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INVESTIGATIVE REPORT ActaDV ActaDV Advances in dermatology and venereology Acta Dermato-Venereologica
Eczema in Psoriatico: An Important Differential Diagnosis Between Chronic Allergic Contact Dermatitis and Psoriasis in Palmoplantar Localization
Malgorzata KOLESNIK 1, Ingolf FRANKE 1, Anke LUX 2, Sven R. QUIST 1 and Harald P. GOLLNICK 1
1
Department of Dermatology and Venereology, and 2 Department for Biometrics and Medical Informatics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
Differential diagnosis of palmoplantar non-pustular psoriasis and chronic allergic contact dermatitis( ACD) and the combination of these conditions, termed“ eczema in psoriatico”( EIP), is difficult, especially in cases of isolated involvement. A blind re-evaluation of 63 archived formalin-fixed palmoplantar samples, previously diagnosed clinically as either psoriasis or chronic ACD, was performed. Samples were allocated to histopathological diagnoses of psoriasis, contact dermatitis or EIP. Immunohistological stainings were performed for better characterization. Immunochemistry of EIP revealed features that overlapped contemporarily with psoriasis( cytokeratin 17( CK17), Ki67, interleukin( IL)-8, IL-17, IL-23) and with ACD( CD1a, major histocompatibility complex( MHC) class I, MHC class II, epidermal T-cell subsets). Surprisingly, a significantly much higher number of dermal CD8 + T cells was found in EIP than in ACD and psoriasis. In conclusion, this study provides insight into the immunohistological differentiation of palmoplantar psoriasis, chronic ACD and EIP.
Key words: eczema in psoriatico; palmoplantar; allergic contact dermatitis; psoriasis; immunohistology.
Accepted Aug 29, 2017; Epub ahead of print Aug 30, 2017 Acta Derm Venereol 2018; 98: 50 – 58.
Corr: Malgorzata Kolesnik, Department of Dermatology and Venereology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, DE-39120 Magdeburg, Germany. E-mail: malgorzata. kolesnik @ med. ovgu. de
Differential diagnosis of palmoplantar non-pustular psoriasis and chronic contact dermatitis is often difficult if other characteristic signs and history are missing. Typical histological patterns are often lacking in the palmoplantar localization( 1). Furthermore, these 2 conditions have similar histological features, such as acanthosis, parakeratosis and spongiosis.
The concept of eczematous psoriasis has been discussed previously( 2, 3). However, there are conflicting results regarding the correlation of psoriasis and contact sensitivity. Some authors have observed an inverse relationship( 4), while others have reported a higher incidence of type IV sensitization only in palmoplantar psoriasis( 5, 6). Another study noted a positive correlation with the duration of the disease, but not with the site of lesions( 7).
Psoriasis and allergic contact dermatitis( ACD) can influence each other’ s course and clinical picture. It has been shown( 8) that occurrence of the ACD reaction in patients with psoriasis sensitized to nickel is delayed and that it resolves more slowly than in patients without psoriasis. Furthermore, mixed histological and immunohistological patterns have been observed in cases of ACD on top of pre-existing psoriasis, combining both psoriasis and eczema. After self-limitation of an artificially induced ACD reaction, the course of psoriasis was unaltered.
A group of patients with palmoplantar lesions and type IV sensitization, contemporarily showing clinical and histological features of both psoriasis and contact dermatitis, has been indentified in our Department of Dermatology. This constellation( Fig. S1a – c 1) is termed“ eczema in psoriatico”( EIP)( 9).
The aim of the current study was to compare the clinical, histological and immunohistological characteristics of patients with EIP with those diagnosed with palmoplantar psoriasis or ACD alone.
MATERIALS AND METHODS Patients
Patient selection is described in the study flow chart( Fig. S2 1). Intralesional punch biopsies were obtained from patients during routine diagnosis, after obtaining written, informed consent and in accordance with the principles of the Declaration of Helsinki. Two experienced dermatopathologists performed a blind re-evaluation of 132 histopathology sections from the palmoplantar localization stained with haematoxylin and eosin( H & E), which had been clinically diagnosed previously as either psoriasis or chronic contact dermatitis. They allocated the samples a diagnosis of psoriasis, contact dermatitis or EIP.
Clinical data and allergy tests were examined retrospectively. Patients presented with well-demarcated scaling palmoplantar erythema. Additional findings, such as erythematous plaques on the elbows, knees or scalp, and oil spots, favoured a diagnosis of psoriasis. Nummular, papulo-vesicular lesions in localizations other than palmoplantar favoured a diagnosis of eczema.
All patients( except for the control group and 4 patients with psoriasis) had been investigated previously with the German baseline series of contact allergens( Almirall Hermal, Reinbeck, Germany). Patch tests were interpreted according to the guidelines
1 https:// www. medicaljournals. se / acta / content / abstract / 10.2340 / 00015555-2779 doi: 10.2340 / 00015555-2779 Acta Derm Venereol 2018; 98: 50 – 58
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2018 Acta Dermato-Venereologica.