IADVL Textbook of Dermatopathology
IADVL Textbook of Dermatopathology
Editors
M Ramam MD
Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India
Sujay Khandpur MD DNB MNAMS
Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India
Neetu Bhari MD DNB MNAMS
Associate Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India
Vishal Gupta MD
Assistant Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India
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© 2023, IADVL - Indian Association of Dermatologists, Venereologists and Leprologists
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IADVL Textbook of Dermatopathology / M Ramam, Sujay Khandpur, Neetu Bhari, Vishal Gupta
First Edition: 2023
9789354653841
Printed at:
To my parents, and to Anuradha, Varun, and Megha.
—M Ramam
To my parents Jayanti and Subhash, my gurus, my wife Shaifali and children Saanchi and Shaurya.
—Sujay Khandpur
To my parents, my husband Amit, and son Aariket.
—Neetu Bhari
To my teachers and parents, and to Riti and Rudroo.
—Vishal Gupta
CONTRIBUTORS
- EDITORS
- M Ramam MD
- Professor
- Department of Dermatology and Venereology
- All India Institute of Medical Sciences
- New Delhi, India
- Neetu Bhari
- MD DNB MNAMS
- Associate Professor
- Department of Dermatology and Venereology
- All India Institute of Medical Sciences
- New Delhi, India
- Sujay Khandpur
- MD DNB MNAMS
- Professor
- Department of Dermatology and Venereology
- All India Institute of Medical Sciences
- New Delhi, India
- Vishal Gupta
- MD
- Assistant Professor
- Department of Dermatology and Venereology
- All India Institute of Medical Sciences
- New Delhi, India
- CONTRIBUTING AUTHORS
- Aanchal Panth
- MD (AIIMS, New Delhi)
- Consultant Dermatologist and Hair Transplant Surgeon Dermafollix Hair Transplant and Skin Clinic Surat, Gujarat, India E-mail: aanchalpanth@gmail.com
- Anisha Manocha
- MD DNB
- Senior Resident Department of Pathology Vardhman Mahavir Medical College and Safdarjung Hospital New Delhi, India E-mail: anisha.manocha15@gmail.com
- Atul Madhusudan Dongre
- MD
- Associate Professor Department of Dermatology TN Medical College and BYL Nair Hospital Mumbai, Maharashtra, India E-mail: atul507@yahoo.co.in
- Bhavya Swarnkar
- MD DNB
- Senior Resident Department of Dermatology All India Institute of Medical Sciences New Delhi, India E-mail: swarnkarbhavya@gmail.com
- Biswanath Behera
- MD (JIPMER) DNB
- Assistant Professor Department of Dermatology and Venereology All India Institute of Medical Sciences Bhubaneswar, Odisha, India E-mail: biswanathbehera61@gmail.com
- Chander Grover
- MD DNB MNAMS
- Professor Department of Dermatology and STD University College of Medical Sciences and GTB Hospital Dilshad Garden, New Delhi, India E-mail: chandergroverkubba76@gmail.com
- Chirag Desai
- DDV L Fellowship in Diagnostic Dermatology (MUHS) Fellowship in Dermatopathology (Germany)
- Consultant Dermatologist and Dermatopathologist Divya Sparsh Skin and Hair Clinic Mumbai, Maharashtra, India E-mail: 83.chirag@gmail.com
- Deepika Yadav
- MD DNB
- Assistant Professor Department of Dermatology and Venereal Disease, Maulana Azad Medical College and Associated Hospitals New Delhi, India E-mail: deepikayadav18.90@gmail.com
- Geetali Kharghoria MD DNB
- Consultant Dermatologist Max Smart Super Speciality Hospital Saket, New Delhi, India E-mail: geetalikharghoria@gmail.com
- Geeti Khullar
- MD DNB
- Specialist-Grade II Department of Dermatology Vardhman Mahavir Medical College and Safdarjung Hospital New Delhi, India E-mail: geetikhullar@yahoo.com
- Indu Kumari MD FMUHS Dermatopathology
- Dermatologist and Founder All India Skin and Hair Hospital New Delhi, India
- E-mail: induderma01@gmail.com
- Madhusmita Sethy MD
- Associate Professor Department of Pathology All India Institute of Medical Sciences Bhubaneswar, Odisha, India E-mail: pathol_madhusmita@aiimsbhubaneswar.edu.in
- Manasa Kayarkatte Narayan
- MD DNB MRCP SCE Derm
- Locum Consultant Dermatologist Amersham Hospital Buckinghamshire Healthcare NHS Trust Amersham HP7 0JD, United Kingdom E-mail: drmanasakn@gmail.com
- Manoj Singh
- MD FRCPath
- Consultant, Dermpath Diagnostics and Lifeline Laboratory Green Park Extension New Delhi, India E-mail: vslaiims@gmail.com
- Neha Taneja
- MD
- Assistant Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India E-mail: taneja.neha2908@gmail.com
- Nikhil Mehta
- MD
- Senior Resident Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India E-mail: nikhilmehtadermatology@gmail.com
- Raghavendra Rao
- MD DN B
- Professor and Head Department of Dermatology Kasturba Medical College, Manipal Manipal Academy of Higher Education Manipal, Karnataka, India E-mail: jenny.rao@manipal.edu
- Rajalakshmi Tirumalae MD DNB
- Professor and Head Department of Pathology St John's Medical College Bengaluru, Karnataka, India E-mail: rajnav@gmail.com
- Rajiv S Joshi MD DVD DN B
- Consultant Dermatologist and Dermatopathologist PD Hinduja Hospital and HN Reliance HospitalConsultant Dermatopathologist SRL LABS Mumbai, Maharashtra, India E-mail: rsjdrs@gmail.com
- Riti Bhatia MD
- Assistant Professor Department of Dermatology, Venereology and Leprosy All India Institute of Medical Sciences Rishikesh, Uttarakhand, India E-mail: ritibhatia_aiims@yahoo.com
- Sanjay Singh MD
- Consultant Dermatologist
- Dr Sanjay Singh's Skin Clinic
- Gorakhpur, Uttar Pradesh, India
- E-mail: sanjaysinghsnmc007@gmail.com
- Saurabh Bhatia MD
- Consultant Dermatologist Felix Hospital Noida, Uttar Pradesh, India E-mail: sabh_kai@hotmail.com
- Savera Gupta MD DNB
- Assistant Professor Department of Dermatology, Seth GS Medical College and KEM Hospital Mumbai, Maharashtra, India E-mail: savera.gupta@gmail.com
- Shipra Agarwal MD
- Additional Professor Department of Pathology All India Institute of Medical Sciences New Delhi, India E-mail: drshipra0902@gmail.com
- Sonal Sharma MD
- Director Professor and Head University College of Medical Sciences and GTB Hospital Dilshad Garden, New Delhi, India E-mail: sonald76@gmail.com
- Sudheer Arava MD
- Professor Department of Pathology All India Institute of Medical Sciences New Delhi, India E-mail: aravaaiims@gmail.com
- Tekumalla Sindhuja MD MRCP-SCE
- Consultant Dermatologist Ankura Hospitals Hyderabad, Telangana, India E-mail: drsindhu.t@gmail.com
- Uma Nahar Saikia MD NAMS
- Professor Department of Histopathology Postgraduate Institute of Medical Education and Research Chandigarh, India E-mail: umasaikia@gmail.com
I am delighted that the “IADVL Textbook of Dermatopathology”, a project which was envisioned during my tenure as President, IADVL in 2019 is finally complete and coming out as a hardcopy in the year 2023. I congratulate the editors Professor M Ramam, Professor Sujay Khandpur, Dr Neetu Bhari, and Dr Vishal Gupta for all their efforts in editing, contributing, and bringing out a much needed easy to read and well-illustrated, multiauthored new textbook that will give a refreshingly new perspective to dermatopathology, not only to dermatologists but to the pathologists as well. I am sure this textbook will enrich, strengthen, and enliven the dermatopathology teaching and discussion practices in medical colleges and other institutes. I am very happy to note that this textbook has nine sections and 38 chapters to cover all aspects of dermatopathology, from basics to cutaneous metastasis, while not being exhaustive at the same time.
I convey my sincere appreciation to all the authors/contributors of various chapters and editors for their efforts in bringing out this much awaited “IADVL Textbook of Dermatopathology”. I am certain that this textbook will be very well received by the medical community and dermatology fraternity.
Best Wishes
P Narasimha Rao MD PhD
President IADVL, 2019
MESSAGE FROM THE ACADEMY CHAIRPERSON AND CONVENER (2020–2021)
It is our great pleasure to pen this message for the “IADVL Textbook of Dermatopathology”. It has been a felt need to have a reference textbook covering the approach to the interpretation of dermatopathology in our patients. Dr M Ramam, Dr Sujay Khandpur, Dr Nitu Bhari, and Dr Vishal Gupta have done a tremendous and painstaking job in bringing out this title to aid the clinician and dermatopathologists toward this end. They carefully crafted the scientific content that includes chapters covering practical aspects of techniques of skin biopsy, transport media, special stains, immunohistochemistry, immunofluorescence, and basic dermatopathology like histology of normal skin and 10 reaction patterns to facilitate ease in differential diagnosis. Inclusion of sections on infections, connective tissue diseases, disorders of pigmentation, cutaneous adverse drug reactions, cutaneous infiltrates, deposition disorders, cysts, epidermal nevi and tumors, disorders of collagen and elastin, and histopathology of skin appendages—hair follicle and nail, make it an all-encompassing reference textbook. The book is replete with the authors' personal experience based inputs, is well illustrated with high-quality images to enable the reader to get a vivid visual impression of the dermatopathological changes and the chapter on clues, observations, and insights by the editors is a unique chapter providing rare tips in dermatopathology, that could only come from clinicians with a keen interest in dermatopathology.
We are sure the title, encompassing varied topics authored by experts of dermatopathology from across the country will be a handy treasure for those who practice dermatopathology and also for the clinician and students to understand dermatopathology and appreciate the variations seen in our patients. The authors of all the 38 chapters in this handbook must be hugely complimented for their mammoth effort in accumulating excellent images to illustrate dermatopathology so well.
We congratulate everyone involved in this project and wish this title achieves its objectives.
Dr Dipankar De
Convener, IADVL Academy (2020–2021)
Dr Deepika Pandhi
Chairperson, IADVL Academy (2020–2021)
PREFACE
In writing this book, the task we set for ourselves and our contributors was simple—we wanted to write an account of the pathology we saw and to provide a framework to think through the problems and challenges associated with these cases. To this end, we encouraged our authors to ground their chapters firmly in their own experience, and where it differed from conventional descriptions, to mention both. We were also careful not to assume any previous knowledge of the subject among our readers, to keep things simple and to point things out clearly both in the text and images. Dermatopathology benefits enormously from the wealth of morphological expertise in clinical dermatology and we have included clinical details and images throughout the book to provide the context in which biopsies are interpreted.
We would like to thank all authors for the high quality of their contributions that make this book what it is. Several friends and colleagues have generously permitted us to use images from their collections and they are gratefully acknowledged. We would like to make a special mention of Dr Meenakshi Batrani who took a large number of photomicrographs of her cases at our request and helped to fill many gaps in the book and our colleague, Professor Sudheer Arava. Our colleagues in the department and outside, read proofs of the book and provided helpful comments and suggestions. Our thanks to Rhea Ahuja, and also to Vaishnavi Verma, Ananya Sharma, Geeti Khullar, Deepika Yadav, Biswanath Behera, Suman Patra, Meenakshi Batrani, KA Seetharam, and V Ramesh.
The team at Jaypee Brothers Medical Publishers (P) Ltd has been a revelation with their professionalism and high standards. Our special thanks to the entire production team specially Ms Pooja Bhandari (Production Head) for their excellent work and willingness to go the extra mile to accommodate our requirements. Our particular thanks to Mr Sumit Kumar (Team Leader – Graphic Designer) who worked diligently and hard on the images to ensure they came out well. A note of thanks to Ms Himani Pandey (Development Editor) who coordinated the project, efficiently and courteously.
We thank the IADVL Academy for entrusting us with this project, giving us a completely free hand and patiently waiting for us to complete it.
In the past, our trainees have pointed out that some of the things we taught them were not in the dermatopathology books they read but matched up with what they observed when looking at slides. They urged us to put the teaching into a book and this is the result. We hope they, and others, will find it useful.
M Ramam
Sujay Khandpur
Neetu Bhari
Vishal Gupta
New Delhi, January 2023
Acknowledgments
My debt to my friend Manoj Singh is enormous. If it had not been for his encouragement and support over several decades of our friendship and partnership in dermatopathology, this book would not have been written. At a time when it was considered odd for a clinical dermatologist to want to see slides every day, Manoj set up a system in his department that allowed me to do so. There were some bumps along the way, some resistance and some disruptions but Manoj dealt with them with his trademark blend of bluster and tact and kept the collaboration going. In effect, he let everyone know that we were his people and could be trusted with resources in his department. Thank you, my friend.
It is a reflection of the simplicity and robustness of the system he helped set up that even today, some 20 years later, my colleagues and I continue to have unfettered access to all the resources we need to be part of a strong dermatopathology service at our Institute, now led by Professor Sudheer Arava and Dr Shipra Agarwal.
Navjeevan Singh was my first teacher when I began to be interested in dermatopathology and among many other lessons, exhorted me to stop squinting at the slide through one eyepiece of a binocular microscope and look through both! Asha Kubba provided encouragement and access to her laboratory and slides and the opportunity to meet and learn from several leading dermatopathologists and some outstanding brownies. She set high standards and showed us what could be achieved if one aimed high. Phil LeBoit and Tim McCalmont were my mentors during a 7-month fellowship at University of California San Francisco (UCSF) and were patient teachers as I slowly learnt to look at and think about slides in a way I had not done before. In addition, Phil found me opportunities to present our work on pigmentary disorders and infections at many places, from the Ackerman Academy to Hawaii.
I also had the support of colleagues and friends not directly a part of the dermatopathology team. My good friend, Binod Khaitan has been a great resource for advice on overcoming obstacles in our path and was always willing to use his good offices to ensure we had what we needed, even at short notice. He finished writing his book on van Gogh while we were working on this book and by example, stimulated us to complete our work, too. His insights into book design have been very valuable. My friend Neena Khanna is the well-known author of an enormously popular undergraduate textbook of dermatology, now in its seventh edition. Her considerable experience and insight helped us at every stage of this book, from conception to writing to image editing to page composition and proofreading. Deepika Pandhi, wise beyond her years, provided sensible advice and guidance in matters related to the book.
I wish to thank my younger colleagues, who are co-editors and/or contributors, for their insistence that this book be written. There was a time when I was not entirely convinced we could do this but they helped me begin and then worked hard to complete the project.
And finally, thanks to Anuradha for a constant supply of invaluable intangibles.
M Ramam
Blessed are those who meet people who define the ideal course of their life, thoughts, and values. I feel blessed to have parents who were my ideals and who provided me a very loving and conducive environment to fulfil my dreams and passions. I would not have been where I am without the immense love and selfless support of my family, my wife Shaifali, and children Saanchi and Shaurya.
I feel extremely blessed and fortunate to have been trained by excellent teachers like Professor BSN Reddy under whom I did my MD, whose guidance, unflagging efforts, and pithy words of wisdom have always encouraged me. I give huge credit to Professor M Ramam, my dermatopathology guru, for shaping my thoughts, scientific temper, and values. His exemplary and endearing personality, indefatigable energy to work, inexhaustible knowledge and experience, philosophy of teaching, and practice of considering the patient a human being and not merely “a case”, have been a source of constant inspiration for me. My interest in dermatopathology reached the next level when I came under the tutelage of Dr Phil Leboit and Dr Tim McCalmont at the Department of Dermatopathology, University of California San Francisco. I was hugely impressed by their excellence in the subject, professionalism, impartial scientific observation, critical analysis, and an insatiable desire to learn more. I pride myself to have been one of the privileged groups to have their guidance and get an opportunity to work with them. I am hugely indebted to Professor Manoj K Singh, Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, without whose incessant support, guidance, and encouragement, the dermatopathology program and training in our institution would not have existed. My sincere thanks to all my colleagues and students whose boundless knowledge and expertise has always inspired and humbled me.
Sujay Khandpur
The entire credit for my dermatopathology interest and knowledge goes to my Professor, Dr M Ramam. In his words, every slide is a puzzle and reaching a diagnosis thus gives immense satisfaction. His way of teaching and his commitment to the subject inspires me daily to work hard. It is my privilege to work in our institute with my esteemed colleagues and enthusiastic students where I get an opportunity to learn and grow everyday. My sincere thanks to my teacher, Professor Neena Khanna, who has greatly inspired my writing and editing skills and has taught me many valuable life lessons.
Lastly, I want to express my immense gratitude to my parents and siblings, who have always encouraged me to achieve my dreams and have been the wind beneath my wings. I feel incredibly blessed to have a supportive husband and a wonderful son, who are my constant source of positivity.
Neetu Bhari
It was a twist of fate that made Professor M Ramam my MD thesis supervisor, and for that, among other things, I am grateful to the almighty. I am deeply indebted to Dr Ramam, my mentor and guide in more ways than one. I learnt the fine art of reading a skin biopsy slide from him; first “blinded” and then opening one's eyes to the clinical information, a concept that I initially found strange but have now come to value. He was instrumental in arranging an observership in Dermatopathology at the UCSF for Riti and me, a short stint that broadened our horizons. That my name appears as an editor of a few books, including this one, and a journal is owed enormously to him showing me the ropes. On a similar note, I thank Professor Binod Khaitan, whom I have watched countless times editing books and chapters with his favorite red pen, for being an inspiration with his diligence and attention to detail.
I was fortunate to train under the best teachers in the country during my formative years, and the credit for all my accomplishments goes to them. It would be remiss of me not to thank my colleagues, senior and junior, as well as the residents of our department who have always made me strive to be a better version of myself.
And lastly, I express my immense gratitude to my family; my parents and sister for their unconditional love and support, my wife Riti for being my friend and teacher (pointing out my blunders in great detail, unasked, and without fail!), and my adorable little son Rudraditya for showing me a different way of looking at life.
Vishal Gupta
Acknowledgements for Diagrams and Images
We would like to thank the following colleagues for permission to use their images:
- Professor Sudheer Arava, Department of Pathology, AIIMS, New Delhi: Fig. 5 and Fig. 6 in Chapter 2; Fig. 4 in Chapter 4; Fig. 20, Fig. 21, Fig. 26, Fig. 27, Fig. 35 in Chapter 6; Fig. 55 in Chapter 8; Fig. 11 in Chapter 15; Fig. 20 in Chapter 17; Fig. 14 to Fig. 16 in Chapter 18; Fig. 4 in Chapter 27; Fig. 1, Fig. 4, and Fig. 6 to Fig. 8 in Chapter 30; Fig. 4, Fig. 11, Fig. 16, Fig. 36, Fig. 37 in Chapter 32; Fig. 20 in Chapter 33; Fig. 22 in Chapter 34.
- Dr Beth Ruben, Palo Alto Medical Foundation, Palo Alto, California, USA: Fig. 7 in Chapter 2; Fig. 17 in Chapter 17; Fig. 32 in Chapter 32.
- Dr Meenakshi Batrani, Delhi Dermpath Laboratory, New Delhi: Fig. 17 and Fig. 18 in Chapter 4; Fig. 23 and Fig. 34 in Chapter 5; Fig. 12, Fig. 13, Fig. 16, Fig. 22 to Fig. 24, Fig. 30, Fig. 38 and Fig. 39 in Chapter 6; Fig. 19 and Fig. 52 in Chapter 8; Fig. 9 in Chapter 15; Fig. 12, and Fig. 21 to Fig. 23 in Chapter 16; Fig. 9, Fig. 10, and Fig. 12 to Fig. 15 in Chapter 24; Fig. 17 and Fig. 18 in Chapter 26; Fig. 10, Fig. 11, Fig. 24 and Fig. 26 in Chapter 27; Fig. 2 to Fig. 4 in Chapter 33; Fig. 27 to Fig. 30, Fig. 36 to Fig. 38 in Chapter 34.
- Dr Mithilesh Chandra, Pathology Consultancy Services, Noida, Uttar Pradesh: Fig. 32 and Fig. 33 in Chapter 5; Fig. 22 in Chapter 30; Fig. 11 in Chapter 33.
- Professor V Ramesh, Department of Dermatology, ESIC Medical College and Hospital, Faridabad: Fig. 19 to Fig. 21 in Chapter 11; Fig. 18, Fig. 19 and Fig. 32 in Chapter 29.
- Professor Navjeevan Singh (Retired), Department of Pathology, University College of Medical Sciences and GTB Hospital, New Delhi: Fig. 12 in Chapter 12.
- Professor Sonal Sharma, Department of Pathology, University College of Medical Sciences and GTB Hospital, New Delhi: Fig. 10 in Chapter 15.
- Dr Kanika Sahni, Department of Dermatology and Venereology, AIIMS, New Delhi: Fig. 24 in Chapter 20.
- Professor Amit Yadav, Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi: Fig. 5 in Chapter 25.
- Dr Sahana M Srinivas, Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka: Fig. 42 in Chapter 28.
- Dr Riti Bhatia, Department of Dermatology, Venereology and Leprosy, AIIMS, Rishikesh, Uttarakhand: Fig. 30 and Fig. 31 in Chapter 29.
- Dr Shruti Sharma, ICMR-National Institute of Pathology, New Delhi: Fig. 22 in Chapter 30.
- Dr Geeti Khullar, Department of Dermatology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi: Fig. 12, and Fig. 13 in Chapter 33.
- Dr Indu Kumari, All India Skin and Hair Hospital, New Delhi: Fig. 21 in Chapter 34.
- Professor Rajalakshmi Tirumalae, Department of Pathology, St John's Medical College, Bengaluru, Karnataka: Fig. 33 and Fig. 34 in Chapter 34.
If we have inadvertently missed crediting the source of any images in the book, please bring it to our notice. We will be happy to acknowledge the contribution in the next printing.