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E-IJD® - CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 3  |  Page : 316
Suprabasal clear cell change in hypopigmented seborrheic keratosis


1 Department of Dermatology, Seth G.S Medical College and K.E.M Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Dermatology, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Web Publication22-Sep-2022

Correspondence Address:
Tejas Vishwanath
Department of Dermatology, Seth G.S Medical College and K.E.M Hospital, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_911_21

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How to cite this article:
Bhargava A, Gole PV, Kharkar VD, Mahajan SA, Joshi R, Chikhalkar SB, Vishwanath T. Suprabasal clear cell change in hypopigmented seborrheic keratosis. Indian J Dermatol 2022;67:316

How to cite this URL:
Bhargava A, Gole PV, Kharkar VD, Mahajan SA, Joshi R, Chikhalkar SB, Vishwanath T. Suprabasal clear cell change in hypopigmented seborrheic keratosis. Indian J Dermatol [serial online] 2022 [cited 2022 Sep 29];67:316. Available from: https://www.e-ijd.org/text.asp?2022/67/3/316/356774




Sir,

Seborrheic keratosis (SK) is a common benign neoplasm with multiple clinical variants. Hypopigmented SK (HSK) is an under-recognised clinical variant with very few cases reported.[1]

Rare histopathological variants have been reported too. One such variant is the clear cell type. Up to date, reports detailing histopathologic features of hypopigmented variants of SK have not shown clear cell change. We report an unexpected histopathologic finding of suprabasal clear cell change in a case of HSK.

A 55-year-old man presented with an asymptomatic white-colored lesion over the chest since 10 years. On examination, a well-demarcated elliptical plaque 1.5 cm in diameter was present on the right side of his chest below the right areola [Figure 1]a. On dermoscopy (non-polarized mode), accentuated skin markings and focal white scales were noted [Figure 1]b. The polarized mode revealed a white structureless area with regularly distributed brown dots at places [Figure 1]c.
Figure 1: (a) An elliptical minimally elevated depigmented plaque on the chest. (b) Videodermoscopy (non-polarized mode) – the lesion is subtly elevated with accentuated skin markings and focal scaling. (c) Videodermoscopy (polarized mode) – structureless white areas with regularly distributed brown dots (more obvious in the top part of the figure) are seen

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Provisional diagnoses considered included HSK and idiopathic guttate hypomelanosis. Histopathological examination of a 4 mm punch biopsy showed focal compact orthokeratosis, irregular acanthosis, reduced melanin, and subtle foci of clear cells which led us to request serial sections [Figure 2]a. Prominent multi-focal nests of clear cells with monomorphic round to oval nuclei without cytologic atypia within the lower-mid stratum spinosum were noted on deeper sections [Figure 2]b. Focal superficial dermal perivascular lymphocytic infiltrate was also noted. The stratum basale was conspicuously spared and somewhat compressed by the overlying clear cells [[Figure 2]c and inset]. To exclude processing artefacts, we requested further step sections which also displayed similar features. The clear cells in all sections were periodic acid–Schiff (PAS)-positive [Figure 2]d, which again ruled out artefacts. PAS positivity disappeared after treatment with diastase, consistent with glycogen accumulation. The final diagnosis was kept as HSK with suprabasal clear cell change. The lesion was subsequently excised uneventfully.
Figure 2: (a) Irregular acanthosis, infundibular plugging, and compact orthokeratosis are noted along with subtle foci of clear cells (circled) (H and E, 2.5x). (b) Serial sections reveal prominent multi-focal clear cell nests (circled) (H and E, 2.5x). (c) and inset – Further magnification shows sparing and flattening of the stratum basale. Inter-cellular desmosomal bridges are preserved, confirming the keratinocyte origin of these cells (H and E, 10x, inset- 40x). (d) PAS positivity is noted in the cytoplasm of keratinocytes (40x)

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The present case highlights, two unusual facets of SK: an uncommon hypopigmented variant with an even more exceptional feature of suprabasal clear cell change. Hypopigmented seborrheic keratosis (HSK) is a rare clinical variant of SK. Except for the absence of pseudohorn cysts in the epidermis and the lack of the melanin pigment in the basal layer, the histopathological features of HSK are similar to other variants of SK.[1]

A less commonly described histologic type is the clear cell variant. The genesis of this change remains obscure: trichilemmal differentiation or an epidermal reaction pattern along with degenerating lysosomes are proposed hypotheses.[2],[3],[4],[5]

Two types of clear cell change have been described in SK: basal and suprabasal. The former is commoner mimics melanoma in situ. Suprabasal clear cell change is even rarer. It may be focal[2],[3] or diffusely involving the spinous layer.[4],[5] Our case showed multi-focal suprabasal clear cell change in the stratum spinosum with complete sparing of the stratum basale.

As compared to the classic dermoscopic features of SK,[2] a rather peculiar picture was noted in our case with a white structureless area and brown dots with regular distribution which appeared as brown islands in a sea of white.

Important histologic differentials were artefactual clearing, verruca vulgaris, clear cell acanthoma, melanoma in situ, and trichilemmoma. [Table 1] elucidates salient points of difference between these entities.
Table 1: Differential diagnosis of clear cell changes on histopathogy with dermoscopic features

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Aggressive epithelial and melanocytic neoplasms with clear cell changes can arise within pre-existing SKs, such as basal cell carcinoma and squamous cell carcinoma. Careful examination of multiple repeated sections ruled out these possibilities in our case.

To our knowledge, the presence of clear cell change has not been reported in HSK up to date. In the present case, a combination of these two rare features in a single lesion is described with dermosopic features. Thorough clinical and histologic examination to rule out a malignancy and consideration of alternative diagnoses are important in such cases with clear cells. In future, elucidation of dermoscopic patterns in this peculiar variant of SK may also help avoid diagnostic pitfalls.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pavithran K. Chronic seborrhoeic keratosis. Indian J Dermatol Venereol Leprol 1989;55:194-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ko CJ, Subtil A. Clear cell acanthosis as an incidental finding. J Cutan Pathol 2009;36:573-7.  Back to cited text no. 2
    
3.
Nakayasu K, Nishimura A, Maruo M, Wakabayashi S. Trichilemmal differentiation in seborrheic keratosis. J Cutan Pathol 1981;8:256-62.  Back to cited text no. 3
    
4.
Han JS, Lee MW, Won CH, Chang SE, Choi JH, Moon KC. A case of seborrheic keratosis with clear cell change. Int J Dermatol 2014;53:e370-2.  Back to cited text no. 4
    
5.
Long TH, Zlotnick D, Hurst SL, Argenyi Z. Seborrheic keratosis with prominent clear cell changes-A rare but important diagnostic variant. Am J Dermatopathol 2018;40:209-11.  Back to cited text no. 5
    


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