High frequency ultrasound examination of inflammatory skin lesions

doi:10.21203/rs.3.rs-1498867/v1

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High frequency ultrasound examination of inflammatory skin lesions

https://doi.org/10.21203/rs.3.rs-1498867/v1

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Only a few examinations dealt with the possibilities of high-frequency ultrasound in the examination of inflammatory skin changes

We wanted to analyze the echographic manifestations of inflammation in different inflammatory dermatoses.

The analyzed skin lesions were biopsied and the clinical diagnosis was confirmed pathohistologically, and the pathohistological characteristics were corelated with echographic manifestations.

Regarding inflammation, cellularity of lesions (presence and amount of inflammatory infiltrate), oedema, dilated lumen of blood vessels was the most significant pathohistological changes that reflect on echosonografic manifestation of inflammatory skin lesions.

In addition to collagen (its amount and distribution), the echogenicity of inflammatory skin changes is significantly affected by the cellularity of changes, and both hypercellularity (primarily inflammatory infiltrate) and hypocellularity (changes in the type of blisters). Monitoring of these data can potentially be used in monitoring the evolution of the disease, but also in monitoring the effectiveness of applied therapy in certain dermatoses.

high-frequency ultrasound

skin

inflammation

Although the use of high-frequency (higher than 20MHz) ultrasound dates back to the 1980s, its use has not yet become routine in everyday dermatological practice. High-frequency ultrasound is now used as an additional diagnostic method, primarily in the examination of cutaneous tumors. Only a few examinations dealt with the possibilities of high-frequency ultrasound in the examination of inflammatory skin changes (1-6). In these works, the ultrasound characteristics of primarily psoriasis, scleroderma as well as cutaneous reactions at the sites of allergological testing were analyzed (1-6). Lately, its application has been mentioned also in cosmetology (1).

The application of ultrasound in dermatology is based on the fact that it is reflected differently in skin changes in relation to the normal skin, just as it is reflected differently in unaltered skin in the epidermis and dermis.

Ultrasound properties of the skin and skin lesions are conditioned by their histological structure. Collagen, the most abundant connective tissue component of the dermis, plays a particularly important role in this regard. Disorder of the skin structure, especially at the level of the dermis, leads to a change in the ultrasound properties, which are most often manifested in the form of hypoechogenicity or complete nonechogenicity. The largest number of pathological changes in the dermis, manifested in the form of hypoechogenic or nonechogenic appearance. Therefore, the structure of the skin lesion cannot be judged only on the basis of data obtained by ultrasound examination, but the finding must be observed within the broader clinical and topographic characteristics of the lesions, and often correlated with pathohistological findings.

Therefore, parallel pathohistological and ultrasound examination of the skin and skin changes and correlation of the obtained results are especially important, in order to indicate which pathohistological elements of certain changes can more or less significantly affect their echographic appearance.

In order to properly interpret ultrasound images and make diagnostic conclusions, it is necessary to properly understand the interactions between ultrasound waves and tissues. The most important parameters of this interaction are attenuation, velocity and impedance (conductivity). The rate and attenuation of ultrasound in tissue are directly proportional to the relative amount of protein and collagen content, and inversely proportional to water content. The speed and impedance of ultrasound in collagen are high due to its high elasticity. Collagen is therefore one of the main sources of tissue echogenicity (8-10).

On the echogram of normal skin, on the intermediate surface between the ultrasound probe and the skin, there is an entry echo. Beneath the entry echo, clearly demarcated, the dermis is visualized, which contains collagen fibers, the main echogenic component of the skin. Collagen fibers, depending on the cross-section, manifest in the form of plaques or banded structures, moderate to strong reflection (8, 9, 11-15).

Beneath the dermis, subcutaneous adipose tissue manifests as almost completely echolucent. Only connective tissue septa are visualized in the form of echogenic irregular banded formations.

The largest number of skin changes, when examined by high-frequency ultrasound, manifests itself in the form of hypoechogenic to nonechogenic formations (9, 11, 15-19), while they are rarely hyperechogenic or isoechoic. In a study by Fornage et al. (1993), of the 200 changes examined, only two were hyperechoic - one subcutaneous lymphoma and one inflammatory reaction at the injection site, and one early hypersensitivity reaction to insect bite was isoechoic, while all other changes (malignant and benign) were hypoechogenic and nonechogenic (20).

In urticaria, the dermis quickly becomes poorly reflective due to edema, and soon the appearance begins to normalize. If the edema spreads to the surrounding papillary dermis, the appearance of a pseudopodia is obtained. In conditions with more persistent inflammation, such as contact dermatitis, patch-test reactions, or atopic dermatitis, a subepidermal weakly echogenic edematous band is seen. This band corresponds to the papillary part of the dermis, because it is looser in structure, and stretcher in cases of edema (11, 15, 19, 21). This is especially noticeable in stasis dermatitis, gravitational syndrome and (hypostatic) ulcer on the lower legs (19, 22, 23). Even in loose rosacea, the edematous-gelatinous dermis may show a hypoechoic band, usually unclear distal borders, on the echogram below the entry echo (7).

In actinic elastosis, as well as on the echogram of the skin of the elderly, immediately below the entry echo, a weakly echogenic strip parallel to the skin surface is also observed, which is a consequence of the elastotic i.e., actinic collagen changes (8, 19, 24-28).

Determining the change in the dimensions of this weakly echogenic band during therapy in various inflammatory conditions can be a significant indicator of the effectiveness of the applied therapy (8, 11, 20, 29).

Psoriatic changes were examined in detail by high-frequency ultrasound. The characteristic of the psoriatic echogram is, weakly echogenic band parallel to the skin surface, as a consequence of acanthosis, but also inflammation and edema in the papillary dermis, and can be related to disease activity, and the thickening of the entry echo. Since echografic feature is related to disease activity it is possible to use ultrasound for monitoring the effects of applied ant psoriatic therapy, as well as to compare the effects of different therapeutics (8, 11, 15, 30-41).

Skin changes in localized and circumscribed scleroderma have also been frequently examined by high-frequency ultrasound. Connective tissue septa and skin are thickened, dermis enhanced echogenicity, homogeneous, even subcutaneous adipose tissue can be echogenic (11, 15, 42-49).

High-frequency ultrasound can be used to monitor the evolution but also the therapeutic response of this disease (15, 40, 42, 43, 47, 50, 51).

Levy et al. (1993) examined the changes of circumscript scleroderma with 20-MHz ultrasound and found complete or subtotal loss of subcutaneous adipose tissue, while the thickness of the dermis was almost unchanged (52).

The aim of our study was to analyze the echographic manifestations of inflammation itself inflammation of the skin and compare them with the its pathohistological characteristics.

The study included 55 different skin changes in 55 patients. There were 27 men and 28 women. Patients ranged in age from 11 to 79 years (median 43, mean age 46 years).

Pathohistological diagnosis and number of examined changes were as follows: Psoriasis vulgaris 21 cases, Psoriasis pustulosa (palmoplantaris) 9 cases, Erythematosus chronicus 3 cases, 2 cases of Contact dermatitis, Granuloma annullare, Pemphigoid bullosus, Pemphigus vulgaris, Scleroderma circumscripta, Pustulosis subcornealis (Sneddon-Wilkinson) each and 1 case each of Lichen amyloidosus, Small plaque parapsoriasis, Prurigo simplex, Sarcoidosis cutis, Erythema nodosum, Pityriasis rosea, Lichen planus, Neurodermatitis, Pseudocystis inflamata, and Polymorphous light eruption.

All skin lesions were examined by 20-MHz y ultrasound and pathohistologically. All patients underwent a biopsy of changes for diagnostic purposes and a pathohistological diagnosis.

Ultrasound examination was performed using 20-MhZ ultrasound.

Ultrasound examination of the changes was performed immediately before (maximum two days) biopsies of skin changes. Echograms were analyzed by a modified method applied by Bamber et al. (1991) and Harland et al. (1993) (10, 53). The following elements were determined and quantified on the echograms of changes: echo intensity, echo appearance (homogeneity), posterior echo intensity, posterior echo appearance (homogeneity), entry echo expression, input echo intensity echo, edge definition, edge regularity. The diameter of the change as well as the width of the entry echo were determined. Pathologic characteristic of inflammation of primary interest were cellularity, oedema, vasodilatation, but also other inflammatory manifestations where they were present.

The material obtained by biopsy was examined on hematoxylin-eosin (HE) preparations

On the echograms of all examined inflammatory changes, a very echogenic band entry echo, of the same or greater width than the entry echo of the surrounding skin, was clearly observed (Figs. 1–5) Changes that were clinically in the form of papules or plaques echographically manifested in the form of hypoechogenic to nonechogenic formations, with relatively clearly defined shape and margins (Figs. 3, 4). Blister efflorescences, bullae, vesicles or pustules, manifested either in the form of completely nonechogenic, or in the form of more or less homogeneous hypoechoic formations, clearly defined shape and margins (Fig. 1). In diffuse inflammatory cutaneous changes, the echogenicity of the dermis was inhomogeneous, with a decrease in echogenicity, or complete nonechogenicity in parts that correlated with a pronounced inflammatory cell infiltrate on pathohistological specimens (Fig. 3). Echogenicity was reduced in places of increased cellularity of lesions and where it was not just an inflammatory infiltrate, as is the case with psoriatic lesions. Namely, in all psoriatic lesions, a weakly echogenic band was observed below the entrance echo, parallel to the skin surface, which correlated not only with the inflammatory infiltrate of the upper part of the dermis, but also with acanthotic epidermal extensions (Fig. 1). Collagen degeneration (Fig. 5) and dermal edema (Fig. 3) were also manifested by reduced echogenicity on echograms. In some cases, dilated lumens of dermal blood vessels were observed (Figs. 3 and 5).

The most common pathohistological manifestations of inflammation in the examined changes, as expected, were the presence of inflammatory infiltrate (i.e., hypercellularity) and edema.

Edema manifests itself by reduced echogenicity in the changes in which it existed on echograms.

Increased cellularity, as well as decreased (in bullae and vesicles) was also manifested by reduced echogenicity, which is actually explained by the influence of increased i.e., reduced cellularity in collagen layout and appearance. Particularly characteristic is the nonechogenic band just below the entry echo in psoriatic lesions which morphologically correlated with the region of epidermal acanthosis, i.e., inflammatory infiltrate in elongated dermal papillae (and another condition is essentially manifested by hypercellularity).

Except in Granuloma annulare, where there was collagen degeneration (in addition to moderate inflammatory infiltrate and pronounced angiomatosis), which was clearly manifested by nonechogenicity on the echogram, in other changes the structure of collagen itself was not morphologically disturbed. However, edema and inflammatory infiltrate disrupted the distribution of collagen fibers and were echographically manifested by non-echogenicity, which confirms the literature that echogenicity is affected not only by the quantity but also by the distribution of collagen fibers. This is supported by the echographic appearance of changes within the scleroderma circumscripta, where sclerotic plaques show thickening of the dermis, irregular amplification of signals in the distal parts of the dermis and increased number and width of echogenic connective tissue septa in the subcutis (increased number and increased density of collagen fibers).

Acknowledgment:

The authors would like to thank the Ministry of Education, Science and Technological Development of Republic of Serbia (Grant No: 451-03-9/2021-14/200113) for financial support.

Funding sources

that supported the work: Ministry of Education, Science and Technological Development of Republic of Serbia (Grant No: 451-03-9/2021-14/200113) for financial support.

Conflict of interest disclosures:

No conflict of interest

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No competing interests reported.

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High frequency ultrasound examination of inflammatory skin lesions

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