Abstract

Acantholysis is a feature of numerous inflammatory conditions and neoplasms.  Depending on the condition, acantholysis may occur alone or in conjunction with dyskeratosis. Disorders with acantholysis can also be differentiated by the level of the epidermis which is involved. Suprabasal acantholysis without significant dyskeratosis is the hallmark of pemphigus vulgaris. We present four cases in which patients had biopsies of a chronic wound on their leg or foot. Three of these patients had the wound arise in a background of venous stasis. The fourth patient did not have venous stasis but had an ulceration thought to be related to his uncontrolled diabetes. The patients did not have any other associated skin or mucosal lesions. On pathologic examination, all biopsies demonstrated suprabasal acantholysis simulating the pattern seen in pemphigus vulgaris.  In addition to pemphigus vulgaris, the finding of suprabasal acantholysis is seen in Galli-Galli disease, pemphigus vegetans, and paraneoplastic pemphigus. In the past, it has also been described in other conditions including pityriasis rubra pilaris, necrolytic migratory erythema, and rashes associated with immune-checkpoint inhibitor therapy. Focal incidental suprabasal acantholysis mimicking pemphigus vulgaris has been previously reported in association with basal cell carcinomas, keratacanthomas, elastolytic granuloma, and tinea corporis. However, to the best of our knowledge, the finding of incidental suprabasal acantholysis in association with chronic wounds on the lower extremities or venous stasis has not been previously reported. It is important to be aware of this pattern in order to avoid misdiagnosis.