Disorders characterized by predominant or exclusive dermal inflammation

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Abstract

Some cutaneous inflammatory disorders are typified by a predominant or exclusive localization in the dermis. They can be further subdivided by the principal cell types into lymphocytic, neutrophilic, and eosinophilic infiltrates, and mixtures of them are also seen in a proportion of cases. This review considers such conditions. Included among the lymphoid lesions are viral exanthems, pigmented purpuras, gyrate erythemas, polymorphous light eruption, lupus tumidus, and cutaneous lymphoid hyperplasia. Neutrophilic infiltrates are represented by infections, Sweet syndrome, pyoderma gangrenosum, and hidradenitis suppurativa, as well as a group of so-called “autoinflammatory” dermatitides comprising polymorphonuclear leukocytes. Eosinophil-dominated lesions include arthropod bite reactions, cutaneous parasitic infestations, the urticarial phase of bullous pemphigoid, Wells syndrome (eosinophilic cellulitis), hypereosinophilic syndrome, and Churg-Strauss disease. In other conditions, eosinophils are admixed with neutrophils in the corium, with or without small-vessel vasculitis. Exemplary disorders with those patterns include drug eruptions, chronic idiopathic urticaria, urticarial vasculitis, granuloma faciale, and Schnitzler syndrome (chronic urticarial with a monoclonal gammopathy).

Section snippets

Dermal inflammation dominated by lymphoid cells

Chronic inflammatory disorders in the dermis may comprise relatively modest numbers of lymphoid cells, or, in counterpoint, they may efface almost the entire corium. Even when only perivascular aggregates of lymphocytes are present, their sizes and densities may lead the histological differential diagnosis in dissimilar directions. In addition, potential associations with pigment deposits, erythrocyte extravasation, zones of edema, or stromal mucinosis are likewise important (Fig. 1).

Dermal inflammation dominated by neutrophils

The prototypical pyodermas—dermatitides dominated by diffuse dermal neutrophilia—are infectious diseases. They include erysipelas, bacterial or fungal cellulitis, erysipeloid, and necrotizing fasciitis (formerly called “synergistic necrotizing cellulitis”). Causal organisms can include beta-hemolytic group-A streptococci, Staphylococcus aureus, Erysipelothrix rhusiopathiae, and various pathogenic fungi.41, 42, 43, 44, 45, 46 Diagnosis of these conditions is often made on clinical grounds, with

Eosinophilic dermal inflammation or infiltrates of eosinophils mixed with neutrophils

Diseases that may cause intense dermal eosinophilia include arthropod bite reactions,71 cutaneous parasitic infestation,72 the urticarial phase of bullous pemphigoid,73 Wells syndrome (eosinophilic cellulitis) 74(Fig. 16), hypereosinophilic syndrome 75(Fig. 17), and Churg-Strauss disease.76 In some other conditions, eosinophils are admixed with neutrophils in the corium, with or without small-vessel vasculitis. Exemplary disorders with those patterns include drug eruptions, chronic idiopathic

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