VDE264.

fm Page 291 Monday, September 17, 2001 3:56 PM

Veterinary Dermatology 2001, 12, 291 296

Case report

Blackwell Science, Ltd

Spongiotic vesicular dermatitis as a cutaneous reaction

pattern in seven horses
ANN M. HARGIS,* EDWARD G. CLARK, DAVID D. DUCLOS, SUZETTE LECLERC
and KEITH WEST
*Dermato Diagnostics, Edmonds, WA 98026, USA, Department of Comparative Medicine, University of
Washington, Seattle, WA 98195, USA, Phoenix Central Laboratory, Everett, WA 98204, USA
Prairie Diagnostic Services, Inc., Saskatoon, SK S7N 5B4, Canada
Animal Skin and Allergy Clinic, Lynnwood, WA 98037, USA
(Received 18 December 2000; accepted 14 March 2001)

Abstract Over a 6-year period seven adult horses of different breeds and genders developed multifocal, exudative, oozing dermatitis characterized histologically by epidermal spongiotic vesicles and perivascular eosinophilic,
neutrophilic and mixed mononuclear inflammation. Three horses were pruritic. Systemic disease was not noted.
Two horses had a history of recurrent urticaria (hives) and one horse had nodules or welt-type lesions that
progressed to exudative, oozing lesions. Interepithelial immunoglobulin (Ig)G was detected by avidinbiotin
complexperoxidase staining, but the pattern of staining was more consistent with epithelial oedema than specific IgG deposition associated with pemphigus. The exudative oozing lesions developed under circumstances
suggesting that dermal oedema progressed to intracellular and intercellular epidermal oedema, which in turn
progressed to the spongiotic vesicular epidermal lesions.
Keywords: horse, pemphigus, skin, spongiosis, urticaria, vesicle.

INTRODUCTION
Intraepidermal vesicles may form in association with
intercellular oedema (spongiosis) such as in allergic or
irritant contact dermatitis. Intraepidermal vesicles can
also develop via acantholysis associated with autoantibody directed against desmosomal or hemidesmosomal proteins such as seen in pemphigus, or in other
diseases in which there is loss of desmosomes such as
familial benign pemphigus and Dariers disease.1 Viral
infection may also cause ballooning degeneration
leading to formation of intraepidermal vesicles. Vesicles
may also develop due to apoptosis, cytolysis or necrosis
of basal cells or keratinocytes, as seen in lupus erythematosus, friction blister, thermal burns, severe sunburn or phototoxicity (photosensitization). In people,
intraepidermal spongiotic to vesicular lesions may also
develop when intraepidermal sweat ducts are obstructed
(miliaria), which may also be the mechanism involved
in the development of epidermal lesions in transient
acantholytic dermatitis.1 Horses fed corn or glucose
cake have developed vesicular or papulovesicular
dermatitis of the distal legs in association with fever

Correspondence: Ann M. Hargis. No reprints will be available.

2001 Blackwell Science Ltd

and systemic signs. Histopathological lesions were not

reported.2 Finally, epidermal and dermal vesicular
lesions have been seen in association with some cases of
urticaria.3 We report seven cases of a severe spongiotic
vesicular dermatitis with proteinaceous fluid exudation in seven adult horses.

MATERIALS AND METHODS

Equine skin samples were received at the biopsy services
of two of the authors (AMH and EGC). Biopsy samples
were collected by clinical veterinarians and submitted
for histopathological diagnosis of the skin disease.
Biopsy samples were fixed in 10% neutral buffered
formalin and were processed routinely through graded
ethanols, xylene and paraffin. Tissue sections were
stained with haematoxylin and eosin (H&E).
All samples were evaluated for alterations in desmoglein staining and for deposition of immunoglobulin
(Ig)G using avidinbiotin immunoperoxidase staining techniques.4,5 For the IgG stain, 6-m sections
of formalin-fixed, paraffin-embedded tissue were
incubated with dilutions of 1:500, 1:1000 and 1:2000
biotinylated goat antihorse IgG antibody (Vector,
Burlingame, CA, USA) overnight at 4 C. This was
followed by peroxidase-labelled avidinbiotin complex
291

VDE264.fm Page 292 Monday, September 17, 2001 3:56 PM

292

A. M. Hargis et al.

(ABC) (Vectastain ABC Elite, Vector). Diaminobenzidine (DAB) was used as a chromogen substrate. Sections
were counter-stained using Gills #3 haematoxylin. For
the desmoglein stain, sections were steamed 20 min in
200 m citrate buffer, pH 6.0 for antigen retrieval,
followed by overnight incubation at 4 C with dilutions
of 1:10 and 1:20 of a monoclonal antibody to desmoglein
(Oncogene Research Products, Cambridge, MA, USA).
This was followed by a biotinylated horse antimouse
secondary antibody. Staining was completed using
ABC, DAB and counter stain as per the IgG stain.
In one horse, skin samples preserved in Michels
media were evaluated for deposition of IgG with direct
immunofluorescence. Briefly, tissue samples were washed,
frozen and mounted in frozen tissue-embedding media.
Six-micrometre sections were cut, mounted on glass
slides and stained with 1:40 dilution of fluorescein
isothiocyanate (FITC)-conjugated rabbit antiequine
IgG (Antibodies Inc, Davis, CA, USA) for 30 min at
37 C in the dark. Skin biopsy samples for histopathology and immunofluorescence were collected at the
same time.

Figure 1. Skin biopsy from a horse. Early epidermal spongiosis

is present. Note intercellular oedema (arrowheads) and dermal
congestion (H&E, 190).

RESULTS
Clinical findings
Table 1 provides information pertaining to the clinical
history. The breeds included two Quarter Horses, one
Thoroughbred, one Miniature Horse, one Appaloosa,
one Arabian and one Morgan cross-bred. The horses
ranged in age from 3 to 15 years. Five horses were
geldings and two mares. The lesions were multifocal,
sometimes involving the face, ears, neck, trunk and
legs. However, 2.5 years after the first episode of
spongiotic vesicular dermatitis, one horse developed a
single lesion considered to be a recurrence. All lesions
were described as exudative, oozing serum or weeping.
The hair was matted with crust. Some horses had
alopecia or ulceration. Pruritus was present in three
horses. Systemic disease was not noted. All horses
were in contact with at least one other horse; contact
horses did hot have clinical lesions. Cutaneous lesions
developed 1 week after vaccination in one horse. Two
horses had a history of urticaria, and one horse had
nodular or welt-like lesions develop before the exudative lesions. Biopsy samples were collected in January,
February, March, October and November. Two horses
developed the lesions during two and three consecutive
winters, respectively, and were normal during summer
months. Ectoparasites were not described in the dermatologic histories of the horses.
Histological findings
Histologically, epidermal lesions consisted of intraand extracellular oedema (epidermal spongiosis) and
spongiotic vesicles (Figs 13). Small numbers of
neutrophils, eosinophils and mononuclear cells were
occasionally present. A few angular separated epidermal
cells, resembling acantholytic cells, were seen in occa 2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 291 296

Figure 2. Skin biopsy from a horse. Epidermal spongiosis has

progressed to epidermal vesicle (V). Note superficial dermal oedema
(e) (H&E, 190).

Figure 3. Skin biopsy from a horse. Area of epidermal spongiosis

with vesicle formation is present. Note separated epidermal cells
(short thick arrowheads) resembling acantholytic cells, intracellular
oedema (long thin arrowheads), and superficial dermal oedema (e)
(H&E, 190).

sional vesicles (Fig. 3). Some sections had areas of

erosion and ulceration with fibrinocellular exudate.
No definitive keratinocyte apoptosis was identified, but
keratinocytes sometimes had brightly eosinophilic

VDE264.fm Page 293 Monday, September 17, 2001 3:56 PM

Table 1. Clinical lesions

Location

Appearance

Pruritus

Systemic
signs

Other horses
affected

Season biopsy
collected

Quarter horse
10 years
Gelding

Generalized trunk

Seborrhoea
Ooze serum
Mat hair

No

No

No

March

Two months; lesions developed two consecutive winters;

horse normal in summer months

Appaloosa
13 years
Mare

Face, neck, flank folds

Exudative
Ulcerative

Yes

Not stated

Not stated

March

Lesions developed 1 week after vaccination

Thoroughbred
15 years
Gelding

Neck, chest, ventral

trunk, between back
legs. Previously some
head and dorsal rump

Nodules and welts

progress to ulcer
and ooze serum

No

No

No

October

Six months. Lesions first noted in April

Quarter horse
9 years
Mare

Trunk, legs, face, ears

Serous crust

No

No

No

November

Two year history of hives on back

Miniature horse
8 years
Gelding

Face, neck, trunk, legs

Ooze serum, crust,

hair loss

Yes

No

No

March

Several year history of skin problems including

hives, signs worse in December

Arabian
14 years
Gelding

Multiple but location

not provided

Thick crust, mat

hair, erythema,
serous weeping

No

No

No

1st November
2nd January

Original lesions developed 2 weeks prior to biopsy.

A single similar lesion recurred 2.5 years after the first

Morgan cross
3 years
Gelding

Neck, chest, lower

abdomen, upper legs

Crust, mat hair,

exudate

Yes

No

No

February

Lesions develop each winter (October or November)

Lesions developed three consecutive winters
Horse normal in summer months

Duration of signs

Spongiotic dermatitis in horses

293

2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 291296

Horse

VDE264.fm Page 294 Monday, September 17, 2001 3:56 PM

294

A. M. Hargis et al.

cytoplasm. No inclusion bodies were noted. The

dermis had mild to moderate superficial and deep
perivascular to interstitial neutrophils, eosinophils
and mast cells. Dermal oedema was variable between
cases, but was marked in five horses, and most severe in
the papillary dermis (Figs 2 and 3). Apocrine glands
were within normal limits. A variable amount of
melanin pigment was present in hair shafts and areas
of the epidermis of all horses.
Immunological findings
Avidinbiotin complexperoxidase staining for IgG
was similar in all cases with no convincing evidence of
antigen-specific deposition of IgG detected. There was
extensive positive staining for immunoglobulin in the
dermis, extending to the basement membrane, in most
biopsy samples. This appeared to be primarily in association with oedema (serum marking). There was what
appeared to be secondary diffusion of immunoglobulin
into intercellular spaces and spongiotic vesicles of the
epidermis. This intercellular staining was smooth and
homogeneous in most areas. The desmoglein staining
in these areas was pericytoplasmic and evenly distributed,
with no evidence of clumping or irregularity. Two
horses, one with a biopsy sample stained by avidin
biotin immunoperoxidase and one with biopsy sample
stained by immunofluorescence, were initially diagnosed as pemphigus foliaceus based on the nonspecific intercellular diffusion of IgG.
One horse had intradermal skin testing for hypersensitivity to aeroallergens. The horse was tested with
a positive and negative control and 61 allergens. It had
two 4+, six 3+, six 2+ and three 1+ reactions.
Therapy
The horses in this study were treated by seven different
veterinarians over a period of 6 years. Some horses
were treated multiple times. Clinical records were no
longer available for two horses when this retrospective
study was undertaken. Some veterinarians only responded
to questionnaires regarding therapy by name of the
therapeutic agent, but not dosage. Exact drug dosages
varied with the practices of the individual veterinarians
and are not provided herein. Four horses improved
when given immunomodulatory therapy (dexamethasone, prednisone or aurothioglucose); however, one
horse did not respond to dexamethasone. The horses
that responded to dexamethasone therapy were also
given concurrent therapy with another product (griseofulvin, trimethoprim potentiated sulfa, prednisone,
chlorhexidine shampoo or hyposensitization). One
horse responded to a diet change from alfalfa to
grass hay, and had a minor recurrence in skin lesions
when it ate a small amount of alfalfa hay. The recurrent lesions were not evaluated histologically. One
horse responded to topical diphenmanil methylsulfate,
but not to dietary changes instituted at a later date.
Lesions in one horse responded to clipping of hair,
whereas lesions in areas that were not clipped remained
unchanged.
2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 291 296

DISCUSSION
Clinically, these seven horses had lesions characterized
by multifocal exudative (weeping, oozing) areas with
matting of hair. Histologically lesions consisted of
spongiotic vesicles with proteinaceous fluid exudation,
which in some cases progressed to ulcers and cellular
crusting. The dermis was oedematous and congested, and
had perivascular and interstitial mixed inflammation
including eosinophils suggesting the potential of a
hypersensitivity response.
A specific cause for the lesions in all horses was not
identified. There was no known exposure to contact
materials, and lesions in some horses developed in
cooler months (including cold winter months) when
biting insects were not likely to play a role. Ectoparasites were not described in the dermatologic history in
any of the horses, so ectoparasites could not be documented as a contributing cause for the lesions in these
horses. One horse had an apparent response to a diet
change from alfalfa to grass hay, and one horse to glucocorticoid therapy plus hyposensitization, suggesting
that hypersensitivity to a dietary factor and atopic dermatitis may have contributed to the lesions in those two
horses. With the exception of one horse in which lesions
developed 1 week after vaccination, there was no known
drug exposure immediately prior to lesion development
so spongiotic drug eruption could not be documented.
The vaccination in one horse could have precipitated
the lesions in that individual.
The lesions occurred in haired skin with pigmented
hair shafts, which was inconsistent with sunburn and
photosensitization. There was no coagulative necrosis
of the epidermis to suggest thermal burn, and no significant basal cell or keratinocyte apoptosis to suggest
lupus erythematosus or erythema multiforme. No inclusion bodies were noted to document viral infection,
and positive response to glucocorticoid or aurothioglucose therapy in four horses, good systemic health of
all horses, and lack of lesions in contact horses suggested against viral aetiology. The lesions in horses
often developed in cooler months and without a history
of sweating, and apocrine sweat gland ducts typically
open in the upper portion of the hair follicle rather
than epidermis, suggesting against a condition similar
to miliaria in people.
Although acantholysis was occasionally seen, the
acantholytic cells were angular and infrequent, and
appeared the result of spongiosis rather than a directed
or specific loss of desmosomal or hemidesmosomal
attachments. The interepithelial staining in these
horses was likely secondary to nonspecific diffusion
of immunoglobulin into the epidermis from dermal
vessels rather than specific immunoglobulin deposition.
The epidermal intercellular staining was only present
in areas of inflammation, in which there was also extensive dermal and basement membrane staining. The
homogeneous nature of the intercellular stain throughout the epidermis was not considered consistent with
pemphigus foliaceus.5 There was also a lack of patchy

VDE264.fm Page 295 Monday, September 17, 2001 3:56 PM

Spongiotic dermatitis in horses

or clumped irregularity in the desmoglein stain as has
been described in human pemphigus foliaceus patients.6,7
Based on these observations the lesions were not considered to be consistent with pemphigus foliaceus or
vulgaris, or other disorders associated with significant
or primary acantholysis.5 However, the presence of
acantholytic cells, although infrequent, and nonspecific diffusion of immunoglobulin into the epidermis can lead to the misdiagnosis of pemphigus
foliaceus.
The pathogenesis of the spongiotic vesicular epidermal lesions in the horses in this study appears to
involve marked dermal oedema that progresses to
intra- and extracellular epidermal oedema (spongiosis),
which in turn progresses to the vesicular lesions. A
similar pathogenesis has been reported with exudative
oozing urticaria and allergic contact dermatitis.3,8 In
exudative oozing urticaria, the serum transudation
may mask the urticarial reaction,3 and it is likely
that exudative oozing urticaria and the spongiotic
vesicular dermatitis described herein are manifestations of the same disease process. It appears that
various causes of significant dermal oedema, including inflammation associated with hypersensitivity,
can result in this spongiotic vesicular reaction
pattern.
In conclusion, an exudative dermatitis characterized histologically by spongiotic vesicular dermatitis
developed in seven horses. The lesions developed
under circumstances suggesting that the epidermal
spongiosis and vesiculation resulted from extension
of papillary dermal oedema. Hypersensitivity reactions to food, environmental allergens, and or to vaccine may have contributed to the development of the
lesions in three horses. The histological lesions thus
represent a cutaneous reaction pattern that may have

295

a variety of different causes. Because of the vesicular

nature of the lesions, presence of acantholytic cells
and diffusion of immunoglobulin into the epidermis,
these cases may be confused with pemphigus foliaceus.

REFERENCES
1. Cohen, L.M., Karp Skopicki, D., Harrist, T.J. et al.
Noninfectious vesiculobullous and vesiculopustular
diseases. In: Elder, D., Elenitsas, R., Jaworsky, C. et al., eds.
Levers Histopathology of the Skin, 8th edn. Philadelphia:
Lippincott-Raven, 1997: 20953.
2. Kral, F., Schwartzman, R.M. Veterinary and Comparative
Dermatology. Philadelphia: J.B. Lippincott Co, 1964: 103.
3. Von Tscharner, C., Kunkle, G., Yager, J. Stannards illustrated equine dermatology notes. Veterinary Dermatology
2000; 11: 1635.
4. Haines, D.M., Chelack, B.J. Technical considerations
for developing enzyme immunohistochemical staining
procedures on formalin-fixed paraffin-embedded tissues
for diagnostic pathology. Journal of Veterinary Diagnostic
Investigation 1991; 3: 10112.
5. Haines, D.M., Cooke, E.M., Clark, E.G. Avidin
biotinperoxidase complex immunohistochemistry to
detect immunoglobulin in formalin fixed skin biopsies in
canine autoimmune skin disease. Canadian Journal of
Veterinary Research 1987; 51: 1049.
6. Burge, S.M., Wilson, C.L., Dean, D. et al. An immunohistologic study of desmosomal components in pemphigus.
British Journal of Dermatology 1993; 128: 36370.
7. Carlotti, A., Balaton, A.J., de Muret, A. et al. Autoimmune pemphigus. A distinct staining pattern with an antidesmoglein antibody. Archives of Dermatology 1993; 129:
5969.
8. Komura, J., Ofuji, S. Ultrastructural studies of allergic
contact dermatitis in man. Archives of Dermatological
Research 1980; 267: 27582

Rsum Sur une priode de 6 ans, sept chevaux adultes de races et de sexe varis ont dvelopp une dermatite
multifocale, exudative et suintante, caractrise sur le plan histologique par des vsicules spongiotiques et une
inflammation privasculaire, osinophilique, neutrophilique et mononucle. Trois chevaux prsentaient un prurit.
Aucune atteinte de ltat gnral ntait prsente. Dans deux cas, des pisodes rcidivants durticaire taient
rapports, et un cheval prsentait galement des lsions nodulaires ou en plaques, qui voluaient en lsions
exudatives et suintantes. Un dpt interepithlial dimmunoglobuline (Ig)G a t observ par raction avidinebiotine-peroxydase. Le type de dpt tait plus en faveur dun oedme pithlial que dun dpt spcifique dIgG
li un pemphigus. Les lsions exudatives se sont dveloppes dans un cadre suggrant quun oedme dermique
a provoqu un oedme pidermique intracellulaire et intercellulaire, qui a provoqu les lsions vsiculeuses
spongiotiques. [Hargis, A. M., Clark, E. G., Duclos, D. D., Leclerc, S., West, K. Spongiotic vesicular dermatitis
as a cutaneous reaction pattern in seven horses. (Dermatite spongiotique vsiculeuse: une modalit de raction
cutane chez sept chevaux.) Veterinary Dermatology 12: 291296.]
Resumen En un periodo de 6 aos, siete caballos adultos de diferentes razas y sexo desarrollaron lesiones dermatolgicas exudativas multifocales, caracterizadas histolgicamente por vesculas epidrmicas espongiticas y
una inflamacin perivascular mononuclear, eosinoflica, neutroflica y mixta. Tres caballos mostraban prurito.
No se detect enfermedad sistmica. Dos caballos tenan una historia de urticaria recurrente y un caballo tena
ndulos o habones que progresaron a lesiones exhudativas. Se detect inmunoglobulina (Ig)G interepitelial
mediante tincin con complejo de peroxidasa avidinabiotina, pero el patrn de tincin era ms compatible con
un edema epitelial que con una deposicin de IgG especfica asociada a pnfigo. Las lesiones exhudativas se
desarrollaron en circunstancias sugestivas de que el edema drmico progres a un edema epidrmico intracelular
e intercelular, que a su vez progres a lesiones espongiticas vesiculares epidrmicas. [Hargis, A. M., Clark, E. G.,
Duclos, D. D., Leclerc, S., West, K. Spongiotic vesicular dermatitis as a cutaneous reaction pattern in seven horses.
2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 291296

VDE264.fm Page 296 Monday, September 17, 2001 3:56 PM

296

A. M. Hargis et al.
(Dermatitis vesicular perivascular espongitica como un patrn de reaccin cutnea en siete caballos.) Veterinary
Dermatology 12: 291 296.]
Zusammenfassung ber eine Periode von 6 Jahren wurde bei sieben ausgewachsenen Pferden verschiedener
Rassen und verschiedenen Geschlechts ein multifokale, exsudative Dermatitis gesehen, die histologisch durch
epidermale, spongiotische Vesikel und perivaskulre eosinophile, neutrophile und gemischt mononuklere
Entzndung charakterisiert war. Drei Pferde zeigten Juckreiz. Systemische Erkrankungen wurden nicht festgestellt. Rezidivierende Urtikaria (Quaddeln) wurde bei zwei Pferden gesehen und ein Pferd hatte Knoten und
Quaddeln, die sich zu exsudativen Lsionen weiterentwickelten. Interepitheliale IgG Antikrper wurden durch
AvidinBiotin KomplexPeroxidasefrbung nachgewiesen, das Frbungsmuster deutete mehr auf epitheliales
dem als auf mit Pemphigus assoziierte spezifische IgG Ablagerung hin. Die Ausschwitzungen entwickelten
sich unter Umstnden, die darauf hindeuteten, dass ein dermales dem sich zu einem intra- und interzellurem
dem und spter zu spongiotischen, vesikulren epidermalen Lsionen entwickelte. [Hargis, A. M., Clark, E. G.,
Duclos, D. D., Leclerc, S., West, K. Spongiotic vesicular dermatitis as a cutaneous reaction pattern in seven horses.
(Spongiotische vesikulre Dermatitis als ein kutanes Reaktionsmuster bei sieben Pferden.) Veterinary Dermatology
12: 291 296.]

2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 291 296