Year : 2007 | Volume
: 52 | Issue : 2 | Page : 111--115
Spectrum of pediatric skin biopsies
D'costa F Grace, Kiran A Bendale, Yoganand V Patil
Department of Pathology, Grant Medical College and Sir J. J. Hospital, Byculla, Mumbai - 400 008, India
D«SQ»costa F Grace
Department of Pathology, Grant Medical College and Sir J. J. Gr. of Hospitals, Byculla, Mumbai - 400 008
Background: Skin diseases are common in childhood and they are common reasons for pediatric visits to the hospital. In spite of this high occurrence, there are very few prospective studies addressing this issue. Aims: The present study was directed at determining the spectrum of dermato-pathological lesions encountered in a large general tertiary care hospital, over a two-year period. Materials and Methods: 107 cases formed the total sample studied, in a part prospective and part retrospective study. A detailed clinical history was recorded on a proforma prepared for the purpose and gross photographs were taken wherever possible. Results: Skin biopsies accounted for 7.29% of the total surgical pathology load, 55.44% of the total pediatric biopsies and 10.82% of the total number of skin biopsies. The age and sex distribution pattern revealed that the maximum number of biopsies (62.61%) were of older children, with a male preponderance (57.94%). The anatomic distribution pattern indicated predominant involvement of the limbs (59.82%). The maximum numbers of cases were of infectious nature (24.29%); the most frequently encountered being borderline tuberculoid Hansen«SQ»s disease (8.4%). A positive correlation with the clinical diagnosis was obtained in 56.07% cases. Conclusions: Histopathology contributed to the diagnosis in a significant number of (82.23%) cases, indicating its importance and utility.
|How to cite this article:|
Grace DF, Bendale KA, Patil YV. Spectrum of pediatric skin biopsies.Indian J Dermatol 2007;52:111-115
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Grace DF, Bendale KA, Patil YV. Spectrum of pediatric skin biopsies. Indian J Dermatol [serial online] 2007 [cited 2020 Dec 6 ];52:111-115
Available from: https://www.e-ijd.org/text.asp?2007/52/2/111/33293
Pediatrics skin biopsies interpretation has its limitation, as the skin has a limited number of reaction patterns, with which it can respond to various pathological stimuli, hence clinically different lesions may show similar histological patterns. Therefore, to obtain the precise diagnosis, it should be accompanied by all the clinical details viz. history, site of biopsy, duration and morphology of the lesions, duration of treatment and clinical differential diagnosis. When the histological picture is not diagnostic, clinicopathological correlation frequently makes diagnosis possible. If clinical doubt persists in view of a negative histopathological report the biopsy should be repeated. We present here a two-year analysis of the spectrum of pediatric skin biopsies, encountered in a large general tertiary care hospital in Mumbai.
Materials and Methods
This is a part prospective, part retrospective two-year study of the dermato-pathological lesions encountered in the pediatric population of a large general tertiary care hospital. One and a half years comprised the retrospective part and half a year the prospective part of the study. 107 cases formed the total sample studied, out of which 77 cases comprised the retrospective study and 30 cases the prospective study.
A detailed clinical history was recorded with particular reference to age, sex, duration of symptoms, mode of onset, characteristics and anatomic distribution of the lesions and associated symptomatology and this information was recorded in a proforma prepared for the purpose.
Gross photographs were taken of some of the lesions and then the biopsy was taken after receiving the guardian's consent. The site for the biopsy was cleaned and draped and the subcutaneous tissue infiltrated with 2 cc of 2% Lignocaine.
Biopsy specimens were immediately placed in 10% buffered formalin. Punch biopsies larger than 3 mm in diameter were bisected for optimal fixation as well as for appropriate plane of sectioning. Excisional biopsies were inked and sectioned at 2-3 mm intervals. Routine sections were 3-5 µm thick. They were stained with routine H and E stains and special stains like Fite, AFB, PAS, Giemsa and Toluidine blue when necessary. In the retrospective part of the study the blocks were retrieved, recut, restained, and reviewed.
Pediatric dermato-pathological biopsies constituted 7.29% of the total surgical pathology load of the department, 55.44% of the total pediatric biopsies and 10.82% of the total number of skin biopsies at our institute. The age distribution pattern revealed that the maximum number of biopsies 62.61% were of children in the 9-12 year age range. The sex distribution pattern revealed that the majority were males (57.94%). The anatomic distribution pattern revealed that the limbs were involved in the maximum number of case (59.82%); the lower limbs were most frequent (32.75%) compared to the upper limbs (27.07%). 97.11% cases had one dermatological diagnosis and 2.89% had two.
An analysis of the broad spectrum of the lesions revealed that the maximum number of cases was of infectious nature (24.29%) [Table 1]; these included both bacterial and viral infections. The next most frequently encountered broad group was noninfectious, papulo-squamous dermatosis (20.56%). A further analysis and split up of the broad categories revealed that borderline tuberculoid Hansen's lesions (8.4%) followed by lupus vulgaris (6.54%), both belonging to the broad category of infectious diseases [Table 1], were most frequently encountered followed by psoriasis in 5.60% and atopic dermatitis in 5.6% [Table 2].
A positive correlation with the clinical diagnosis was obtained in 56.07% cases. As far as the contribution of histopathology to the diagnosis was concern, histopathology confirmed the diagnosis in the maximum number of cases (56.07%) and it gave the clinical diagnosis in 26.16% and was noncontributory in 17.75%. Thus in a significant number of cases (82.23%), histopathology contributed to the diagnosis.
Skin diseases are common in children and surveys indicate that they are common reasons for pediatric visits to the hospital. At our institute pediatric dermato-pathological biopsies constituted 7.29% of the total surgical pathology load of the department, 55.44% of the total pediatric biopsies and 10.82% of the total number of skin biopsies at our institute. Comparative data is not available in the literature; however the study of Hayden et al.,  indicated that primary skin complaints prompted 6% of pediatric visits to the hospital and Tunnessen et al.,  found that skin complaints accounted for 24% of the primary and secondary reasons for initiating clinic visits. Hubert et al.,  found a very high percentage of 95% admission of children with medical problems had cutaneous findings. Similar findings were also noted by Tunnessen et al.,  who found that 81.5% of pediatric clinic visits were because of dermatological conditions. The age-distribution pattern revealed that the maximum number of cases (62.61%) were older children in the 9-12 year age range, particularly the infectious diseases (29.85%) and noninfectious papulo-squamous dermatosis (19.40%). The least number of cases were in the 0-4 year age range (9.34%). This finding is in contrast to that of Nanda et al.,  who found that infants constituted, the largest group accounting for 28.7% of the cases. Our youngest patient was five month old and our oldest patient was 12 years old, with a mean of 8.87 years. In a similar study by Hubert et al.,  the youngest patient was four-day-old, younger than our youngest patient and the oldest patient was 17 years, older than our oldest patient. The mean age was 3.6 years less than our mean age of 8.87 years.
The sex distribution pattern of the cases revealed that the majority of cases were male (57.94%) contrasting with the study of Nanda et al.,  who found a female preponderance of 52% and that of Hubert et al.,  who also found a female preponderance of 52%. We found a male preponderance in the noninfectious papulo-squamous dermatosis (54.54%) and eczematous dermatosis (85.71%), whereas Nanda et al.  in Kuwait found a female preponderance in pityriasis rosea and psoriasis, which come under the category of noninfectious papulo-squamous dermatitis and contact dermatitis, which comes under the category of eczematous dermatitis.
The anatomic distribution pattern revealed that the limbs were involved in the maximum number of cases (59.76%) followed by the trunk in 30.18% and the involvement of the head, neck and face was seen in the least number of cases 10.06%. The lower limbs were more frequently involved (32.75%) compared to the upper limbs (27.07%).
The majority of the cases (97.11%) had one clinical dermatological diagnosis and a minority of 2.89% had two dermatological diagnosis. In the study of Hubert et al. ,  49.09% had one dermatological diagnosis 32.72% had two dermatological diagnosis and 13.63% had three to four dermatological diagnosis.
An analysis of the broad spectrum of the pediatric dermatological lesions revealed that the maximum number of lesions (24.29%) were of infectious nature 24.29%. These included both bacterial and viral infections, bacterial being much more frequent than viral i.e., 88.6% vs 11.34%. The studies of Tunnessen et al.,  and Hayden et al.,  also revealed that skin infections topped the list of diagnosis, but they encountered them in a higher percentage of 38.5% and 36% respectively. Hubert et al. ,  found infections in 10% of his cases and viral exanthemas in 10.9%, totally accounting for 20.90% of his cases. This was lower than our figure of 24.25%. Infections however did not feature in the study of Nanda et al.,  from Kuwait. The next most frequently encountered broad group was noninfectious papulo-squamous dermatosis (20.56%) in which psoriasis accounted for 5.6% of all the lesions. This figure was slightly higher than that of Nanda et al.,  from Kuwait who found psoriasis in 4% of his cases and reported that this percentage was higher than that reported earlier in other ethnic groups. We found eczematous dermatitis in a small percentage of cases (6.54%). This figure is much lower than that of Hubert et al.,  who found it in 43.63% of cases. Out of total cases of dermatitis, atopic dermatitis accounted for the maximum number of cases (85.71%), it however only formed 5.60% of the total number of lesions, which is much lower than the percentage of Nanda et al. ,  who found it in 9% cases. In the study of Nanda et al.,  atopic dermatitis was seen in all age groups, whereas we found it in mainly the older children in the age range of 5-12 years.
The genodermatoses were seen in 3.73% cases, which was in marked contrast to that of Hubert et al.,  who found congenital lesions in 45% of cases. Pigmentary lesions were seen in 6.54%, which figure is lower than the figure of 21.81% as seen by Hubert et al. but we found vitiligo in a higher percentage (1.86%) compared to his 0.9% cases. We found vascular tumors and malformations in a small percentage of cases (2.79%), these included two cases of lymphangioma circumscriptum and one case of granuloma pyogenicum. In contrast Hubert et al.,  found vascular malformation and tumors in a high percentage (19.08%) of cases. We had just one case of viral warts i.e. verrucae vulgaris but Nanda et al.,  found viral warts in 13.1% of cases. We also had only one case of leuco-cytoclastic vasculitis in association with Henoch -Schonlein purpura. We did not encounter any cases of diaper dermatitis as well as alopecia areata and trauma seen by Nanda et al. 
Further analysis and split-up of the broad categories, revealed that the most frequently encountered lesions was borderline tuberculoid Hansen's disease (8.41%) followed by lupus vulgaris (6.54%) both belonging to the broad category of infections.
Amongst the noninfectious papulosquamous dermatosis, which accounted for the second highest percentage 20.56% in the broad categories, psoriasis accounted for most of the lesions (27.27%). This was followed by lichen nitidus and lichen striatus in 13.63% each, lichen planus, hypertrophic lichen planus and pityriasis rosea in 1.86% each and lastly linear lichen planus, pityriasis rubra pilaris, polymorphus light eruption (PLE) and inflammatory verrucous epidermal nevus (ILVEN) in 6.54% each.
In our survey leprosy led the list 57.69% in the group of infectious disease. In this group borderline tuberculoid leprosy was most frequent 33.33%. It was also the most frequently encountered lesion amongst all the lesions. Leprosy was followed by Lupus vulgaris 26.92%. Ecthyma contagiosum verruca vulgaris and scrofuloderma were hardly seen.
In the group of vasculitis/folliculitis/panniculitis seen in 3.73% of lesions, there were three cases of hair follicular lesions which included one case each of acute deep folliculitis, pseudopalade of Broque and keratosis pilaris and only one case of vasculitis, which was Henoch Schonlein Purpura. Leukocytoclastic vasculitis with Henoch Schonlein purpura was seen more frequently in the surveys of Hubert et al.,  (1.81%).
In the pigmentory disorder group, which accounted for 6.54% cases the commonest lesion seen was vitiligo (28.58%) followed by one case each of postinflammatory hyperpigmentation, cafι-au-lait spots, idiopathic guttate hypermelanosis, acropigmentosa symmetrica of Dohi and progressive cribriformis and zosteriform dermatosis in 14.29% each. Our percentage of pigmentary lesions was lower than that of Hubert et al.,  who found it in 21.81% cases, however we found vitiligo in a higher percentage of cases, 1.86% compared to the 9% by Hubert et al. 
In the group of systemic and metabolic disorders, which accounted for 6.50% cases, linear morphea was most commonly seen in 42.85% cases followed by discoid lupus erythematosus (DLE), Langerhan's cell histiocytosis (LCH), phrynoderma and acanthosis nigricans. Tumors were not very frequently seen (5.6%). In this group nevoid and melanocytic lesions, were the most frequent (49.8%) followed by lymphangioma circumscriptum in 33.2% and granuloma pyogenicum in 16.6%. Thus vascular malformations were noted in only 2.8% of all lesions, which is much lower than the 19.08% lesions by Hubert et al. 
A positive correlation with the clinical diagnosis was obtained in 56.07% of the cases. As far as contribution of histopathology to the diagnosis was concerned, histopathology confirmed the diagnosis in the maximum number of cases (56.07%). It gave the clinical diagnosis in 26.16% cases when there was no clinical suspicion of the disease and it was noncontributory in 17.75% cases. Thus in a significant number of cases (82.23%), histopathology contributed to the diagnosis. This is of great importance, as arriving at a definitive diagnosis reduces morbidity and cost of hospitalization of the patient.
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