and granuloma annulare (Table/Fig 3)a, (Table/Fig 3)b.
In this study, out of 105 cases, non infectious papulosquamous diseases were seen in 25 (23.81%) cases. In which, the most common histological diagnosis was psoriasis 11 (10.48%) cases followed by 5 (4.76%) cases of Lichen planus 3 (2.86%) cases each of pityriasis rubra pilaris pityriasis Lichenoides and 1 (0.95 %) case each of Parapsoriasis, Pityriasis rosea, Lichenoid keratosis (Table/Fig 4)a-(Table/Fig 4)d.
In this study, 2 (1.90%) cases of genodermatoses were seen, each one of Acrokeratosis verruciformis and Urticaria pigmentosa respectively.
In this study, out of 105 cases, vesiculobullous and vesiculopustular diseases were seen in 24 (22.86%) cases, in which Pemphigus vulgaris being the most common histological diagnosis in 6 (5.71%) cases followed by 4 (3.81%) cases of Pemphigus foliaceous, 3 (2.86%) cases of Dermatitis herpetiformis 2 (1.90 %) cases each of Bullous pemphigoid, endogenous dermatitis, Lichen simplex chronicus and 1 (0.95%) case each of spongitic dermatitis, contact dermatitis, atopic dermatitis, nummular eczema, subcorneal pustular dermatosis (Table/Fig 5)a-(Table/Fig 5)c.
In this study, out of 105 cases, pigmentary diseases were seen in 3 (2.86%) cases, in which 2 (1.90%) cases of post inflammatory hyperpigmentation and 1 (0.95%) case of intradermal nevus (Table/Fig 6). All three cases were seen in males.
In this study, out of 105 cases, connective tissue diseases were seen in 5 (4.76%) cases, in which, 2 (1.90%) cases of morphea and 1 (0.95%) case each of Lichen sclerosus et atrophicus, dermatomyositis and Discoid Lupus Erythematosus (DLE) (Table/Fig 7)a,b.
In this study, out of 105 cases, neoplastic diseases were seen in 13 (12.38%) cases. Out of which, benign tumours 10 (9.52%) cases were more common than malignant lesions 3 (2.86%) cases. In benign tumour the most common histological diagnosis was epidermoid cyst 4 (3.81%) cases followed by dermoid cyst and lipoma in 2 (1.90%) cases each and 1 (0.95%) case each of seborrheic keratosis and lymphangioma circumscriptum (Table/Fig 8)a, (Table/Fig 8)b. In malignant tumours, there were 2 (1.90%) cases of squamous cell carcinoma and 1 (0.95%) case of keratoacanthoma (Table/Fig 8)c, (Table/Fig 8)d.
The variations in the present study as compared to studies carried out elsewhere in the past could be due to difference in the geographical distribution of the several aetiological factors responsible for causation of these conditions.
Skin lesions are due to disparity in homeostasis that results in various conditions such as wrinkles hair loss, rashes, blisters and life threatening cancers. All the skin lesions may not required biopsy but for the proper diagnosis and identification of causative agents, dermatologist used to do it (5). The pattern of skin diseases are variable depending on economy, education level, variation in climate, primary health care facilities, industrialisation and variation in religious and cultural factors (6). Skin lesions are heterogeneous with a wide clinical and histopathological spectrum. Histopathological examination is the gold standard technique for diagnosing skin lesions. However, good clinical history, a close histopathological examination of the skin biopsy, clinicopathological correlation is essential for making final diagnosis so that the appropriate treatment can met (7). Special stains in conjunction with histopathological examination may also be required to reach final aetiological diagnosis (7). Skin biopsy is a simple outpatient procedure that helps in the confirmation of the clinical diagnosis (8).
The present study was aimed to study histomorphological spectrum of skin lesions, the aetiology of skin lesions using special stains like ZN stain, Fite stain as and when required and to study the age wise prevalence of different aetiologies of skin lesions. Biopsy specimen is expected to provide a fairly good estimate of patterns of skin disorders.
In this study, youngest case was seen in eight years of age and the oldest case encountered was 70 years of age. The present study encountered patient’s age between 1st to 7th decades, which is concordant with Mamatha K. et al., Singh S. et al., Agarwal D et al., Narang S et al., and Kafle SU et al., (2),(9),(10),(11),(12). However, Ayesha N et al., Mehar R. et al., Yalla ASD et al., George VP et al., Deepthi KN et al., Gaikwad SL et al., Bhardwaj V et al., Sushma C, Gupta P et al., found patients from 1st to 8th decade and Gulia SP et al., Bezbaruah R et al., Adhikari RC et al., found patients in 1st to 9th decade of life (1),(3),(6),(8),(13),(14),(15),(16),(17),(18),(19),(20).
In this study, maximum numbers of cases were found in 21-30 years age group (28.57%) followed by 11-20 years age group (23.81%), which is comparable with different studies and different age group being the most common age group in other studies (Table/Fig 9).
In this study, male predominance with male to female ratio of 1.5:1 was found and that was in concordance with other studies (1),(3),(4),(9),(10),(11),(13),(14),(16),(17),(18),(20),(21),(22). While it was not concordant with the findings in the studies by with Bezbaruah R et al., (20), Mamatha K et al., Kafle SU et al., and Gulia SP et al., as they found female predominance (2),(12),(19).
In this study, the most common site of lesion was trunk (40%) followed by upper limb (23.81%), while Bezbaruah R et al., (57.52% cases), Bhardwaj V et al., (33% cases); Chalise S et al., (29.32% cases) and Adhikari RC et al., (30.2% cases) found head and neck region being the most common site (5),(6),(8),(20). This could be due to the geographical differences of the study place.
In this study, non neoplastic lesions including infectious and non infectious disease i.e. 22 (20.95%) cases and 70 (66.67%) cases respectively outnumbered neoplastic lesions 13 (12.38%) cases which was found concordant with some studies (2),(3),(4),(6),(8),(9),(10),(12),(15),(16),(18),(22). This study was found non concordant with Gaikwad SL et al., (58.0% cases), Bezbaruah R et al., (81.42% cases), Yadav S et al., (68.4% cases) as they found overall neoplastic lesions outnumbered non neoplastic lesions with epidermal cyst being most common histological diagnosis (1),(20),(21).
In this study, the most common type of skin lesion group was non infectious papulosquamous diseases 25 (23.81%) cases followed by Vesiculobullous and vesiculopustular diseases 24 (22.86%) cases and Infectious diseases 22 (20.9%) cases which was concordant with some studies and however other found different type of skin lesion being most common (Table/Fig 10). In this study, the second most common type of skin lesion group was vesiculobullous and vesiculopustular diseases (22.86%) cases, while non infectious papulosquamous diseases was second most common in study of Kafle SU et al., (18.01% cases) and neoplastic lesions were second most common in George VP et al., (22.4% cases) and vesiculobullous lesion were second most common in study of Patel A et al., (15.0% cases) (4),(12),(15).
In this study, psoriasis 11(10.48%) cases was most common histological diagnosis followed by tuberculosis and leprosy 9 (8.57%) cases in each and different studies found different histological type being the most common histological diagnosis (Table/Fig 10). In this study, among neoplastic lesions, epidermal cyst was found most common histological diagnosis in 30.76% cases concordant with Bharadwaj V et al., (44.56% cases) (8). However, Achalkar GV et al., (52.8% cases), Ayesha N et al., found squamous cell carcinoma, Agarwal D et al., (30.43% cases) found basal cell carcinoma and Gupta P et al., (20.75% cases) found lipoma as most common histological diagnosis among the neoplastic lesions (10),(13),(18),(22). So meticulous histopathological examination combined with awareness in mind regarding prevalence of diverse skin lesions can help in correct diagnosis.
Limitation(s)
Limitations of present study was lack of clinicohistological correlation and absence of follow-up.
Present study was conducted to study histopathological spectrum of skin lesions, aetiology of skin lesions using special stain and age, sex and site wise prevalence of skin lesions. The major cases of skin lesions requiring biopsy in developing countries is still psoriasis in non infectious papulosquamous diseases group. Tuberculosis and leprosy in infectious diseases category were being the leading cause of morbidity. The age distribution pattern showed highest prevalence in 21-30 years age group i.e. 28.57%. The sex distribution pattern showed males preponderance. The non infectious papulosquamous diseases were the most common type of skin lesions.
DOI: 10.7860/JCDR/2022/56863.16836
Date of Submission: Apr 04, 2022
Date of Peer Review: Apr 19, 2022
Date of Acceptance: Jul 14, 2022
Date of Publishing: Sep 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: No
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 11, 2022
• Manual Googling: May 23, 2022
• iThenticate Software: Jul 14, 2022 (15%)
Etymology: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com