Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Case Report
Guest Editorial
Images in Clinical Practice
Invited Commentary
JSSTD Symposium
Letter to Editor
Letter to the Editor
Letter to the Editor - Study Letter
Media and News
Net Case
Net Consensus Statement
Net Educational Video for Residents
Net Image
Net Letter
Net Quiz in Dermatology
Original Article
Resident’s Page
Review Article
Study Letter
Study Letter Case Series
View/Download PDF

Translate this page into:

Case Report
3 (
); 77-79

Fine-needle aspiration cytology – A novel diagnostic technique in pemphigus

Department of Dermatology, Government Medical College, Kottayam, Kerala, India
Department of Dermatology, Primary Health Center, Wayanad, Kerala, India
Department of Dermatology and Venereology, Government Medical College, Thrissur, Kerala, India
Corresponding author: Beena Narayanan, Professor and Former Head, Department of Dermatology, Government Medical College, Kottayam, Kerala, India.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Narayanan B, Dhanya OT, Asokan N. Fine-needle aspiration cytology – A novel diagnostic technique in pemphigus. J Skin Sex Transm Dis 2021;3(1):77-9.


The term pemphigus is collectively used to describe a group of immunobullous disorders characterized by intraepidermal cleft and circulating antibodies against intercellular adhesion molecules. Pemphigus vegetans was first described as a variant of pemphigus vulgaris by Neumann in 1876. We report a case of 36-year-old female who presented with swelling of scalp, which was diagnosed as pemphigus by fine-needle aspiration cytology.


Pemphigus vegetans
Fine-needle aspiration cytology


Pemphigus is a group of autoimmune blistering disorders with intraepidermal cleft caused by immunoglobulins directed against keratinocyte cell surface antigens.[1] Pemphigus vegetans (PVe) is a rare variant of pemphigus vulgaris (PVu) which commonly presents with vegetating lesions on the flexural regions, face, and scalp and mucosal erosions. The disorder affects chiefly middle-aged adults.[2-5] We report a case of PVe presenting with a firm swelling on the scalp which was diagnosed as pemphigus by fine-needle aspiration cytology (FNAC).


A 36-year-old lady presented with pustular lesions on the left big toe, axillae, groins, and face of 1 month duration, and an asymptomatic smooth swelling on the scalp, which was gradually increasing in size. Physical examination revealed well-defined erythematous plaques of size 5 × 4 cm, with pustules, erosions, slough, and crusting below the left eye and the left big toe [Figure 1a] and vegetating plaques in the axillae [Figure1b] and groins. There was a well-defined, firm, non-tender swelling on the vertex of the scalp of size 16 × 10 cm without any hair loss. Oral mucosa showed multiple erosions. The patient was investigated with a differential diagnosis of pyoderma gangrenosum and PVe. Pathergy test was negative. Tzanck smear from the pustules revealed numerous acantholytic cells and eosinophils. Histopathology showed hyperkeratosis, acanthosis, suprabasal cleft with acantholytic cells, and dermal inflammatory infiltrate composed of eosinophils, neutrophils, and lymphocytes [Figure 2].

Figure 1:: (a) Erythematous plaques with pustules, erosions, and slough on the left big toe of a patient with pemphigus vegetans. (b) Vegetative plaques in the axilla.
Figure 2:: Histopathology showing suprabasal cleft with acantholytic cells and eosinophils. Dermis showing eosinophils and neutrophils (H and E, ×400).

Direct immunofluorescence (DIF) of perilesional skin showed intercellular staining (ICS) of epidermis with IgG and C3 [Figure 3]. Indirect immunofluorescence (IIF) showed ICS with IgG in 1:10 titer. Although we could confirm the diagnosis of PVe (Hallopeau type), the cause of the scalp swelling was obscure. We, therefore, proceeded with ultrasonography of the scalp swelling and FNAC from it. To our surprise, FNAC demonstrated plenty of acantholytic cells and eosinophils [Figure 4]. This confirmed that the scalp swelling was a component of PVe. The patient was treated with parenteral dexamethasone (initiated at 4 mg twice a day); swelling of the scalp flattened [Figure 5] and subsided in a week, leaving no residual changes. Other lesions also resolved in a month’s time.

Figure 3:: Direct immunofluorescence on perilesional skin of a patient with pemphigus vegetans showing intercellular staining with IgG and C3.
Figure 4:: Fine-needle aspiration cytology from a swelling on the scalp of a patient with pemphigus vegetans showing acantholytic cells (Papanicolaou stain, ×400).
Figure 5:: Swelling of the scalp showing flattening after administration of systemic corticosteroids.


PVe constitutes about 1%–2% of all cases of pemphigus. The principal autoantigen in Pve is desmoglein 3. Other antigens identified are desmoglein 1 and desmocollins.[5] Historically, PVe has been divided into two subtypes – Neumann and Hallopeau.[6,7] In Neumann type, the lesions begin as vesicles and bullae that evolve into vegetating masses which bleed easily on trauma.[6] The disease is similar to PVu in relapses, remissions, response to therapy, and prognosis.[6] Hallopeau type is relatively benign. Pustules are the primary lesions which gradually progress to vegetating plaques. Spontaneous healing and remissions may occur.[6,8] Oral lesions are present in over 90% of the patients.[6] Scalp lesion is common in PVu but not a classic feature of PVe.[9]

Histopathology shows hyperkeratosis, papillomatosis, acanthosis with plenty of eosinophils, and acantholytic cells in the suprabasal clefts and a heavy infiltrate of eosinophils, lymphocytes, and neutrophils in the dermis.[10] DIF of perilesional skin demonstrates epidermal intercellular IgG, sometimes with C3.[2,4,5,6,11] IIF demonstrates circulating intercellular antibodies in many patients.[11,12] FNAC is proved useful in diagnosing various benign and malignant skin conditions, but to the best of our knowledge, is not yet utilized in diagnosing pemphigus.[13]


We, suggest that FNAC can be added to the diagnostic armamentarium in pemphigus, as a simple, fast, and reliable technique.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship


Conflicts of interest

Dr. Beena Narayanan and Dr. N Asokan are on the editorial board of the Journal.


  1. , , , . Non-classical forms of pemphigus: Pemphigus herpetiformis, IgA Pemphigus, paraneoplastic pemphigus and IgG/IgA pemphigus. An Bras Dermatol. 2014;89:96-117.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , . Pemphigus vegetans: An unusual presentation. Indian Dermatol Online J. 2012;3:193-5.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , . Pemphigus vegetans in a patient with colonic cancer. Indian J Dermatol Venereol Leprol. 2009;75:603-5.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , . Localized pemphigus vegetans without mucosal involvement. Indian J Dermatol. 2014;59:210.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . Pemphigus vegetans localized to unusual sites. Indian J Dermatol Venereol Leprol. 2015;81:509-11.
    [CrossRef] [PubMed] [Google Scholar]
  6. , . Pemphigus vegetans, Neumann type and Hallopeau type. Int J Dermatol. 1984;23:135-41.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , , . Three cases of pemphigus vegetans: Induction by enalapril-association with internal malignancy. Int J Dermatol. 1994;33:168-71.
    [CrossRef] [PubMed] [Google Scholar]
  8. , . Immunobullous diseases In: , , , , eds. Rook's Textbook of Dermatology (8th ed). Oxford: Wiley-Blackwell; . p. 40-58.
    [CrossRef] [Google Scholar]
  9. , , , , . Treatment-resistant pemphigus vegetans of scalp. Int J Dermatol. 1995;34:865-6.
    [CrossRef] [PubMed] [Google Scholar]
  10. , , . Noninfectious vesiculobullous and vesiculopustular diseases In: , , , , eds. Lever's Histopathology of the Skin (9th ed). Philadelphia, PA: Lippincott Williams & Wilkins; . p. 243-92.
    [Google Scholar]
  11. , , , , , , et al. Pemphigus vegetans: A clinical, histological, immunopathological and prognostic study. J Eur Acad Dermatol Venereol. 2011;25:1160-7.
    [CrossRef] [PubMed] [Google Scholar]
  12. , , , , . Pemphigus vegetans induced by use of enalapril. An Bras Dermatol. 2011;86:1197-200.
    [CrossRef] [PubMed] [Google Scholar]
  13. , . Fine needle aspiration cytology in dermatology: A clinicopathological appraisal. Br J Dermatol. 1986;115:317-27.
    [CrossRef] [PubMed] [Google Scholar]
Show Sections