|Year : 2018 | Volume
| Issue : 1 | Page : 37-41
Comparison of clinical diagnosis with histopathology in inflammatory skin diseases: a retrospective study of 455 cases
Seema Umarji1, Gayatri Ravikumar1, Meryl Antony2, Rajalakshmi Tirumalae1
1 Department of Pathology, St John's Medical College and Hospital, Bangalore, Karnataka, India
2 Department of Dermatology, St John's Medical College and Hospital, Bangalore, Karnataka, India
|Date of Submission||18-Nov-2016|
|Date of Acceptance||27-Apr-2017|
|Date of Web Publication||12-Mar-2018|
Department of Pathology, St John’s Medical College and Hospital, Sarjapur Road, Koramangala, Bangalore, Karnataka, 560019
Source of Support: None, Conflict of Interest: None
Background Skin biopsies are performed to support the clinical diagnosis of inflammatory skin diseases. Clinical information is conveyed to the pathologist as a list of differential diagnosis.
Aims The aims of this article are to correlate the clinical diagnosis with histopathologic diagnosis and to determine the correlation rank order of differentials with histopathologic diagnosis.
Methods Four hundred and fifty-five skin biopsies signed out as inflammatory lesions were identified using the laboratory information system. Clinical differential diagnosis from the biopsy requisition forms were tabulated and compared with the final histopathologic diagnosis.
Results Out of the 455 individuals considered, 237 (52.08%) were men and 218 (47.9%) were women. The clinical diagnosis with more than 40 mentions included vasculitis, lichenoid dermatitis, discoid lupus erythematosus, psoriasis and eczema. The histopathologic diagnosis with more than 20 mentions included lichenoid dermatitis, cutaneous vasculitis, pemphigus vulgaris, psoriasis and Hansen’s disease. The median number of differential diagnosis per patient was 3 (range: 1–5). The final diagnosis was included in the differentials in 412 (90.5%) and absent in 43 (9.5%) cases. In 339/412 (82.3%) cases, the final diagnosis was the first differential. In 70/412 (16.9%) cases, the final diagnosis was listed as the second or third differential and in 3/412 (0.007%) cases as the fourth and fifth. Among the 37 discordant cases where the clinical details were available, the clinical description correlated with the final diagnosis in 15 cases; clinical and histopathologic diagnoses fell under the same broad disease category in 19 cases. Only 3/37 cases were truly discordant.
Limitations The sample size and the possibility of lesions being overbiopsied are the only possible limitations.
Conclusion The overall concordance between the first three clinical diagnosis and histopathology was a good 98%. A longer list of differential diagnosis is not helpful. In situations where a specific clinical diagnosis is deferred, an accurate description of the lesions aids the pathologist.
Keywords: clinicopathological concordance, differential rank order, inflammatory skin diseases
|How to cite this article:|
Umarji S, Ravikumar G, Antony M, Tirumalae R. Comparison of clinical diagnosis with histopathology in inflammatory skin diseases: a retrospective study of 455 cases. Egypt J Dermatol Venerol 2018;38:37-41
|How to cite this URL:|
Umarji S, Ravikumar G, Antony M, Tirumalae R. Comparison of clinical diagnosis with histopathology in inflammatory skin diseases: a retrospective study of 455 cases. Egypt J Dermatol Venerol [serial online] 2018 [cited 2018 Nov 15];38:37-41. Available from: http://www.ejdv.eg.net/text.asp?2018/38/1/37/227099
Present address: Seema Umarji, Department of Transfusion Medicine and Immunohematology, St Johns Medical College Hospital, Bangalore, India
| Introduction|| |
Inflammatory skin diseases are the commonest reason for patients to visit a dermatology clinic , since many of these diseases have varied clinical presentations with clinical overlaps; they remain challenging for the dermatologist. Skin biopsies are often performed to confirm or support the clinical suspicion. Clinical information has a pivotal influence on the histopathological diagnosis. This information is mostly provided in the pathology request forms, which describe the nature, the duration and the location of these lesions, based on which either a single diagnosis or a list of differential diagnoses is provided to the pathologist. Although clinicopathological concordance is much higher for dermatologists than clinicians of other disciplines, there is limited literature from India on the comparison of clinical diagnosis with pathologic diagnosis among inflammatory skin diseases. The aims and objectives of this study were (a) to compare the clinical diagnosis with histopathologic diagnosis in inflammatory skin diseases and (b) to determine the correlation of differential rank order with the final diagnosis.
| Materials and methods|| |
This retrospective study included all skin biopsies received at the Department of Pathology, in a tertiary care hospital, between August 2013 and June 2014.The pathology database was searched for cases signed out as inflammatory skin diseases. The histopathological diagnoses were made on routine H and E sections with special stains wherever required. The reporting terminologies are those used in standard dermatopathology practise. Clinical diagnoses were recorded with the number of differentials, which was noted down in the order of priority from the pathology request forms. Patient demographics were noted. The suggested clinical diagnosis was compared with the histopathological diagnosis. The percentage of cases in which the listed clinical differential diagnosis included the histopathological diagnosis was calculated. Also the percentage of cases where the histopathological diagnosis fell in the first three listed differential diagnosis was calculated. In cases where the clinical diagnosis was not provided, we utilised the information on the description of lesions, as written in the request forms to formulate a list of clinical differential diagnosis and compared that with the histopathological diagnosis.
The study being descriptive, the results are expressed in terms of percentages and the data are represented in the form of tables.
| Results|| |
The total number of inflammatory dermatoses reported between August 2013 and June 2014 was 463. Of these, two cases were excluded due to lack of clinical diagnosis and six cases due to lack of descriptive histopathology report. The study included 455 cases. The differential diagnosis ranged from 1–6 with a median number of 3 per case.
There were 237 (52.1%) men and 218 (47.9%) women. The most common clinical diagnosis included vasculitis, lichenoid disorders, lupus erythematosus, psoriasis, bullous disorders and eczema. [Table 1] enumerates the list of clinical diagnosis. The histopathologic diagnosis with more than 20 mentions included lichenoid dermatitis, cutaneous vasculitis, pemphigus vulgaris, psoriasis and Hansen’s disease. The most common histopathological diagnosis with more than 10 mentions are listed in [Table 2].
The final diagnosis was included in the differentials in 412 (90.5%) cases (concordant) and was absent (discordant) in 43 (9.5%) cases. [Table 3] details the most common lesions with discordant diagnosis. Among the concordant group, in 339 (82.3%) cases, the final diagnosis was the first differential. In 72 (17.4%) cases, the final diagnosis was listed in second or third differential and three (0.007%) cases in fourth and fifth ([Table 4]). One case had six differentials and none of them was concordant with the histopathology diagnosis. Among the 43 discordant cases, clinical description of the skin lesions were available in 37 cases. A list of differential diagnosis was formulated on the basis of clinical description such as location, duration and distribution of lesions. The differential diagnosis was compared with the histopathological diagnosis. The clinical description correlated with the final diagnosis in 15 out of 37 cases ([Table 5]).
|Table 5 Cases with clinical description concordant with histopathological diagnosis|
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| Discussion|| |
Inflammatory skin diseases often pose challenges to the dermatologist and are sometimes biopsied for histopathological confirmation of the various differential diagnoses. A detailed clinical examination, with thorough history taking is required to narrow down the differential diagnosis and to help in histopathological interpretation. Despite this effort, a list of differential diagnosis is often found in the histopathology request forms. The biopsy interpretation of an inflammatory disease is complicated due to factors such as: histologic overlaps, sampling, temporal changes in lesions and effects of previous therapy . Subtle changes in the nature of the infiltrate or architectural pattern lead to variable morphological appearance of inflammatory diseases, making histopathological diagnosis difficult . In this study, we tried to compare the clinical diagnosis with histopathology and see if increasing the number of differential diagnosis would improve the diagnostic accuracy in inflammatory diseases.
The clinicopathological concordance was 90.5% in the present study. In a study on 3949 pathology reports of skin biopsy specimens, Aslan and colleagues reported a concordance rate of 76.8%. This study however included skin biopsies done for various skin diseases including malignancy. The subset of inflammatory dermatoses included in this study had a concordance of 93.9% which is similar to the present study. The discordance reported was 5.9% which is lower than our study (9.5%). Rajaratnam et al.  compared the frequency with which a blind diagnosis was made without the clinical data against a posthistory diagnosis in inflammatory skin diseases. In 55% of cases, histopathology alone was able to provide a specific diagnosis without clinical history. In 31% of cases, histopathology was not able to provide a specific diagnosis but could provide a differential diagnosis. In two-thirds of these (20 of the 31 cases), the diagnosis was reached when history was provided, with good clinicopathologic correlation.
A good clinical description of the lesion aided the histopathology diagnosis, in cases where differential diagnosis was not provided. Also among the discordant cases in this study, when the clinical description was used to formulate a set of differential diagnosis, in 40.5% cases the clinical description correlated with the final diagnosis. Cerroni et al.  suggested that adding clinical photographs improved the diagnostic accuracy by dermatopathologists. With advancement in technology, adding clinical images could be sought as a valid tool to improve diagnosis.
There have been studies that have compared prebiopsy clinical diagnoses with final histopathological diagnoses in neoplasms ,,,,,. Sellheyer and Bergfeld  compared histopathological diagnosis with the clinical differentials in 4451 cases. Their study compared the diagnostic accuracy of dermatologists with nondermatologists in cutaneous neoplasms. They also included a subset of 364 inflammatory skin diseases. They used histopathologic diagnosis as the gold standard and found that the histopathologic diagnosis was included among the clinical differential diagnosis in 71% cases of inflammatory skin diseases . Dai et al.  found a diagnostic accuracy of 78% in a study of 348 skin biopsies for inflammatory skin diseases. They used the final clinical diagnosis obtained after compiling all clinical and laboratory data as the ‘gold standard’ rather than the histopathologic diagnosis. The accuracy rate was higher in the present study as compared with the above studies.
Increasing the number of differentials did not improve the diagnostic accuracy, as evident in this study. We found the first listed clinical diagnosis was correct in 82.3% as compared with 55% in Dai et al. . The diagnoses listed in second and third positions were given as the final diagnosis in 19.6%, 28.9% (second listed differential) and 23.2% (third listed differential) of cases. The Dai et al.  study report only 2–12% of cases listed among second through fourth positions as the final histopathology diagnosis, and none of the fifth and sixth suggested diagnoses were correct. Also Aslan et al.  demonstrated that the first listed differential was more likely to be the final diagnosis (68.8%) than the second (22%). This confirms that dermatologists tend to list the diagnoses in the order of likelihood. The number of suggested diagnoses on requisition forms did not correlate with the overall diagnostic accuracy, indicating that a lengthy differential diagnosis does not increase the likelihood of a correct diagnosis. The chances of higher order differentials (more than third differential) being the final diagnosis were extremely low.
Among the 43 discordant cases, 37 had clinical data such as description, distribution and duration of lesions with which we made a list of clinical differentials. In 15 out of these 37 cases, the clinical descriptions correlated with the histopathological diagnosis. In the remaining 23 of 37 cases, most fell under the same broad category of the diseases when clinical differentials and histopathological diagnosis were compared (e.g. Discoid Lupus Erythematosus, DLE and lichen planus − lichenoid, borderline tuberculoid Hansen’s and sarcoidosis − granulomatous). In some of the cases, the lesions could represent the varied clinical presentations of the same disease. For example, various causes for lichenoid dermatitis have been identified such as viral infections, drugs, allergies, amyloidosis and organophosphorus poisoning. The clinical presentation of these disorders is also varied from papules to bullae. Likewise psoriasis, lichen simplex chronicus, prurigo nodularis, pityriasis rubra pilaris, secondary syphilis and Reiter’s syndrome may all give rise to psoriasiform dermatitis . Atypical clinical presentations, unexpected histologic variants, superimposition of secondary changes due to rubbing/scratching, application of topical medications, failure to recollect prior exposure to an allergen or irritant could be the reason for lack of clinical suspicion in cases of contact dermatitis . Similarly in the case of insect bite reaction, distinctive clinical manifestations and failure to recollect may account for the lack of clinical suspicion .
On considering these possibilities, only three out of 37 cases were truly discordant ([Table 6]). Lichen sclerosus et atrophicus can present with hypopigmented patches and thickened collagen can lead to diminished sensation, mimicking Hansen’s disease. We cannot explain the discordance in the other two cases, but they could be attributed to sampling or transcriptional errors.
Therefore, we would like to emphasise that histopathological assessment of inflammatory skin biopsies yields the greatest accuracy when a concise and pertinent clinical history including a description of the cutaneous lesion (i.e. morphology of the lesion, distribution, duration and symptomatology), history of medication and other medical comorbidities are included on the pathology requisition. With the clinical information, a definitive histopathologic diagnosis can be made, thus reducing the number of cases signed out using descriptive terms. The potential need for ancillary studies (such as immunostaining) and rebiopsy are also decreased as a result of clinicopathological correlation.
There are no potential limitations for the study. Probably, if more number of cases were studied the concordance rate would have been better. Also since the study was done in a tertiary referral centre, the possibilities of lesions being overbiopsied exist.
In summary, we assessed the diagnostic accuracy with respect to inflammatory skin diseases by correlating the clinical differential diagnoses listed on pathology request forms with the histopathological diagnoses. Our study supports the previous observations , and demonstrates that dermatologists include the correct final diagnosis in the initial differential diagnosis in 90.5% of cases. Longer lists of differential diagnoses were not associated with increased accuracy. In addition to the clinical diagnosis, providing a detailed history in terms of description, distribution and duration of lesions enhances the chances of obtaining a correct histopathological diagnosis.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]