Vision transformer-based diagnosis of psoriasis and eczema in whole-slide histology

Psoriasis and eczema are chronic inflammatory skin diseases with overlapping histopathological features, which often lead to diagnostic uncertainty even among experienced dermatopathologists. To address this challenge, we developed a computer-assisted diagnostic framework that combines the Virchow foundation model, pretrained on 1.5 million whole-slide images, with multi-instance learning (MIL) to classify psoriasis and eczema from digitized histopathology slides. Using an internal dataset (n = 40) and an external validation cohort (n = 40), equally balanced between both conditions and annotated by board-certified dermatopathologists, our best-performing configuration (Virchow + CLAM) achieved 85% accuracy, a macro-averaged F1 score of 0.80, and an AUC of 0.81 on the external cohort. This substantially outperformed baseline convolutional neural networks, which reached 61% accuracy, and models relying solely on pretrained feature extractors without MIL, which achieved an average accuracy of 68.8%. In a reader study on the same external cohort, individual dermatopathologist accuracies ranged from 47.5 to 70.0%, with a majority-vote consensus accuracy of 62.5%; our method outperformed both the average individual reader and the consensus under histology-only conditions. Furthermore, the model generates attention heatmaps that provide supportive visual context by highlighting regions associated with model predictions. Importantly, this study is designed as a methodological proof-of-concept conducted under controlled, histology-only conditions and is not intended for direct clinical deployment. Rather than demonstrating clinical readiness, it illustrates the potential of domain-specific foundation models combined with MIL for addressing diagnostically challenging inflammatory dermatoses.