Vesiculobullous Disorders

Vesiculobullous disorders represent a heterogenous group of dermatoses with protean manifestations Vesicles and Bullae are fluid filled cavities formed within or beneath the epidermis. In this study, skin punch biopsy is used for diagnosis. Punch biopsy is a simple, inexpensive, safe OPD procedure, causing minimal discomfort to the patient and no scarring. These disorders have remarkable impact on the patient and their family, and have severe economic consequences.

Pathologic evaluation of blisters involves systematic analysis, which includes the blister separation plane, the mechanism of blister formation and the character of the inflammatory infiltrate, including its presence or absence. Recent advances in investigative dermatology have created new horizons. The most important techniques for the investigation of patients with Vesiculobullous disease are conventional histopathology and confirmative tests like direct and indirect immunofluorescence

Immunofluorescence has a very important role in the diagnosis, treatment and understanding of the pathophysiology of Vesiculobullous lesions of skin. It is also an important prognostic tool, as positive direct immunofluorescence (DIF) findings in patients in remission predict early relapse of disease Research techniques such as immunoblotting and immunoelectron microscopy may refine the diagnosis in the individual patient. However, these investigations are available only in advanced research laboratories. DIF is also done only in a few centres in developing countries like India. With the availability of transport media like Michel’s media, majority of dermatologists can have access to DIF.Therefore,this study is an attempt to evaluate Vesiculobullous lesions using both histopathology and direct IF (DIF) studies and to assess the diagnostic potential of the IF studies.

Objectives

1. To study histopathological changes by light microscopy in Vesiculobullous disorders of the skin and to correlate clinical diagnosis and histopathological diagnosis of Vesiculobullous disorders of the skin.
2. To correlate the histopathological diagnosis with immunofluorescence findings and determine the utility of Direct immunofluorescence in the diagnosis of Vesiculobullous disorders.
3. To evaluate the clinical diagnosis of Vesiculobullous lesions and correlate it with histopathological findings and the findings from immunofluorescence

Materials and Methods

• Study duration:4 months
• Place of study: Ramaiah Medical College
• Study design:Retrospective cross sectional study
• Inclusioncriteria: Patients clinically diagnosed with active Vesiculobullous diseases irrespective of age and sex.
• Exclusion criteria:
  1. Patients with no active lesions
  2. Patients on systemic steroids
  3. Patients on immunosuppressive therapy.
• Procedure and Materials required: Biopsy for Direct immunofluorescence was taken from the perilesional skin. On DIF examination, the following parameters were evaluated:
  1. Site of deposition of immunoreactants (Epidermis/Basement membrane zone/dermis)
  2. Pattern of immunofluorescence(Linear/Granular) Intensity ofimmunofluorescence- graded as +++ strongly positive, ++ Moderately positive and Negative.
• Statistical Analysis
  1. Sample size: 68
  2. Rationale for sample size: Based on the literature review,in previous studies it was found that Vesiculobullous lesions constitutes 22.08% of total number of skin biopsies.

The most common being Pemphigus vulgaris followed by bullous pemphigoid, pemphigus foliaceous and dermatitis herpetiformis. In a present study expecting similar proportions considering absolute precision of 4% to achieve a desired confidence level of 95% the sample size worked out to 68 cases of Vesiculobullous lesions.

Implications of Study

Through this study we aim to categorize Vesiculobullous lesions based on their response to IF. We aim to find a quicker and accurate diagnosis for Vesiculobullous skin lesions that are difficult to diagnose on the basis of clinical and histopathological features. So, in this study we corelate and evaluate the clinical findings of Vesiculobullous lesions with positive or negative results of histopathological and IF evaluation.

References

1. Rajeswari Thivya Dhanabalan et al,The utility of immunofluorescence in diagnosing dermatological lesions and its correlation with clinical and histopathological diagnosis in a tertiary health care setup,Indian Journal of Dermatopathology and Diagnostic Dermatology. 2016: 63-70
2. Rohit Bhalara et al. A histopathological study of Vesiculobullous lesions of skin, Annals of Pathology and Laboratory Medicine, 2016; 3: 7-9
3. Prashant R Patel et al. Histopathologicalstudy of Vesiculobullous Lesions ofthe skin: A Study at Tertiary Care Hospital, International Journal of Medical Science and Public Health , 2014;3 :738-740
4. Huilgol SC , Bhogal BS, Black MM. “Immunofluorescence of immunobullous disorders part one : methodology”’ Indian J Dermatol Veneral Leprol. 1995; 61; 187-95
5. Inchara YK, Rajalakshmi T. Direct Immunofluorescence in cutaneous Vesiculobullous lesions. Indian J Pathol Microbiol. 2007; 50(4): 730-32