Morphologic and Histochemical Studies of Atopic Eczema in Infants and Children*

MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA IN INFANTS AND CHILDREN* PHILIP H. PROSE, M.D. AND EMILIA SEDLIS, M.D.

Despite the high incidence of atopic eczema in

Five specimens of diseased skin were received

histological or histochemical studies of the skin in this phase of the disease. Most of these reports

during the acute phase of the eruption and three during clearing of a lesion or after a lesion was grossly healed. The thirty-one specimens of grossly healthy skin were from sites contralateral or adjacent to the biopsied eezematous site or sites. Included in these specimens were two from each of three patients; one specimen was removed prior to profuse heat-induced sweating and the other from an adjacent site immediately following sweating. These three patients were in the group of 8 patients from each of whom we received a specimen of diseased skin biopsied both prior to and after sweating as previously noted. In addition, 9 biopsy specimens of healthy skin from noneczematous, healthy children were examined; 4 specimens were from the face and the remainder, from the extremities. All but 16 specimens (one specimen of diseased skin and one of healthy skin from each of eight eczematous children) were fixed in cold acetone or neutral formalin immediately after removal, then dehydrated in alcohol, cleared in toluene, embedded in paraffin in a vacuum oven (55° C. for 10 minutes) and serially sectioned at 6 The sections were studied with a variety of stains; Delafleld's hematoxylin and eosin; phosphotungstic acid hematoxylin; toluidine blue buffered to pH 3.0 and pH 5.0; periodic acid-Schiff-hematoxylin; Alcian Blue-periodic acid-Schiff; Brown and Brenn's Gram stain; Verhoeff's elastic tissue stain combined with the Van Gieson; and Wilder's

infants and children, there are few reports of from 2 patients; one from each patient was taken were prepared some years ago and cannot be correlated with recently reported physiological observations (1) and recently proposed pathophysiological mechanisms (2). It is the purpose of this presentation to report on such studies and to attempt to correlate these observations and suggested mechanisms with the histological and histochemical findings. MATERIAL AND METHODS

Eighty-six biopsy specimens of diseased skin and thirty-one biopsy specimens of healthy skin from 71 patients, 35 girls and 36 boys, were submitted for examination. Forty-four of these patients were between six weeks and one year old; 17, between 1 and 2 years old; 7, between 2 and 4 years old, and 1 each, 5 years, 6 years and 11 years

old. All but two of the specimens of skin were removed from non-anesthetized areas with an electrically driven biopsy punch (diameter 0.3 to 0.5

cm.) (3); two specimens were excised with the scalpel after the skin had been anesthetized.

The majority of the biopsy specimens of diseased skin were from the extremities; there were 7 each from the scalp and face; and an occasional specimen was obtained from the trunk. Twenty-five of the eighty-six specimens had been removed during the summertime. Two specimens of diseased skin were obtained from each of 8 patients; one specimen was taken immediately prior to profuse, beat-induced sweating and the other from an adjacent site immediatély following prolonged sweating. During the sweating period, gross examination or the use of

Bromphenol blue impregnated filter paper (4) failed to reveal the presence of sweat droplets on the sites chosen for biopsy.

the Department of Pathology (Dr. Prose) and the Department of Pediatrics (Dr. *

From

Sedlis), New York University-Bellevue Medical Center; New York, N. Y. Presented at the Twentieth Annual Meeting of the Society for Investigative Dermatology, Inc., Atlantic City, N. J., June 7, 1959. This study was supported by a grant from the John A. Hartford Foundation, Inc. 149

reticulum stain. Alkaline phosphatase and 5nucleotidase activity were studied in paraffin sections of the acetone fixed specimens (5); the sections were incubated for three and four hours with sodium-beta-glycerophosphate in the alkaline phosphatase determinations and with muscle adenylic acid in the 5-nucleotidase determinations. Some of the sections were incubated with testicular hyaluronidase, 1 mgm/cc. of 0.1 M phos-

phate buffer, pH 6.5, at 37° C. for one hour and

then stained with both the toluidine blue and Alcian Blue-periodic acid-Schiff stains. Not treated as described above were one specimen of diseased skin and one of healthy skin from each of eight patients. These specimens were rap-

idly frozen and then sectioned in a cryostat at —16° C. The sections were examined for specific

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and non-specific cholinesterase activity (6), suc- Occasionally, younger patients were seen with cioic dehydrogenase activity (7, 8), and protein- erythematous and liehenified plaques and older bound sulfhydryl and disulfide groups (9, 10, 11). patients presented with acute lesions. DPN (diphosphopyridine nucleotide) diaphorase With the aforementioned differences in mind, activity was studied (12): DPNH was the subgeneralizations regarding the histological strate; neotetrazolium, the hydrogen acceptor; some the sections were incubated for one hour at 37° C. features of the diseased skin of infants and chilIn addition some sections were stained with hema- dren with atopie eczema are permissible. Sections of involved skin revealed a hypertoxylin and eosin, and toluidine blue.

keratotie or more frequently a parakeratotie OBSERVATTONS

Uniform histological findings among biopsy specimens from clinically diverse lesions were

epidermis. Occasional specimens showed horizontally and/or vertically alternating zones of hyper-

keratosis and parakeratosis. Although bacteria were not infrequently seen in the sections, either patients tended to present with the more acute on the skin surface or within the hyperkeratotie lesions (erythematous, edematous, sealing and or parakeratotic zones, a leukocytie response neither to be expected nor observed. The younger

crusted areas) and the older patients usually was unusual. presented with the more chronic lesions (cryThe granular cell layer was usually prominent thematous and liehenified patches). The differ- in the diseased skin. It was often narrow or ence between these two types of lesions was absent beneath an infected crust or over a usually evident in histological sections; the acute

severely edematous corium.

lesion showed a more aeanthotie epidermis, a

The stratum spinosum was acanthotie and

more edematous eutis, and a sparser perivaseular

except for specimens of skin from the scalp, the aeanthosis was usually more pronounced in the

cellular infiltrate. There were variations in the severity of the acute and chronic lesions and rete ridges than in the suprapapillary zones. these were mirrored in the histologic findings. The rete ridges in individual specimens tended

Fia. 1. The length of the rete ridges is fairly uniform within the corium. Occasional ridges are fused. The cellular infiltrate about the subpapillary plexus of vessels is greater than the infiltrate about the vessels in the papillae (II. & E. X 134).

MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA

FIG.

151

2. The epidermis is psoriasiform. The rete ridges are very long and occasional suprapapillary

plates are thin (H & E. X 178).

to extend into the cutis to a uniform depth

times extending into the parakcratotic zone.

Alcian Blue staining material was occasionally positively correlated with the edema in the noted in the intercellular bridges. The sweat pores in the diseased skin were frepapillae. The deepest ridges were usually seen in the younger patients in this study. Occasional quently slit-like and surrounded by compact ridges fused into plates. Sometimes the increased keratin (Fig. 3). Even in areas of parakeratosis, acanthosis of the ridges was exaggerated and the the pore was usually encompassed by keratin epidermis assumed a psoriasiform appearance since the nucleated parakeratotic cells tended to (Fig. 2). However, Munro's abscesses and stop abruptly at the "sweat beaker". The granu"rigid" capillaries were not seen and the papillae lar layer surrounding the beaker was almost usually showed more edema than one sees in always intact. In the many serial sections that psoriasis. Nevertheless, on occasion the histo- were examined, including those of specimens logical differentiation betweeu these lesions obtained during the summer and after thermally (atopic eczema) and psoriasis appeared difficult induced sweating, only one duct, occluded at its or impossible. In the diseased scalp, acanthosis pore by a parakcratotic scale, was ruptured in was slight to moderate and the rete ridges ex- its intracpidermal course (Fig. 4, 5). All the other sweat ducts within the epidermis were neither tended into the cutis for varied distances. The nuclei were more prominent in the in- perceptibly transversely dilated nor ruptured. volved epidermis, but the nucleoli did not appear They were, however, occasionally vertically to be unusual. Mitoses were seen in the lowest elongated as the spiraling of this part of the duct regions of the epidermis; the number of mitoses became steeper in the acanthotic ridges. Compact and increased amounts of kcratin varied but were never numerous. In acute lesions, melanin pigment was usually less pronounced were often present in the pilo-sebaccous orifices than in the corresponding healthy skin; in chronic in the involved skin. The basement membrane was well outlined by lesions, melanin was often more prominent and diffusely scattered through the epidermis, some- the periodic acid-Schiff and the silver techniques (Fig. 1). The depth of the ridges appeared to be

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FIG. 3. The epidermis showing keratin surrounding a slit-like sweat pore (II & E. X 225).

except in areas of severe edema. Small, focal grating cells were mainly monocytes except in the separations of the basal cell layer from the sub- vicinity of an infected crust where numerous jacent cutis by edema fluid were occasionally polymorphonuclear leukocytes were seen. observed. Spongiosis, when present, was more Significant epidcrmal changes with few alteraprominent in the lower epidermis. Rarely, vcsi- tions in the cutis were occasionally observed. des were seen and these were usually situated Usually, the papillae were either entirely pale beneath the stratum corneum; they were small and edematous or they contained a peripheral and contained epidermal cells and rare mono- zone of hyalinized collagen abutting on the rete nuclear cells. ridges. In healing or healed lesions they were Exocytosis was not a prominent feature; mi- composed of dense, hyalinizcd collagen. The

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Fin. 4. A twice transcctcd seat duct within the epidermis showing an intact lumen near the base of the rctc ridge and beginning disruption of the lumen beneath the parakcratotic surface (Periodic acidSchiff-ilematoxylin X 740).

vessels within the papillac were dilated and tor- polymorphonuclear leukocytcs were seen in the tuous, with swollen endothelium; perithelial papillac. Within the upper and mid-corium, rarely in cellular proliferation was minimal to moderate.

Occasional monocytes of the lymphocytic, the deep corium, the smaller blood vessels histiocytic or mast cell variety infiltrated the appeared prominent due to their swollen endopapillac. In the vicinity of an infected crust, thclial lining, the pcrivascularly situated edema,

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Fjo. 5. The sweat duct within the epidermis showing further disruption of its lumen (see Fig. 3). The pore is not seen; it is filled by parakeratotie cells (Periodic acid-Schiff-llematnxylin X 500).

proliferated fibroeytes, increased numbers of fibrils, and prominent collections of monoeytes

dilated lymphaties were not unusual. Rarely, collections of plasma cells were found about

with proportionately rare neutrophilie or ensinophilie polymorphonuelear leukoeytes. The latter were more numerous in cases of chronic eczema

vessels or in the vicinity of the coiled portion of the sweat gland; in this series of cases, the youngest patient with prominent collections of plasma cells in the involved skin was a four month old

or superficially infected eczema. Markedly

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FIG. 0. Coiled part of a sweat gland in the grossly healthy skin of a 2 year old girl showing a small amount of fibrillar material between the transected, closely-set tubules (Alcian Blue-Periodic Acid-

Schiff X 750).

boy. Mast cells tended to be most numerous in cases of chronic, severe eczema and they were usually situated about vessels, between collagen bundles and sometimes concentrated about hair papillae.

The sites of moderate or severe edema in the corium, i.e., in the papillae, about vessels, and

not unusual; they were occasionally surrounded by small or moderate numbers of hyaluronidaselabile, positively stained Alcian Blue fibrils. On rare occasions, these fibrils appeared to project between cells of the duct.

The coiled portions of the sweat glands in

most specimens of diseased skin showed wide between collagen bundles, showed varied amounts separation of the sectioned, normal appearing of delicate reticulum fibers that stained bright tubules by fibrils which were stained blue with red with the periodic acid-Schiff stain and were Delafield's hematoxylin, purple-red with toluidiastase and hyaluronidase resistant, and fibrils dine blue buffered to pH 3.0 or 5.0 (the staining that were stained blue or blue-green with Alcian was more intense at pH 5.0), and blue green with Alcian Blue (Fig. 6, 7). These staining charBlue and were hyaluronidase labile. The straight portions of the sweat ducts were acteristics were abolished by prior incubation of

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Fio. 7. Coiled part of a sweat gland in the eezematous skin of a 2 year old girl (see Fig. 6) showing separation of the traoseeted tubules and the intervening increased amounts of fibrillar material (Alcian Blue-Periodic acid-Schiff X 693). the sections with hyaluronidase. Although fibrils

tremities, trunk, face and scalp, the sebaceous

with these features were sometimes rather

glands were small and they were composed either entirely of basal-like cells or mainly of basal-like cells with rare vaeuolatcd cells (Fig. 8, 9). The nerve fibers in both healthy and diseased

diffusely distributed through diseased skin, they were most concentrated in the area of the coiled portion of the sweat glands; the situation of the

coiled portion, i.e., within collagen or areolar skin were similar in appearance; Alcian Blue tissue, appeared to be unimportant in this re- staining material was seen within many of the spect. While these fibrils were usually more nerves. numerous in the younger patients in this study, The subcutaneous fat in both healthy and the correlation was not absolute since occasional diseased skin showed no pathological changes. specimens of diseased skin from the older patients Elastic tissue in diseased skin was similar in showed this change to a significant degree. These appearance to that in healthy skin except for hyaluronidasc-labile, Alcian Blue stained fibrils some thinning of the fibers in the edematous

were either entirely absent or minimal in num-

tissue around vessels and in the edematous

bers in specimens of grossly healthy skin of

papillae.

atopic children. Scattered mast cells were seen Glyeogen was very often noted in the epidermis about the coiled tubules, but they were not more of diseased skin usually extending from just above numerous in this location than in the contra- the basal cell layer to the granular layer; in lateral or adjacent healthy skin in the same some cases the cytoplasm of the basal cells was rich in glycogen. The epidermis of healthy skin patient. The sebaceous glands in the minimally diseased contained little or no glycogcn. No consistent skin and in healthy skin of eczematous and non- differences were noted in the amounts of glycogen cczematous children were not unusual; they were within the sweat glands of the healthy and dismoderate in size and contained mainly vacuo- eased skin in one and the same patient. The lated cells. In the moderately severe eruptions in sebaceous glands with non-vacuolated, basal-like all the areas examined, e.g., skin from the cx- cells were rich in glycogen. Smooth muscle cells

157

MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA

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FIG. 8. Two obliquely sectioned hairs within the eorium of the eczematous scalp of a two-month old boy showing small sebaceous glands with vacuolated cells to the left of external root sheaths (II. & E. X 211).

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Fin. 9. Sebaceous glands extending from the upper part of the sides of an obliquely sectioned hair in a specimen of eczematous skin. The glands contain cells that are flattened, resemble basal cells, and are not vacuolated(H. &E. X 240).

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contained glycogen granules. Glycogen was not and epidermis of the healthy skin when it was compared with the diseased skin of the same seen in the subcutaneous fat. Within healthy and diseased skin, diastase- patient. No consistent differences were seen when resistant, periodic-acid Schiff stained material was seen occasionally in the kcratin layer or histochemically determined alkaline phosphatase parakeratotic zone, lining the sweat pore in its activity in diseased skin was compared with "beaker", and within the lumen of the straight that in healthy skin of the same patient. Conand coiled part of the sweat gland. sistent differences in this activity were not obIn the sections of diseased skin obtained imme- served when specimens of skin from the same diately after profuse, heat-induced sweating the patient prior to and after profuse, heat-induced epidermis showed increased intracellular and sweating were compared. Alkaline phosphatase intercellular edema, the cutis revealed increased activity was seen in the walls of capillaries in the edema of its upper one-third. Glycogen within the upper corium and occasionally in the more deeply secretory portion of the sweat gland was dimin- situated capillaries, in the cytoplasm of cells in ished or absent. The collections of hyaluronidase- the coiled portion of the sweat glands, in the hair labile Alcian Blue stained fibrils between the papillae and adjacent epidermal cells, in the cytotubules of the coiled portion of the sweat gland plasm of the peripherally situated cells of the sebaceous glands and occasionally within the appeared unchanged. Histochemical determinations of protein-bound cytoplasm of the cells situated perivascularly sulfhydryl and disulflde usually showed more and between the coiled portion of the sweat intense staining for both these substances in the gland. parakeratotic zone and epidermis of abnormal 5-Nucleotidase activity could not be histoskin. In one specimen, the protein-bound sulf- chemically demonstrated in the specimens of hydryl appeared increased in the keratin zone healthy and diseased skin.

FIG. 10. Section of grossly healthy skin in a nine-month old boy showing darkly stained areas representing formazan deposition at sites of DPN diaphorase activity. The latter is marked in the tightly coiled part of the sweat gland, external root sheaths and in the epidermis. Blood vessels are faintly outlined. The keratin layer does not contain formazan crystals (X 47).

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MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA

Frozen sections of healthy and diseased skin Attempts at histochemieally demonstrating from the same patients examined for specific sueeinie dehydrogenase activity with the techcholinesterase activity showed this activity to flies employed were nnsuceessful. Formazan crysbe present about the tubules in the coiled portion

tals were not seen in any of the sections examined;

of the sweat gland and in some nerves in the occasionally faint pink staining of a hair shaft, vicinity of this part of the sweat gland. There fat or a sweat gland was noted. were no consistent differences in enzymatic The deposition of formazan crystals at the activity when the diseased and healthy skin of sites of DPN diaphorase activity appeared to be the same patient were compared.

heaviest in the coiled portion of the sweat gland.

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Fxo. 11. Section of eczematous skin in a nine-month old boy showing marked DPN diaphorase activity (see Fig. 10) in the widely separated coils of the sweat gland and in the basal layer of the epidermis. The blood vessels are more prominent (X 55).

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and this was also noted by Heimann (15) and what less reactive and the intracpidcrmal por- Dind (16). The latter concluded that this finding tion, faintly reactive; the latter stained pink and linked neurodermatitis and lichen planus. A more was prominent in the very reactive, purple- marked perivascular infiltrate in the corium as stained epidermis. When staining of the epi- compared with that in the papillac has been dermis was not maximal and uniform, the crys- described (20) and is in agreement with what we tals appeared to be intracytoplasmic and the have found. A correlation between the varied The straight portion of the sweat duct was some-

basal cell layer seemed to be more reactive than clinical findings and the histological findings in the remainder of the epidermis. The keratin and eczema has been reported (13, 19). Little or no maturation of sebaceous glands as parakeratotic zones did not show formazan crystals; they were stained pink. The external evidenced by the paucity or absence of vacuoroot sheath, sebaceous gland, vessels, some of the lated cells was observed in specimens of modercells in the perivascular infiltrate and some of ately to severely diseased skin from all the areas the cells between the collagen bundles showed examined; some of the specimens were from the

intense reactivity. The structures in diseased scalp of patients with the severe, "seborrheic skin and normal skin stained with almost equal variety" of atopic eczema. By contrast, the intensity, however the diseased skin differed from

healthy skin of eczematous and healthy children

the healthy skin in a quantitative fashion, e.g. showed mature vacuolated glands. However, the it showed more blood vessels and more cells volume of the sebaceous glands in the grossly healthy skin of atopic children was not compared about vessels (Fig. 10, 11). with the volume of these glands in the skin of nJscUsSIoN

healthy children of the same age group. Although

Despite some confusion engendered by the somewhat similar changes in sebaceous glands morass of names for this disease and by the have been experimentally produced or have been occasional report based on very few biopsy described in other conditions (24), the findings in specimens of skin from patients whose ages were eczematous skin do not entirely coincide with unspecified and who showed different clinical these observations since severe inflammation is manifestations of the disease, there is much rarely noted about these glands. Comedo formaagreement between the observations of others tion was not observed. Of interest in this regard is Unna's (13) ob(13—23) on the histological morphology of atopic eczema and our own observations. The tendency servation that the sebaceous glands in infants of the epidermis to mimic that seen in psoriasis are normally small. He concluded that the sebawas noted by some investigators (13, 15, 23); ceous glands do not contribute to the surface fairly regular epidermal acanthosis, the so-called neurodermatitic reaction (21, 22) was emphasized

by others; and the long and narrow rete ridges

oiliness in scborrheic eczema since the follicular orifices were blocked in this disease. He equated "scborrheic catarrh" of the forehead and cars in children with infantile eczema. He reported that

were seen in a case of infantile eczema studied by MacCardle et at. (20). Spongiosis of the epidermis in "scborrheic catarrh" these glands are in a with little tendency to exocytosis had been men- state of arrested secretion and do not show the

tioned by Unna (13) as one of the criteria for

slightest sign of hypersecretion. He attributed

the diagnosis of eczema and this was concurred in by others and ourselves. Heimann (15) failed to observe intraepidermal vesicles, Brocq and Jacquet (14) noted a tendency to vesiculation which was never more than minimal; and frank vesicles were described by Unna (13). We observed subcorneal vesiculation

the surface oiliness to increased coil gland secretion. On the other hand, Hcimann (15) failed to observe excessive fat in the epidermis, follicular

involvement, or disturbances in the piloscbaceous or sweat organs.

In atopic eczema sensible sweating is not detected on the skin surface of some established

but it occurred infrequently and there would lesions; we have made similar observations in appear to be little likelihood therefore of observ- our infant patients. In a monograph on sweat ing this change in a routine diagnostic section.

disturbances, Sulzbcrgcr and Hcrrmann (2) have

We observed occasional small collections of edema

proposed a pathologic mechanism for sweat

fluid between the basal cell layer and the cutis

retention in atopic skin. This mechanism is simi-

MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA

161

lar to that observed in miliaria and tropical evidence for impeded sweat delivery to the skin anhidrosis (25, 26). They suggested that many surface by poral obstruction is "actually relaof the symptoms and clinical findings in atopic tively sparse". eczema are the result of keratin plugging of sweat From the foregoing discussion, it would be of pores with resultant dilatation of the subjacent interest to explore other possible mechanisms ducts and consequent seepage of sweat (possibly that might explain impaired delivery of sweat to containing irritants or allergens) into the epi- the skin surface in atopie eczema. An inability of dermis or cutis. However, reports of histological the secretory portion of the gland to produce studies of adult atopic skin excluding infected, sweat appears unlikely; we did not observe conpustular lesions that are oriented toward the sistent differences in the amounts of glycogen, problem of sweat duet obstruction are few (27, and the amounts of alkaline phosphatase and eholinesterase activity in or about the secretory 28) and do not permit definitive conclusions. On the basis of the histological examination of portion of the sweat gland in the diseased and approximately one-half the number of biopsy healthy skin of the same patient. Also, following specimens being reported here, we seriously thermally induced sweating the glycogen disquestioned the role of sweat duct obstruction in appeared from the secretory part of the sweat the pathogenesis of atopic eczema (29) in infants apparatus in both diseased and healthy skin. and children. These observations and subsequent Further evidence of a more substantial nature ones to the present fail to substantiate the im- was supplied by Davis and Lawler (1) when portance of poral occlusion with resultant sweat they demonstrated that following injection of duct obstruction in this disease. We observed acetyleholine into atopic skin, sweat retention many sweat "beakers" with keratin rings contain- was noted in the intact skin and sweat droplets ing narrowed or slit-like pores in the biopsy speci- were delivered to the surface of the adjacent skin mens of atopic skin. It was of interest that even from which the keratin layer had been stripped. in parakeratotic zones, the beakers were usually The secretory part of the sweat gland was therefilled with keratin rather than parakeratotic cells; fore active; the keratin appeared to be of parapresumably normal maturation of the epidermal mount importance in sweat retention. cells tends to be maintained about the beaker. As previously discussed, histologic evidence Using miliaria as the prototype of sweat duct does not appear to suggest that the role played obstruction, one would expect that effective by keratin in sweat retention is to any great exocclusion of the pore would result in dilatation tent that of a pore plug. Sections examined by us and rupture of subjacent duets. We observed show that stripping of the keratin layer would definitive anatomic evidence of sweat pore occlu- have to be carried in occasional instances almost sion in one duet only in all of the specimens and to the mid-epidermis to remove the twisting multiple sections studied; this duct was occluded keratin lining of some of the pores. Another by a parakeratotic scale and rupture of its intra- mechanism by which keratin could produce sweat

epidermal portion was seen. This, extremely retention appears worthy of consideration— rare, almost accidental finding in our biopsy namely, the relative defatted state of the keratin specimens of skin with atopic eczema assumes layer, the consequence of poorly maturated added weight since eight of the eighty-six specimens of diseased skin were biopsied following induced thermal sweating and twenty-five others were biopsied in the summer months. In atopic eczema therefore, the presence of keratin rings about narrowed sweat pores does not appear to

sebaceous glands in atopic skin, might result in imbibition of sweat by keratin in a manner similar to that observed when the surface of cadaver skin was defatted (4). In a previous communication, we reported the finding of poorly maturated sebaceous glands in the diseased skin of children

indicate occlusion of the duct and these pores with moderate to severe atopic eczema (29); seem to be entirely adequate to their task, i.e. further studies to date reveal the same changes sweat delivery.

in the sebaceous glands. In two of five specimens

Recently, Sulzberger et al. (30) have reex- of atopic skin examined by Sulzberger and coamined the problem of sweat retention in atopic workers (30), they observed that the sebaceous children and made the observations which are in glands were greatly reduced in number and size. agreement with ours. They conclude that the These investigators were able to study the lipid

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level on the skin of one child with atopic eczema and found this level to be low. It would appear

skin removed prior to sweating. When these comparisons were made, there were no consistent

to us that there is suggestive evidence for the differences in the appearance of these fibrils. interdependence of poorly maturated sebaceous An alternative explanation for the mucopolyglands, lowered lipid levels on the skin surface saecharide accumulations is the stimulus of edema and probably in the keratin layer, and sweat fluid to connective tissue regeneration as has "retention" in atopic skin. Much further in- been shown to occur experimentally (32). Howvestigation is required to prove these relation- ever, in contrast to the experimental findings, we did not observe increased numbers of mast ships. The large accumulations of hyaluronidase- cells in the areas showing increased amounts of labile, acid mucopolysaccharides about the sweat mueopolysaeeharides. coils in many specimens of atopic skin are of Hyaluronidase-labile mucopolysaceharides were interest. These mucopolysaccharides are strongly also present in increased amounts between the

water-binding and it is entirely probable that collagen bundles of the eorium in some of the specimens of atopie skin. This finding may

the function of the sweat gland undergoes some alteration in its changed environment, e.g. altered

explain Davis and Lawler's (1) observation that

sweat secretion and/or reabsorption of sweat.

hyaluronidase introduced into atopie skin to-

The disposition of acid-mucopolysaceharides in psoriatic skin as reported by Braun-Falco (31)

gether with or prior to the injection of acetyleholine solution resulted in smaller wheals and ab-

is similar to what we have observed in atopic sence of the delayed blanch phenomenon. The skin. However, in psoriatic skin most of these edema fluid of the wheal and the edema fluid mucopolysaccharides were resistant to testicular thought to result in the delayed blanch phehyaluronidase. Braun-Falco believed that the nomenon would be dissipated by the depolymermucopolysaccharide accumu]ation in the region izing action of the enzyme (hyaluronidase) on of the sweat gland resulted from sweat retention

in psoriasis with diffusion of sweat, possibly containing "proteolytic (?)" components, into the surrounding tissue. "Acid mucopolysaccharide phanerosis" was supposedly due to the proteolytic dissociation of the protein-mucopolysaccharide complex. We can not exclude the possibility of sweat seepage through the proximal part of the gland in atopic skin. However, the possibility that sweat seepage causes sweat retention in atopic skin appears unlikely in view of the previously noted observations of Davis and Lawler (1), namely the removal of keratin from the surface of atopic skin previously

these mucopolysaeeharides.

It would appear unlikely that these mucopolysaeeharides are important in the production of itching; their accumulation within the skin is also seen in non-pruritie eruptions. In addition,

there were no discernible differences in the amounts of mucopolysaceharides within the nerves of healthy and diseased skin.

There were usually more histoehemieally demonstrable protein-bound sulfhydryl and disulfide groups in the parakeratotic zone and epidermis of involved skin when compared with uninvolved skin in the same individual. The atopie skin of infants and children showed

injected with acetylcholine results in grossly neither glyeogen nor alkaline phosphatase detectable sweat delivery to the skin surface. In activity in the subcutaneous fat. Both were addition, it is difficult to reconcile the hypothesis noted in the fat of infants fed a synthetic diet of sweat seepage in atopic skin with our failure to find anatomical evidence of sweat retention or sweat seepage. As previously discussed, we observed only one dilated and ruptured sweat

lacking either histidine or tryptophane. In addi-

tion, very young, histidine deficient infants developed an eczematous eruption which resembled atopie eczema. The eruption cleared

duct in the many specimens and sections ex- when histidine was added to the diet (33). The amined. If sweat seepage was occurring from histological differences between the skin of the the coil, one would have expected to see separa- atopie children and the amino acid deficient tion or swelling of the Alcian Blue stained fibrils infants would appear to indicate that histidine, about the coil when specimens of diseased skin tryptophane, or possibly other amino acid deremoved after profuse, heat-induced sweating ficiencies are not etiologieal factors in atopie were compared with specimens from adjacent eczema.

MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA

With the methods employed attempts at demonstrating suecinie dehydrogenase activity ia frozea sections of both normal and involved skin were unsuccessful. Some reports in the litera-

ture describe succinic dehydrogenase activity in human skin (34) based on the use of these methods on unfrozen tissues. Under these latter circumstances, it has been shown that other dehydrogenases acting on endogenous substrates are responsible for the formazan precipitation (35); freezing abolishes this interfering activity prob-

163

compared to the infiltrate about the subpapillary plexus of vessels. The infiltrate usually consists of chronic inflammatory cells. Mast cells and eosinophiles are more numerous in chronic, moderate to severe eruptions. 2. Serial sections of many biopsy specimens of atopic skin, including some specimens excised

during the summer months and some excised immediately following profuse, heat-induced sweating, showed only one sweat duct with obvious dilatation and rupture. There was little ably by leaching of these substrates from the resemblance between our findings and those in tissue. The inability to demonstrate succinic the prototype of poral obstruction, i.e. miliaria dehydroginase with the methods used in a tissue and tropical anhidrosis. It appears unlikely that with high metabolic activity is of interest. We the symptomatology and clinical findings in were similarly unable to demonstrate 5-nucleo- atopic eczema in the age group studied are based tidase activity in specimens of normal and on poral obstruction. Other mechanisms that may be operative in sweat retention are sugdiseased skin. DPN diaphorase activity was easily demon- gested. The possible role of the observed lack of strated in frozen sections; reactivity was marked maturation of sebaceous glands and the increased in the basal cell layer of the epidermis, the coiled accumulations of hyaluronidase-labile mucopart of the sweat glands, sebaceous glands, blood polysaceharides about the coiled portion of the vessels, and cellular infiltrate. The enzyme there- sweat gland are discussed. fore is located in sites of high metabolic activity. 3. When the atopic skin and the grossly DPNH, the substrate in these studies, may be a healthy skin from the same individuals were limiting factor in the activity of DPN dependent compared, there were no consistent differences enzymes and DPN diaphorase studies may be of in the histochemically determined alkaline phosuse in a true evaluation of the DPN-dependent phatase, 5-nucleotidase, specific cholinesterase,

dehydrogenase systems (12). Healthy and in-

succinic dehydrogenase, and DPN diaphorase

volved skin of the same patient showed no qualitative differences in reactivity. There was how-

activities. The results of protein-bound sulfhydryl and disulfide determinations in the diseased and

ever, a quantitative difference in that the dis- grossly healthy skin in the same individuals are eased skin had more blood vessels and more presented. infiltrative cells capable of reacting with the REFERENCES substrate. 1. DAvis, M. J. AND LAWLER, J. C.: Observations on the delayed blanch phenomenon in

SUMMARY

atopic subjects. J. Invest. Dermat., 30: 127—

1. The histological morphology of the diseased

131, 1958. 2. SULzBEROER, M. B. AND HERRMANN, F.: The

skin in infants and children with atopic eczema is presented. Since the pathologic findings vary with the variable clinical findings, there is no

Charles C Thomas, 1954. 3. URBAcH, F. AND SHELLEy, W. B.: A rapid and

Clinical Significance of Disturbances in the Delivery of Sweat. p. 113. Springfield, Ill.

single, specific histological entity that can be correlated with the atopic skin. Nevertheless,

simple method for obtaining punch biopsies without anesthesia. J. Invest. Dermat., 17:

there is a tendency for the acanthotic epidermis to be regular (so-called neurodermatitic reaction) with the rete ridges showing greater increase in

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131—134, 1951.

size than the suprapapillary plates. When the

PROSE, P. II.: Studies on sweating: IV. A new quantitative method of assaying sweatdelivery to circumscribed areas of the skin surface. J. Invest. Dermat., 17: 241—249,

latter feature is exaggerated, the epidermis

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assumes a psoriasiform pattern. Spongiosis with relatively minimal exocytosis is common; frank vesiculation is infrequently seen. The papillae are often edematous with few infiltrated cells as

1951.

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three groups of enzymes, Am. J. Path., 26: 257—305, 1950.

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diffusion artifacts in the histochemical localization of cholinesterases and a survey of their cellular distributions. J. Pharmacol. & Exper. Therap., 103: 153—171, 1951.

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histochemical demonstration of succinic dehydrogenase. Science, 113: 317—320, 1951.

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of succinic dehydrogenase in six mammals and modification in the histochemical technic. J. Histochem. & Cytochem., 1: 66—81, 1953.

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influencing the histochemical demonstration of coenzyme -dependent dehydrogenases and diaphorases. J. Biophys. Cytol., 5: 309— 318, 1959.

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man with the assistance of the author by Norman Walker. p. 190—244. Edinburgh,

Wm. F. Clay, 1896. 14. Baoco, L. AND JACQUET, L.: Notes pour servir

a l'histoire des névrodermites: du lichen circumscriptus des anciens nuteurs, ou lichen simplex chronique de M. le Dr. E. Vidal. Ann. de dermat. et syph., 2: 193—208, 1891.

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ENGMAN, M. F., Sa.: XCII Histology of neurodermatitis. Arch. Dermat. & Syph., 44:

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logic patterns of the sebaceous gland. J. Invest. Dermat., 30: 51—61, 1958. 25. O'BRIEN, J. P.: A study of miliaria rubra, tropical anhidrosis and anhidrotic asthenia. Brit. J. Dermat., 59: 125—158, 1947.

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F. C.: Studies of sweating: I. Preliminary report with particular emphasis on a sweat retention syndrome. J. Invest. Dermat., 9: 221—242, 1947.

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dermatitis. II. Role of sweating

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of Pediatrics, April 23, 1958. Pediatrics,

23: 802—811, 1959. 30. SULzBERGER, M. B., HEEEMANN, F., MOERILL, S. D., PASCHEE, F. AND MILLER, K.: Studies of

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dren with "dry skin" (xerosis). Int. Arch. Allergy, 14: 129—143, 1959.

The Lichens: lichenifications and neuro- 31. BRAUN-FALCO, 0.: The histochemistry of dermatitis. J. Cutan. Dis., 35: 28—34, 1917. psoriasis. Ann. New York Acad. Sc., 73: 16. DIND, M.: Essai sur les lichens, la lichenfica936—976, 1958. tion. (Névrodermites, névrodermes de 32. A5BOE-HAN5EN, C., DYRBYR, M. 0., MOLYKE, E. AND WEGELIU5, 0.: Tissue edema—a Brocq-Jacquet, prurigo vulgaire de Darier, stimulus of connective tissue regeneration. prurigo diathesique de Besnier): leur caractère histologique, biologique et leur J. Invest. Dermat., 32: 505—506, 1959. traitement. Ann. de dermat. et syph., 6: 33. SNYDERMAN, S. E., PaosE, P. H. AND HOLY, L. 273—298, 1920.

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1952.

DISCUSSION DR. HERBERT MEscoN (Boston, Mnss.): In amount of metaehromatic staining and polythe controls on the same age group from the saceharide? same area, do you or do you not get the same Secondly, I would submit that the changes

MORPHOLOGIC AND HISTOCHEMICAL STUDIES OF ATOPIC ECZEMA

165

that were demonstrated in the pilosebaceous of the skin of these children before and after apparatus are similar to those described experi-

sweating and if he did, whether he observed any

mentally by Strauss and Kligman, and Ham- of the changes in the sweat gland which we have brick. These changes are a normal response to previously reported. the dermal inflammatory reaction of the experi-

My third comment concerns the failure to find

mental or disease process itself (Mescon & succinic dehydrogenase activity. Using several Strauss, Arch. Derm. accepted for publication). methods we found that the sweat gland is exDE. FRANZ HERRMANN (New York, N. Y.):

There was a beautiful instance of a sweat retention lesion with disintegration of the sweat duct wall and internal sweating in a baby with atopic dermatitis. I wonder how high or how low the incidence actually is of such lesions in babies with atopic dermatitis and anhidrosis. As to the

"decrease of glycogen" in the tubules after

ceptionally rich in succinic dehydrogenase, with the duct containing more activity than the secretory portion. DR. PHILIP H. PROSE (in closing): I want to

thank the discussants for their comments. As regards Dr. Mescon's questions, we examined normal skin as well as diseased skin. Normal skin shows very little or no mucopolysaccharides as compared to the abnormal skin. As regards the sebaceous glands, we were aware of Strauss and Kligman's valuable find-

exposure to heat, I agree that a decrease would be compatible with glandular activity, but am not convinced that it can irrevocably evidence activity (though the absence of a decrease does ings and we comment upon them in our publicaindicate inactivity). The observation by the tion. We could not correlate the mechanisms they presenters of abnormally poor sebaceous gland described with our histological findings because development, as well as the comment that the there is very little in the ivay of an inflammatory asteatosis may account for the absence of sweat exudate around the sebaceous glands. I want to thank Dr. Herrmann for his comdroplets on the skin surface are in perfect agreement with the findings obtained in similar chil- ments. We saw anatomical evidence for sweat dren and described as "pseudoanhidrosis" by duet obstruction due to plugged sweat pores in Sulzberger, Herrmann, Morrill, Paseher, and only one sweat duct in the thousands of serial Miller (Internat. Arch. of Allergy, 14: 129—143, sections of biopsy specimens from 71 patients. It is very true that in this instance and perhaps in 1959). DR. RICRARD L. DoBsoN (Hanover, N. H.): this very site, sweat pore plugging may be a I certainly enjoyed this presentation enormously pathogenetic mechanism in sweat retention, but and I look forward to being able to study the it is extremely rare in this age group. I tried to indicate, in answer to Dr. Dobson's question, paper in detail. I have several questions I would like to ask. that we did have sections before and after sweatSeveral years ago Dr. Lobitz and I reported that ing, that we saw no diastase resistant P.A.S. the initial change in miliaria is not in abnormal staining material plugging the sweat pore. but apparently normal skin and consists of a Occasionally this material surrounded the pore. plugging of the pore with Schiff-positive, dias- After sweating the glyeogen disappeared from tase-resistant material. I would like to inquire the secretory portion of the gland in a similar whether or not this material was noticed. I manner from both in the diseased and normal would also like to know if Dr. Prose took biopsies

skin.

THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

94

linolenic acid extract. Arch. This pdf is a scanned copy UV of irradiated a printed document.

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