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Wilk M, Zelger BG, Zelger B. Vasculitides and occluding vasculopathies, challenges in recognizing histopathological patterns, and their solutions. Front Med (Lausanne) 2023; 9:994450. [PMID: 36816722 PMCID: PMC9929945 DOI: 10.3389/fmed.2022.994450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/12/2022] [Indexed: 02/04/2023] Open
Abstract
In this review, we propose a classification of vasculitides and occluding vasculopathies using the clinicopathological correlation as the basic process. We use an algorithmic approach with pattern analysis, which allows reliable reporting of microscopic findings. We first differentiate between small and medium vessel vasculitis. Second, we differentiate the subtypes of small- and medium-sized vessels. Finally, we differentiate vasculitides according to the predominant cell type into leukocytoclastic and/or granulomatous vasculitis. Regarding leukocytoclastic vasculitis as a central reaction pattern of cutaneous small/medium vessel vasculitides, its relation or variations may be arranged in a wheel-like order. With respect to occluding vasculopathies, the first two steps are identical to the algorithm of vasculitides, and we finally differentiate according to the time point of the coagulation/reorganization process and the involved inflammatory cells/stromal features. By visualizing the criteria in the style of bar codes, clinical and histological overlaps and differences may become more transparent.
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Affiliation(s)
- Michael Wilk
- Private Dermatohistological Laboratory, Nuremberg, Germany,*Correspondence: Michael Wilk,
| | - Bettina G. Zelger
- Institute of Pathology, Medical University Innsbruck, Innsbruck, Austria
| | - Bernhard Zelger
- Private Dermatohistopathological Laboratory Zelger, Innsbruck, Austria
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2
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Trica OC, Mocan LP, Boit-Trapcea R. Mepolizumab is highly effective in a rare case of Wells syndrome - eosinophilic granulomatosis with polyangiitis overlap. Dermatol Ther 2022; 35:e15799. [PMID: 36045257 DOI: 10.1111/dth.15799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/26/2022] [Accepted: 08/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- O C Trica
- "Dr Boit and Dr Schuh" Dermatological Practice, Tuttlingen, Germany
| | - L P Mocan
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - R Boit-Trapcea
- "Dr Boit and Dr Schuh" Dermatological Practice, Tuttlingen, Germany
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3
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Abstract
Eosinophilic dermatoses encompass a broad spectrum of diseases of different etiologies hallmarked by eosinophilic infiltration of the skin and/or mucous membranes, with or without associated blood eosinophilia. The wide range of dermatological manifestations of this spectrum, including nodules and plaques, pustules, blisters, ulcers, and urticarial lesions, is reflected in a non-univocal classification system. We identified six groups of eosinophilic dermatoses based on the predominant anatomic level of involvement: (1) epidermal; (2) of the dermal-epidermal junction; (3) dermal; (4) of the hypodermis and muscle fascia; (5) of the pilosebaceous unit; and (6) vascular/perivascular. We review clinicopathologic features and management of diseases belonging to each group, particularly: (1) pemphigus herpetiformis and atopic dermatitis as prototypes of the epidermal group; (2) bullous pemphigoid as prototypic eosinophilic dermatosis of the dermal-epidermal junction; (3) eosinophilic cellulitis (Wells syndrome), hypereosinophilic syndromes, Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, eosinophilic dermatosis of hematologic malignancy and chronic spontaneous urticaria as paradigmatic dermal eosinophilic dermatoses; (4) eosinophilic fasciitis as an eosinophilic dermatosis with predominant involvement of the hypodermis and muscle fascia; (5) eosinophilic pustular folliculitis as a model of the pilosebaceous unit involvement; and (6) granuloma faciale, angiolymphoid hyperplasia with eosinophilia, and eosinophilic granulomatosis with polyangiitis, belonging to the vascular/perivascular group.
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Frumholtz L, Laurent-Roussel S, Lipsker D, Terrier B. Cutaneous Vasculitis: Review on Diagnosis and Clinicopathologic Correlations. Clin Rev Allergy Immunol 2020; 61:181-193. [DOI: 10.1007/s12016-020-08788-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Chen S, Li Z, Wang L. Cutaneous mastocytoma associated with abundant eosinophil infiltration and flame figures. J Cutan Pathol 2019; 46:397-400. [PMID: 31034654 DOI: 10.1111/cup.13452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 02/18/2019] [Accepted: 03/03/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Siyu Chen
- Department of Dermatovenereology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhongtao Li
- Department of Dermatovenereology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lin Wang
- Department of Dermatovenereology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Abstract
Das Wells-Syndrom, auch als eosinophile Zellulitis bezeichnet, ist eine seltene, sporadisch auftretende eosinophile Dermatose mit polymorphem klinischem Bild. Als typisch gelten entzündliche Erytheme oder Plaques an den Extremitäten, die initial als Erysipel imponieren können, unter antimikrobieller Behandlung aber persistieren. Die eosinophile Zellulitis ist eine Ausschlussdiagnose, die in Zusammenschau von klinischem Befund und charakteristischem histologischem Bild (Flammenfiguren) nur im Verlauf gestellt werden kann. Mit einer Vielzahl möglicher Triggerfaktoren ist die Ätiologie nicht geklärt. Die Beteiligung abnormer Th2-Zellen, des Zytokins IL-5 und aktivierter eosinophiler Granulozyten lässt eine unspezifische Hypersensitivitätsreaktion auf exo- und endogene Stimuli vermuten. Die häufiger vorkommenden chronisch- rezidivierenden Formen lassen sich durch Glukokortikoide günstig beeinflussen. Der Verlauf ist meist selbstlimitierend, ohne Residuen. Aufgrund von Übergängen in hämatoonkologische Erkrankungen sind Verlaufskontrollen angezeigt.
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Affiliation(s)
- Andreas Benedikt Weins
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Ulm.,Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Tina Weiss
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Ulm
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Abstract
A rare eosinophilic dermatosis, Wells syndrome, also referred to as eosinophilic cellulitis, is characterized by great clinical variability. Typical findings include infiltrated erythematous plaques arising on the extremities. Lesions initially resemble erysipelas/cellulitis, however, they do not improve with antibiotic treatment. Eosinophilic cellulitis is a diagnosis of exclusion that may only be made over the course of the disease, taking into account clinical and characteristic histological findings (flame figures). Although multiple potential triggers have been proposed, the exact etiology remains unresolved. Involvement of abnormal Th2 cells, IL-5, and activated eosinophilic granulocytes suggest a nonspecific hypersensitivity response to exogenous or endogenous stimuli. Corticosteroids may have a beneficial effect on the chronic, recurrent course frequently observed. The disease is often self-limiting, healing without sequelae. Given that transitions to hematological and oncological disorders have been observed, patients should be closely followed up.
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Affiliation(s)
- Andreas Benedikt Weins
- Department of Dermatology and Allergology, University Hospital Ulm, Ulm, Germany.,Department of Dermatology and Allergology, Biederstein Campus, Technical University Munich (TUM), Munich, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergology, Biederstein Campus, Technical University Munich (TUM), Munich, Germany
| | - Tina Weiss
- Department of Dermatology and Allergology, University Hospital Ulm, Ulm, Germany
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Kim YS, Song YM, Seo HM, Bang CH, Lee JH, Lee JY, Park YM. Eosinophilic Annular Erythema Associated with Churg-Strauss Syndrome. Ann Dermatol 2017; 29:813-814. [PMID: 29200781 PMCID: PMC5705374 DOI: 10.5021/ad.2017.29.6.813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/11/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yoon Seob Kim
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Mee Song
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun-Min Seo
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Hwan Bang
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Hyun Lee
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Young Lee
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Min Park
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Santos RP, Carvalho SD, Ferreira O, Brito C. Wells syndrome associated with lung cancer. BMJ Case Rep 2017; 2017:bcr-2017-220323. [PMID: 28951508 DOI: 10.1136/bcr-2017-220323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Wells syndrome (WS) or eosinophilic cellulitis is a rare, idiopathic, inflammatory dermatosis. The typical clinical presentation is urticarial plaque without preferential location that usually heals without scarring. We present a 62-year-old man with history of lung cancer that had undergone a right superior lobectomy 12 months previously. The patient had a relapsing dermatosis beginning about 6 months before the diagnosis of the lung cancer, characterised by pruritic, erythematous plaques located on the trunk and arms. These lesions spontaneously resolved within a few weeks without scarring. A skin biopsy revealed findings compatible with WS. Several diseases have been associated with WS. These include haematological diseases, fungal, parasitic and viral infections, drug reactions and rarely non-haematological malignancies. We present a case of this rare syndrome in a patient with history of lung cancer that we believe acted as a triggering event. To our knowledge, this is the second case reporting this association.
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Affiliation(s)
| | | | - Olga Ferreira
- Department of Dermatology, Hospital de Braga, Braga, Portugal
| | - Celeste Brito
- Department of Dermatology, Hospital de Braga, Braga, Portugal
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Muller T, Baubion E, Amazan E, Dufrenot-Petitjean Roget L, Deligny C. La cellulite de Wells : à propos d’une observation. Rev Med Interne 2017; 38:407-411. [DOI: 10.1016/j.revmed.2016.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/15/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
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Gallard C, Law-Ping-Man S, Darrieux L, Tisseau L, Safa G. Syndrome de Wells mimant une cellulite infectieuse de la face : trois observations. Ann Dermatol Venereol 2017; 144:284-289. [DOI: 10.1016/j.annder.2016.09.676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/22/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
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Abstract
Eosinophilic cellulitis or Wells syndrome is an uncommon skin condition of unknown
etiology that can occur alone or associated with other conditions. Typically, it
presents with recurrent pruritic, erythematous and edematous plaques, but it can also
show clinical polymorphism. Besides the cutaneous lesions, patients can experience
systemic manifestations like fever, malaise, arthralgia and peripheral blood
eosinophilia. We describe a case of this rare syndrome that presented with
polymorphic cutaneous lesions associated with a serious systemic disease, which was
revealed through the investigation of the cutaneous disease.
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Ratzinger G, Zelger BG, Carlson JA, Burgdorf W, Zelger B. Das Vaskulitis-Rad - ein algorithmischer Ansatz für kutane Vaskulitiden. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.20_12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Gudrun Ratzinger
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Innsbruck; Innsbruck Österreich
| | | | - J. Andrew Carlson
- Department of Pathology; Divisions of Dermatology and Dermatopathology, Albany Medical College; Albany New York USA
| | - Walter Burgdorf
- Abteilung für Dermatologie und Allergologie; Ludwig-Maximilians-Universität München; München Deutschland
| | - Bernhard Zelger
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Innsbruck; Innsbruck Österreich
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Ratzinger G, Zelger BG, Carlson JA, Burgdorf W, Zelger B. Vasculitic wheel - an algorithmic approach to cutaneous vasculitides. J Dtsch Dermatol Ges 2015; 13:1092-117. [DOI: 10.1111/ddg.12859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Gudrun Ratzinger
- Department of Dermatology and Venereology; Medical University Innsbruck; Innsbruck Austria
| | | | - J. Andrew Carlson
- Department of Pathology; Divisions of Dermatology and Dermatopathology; Albany Medical College; Albany New York
| | - Walter Burgdorf
- Department of Dermatology and Allergology; Ludwig Maximilian University; Munich Germany
| | - Bernhard Zelger
- Department of Dermatology and Venereology; Medical University Innsbruck; Innsbruck Austria
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Abstract
The skin is one of the organs most frequently involved in vasculitides. Cutaneous vasculitis may present (1) part of a systemic vasculitis (e.g., IgA vasculitis), (2) a skin-restricted or skin-dominant variant of the corresponding systemic vasculitis without clinically apparent visceral involvement (e.g., cutaneous IgA vasculitis), or (3) a vasculitis occurring exclusively in the skin (e.g., erythema elevatun diutinum). The clinical symptoms of vasculitides are markedly determined by the size of the predominantly affected blood vessels. Systemic polyarteritis nodosa is regarded as a medium vessel vasculitis and is associated with multiple skin symptoms: (1) vasculitis of digital arteries with ensuing digital infarction, (2) livedo racemosa and subcutaneous nodules, and (3) in some patients even purpura and hemorrhagic macules due to additional small vessel vasculitis. In contrast, in its skin-restricted entity (i.e., cutaneous polyarteritis nodosa), the predominant symptoms are subcutaneous nodules surrounded by livedo racemosa, often on the lower legs. Among small-vessel vasculitides palpable purpura with predilection for the legs is a nearly pathognomonic feature of immune complex vasculitis. Variations in clinical symptoms indicate additional pathophysiological mechanisms or different vascultides: (1) ANCA-associated vasculitides often also entail nodules or sometimes livedo, (2) cryoglobulinemic vasculitis additionally may present with necrosis at cold exposed areas and involvement of vessels of various size, (3) small vessel vasculitis associated with systemic lupus erythematosus or rheumatoid arthritis shows predilection for additional sites (e.g., nailfolds) and also involvement of vessels beyond postcapillary venules, (4) recurrent macular vasculitis in hypergammaglobulinemia also occurs on dependent parts, but shows numerous small hemorrhagic macules instead of palpable purpura, (5) erythema elevatum diutinum begins with brightly red to violaceous plaques at extensor sites, followed by fibrotic nodules. Consequently, cutaneous symptoms provide pivotal clues for further diagnosis and ensuing management of vasculitides.
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Cormerais M, Poizeau F, Darrieux L, Tisseau L, Safa G. Wells' Syndrome Mimicking Facial Cellulitis: A Report of Two Cases. Case Rep Dermatol 2015; 7:117-22. [PMID: 26120307 PMCID: PMC4478307 DOI: 10.1159/000432392] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Wells’ syndrome (WS), or eosinophilic cellulitis, is an uncommon inflammatory dermatosis of unknown etiology that typically presents with pruritic cellulitis-like plaques on the extremities. Therefore, WS is often misdiagnosed as bacterial cellulitis due to its similarity in presentation. Here, we report two cases of WS that masqueraded as bacterial facial cellulitis. Under treatment with oral prednisone and/or a combination therapy with levocetirizine and hydroxyzine, both patients showed a dramatic improvement of the skin lesions. These cases highlight the need for clinicians to consider WS in the differential diagnosis when evaluating a patient with facial cellulitis that does not respond to an initial antimicrobial regimen. In addition, our cases suggest that combination therapy with levocetirizine and hydroxyzine may be successfully used as corticosteroid-sparing treatment or to prevent relapse after the discontinuation of corticosteroid treatment.
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Affiliation(s)
- Maxence Cormerais
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, Armor Pathology Laboratory, Plérin, France
| | - Florence Poizeau
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, Armor Pathology Laboratory, Plérin, France
| | - Laure Darrieux
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, Armor Pathology Laboratory, Plérin, France
| | | | - Gilles Safa
- Department of Dermatology, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, Armor Pathology Laboratory, Plérin, France
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