Significance of vascular endothelial growth factor and CD31 and morphometric analysis of microvessel density by CD31 receptor expression as an adjuvant tool in diagnosis of psoriatic lesions of skin

1. Presenter : Moderator :
Dr. Varughese George Dr. Shanmugasamy

2. Significance of vascular endothelial growth factor &
CD31 & morphometric analysis of microvessel density
by CD31 receptor expression as an adjuvant tool in
diagnosis of psoriatic lesions of skin
Indian Journal of Pathology & Microbiology
Vol 60
April-June 2017
Chawla N, Kataria SP, Aggarwal K, Chauhan P, Kumar D. Significance of vascular
endothelial growth factor & CD31 & morphometric analysis of microvessel density by CD31
receptor expression as an adjuvant tool in diagnosis of psoriatic lesions of skin. Indian
Journal of Pathology & Microbiology. 2017 Apr 1;60(2):189.

3. INTRODUCTION

4. Psoriasis vulgaris is fairly
common chronic inflammatory
dermatoses characterized by
erythematous papules &
plaques with overlying thick
silvery scales, most commonly
on extensor surfaces of
extremities.

5. Epidermal findings include epidermal hyperplasia, elongated rete ridges,
hypogranulosis, & parakeratosis.

6. The epidermis
becomes infiltrated
by neutrophils &
activated CD8+ T
lymphocytes
forming Munro’s
microabscesses &
pustules of Kogoj

7. •2 most important histologic features of psoriasis are
•mounds of parakeratosis with Munro’s microabscesses
•spongiform pustules of Kogoj in the uppermost layers of
spinous layer.
•All the other features may be seen in chronic eczematous
dermatitis like atopic dermatitis/nummular dermatitis/
allergic contact dermatitis, which then may appear to be
psoriasiform.
•Typical pustules similar to Kogoj spongiform pustules occur in
pustular dermatophytosis, bacterial impetigo, pustular drug
eruptions, & c&idiasis.

8. PATHOGENESIS

10.  Morphological changes like increase in tortuosity,
dilatation, & permeability of dermal papillary
capillaries precede hyperplastic changes in psoriasis.
 Papillary dermal microvessels show increased expression
of inflammation-associated adhesion molecules (E-
selectin, ICAM-1, & vascular cell-adhesion molecule-1).
 Adhesion molecules allow tethering & firm adhesion
of leukocytes to the endothelium.
 Various studies carried out focusing on the identification
of pro-angiogenic mediators in psoriatic skin.
 Studies showed evidence for keratinocyte-derived
proangiogenic signals comparing the angiogenic activity
of conditioned media from keratinocytes isolated from
either lesional or nonlesional skin of psoriasis patients

11.  Several studies indicate a crucial role of vascular
endothelial growth factor (VEGF)-A in the pathogenesis
of psoriasis:
i. epidermis-derived VEGF is strongly upregulated in
psoriatic skin lesions
ii. VEGF serum levels correlate with disease severity
iii. a genetic predisposition caused by single-nucleotide
polymorphisms of the VEGF gene may be involved.
iv. K14-VEGF transgenic mice expressing mouse VEGF164
in the epidermis spontaneously develop a chronic
psoriasiform skin inflammation.

12. Platelet endothelial cell adhesion molecule (CD31)
 A 130-140 kD glycoprotein member of the immunoglobulin
(Ig) superfamily.
 CD31-mediated endothelial cell–cell interactions are
involved in angiogenesis.
 CD31 confirms vascular origin of tumors
 CD31 may also stain nodal sinuses.

13. AIMS & OBJECTIVES

14.  To compare the pattern & distribution of VEGF & CD31
in patients with psoriasis & psoriasiform lesions of skin.
 To establish correlation between VEGF expression by
suprabasilar keratinocytes & CD31 expression in
microvessels of papillary dermis.
 To evaluate microvessel density (MVD) by using
immunohistochemical methods & computer-assisted
quantitative image analysis in psoriatic & psoriasiform
skin lesions.

15. MATERIALS & METHODS

16. Study involved
 80 cases - psoriasis (40) & psoriasiform lesions (40) of
skin submitted in the Department of Pathology, Pt. B.D.
Sharma, University of Health Sciences, Rohtak, for
histopathological examination.
 80 cases were further subjected to immunohistochemical
methods & morphometry.

17. Inclusion criteria
a) Manifest cases, in which strong clinical suspicion of
psoriasis & psoriasiform lesions was evident.
b) Histopathological Examination of the biopsy
specimens showing histological features & alterations
suggestive of psoriasis & psoriasiform lesions.

18. Gross examination of the specimen & proper sampling,
Tissues processed by routine histological technique for
paraffin embedding & sectioning at 4 μ thickness.
Histopathological sections were stained by routine
hematoxylin & eosin staining
Histopathological examination followed by diagnosis.
Representative sections of lesional biopsies were subjected
to immunohistochemical staining with VEGF & CD31

19.  The quantitative morphometric studies were done by
image analysis.
 MV defined as
 MVD assessed by light microscopy in representative areas
of sections with highest number of capillaries & small
venules.
 Most intense area of neovascularization (Hot Spot) is
identified.
 MV counts were done on a minimum of two fields of
magnification ×400.
 The final MVD was calculated by taking the mean of MV
counts in the two Hot Spots in psoriatic & psoriasiform
lesions.
any highlighted endothelial cell/endothelial cell
cluster clearly separated from adjacent
MVs or other connective tissue elements.

20.  Computer-assisted image analysis was performed on all
cells, tissues & vessels expressing antibody staining.
 Appropriate areas of most of the epithelium/adjacent
stroma fulfilling morphologic criteria were analyzed.
 Contaminated areas were excluded using the pixel
exclusion.
 The data were collected as the number of MVs in ×400 field
using CD31 antibody.
 Mean of two microscopic fields was taken & was expressed
as MVD per mm².
 All the data were tabulated from which mean & median
was calculated in all types of psoriatic & psoriasiform
lesions.

21. STATISTICS

22.  Data were calculated, tabulated & statistically analyzed.
 The values entered were mean of morphometric parameters.
 In all tests, P < 0.05 was statistically significant.
 Pearson correlation applied for correlating various
histopathological parameters of psoriasis.
 Chi-square test applied for comparison between psoriasis
& psoriasiform lesions.
 t-test applied to
 compare the no: of MVs & MVD between psoriasis &
psoriasiform lesions.
 to study their correlation with VEGF expression.

23. RESULTS

24.  The mean age of patients with
 psoriasis was 43.8 years
 psoriasiform lesions were 39.9 years
 Incidence of psoriasis
 very high in males v/s females.
 male:female ratio of 39 : 1.
 97.5% were males
 Of all 40 psoriasiform lesions studied
 72.5% were men.
 Male:female ratio was 2.61 : 1.

25.  Hyperkeratosis
 Epidermal hyperplasia
 Hypogranulosis
 Suprapapillary thinning
 Inflammatory infiltrate
graded on a scale of 0–3
Grade 0  absent
Grade 1+  mild
Grade 2+  moderate
Grade 3+  marked

26. Psoriasis
 50% have Grade 1+
hyperkeratosis.
 30% have Grade 3+
hyperkeratosis.
 100% have parakeratosis 
significant correlation (P<0.01)
 65% have Munro’s
microabscesses & pustules of
Kogoj.
 57.5% have Grade 2+
epidermal hyperplasia
Psoriasiform lesions
 Majority fell into Grade 0
hyperkeratosis.
 7.5% have Grade 3+
hyperkeratosis.
 42.5% have parakeratosis
 7.5% cases have Munro’s
microabscesses & pustules of
Kogoj.
 62.5% have Grade 1+
epidermal hyperplasia.

27. Psoriasis
 100% showed hypogranulosis
 52.5% have severe Grade 3+
hypogranulosis.
 45% has Grade 2+ suprapapillary
thinning.
 27.5% has Grade 3+
suprapapillary thinning.
 22.5% have Grade 3+
inflammatory infiltrate.
 All lesions revealed some degree
of elongation of rete ridges
Psoriasiform lesions
 22.5% showed some degree of
hypogranulosis.
 0 % have Grade 3+
hypogranulosis.
 60% had no suprapapillary
thinning (Grade 0)
 1 case of lichen simplex
chronicus showed Grade 3+
suprapapillary thinning.
 7.5% have Grade 3+
inflammatory infiltrate.
 35% revealed no elongation of
rete ridges.

28. Significance of VEGF, CD31 & morphometric analysis of
MVD in diagnosis of psoriatic lesions of skin
Grades of VEGF staining in psoriasis & psoriasiform lesions
Correlation b/w psoriasis &VEGF staining of suprabasal keratinocytes was highly significant

29. Intense VEGF staining(Grade 3+) in psoriasis
(VEGF, ×40)
Keratinocytes are -ve for VEGF staining
(Grade 0) in seborrheic dermatitis
(VEGF, ×200)

30. Association of various morphological parameters with each
other in psoriasis lesions

31. Microvessels in psoriasis (CD31, ×100) Microvessels in pityriasis rubra pilaris (CD31, ×200)
Comparison of no: of MVs & MVD in psoriasis &
psoriasiform lesions
(830.5)
(531.5)

32. Correlation of MVD with VEGF in psoriasis & psoriasiform
lesion patients

33. DISCUSSION

34.  In this study,
 Most patients with psoriasis presented in 5th decade of
life(mean age 43.8 years)
 Patients with psoriasiform lesions had slightly lower mean
age of onset (mean age 39.9 years)
 This was similar to the study done by Moorchung et al.
 Earlier onset of psoriasis  in 3rd & 4th decade of life was
noted by Okhandiar et al. & Bedi et al.

35. In this study,
 Incidence of psoriasis(39 : 1) & psoriasiform lesions (2.6
: 1) were higher in males which correlated with most of the
studies.
 Higher grades of hyperkeratosis, epidermal hyperplasia,
hypogranulosis, suprapapillary thinning, elongation
of rete ridges & inflammatory infiltrate were found in
psoriasis than in psoriasiform lesions.


36.  In this study,
 No significant correlation with respect to grades of
inflammatory infiltrate, similar to study of Rana et al.
 A study by Moorchung et al. observed
 correlation of epidermal hyperplasia & hyperkeratosis
with parakeratosis.
 strong correlation of inflammatory infiltrate with
capillary proliferation & grade of suprapapillary
thinning.
 This suggests the role of inflammation in the
pathogenesis of psoriasis.

37.  In this study,
 Higher intensity of VEGF staining was observed in
suprabasilar keratinocytes of psoriasis as compared to
psoriasiform lesions which was in concordance with
studies of Man et al.,[17] Young et al.,[18] Canavese et
al.,[19] Nofal et al.,[20] Xia et al.,[8] Simonetti et al.,[21]
Detmar et al.,[1] Schonthaler et al.,[9] & Zhu et al.[22]
 This suggests the role of VEGF in pathogenesis of
psoriasis.

38.  In this study
 average number of MVs & MVD greater in psoriasis
lesions as compared to psoriasiform lesions which were
in concordance with the studies done by Simonetti et
al.,[21] Creamer et al.,[23] Barton et al.,[24] Gupta et
al.,[25] Detmar et al.,[26] Hern et al.,[27] Krajewska et
al.,[28] & Tursen et al.,[29]
This supports the theory of role of angiogenesis
&VEGF in pathogenesis of psoriasis.

39. CONCLUSION

40.  Psoriatic lesions exhibit potent angiogenic activity.
 VEGF drives angiogenic activity in psoriatic lesions &
plays an important role in the pathogenesis of
psoriasis.
 Both VEGF & MVD may be considered as prognostic
markers for angiogenic therapy, especially in early
lesions of psoriasis to minimize the progression of
disease to more severe stages.

41. REFERENCES
•Burg G, Kempf W, Kutzner H, Feit J, Karai L, editors. Atlas of Dermatopathology:
Practical Differential Diagnosis by Clinicopathologic Pattern. John Wiley & Sons;
2015
•Chawla N, Kataria SP, Aggarwal K, Chauhan P, Kumar D. Significance of vascular
endothelial growth factor & CD31 & morphometric analysis of microvessel density
by CD31 receptor expression as an adjuvant tool in diagnosis of psoriatic lesions of
skin. Indian Journal of Pathology & Microbiology. 2017 Apr 1;60(2):189.
•Moorchung N, Khullar J, Mani N, Chatterjee M, Vasudevan B, Tripathi T.A study
of various histopathological features & their relevance in pathogenesis of
psoriasis. Indian J Dermatol 2013;58:294-8.
•Bedi TR. Psoriasis in North India. Geographical variations.Dermatologica
1977;155:310-4.
•Bedi TR. Clinical profile of psoriasis in North India. Indian J Dermatol
Venereol Leprol 1995;61:202-5.
•Okhandiar RP, Banerjee BN. Psoriasis in the tropics: An epidemiological
survey. J Indian Med Assoc 1963;41:550-6.