Clinical differential diagnosis for singly dispersed necrotic keratinocytes in the superficial epidermis and cornified layers
| Condition | Key non-cutaneous clinical features | Typical cutaneous findings | Other histological findings |
|---|---|---|---|
| Systemic inflammatory disease | |||
| AOSD (1, 4, 13, 15, 16, 17) | High fever, myalgias, hyperferritinemia, and pharyngitis | Evanescent salmon-coloured eruption Linear urticaria Persistent pruritic papular eruption | Vacuolar interface dermatitis; mild dermal infiltrate of eosinophils/neutrophils |
| aGVHD (33, 34) | History of transplant, gastrointestinal symptoms | Erythematous macules and papules with varying body surface area, rarely bullae or erythroderma | Confluent or diffuse keratinocyte necrosis; variable superficial inflammatory infiltrates without neutrophils; vacuolar interface dermatitis with hair follicle involvement |
| Bacterial-toxin-associated–mediated erythemas | |||
| TSS (35) | Recent surgery, high fever, myalgias, pharyngitis, and shock | Erythroderma or flexure-predominant macular eruption Desquamation of palms and soles | Variable dermal perivascular inflammatory infiltrate; epidermal spongiosis without interface dermatitis |
| Photodermatologic disorders | |||
| Acute inflammatory erythema (sunburn) (36) | Exposure history | Erythema of sun-exposed skin with burning sensation and possible edema or blistering | Minimal dermal inflammation without eosinophils or vacuolar interface dermatitis |
| Phototoxicity (37) | Exposure to phototoxic agent and UV radiation | Erythema of sun-exposed skin with burning sensation and possible edema or blistering | Variable spongiosis and/or interface dermatitis; variable dermal inflammatory infiltrate |
| Other inflammatory skin diseases | |||
| Early acute phase of prurigo pigmentosa (38) | Young adult female, systemically well except for ketosis | Pruritic erythematous papules and vesicles symmetrically distributed on the back, neck, and/or chest evolving into a reticulated configuration of hyperpigmented macules | Spongiotic dermatitis with intraepidermal and superficial perivascular lymphocytes; possible confluent keratinocyte necrosis and/or intraepidermal neutrophilic microabscesses; abundant bacteria within hair follicles |
| Irritant contact dermatitis (39) | History of exposure | Painful and/or pruritic erythema, edema and/or bullae on exposed sites | Spongiotic dermatitis with intraepidermal and superficial perivascular lymphocytes and neutrophils |
| Genodermatoses | |||
| Verrucous phase of incontinentia pigmenti (40) | Family history, pediatric onset, dental, hair (“woolly”), nail, central nervous system, eye, and breast abnormalities | Erythematous, vesicular or verrucous linear plaques following lines of Blaschko | Eosinophilic spongiosis in earlier lesions; verrucous epidermal hyperplasia in later lesions; dermal lymphocytes, eosinophils, and/or melanophages, without neutrophils |
| Condition | Key non-cutaneous clinical features | Typical cutaneous findings | Other histological findings |
|---|---|---|---|
| AOSD ( | High fever, myalgias, hyperferritinemia, and pharyngitis | Evanescent salmon-coloured eruption | Vacuolar interface dermatitis; mild dermal infiltrate of eosinophils/neutrophils |
| aGVHD ( | History of transplant, gastrointestinal symptoms | Erythematous macules and papules with varying body surface area, rarely bullae or erythroderma | Confluent or diffuse keratinocyte necrosis; variable superficial inflammatory infiltrates without neutrophils; vacuolar interface dermatitis with hair follicle involvement |
| TSS ( | Recent surgery, high fever, myalgias, pharyngitis, and shock | Erythroderma or flexure-predominant macular eruption | Variable dermal perivascular inflammatory infiltrate; epidermal spongiosis without interface dermatitis |
| Acute inflammatory erythema (sunburn) ( | Exposure history | Erythema of sun-exposed skin with burning sensation and possible edema or blistering | Minimal dermal inflammation without eosinophils or vacuolar interface dermatitis |
| Phototoxicity ( | Exposure to phototoxic agent and UV radiation | Erythema of sun-exposed skin with burning sensation and possible edema or blistering | Variable spongiosis and/or interface dermatitis; variable dermal inflammatory infiltrate |
| Early acute phase of prurigo pigmentosa ( | Young adult female, systemically well except for ketosis | Pruritic erythematous papules and vesicles symmetrically distributed on the back, neck, and/or chest evolving into a reticulated configuration of hyperpigmented macules | Spongiotic dermatitis with intraepidermal and superficial perivascular lymphocytes; possible confluent keratinocyte necrosis and/or intraepidermal neutrophilic microabscesses; abundant bacteria within hair follicles |
| Irritant contact dermatitis ( | History of exposure | Painful and/or pruritic erythema, edema and/or bullae on exposed sites | Spongiotic dermatitis with intraepidermal and superficial perivascular lymphocytes and neutrophils |
| Verrucous phase of incontinentia pigmenti ( | Family history, pediatric onset, dental, hair (“woolly”), nail, central nervous system, eye, and breast abnormalities | Erythematous, vesicular or verrucous linear plaques following lines of Blaschko | Eosinophilic spongiosis in earlier lesions; verrucous epidermal hyperplasia in later lesions; dermal lymphocytes, eosinophils, and/or melanophages, without neutrophils |
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