Offering a highly visual, systematic approach to diagnosing skin diseases, Atlas of Dermatopathology: Synopsis and Atlas of Lever’s Pathology of the Skin, 4th Edition, is an ideal reference tool or teaching aid for dermatopathologists, pathologists, dermatologists, and trainees. This unique atlas uses a pattern-based approach to differential diagnosis, clearly organized according to what is seen on a microscopic slide. More than 1600 high-quality images assist in the understanding of cutaneous reaction patterns and diagnosis.

• Classifies patterns according to location, reaction patterns, and cell type if applicable, including diseases that have been recently described.
• Color-codes each chapter for consistency, helping you navigate quickly to the information you need.
• Compares “look-alike” diseases in easy-to-reference tables.
• Includes multiple color photomicrographs for each disease, in addition to providing an online image bank.

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How to Use This Book vii
Preface xvii
Preface to the First Edition xix
Acknowledgments xxi
Introduction xxiii
Disorders Mostly Limited to
the Epidermis and Stratum
Corneum 1
A. Hyperkeratosis With Hypogranulosis 1
1. No Inflammation 1
Ichthyosis Vulgaris 2
B. Hyperkeratosis With Normal or Hypergranulosis 2
1. No Inflammation 3
X-Linked Ichthyosis 3
Epidermolytic Hyperkeratosis 3
Epidermodysplasia Verruciformis 5
2. Scant Inflammation 6
Lichen Amyloidosis and Macular Amyloidosis 7
C. Hyperkeratosis With Parakeratosis 8
1. Scant or No Inflammation 8
Dermatophytosis 8
Granular Parakeratosis 9
D. Localized or Diffuse Hyperpigmentations 10
1. No Inflammation 10
Mucosal Melanotic Macules (Mucosal Lentigines) 11
Ephelids (Freckles) 12
2. Scant Inflammation 13
Pityriasis (Tinea) Versicolor 13
E. Localized or Diffuse Hypopigmentations 14
1. With or Without Slight Inflammation 14
Vitiligo 14
References 16
Localized Superficial
Epidermal or Melanocytic
Proliferations 17
A. Localized Irregular Thickening of the Epidermis 18
1. Localized Epidermal Proliferations 18
I
II
Actinic Keratosis 18
Eccrine Poroma 20
Squamous Cell Carcinoma In Situ and Bowen Disease 20
Bowenoid Papulosis 22
Clear Cell Squamous Cell Carcinoma In Situ 23
Clear Cell Acanthoma 23
2. Superficial Melanocytic Proliferations 26
Superficial Melanocytic Nevi and Melanomas 26
Pigmented Spindle Cell Nevus 27
Acral Melanoma 27
B. Localized Lesions With Thinning
of the Epidermis 30
1. With Melanocytic Proliferation 30
Lentigo Maligna Melanoma, In Situ or
Microinvasive (High CSD) 30
Recurrent (“Persistent”) Nevus, Lentiginous Patterns 31
Superficial Atypical Melanocytic Proliferations of
Uncertain Significance (SAMPUS and IAMPUS),
Lentiginous Patterns 33
2. Without Melanocytic Proliferation 34
Atrophic Actinic Keratosis 34
Porokeratosis 34
C. Localized Lesions With Elongated Rete Ridges 36
1. With Melanocytic Proliferation 36
Actinic Lentigo 36
Lentigo Simplex 37
Lentiginous Junctional Nevus 37
Nevus Spilus 38
Junctional or Superficial Compound Dysplastic Nevi 40
Nevoid Lentigo Maligna 42
2. Without Melanocytic Proliferation 44
Epidermal Nevus 44
Seborrheic Keratoses 45
Acanthosis Nigricans 45
D. Localized Lesions With Pagetoid
Epithelial Proliferation 47
1. Keratinocytic Proliferations 47
Pagetoid Squamous Cell Carcinoma In Situ (Bowen Disease) 47
Clonal Seborrheic Keratosis 47
2. Melanocytic Proliferation 48
Melanoma In Situ or Microinvasive, Superficial
Spreading Type 48
Recurrent Nevus (Pseudomelanoma), Pagetoid Pattern 51
Junctional Spitz Tumor (Nevus) With Pagetoid
Proliferation 51
Superficial/Intraepidermal Atypical Melanocytic
Proliferations of Uncertain Significance
(SAMPUS/IAMPUS), Pagetoid Patterns 51x Detailed Contents
3. Glandular Epithelial Proliferations 54
Paget Disease 54
4. Lymphoid Proliferations 55
Pagetoid Reticulosis (Woringer–Kolopp Disease) 55
E. Localized Papillomatous Epithelial Lesions 55
1. With Viral Cytopathic Effects 55
Verruca Vulgaris 55
Verruca Plana 55
Deep Palmoplantar Warts (Myrmecia) 57
Condyloma Acuminatum 57
Molluscum Contagiosum 58
Parapox Virus Infections (Milkers’ Nodules, Orf) 60
2. No Viral Cytopathic Effect 61
Seborrheic Keratosis 61
Dowling–Degos Disease 61
Confluent and Reticulated Papillomatosis
(Gougerot–Carteaud) 62
Verrucous Melanoma 64
F . Irregular Proliferations Extending
Into the Superficial Dermis 65
1. Squamous Differentiation 65
Inverted Follicular Keratosis 65
2. Basaloid Differentiation 67
Basal Cell Carcinoma 67
G. Superficial Polypoid Lesions 69
1. Melanocytic Lesions 69
Polypoid Dermal and Compound Nevi 70
2. Spindle Cell and Stromal Lesions 70
Neurofibroma 71
Fibroepithelial Polyp 71
References 72
Disorders of the Superficial
Cutaneous Reactive Unit 77
A. Superficial Perivascular Dermatitis 79
1. Superficial Perivascular Dermatitis, Mostly Lymphocytes 79
Viral Exanthem 79
Pityriasis Versicolor 81
Lupus Erythematosus, Acute 81
Small Plaque Parapsoriasis (Guttate Parapsoriasis) 83
1a. Superficial Perivascular Dermatitis With Eosinophils 84
Morbilliform Drug Eruption 84
Urticaria 84
Urticarial Bullous Pemphigoid 87
1b. Superficial Perivascular Dermatitis With Neutrophils 87
Erysipelas 87
Erysipelas/Cellulitis 87
1c. Superficial Perivascular Dermatitis With Plasma Cells 88
Secondary Syphilis 88
Kaposi Sarcoma, Patch Stage 90
III
1d . S uper ficial P eriv asc ular D erma titis , W ith
Extravasated Red Cells 92
Pityriasis Rosea 92
Pityriasis Lichenoides 93
Pigmented Purpuric Dermatosis 95
1e. Superficial Perivascular Dermatitis, Melanophages
Prominent 97
Postinflammatory Hyperpigmentation 97
2. Superficial Perivascular Dermatitis, Mast
Cells Predominant 98
Urticaria Pigmentosa 98
B. Superficial Dermatitis With Spongiosis
(Spongiotic Dermatitis) 100
Acute Spongiotic Dermatitis 100
Subacute Spongiotic Dermatitis 100
Chronic Spongiotic Dermatitis 100
1. Spongiotic Dermatitis, Lymphocytes Predominant 101
Nummular Dermatitis (Eczema) 101
Meyerson Nevus 101
1a. S pongiotic D erma titis , W ith E osinophils 103
Allergic Contact Dermatitis 103
Allergic Contact Dermatitis 104
1b. Spongiotic Dermatitis, With Plasma Cells 106
1c . S pongiotic D erma titis , W ith N eutr ophils 106
Seborrheic Dermatitis 106
C. S uper ficial Derma titis W ith Epidermal
Atrophy (Atrophic Dermatitis) 107
1. Atrophic Dermatitis, Scant Inflammatory Infiltrates 107
Aged Skin 108
Chronic Radiation Dermatitis 108
2. Atrophic Dermatitis, Lymphocytes Predominant 108
Poikiloderma Atrophicans Vasculare 108
Dermatomyositis 110
3. Atrophic Dermatitis With Papillary Dermal Sclerosis 111
Lichen Sclerosus Et Atrophicus 111
D. Superficial Dermatitis With Psoriasiform Proliferation
(Psoriasiform Dermatitis) 113
1. Psoriasiform Dermatitis, Mostly Lymphocytes 113
Pityriasis Rubra Pilaris 113
Mycosis Fungoides, Patch-Plaque Stage 113
Parapsoriasis 117
1a. P soriasif orm D erma titis , W ith Plasma C ells 118
Lichen Simplex Chronicus (See also IIIE) 118
1b . P soriasif orm D erma titis , W ith E osinophils 120
Chronic Spongiotic Dermatitis 120
2. Psoriasiform Dermatitis, Neutrophils Prominent
(Neutrophilic/Pustular Psoriasiform Dermatitis) 120
Psoriasis Vulgaris 120
Guttate Psoriasis 121
3. Psoriasiform Dermatitis, With Epidermal Pallor
and Necrosis (“Nutritional Pattern” Dermatoses) 123
Necrolytic Migratory Erythema (Glucagonoma Syndrome) 124
Necrolytic Acral Erythema 125
Pellagra 126Detailed Contents xi
E. Superficial Dermatitis With Irregular Epidermal
Proliferation (“Hypertrophic Dermatitis”) 128
1. Hypertrophic Dermatitis, Lymphocytes Predominant 128
Prurigo Nodularis 128
1a. Irregular Epidermal Proliferation, Plasma
Cells Present 129
Actinic Keratosis (See also IIA1) 129
2. Irregular Epidermal Proliferation,
Neutrophils Prominent 130
Keratoacanthoma (See also VIB1) 130
Deep Fungus Infection (See also VD1) 130
3. Irregular Epidermal Proliferation, Above A Neoplasm 130
Verrucous Melanoma (See also VIB3) 130
F . Superficial Dermatitis With Lichenoid
Infiltrates (Lichenoid Dermatitis) 131
1. Lichenoid Dermatitis, Lymphocytes Exclusively 131
Lichen Planus 131
Graft-Versus-Host Disease 133
Mycosis Fungoides, Patch/Plaque Stage 134
2. Lichenoid Dermatitis, Lymphocytes Predominant 135
Lichen Planus–Like Keratosis (Benign
Lichenoid Keratosis) 135
2a. Lichenoid Dermatitis, Eosinophils Present 136
Lichenoid Drug Eruptions 136
2b. Lichenoid Dermatitis, Plasma Cells Present 138
Lichenoid Actinic Keratosis 138
Secondary Syphilis 138
2c. Lichenoid Dermatitis, With Melanophages 139
3. Lichenoid Dermatitis, Histiocytes Predominant 140
Lichen Nitidus 140
4. Lichenoid Dermatitis, Mast Cells Predominant 141
Urticaria Pigmentosa, Lichenoid Examples 141
5. Lichenoid Dermatitis With Dermal Fibroplasia 142
Mycosis Fungoides, Patch Stage 142
G. Superficial Vasculitis and Vasculopathies 143
1. Neutrophilic Vasculitis 143
Cutaneous Necrotizing (Leukocytoclastic) Vasculitis 144
Septic Vasculitis (Gonococcemia) 145
2. Mixed Cell and Granulomatous Vasculitis 146
Granuloma Faciale 146
3. Vasculopathies With Lymphocytic Inflammation 147
Pigmented Purpuric Dermatoses 148
4. Vasculopathies With Scant Inflammation 149
Stasis Dermatitis 149
Stasis Dermatitis 149
5. Thrombotic, Embolic and Other Microangiopathies 150
Lupus Anticoagulant and Antiocardiolipin Syndromes 150
Cryoglobulinemia 151
H. Superficial Dermatitis With Interface
Vacuoles (Interface Dermatitis) 152
1. Vacuolar Dermatitis, Apoptotic/Necrotic Cells Prominent 152
Erythema Multiforme 152
Fixed Drug Eruption 155
Graft-Versus-Host Disease, Acute 155
2. Vacuolar Dermatitis, Apoptotic Cells Usually Absent 156
Dermatomyositis 156
3. Vacuolar Dermatitis, Variable Apoptosis 157
Subacute Cutaneous Lupus Erythematosus 157
4. Vacuolar Dermatitis, Basement Membranes Thickened 159
Discoid Lupus Erythematosus 159
References 161
Acantholytic, Vesicular, and
Pustular Disorders 165
A. Subcorneal or Intracorneal Separation 166
1. Sub/Intracorneal Separation, Scant Inflammatory Cells 166
Pemphigus Foliaceus 166
2. Sub/Intracorneal Separation, Neutrophils Prominent 167
Impetigo Contagiosa 167
Staphylococcal Scalded Skin Syndrome 168
Folliculitis With Subcorneal Pustule Formation 169
Acute Generalized Exanthematous Pustulosis 169
Pustular Psoriasis and Palmoplantar Pustulosis 170
3. Sub/Intracorneal Separation, Eosinophils Predominant 173
Erythema Toxicum Neonatorum 173
Scabies With Eosinophilic Pustulosis 173
B. Intraspinous Keratinocyte Separation, Spongiotic 174
1. Intraspinous Spongiosis, Scant Inflammatory Cells 174
Friction Blister 174
2. Intraspinous Spongiosis, Lymphocytes Predominant 175
Dyshidrotic Dermatitis/Eczema (Pompholyx) 176
2a. Intraspinous Spongiosis, Eosinophils Present 176
Acute Contact Dermatitis 177
Bullous Pemphigoid, Urticarial Phase 178
Incontinentia Pigmenti 178
3. Intraspinous Spongiosis, Neutrophils Predominant 180
Dermatophytosis 180
C. Intraspinous Keratinocyte Separation,
Acantholytic 181
1. Intraspinous Acantholysis, Scant Inflammatory Cells 181
Familial Benign Pemphigus (Hailey–Hailey Disease) 181
Transient Acantholytic Dermatosis (Grover Disease) 182
2. Intraspinous Acantholysis, Predominant Lymphocytes 184
Herpes Simplex 184
Varicella-Zoster Infection 187
Toxic Epidermal Necrolysis, Stevens–Johnson
Syndrome, and Erythema Multiforme
With Intraepidermal Vesiculation 187
Paraneoplastic Pemphigus 188
2a. Intraspinous Acantholysis, Eosinophils Present 190
Pemphigus Vegetans 190
3. Intraspinous Separation, Neutrophils or
Mixed Cell types 191
IgA Pemphigus 191
IVxii Detailed Contents
D. Suprabasal Keratinocyte Separation 192
1. Suprabasal Vesicles, Scant Inflammatory Cells 192
Keratosis Follicularis (Darier Disease) 192
Warty Dyskeratoma 194
2. Suprabasal Separation, Lymphocytes and Plasma Cells 195
Acantholytic Actinic Keratosis 195
3. Suprabasal Vesicles, Lymphocytes and Eosinophils 195
Pemphigus Vulgaris 195
E . S ubepidermal V esic ular Derma titis 198
1. Subepidermal Vesicles, Scant /No Inflammation 198
Porphyria Cutanea T arda and Other Porphyrias 198
2. Subepidermal Vesicles, Lymphocytes Predominant 200
Bullous Lichen Planus 200
Polymorphous (Polymorphic) Light Eruption 201
Bullous Dermatophytosis 201
Bullous Lichen Sclerosus et Atrophicus 203
3. Subepidermal Vesicles, Eosinophils Prominent 204
Bullous Pemphigoid 204
Bullous Drug Eruption 204
Pemphigoid Gestationis (Herpes Gestationis) 204
4. Subepidermal Vesicles, Neutrophils Prominent 208
Dermatitis Herpetiformis (Duhring Disease) 208
Linear IgA Bullous Dermatosis 209
Bullous Lupus Erythematosus 210
Epidermolysis Bullosa Acquisita 211
5. Subepidermal Vesicles, Mast Cells Prominent 213
Bullous Mastocytosis 213
References 214
Perivascular, Diffuse, and
Granulomatous Infiltrates
of the Reticular Dermis 217
A. Superficial and Deep Perivascular
Infiltrates Without Vasculitis 219
1. Perivascular Infiltrates, Lymphocytes Predominant 219
Erythema Annulare Centrifugum 219
Erythema Chronicum Migrans 219
Tumid Lupus Erythematosus 219
2. Perivascular Infiltrates, Neutrophils Predominant 222
Cellulitis 222
3. Perivascular Infiltrates, Lymphocytes and Eosinophils 223
Papular Urticaria 223
Urticaria 223
Pruritic Urticarial Papules and Plaques of Pregnancy 224
4. Perivascular Infiltrates, With Plasma Cells 226
Secondary Syphilis 226
Tertiary Syphilis 228
Morphea (See Description in VF) 228
5. Perivascular Infiltrates, Mixed Cell Types 230
Erythema Chronicum Migrans 230
V
B. Vasculitis and Vasculopathies 231
1. Vascular Damage, Scant Inflammatory Cells 231
Degos Syndrome 231
2. Vasculitis, Lymphocytes Predominant 232
Pernio 232
Pityriasis Lichenoides 232
Cytomegalovirus Infection 235
Erythema Chronicum Migrans 235
3. Vasculitis, Neutrophils Prominent 236
Polyarteritis Nodosa and Microscopic Polyangiitis 236
Neutrophilic Small-Vessel Vasculitis
(Leukocytoclastic Vasculitis) 237
Erythema Elevatum Diutinum 239
4. Vasculitis, Mixed Cell Types and/or Granulomas 240
Eosinophilic Granulomatosis With Polyangiitis 240
Papulonecrotic Tuberculid 240
5. Thrombotic and Other Microangiopathies 242