2007 Banff Schema for Grading of Composite Skin-Containing Allograft Rejection

Based on adequate specimen defined as at least one 4mm skin punch biopsy from most reddened or indurated area of viable inolved skin and containing epidermis, dermis, subcutaneous tissue, adnexa and vessels, and minimally stained with H&E and PAS stains.

Acute Cell-Mediated Rejection

No inflammation OR rare inflammatory infiltrates 1. Essentially normal looking skin
I (Mild)

Mild perivascular inflammation WITHOUT involvement of the overlying epidermis.

1. Mainly lymphocytic, begins in upper dermis.

2. Nonspecific, may be seen with viral exanthems, etc.

3. Diagnosis of rejection remains "somehow tentative" at this stage.

II (Moderate)

Moderate to severe perivascular inflammation WITHOUT epithelial dyskeratosis and/or apoptosis and/or keratinolysis. MAY HAVE mild spongiosis and/or exocytosis of epidermis and/or adnexae

1. Typically inflammation in upper and mid-dermis, may have mild interface dermatitis, rarely vesicle formation.

2. Differential diagnosis includes viral/drug eruptions (often with some extravasated red cells), contact dermatitis, insect bites (may contain more eosinophils), dermatophyte infections (eczematoid epidermal changes, PAS-positive organisms).

III (Severe)

Dense inflammation and epidermal involvement WITH epithelial apoptosis and/or dyskeratosis and/or keratinolysis

1. Dermal infiltrates form perivascular and periadnexal nodules, epidermis may have lichenoid changes.

2. Differential diagnosis includes pseudolymphoma (T cells, B cells, variable eosinophils and histiocytes), Drug rash with eosinophilia and systemic symptoms (DRESS syndrome), PTLD/B cell lymphoma (B cell predominance, may contain EBV, clonal- note: no examples yet described)

IV (Necrotizing)
Frank necrosis of epidermis or other skin structures

1. Inflammation mainly lymphocytic, may have numerous eosinophils.

2. Differential diagnosis includes drug eruption, i.e., toxic epidermal necrolysis (less dermal inflammation than necrotizing rejection), pseudolymphoma, insect bites, eosinophilic cellulitis.

Chronic Rejection

Insufficient data at present for classification of chronic rejection Likely correlates include vessel narrowing, loss of adnexa, atrophy of skin and muscle, myointimal proliferation, deep tissue fibrosis, nail changes.

1. Likely to reflect both chronic rejection-associated and/or nonimmune events in individual cases. Further study needed.

Antibody-Mediated Rejection

Insufficient data at present for classification of antibody mediated rejection Likely histopathologic correlates would include C4d deposition, vasculitis, neutrophil margination, vascular thrombi, and/or necrosis.

1. Recommended to gather this information along with donor-specific antibody levels, PRA, cross-match results including both T and B cell, transfusions, pregnancies, prior allografts, autoantibody levels in order to prospectively assess the pathobiology and diagnostic criteria appropriate for antibody-mediated rejection of composite allografts.


1. Cendales LC, Kanitakis J, Schneeberger S, Burns C, Ruiz P, Landin L, Remmelink M, Hewitt CW, Landgren T, Lyons B, Drachenberg CB, Solez K, Kirk AD, Kleiner DE, Racusen L: The Banff 2007 Working Classification of Skin-Containing Composite Tissue Allograft Pathology. Am J Transplant 8: 1396-1400, 2008.

2. Kanitakis J: The Challenge of Dermatopathological Diagnosis of Composite Tissue Allograft Rejection: A Review. J Cutan Pathol 35:738-744, 2008.

Last Modified: Mon Aug 03 10:14:43 EDT 2009