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Dermoscopy in General Dermatology: A Practical Overview

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• Published: 09 September 2016
• Volume 6 , pages 471–507, ( 2016 )

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• Enzo Errichetti 1 &
• Giuseppe Stinco 1  

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Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides and subacute cutaneous lupus erythematosus), papulosquamous/papulokeratotic dermatoses (lichen planus, pityriasis rosea, papulosquamous sarcoidosis, guttate psoriasis, pityriasis lichenoides chronica, classical pityriasis rubra pilaris, porokeratosis, lymphomatoid papulosis, papulosquamous chronic GVHD, parakeratosis variegata, Grover disease, Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis), facial inflammatory skin diseases (rosacea, seborrheic dermatitis, discoid lupus erythematosus, sarcoidosis, cutaneous leishmaniasis, lupus vulgaris, granuloma faciale and demodicidosis), acquired keratodermas (chronic hand eczema, palmar psoriasis, keratoderma due to mycosis fungoides, keratoderma resulting from pityriasis rubra pilaris, tinea manuum, palmar lichen planus and aquagenic palmar keratoderma), sclero-atrophic dermatoses (necrobiosis lipoidica, morphea and cutaneous lichen sclerosus), hypopigmented macular diseases (extragenital guttate lichen sclerosus, achromic pityriasis versicolor, guttate vitiligo, idiopathic guttate hypomelanosis, progressive macular hypomelanosis and postinflammatory hypopigmentations), hyperpigmented maculopapular diseases (pityriasis versicolor, lichen planus pigmentosus, Gougerot-Carteaud syndrome, Dowling-Degos disease, erythema ab igne, macular amyloidosis, lichen amyloidosus, friction melanosis, terra firma-forme dermatosis, urticaria pigmentosa and telangiectasia macularis eruptiva perstans), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), erythrodermas (due to psoriasis, atopic dermatitis, mycosis fungoides, pityriasis rubra pilaris and scabies), noninfectious balanitis (Zoon’s plasma cell balanitis, psoriatic balanitis, seborrheic dermatitis and non-specific balanitis) and erythroplasia of Queyrat, inflammatory cicatricial alopecias (scalp discoid lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans), nonscarring alopecias (alopecia areata, trichotillomania, androgenetic alopecia and telogen effluvium) and scaling disorders of the scalp (tinea capitis, scalp psoriasis, seborrheic dermatitis and pityriasis amiantacea).

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Introduction

Over the last few years, several studies have shown that dermoscopy may come in very handy for assisting the noninvasive diagnosis of various general dermatological disorders [ 1 – 6 ], including scalp/hair diseases (trichoscopy) [ 7 ], nail/nailfold abnormalities (onychoscopy) [ 8 ], cutaneous infections/infestations (entomodermoscopy) [ 5 ] and inflammatory dermatoses (inflammoscopy) [ 1 ]. Indeed, such a technique provides additional information at a submacroscopic level that may help the dermatologist differentiate between two or more conditions that are hardly distinguishable with the naked eye [ 1 ]. The most important criteria to be considered when using dermoscopy in general dermatology are: (1) the morphology/arrangement of vascular structures, (2) scaling patterns, (3) colours, (4) follicular abnormalities and (5) specific features (clues) [ 1 , 2 ]. Obviously, dermoscopic findings must be interpreted within the overall clinical context of the patient (personal/family history, number, location, morphology and distribution of the lesions, etc.) because only the combination between such data can really enhance the diagnostic accuracy in the field of general dermatological disorders [ 1 – 6 ]. In fact, even though it has been demonstrated that some skin diseases may display “specific” dermoscopic criteria, there are others featuring just “nonspecific” findings, which may be considered useful only if coupled with proper and accurate clinical and anamnestic information [ 1 – 6 ]. Another crucial factor that must be taken into account in dermoscopic examination of most dermatoses is the choice of the equipment [ 1 – 6 ]. In particular, polarised light noncontact dermoscopy is usually preferred over conventional nonpolarised light contact dermoscopy as the latter may reduce the vessels (due to pressure) and/or scaling (when using a liquid interface) visibility, even though some clues are better seen with non-polarised light devices (i.e. more superficial findings, such as comedo-like structures) [ 1 , 3 ].

The purpose of this article is to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of several groups of relatively common dermatological disorders sharing the same (or similar) clinical presentation (erythematous-desquamative dermatoses, papulosquamous/papulokeratotic dermatoses, etc.) according to the available literature data and our personal experience. All published information about the dermoscopy of the conditions considered in the present article was retrieved by a comprehensive search of the literature using the PubMed electronic database (including all publications describing at least one instance); the search terms were the names of the diseases and the words “epiluminescence microscopy”, “dermatoscopy” and “dermoscopy”. A manual search was also carried out by analysing the reference sections of all relevant studies or reviews about such a topic.

For each clinical category, we will first describe the diseases for which there is good evidence (if any) and afterwards mention those having weaker evidence, specifying the highest level of evidence available for each considered dermatosis, according to the most recent guidelines for evidence-based medicine, The Oxford 2011 Levels of Evidence : [ 9 ] level of evidence I, systematic review of cross sectional studies with consistently applied reference standard and blinding; II, individual cross sectional studies with consistently applied reference standard and blinding; III, non-consecutive studies or studies without consistently applied reference standards; IV, case-control studies or “poor or non-independent reference standard”; V, mechanism-based reasoning. All the retrieved studies were classified according to standard definitions for diagnostic accuracy studies [ 10 – 12 ]. Importantly, blinded cross-sectional studies not mentioning the sampling method (consecutive or non-consecutive) were considered as non-consecutive studies (level of evidence III), while case series studies (CSS), single case reports (SCR) and personal observations (PO) were labelled as level of evidence V. To be more accurate, we will also specify the information source type (CSS, SCR and/or PO) in case the level V turns out to be the best evidence available.

Tables  1 , 2 , 3 , 4 , 5 and 6 provide a summary of the dermoscopic clues of all the dermatological disorders considered, divided according to their clinical pattern.

The article is based on previously conducted studies and does not contain any new studies with human or animal subjects performed by any of the authors.

Dermatoses Presenting with Erythematous-Desquamative Patches/Plaques

Plaque psoriasis (level of evidence: ii).

Dermoscopy of plaque psoriasis typically shows a characteristic pattern consisting of diffuse white scales and symmetrically and regularly distributed dotted vessels on a light or dull red background (Fig.  1 a) [ 13 – 24 ]. When the presence of marked hyperkeratosis impedes the view of underlying features, scale removal may be useful to display the above-mentioned vascular pattern as well as possible tiny red blood drops (dermoscopic “Auspitz sign”) [ 21 ]. The “red globular ring” pattern is another less common (but specific) vascular pattern visible in plaque psoriasis lesions, while other patterns of vessel distribution are extremely rare [ 25 ].

Dermoscopy of plaque psoriasis typically shows white scales and symmetrically and regularly distributed dotted vessels on a red background ( a ). The main dermoscopic criteria in eczematous dermatitis are dotted vessels (black circle) in a patchy distribution and yellow serocrusts (black arrowhead) ( b ). Both the herald patch and the secondary lesions of pityriasis rosea are dermoscopically characterised by peculiar peripheral whitish scales (“collarette” sign) as well as irregular or patchy dotted vessels (black circle); structureless orangish areas are also visible (black arrow) ( c ). Dermoscopic examination of mycosis fungoides reveals a combination of fine short, linear vessels with orange-yellowish patchy areas ( d )

Eczematous Dermatitis (Level of Evidence: II)

The most important dermoscopic features of eczematous dermatitis include dotted vessels in a patchy distribution and yellow serocrusts/scaling (Fig.  1 b) [ 13 , 26 – 28 ]. Focal whitish scales are sometimes visible, but they are always associated with the aforementioned “yellowish findings” [ 13 , 26 – 28 ]. According to the disease stage, eczematous dermatitis may display some differences, with acute exudative lesions mainly showing yellow scale/crusts (“yellow clod sign”) and chronic and lichenified lesions predominantly displaying dotted vessels in a patchy distribution and scaling [ 1 , 13 , 29 , 30 ].

Pityriasis Rosea (Level of Evidence: II)

Both the herald patch and the secondary lesions of pityriasis rosea typically show a characteristic peripheral whitish scaling (“collarette” sign) as well as dotted vessels, which, differently from psoriasis, are distributed in an irregular or focal pattern; diffuse or localised yellowish-orange structureless areas may be visible as well (Fig.  1 c) [ 13 , 31 , 32 ].

Mycosis Fungoides (Level of Evidence: III)

The most common dermoscopic aspect of mycosis fungoides consists of a combination of fine short linear vessels with orange-yellowish patchy areas (Fig.  1 d) [ 33 ]; a peculiar vascular structure resembling spermatozoa (composed of a dotted and a short curved linear vessel) is also quite frequently visible [ 33 ]. Additional dermoscopic features are represented by fine white scaling, dotted vessels and purpuric dots [ 33 ].

Subacute Cutaneous Lupus erythematosus (Level of Evidence: V—CSS)

Subacute cutaneous lupus erythematosus is characterised by two constant dermoscopic findings, namely whitish scales (diffusely or peripherally distributed) and a mixed vascular pattern (at least two types of vessels among dotted, linear-irregular, linear and branching vessels) over a pinkish-reddish background [ 34 ]. Focally distributed orange-yellowish structureless areas may also be seen less commonly [ 34 ].

Papulosquamous/Papulokeratotic Dermatoses

Classical lichen planus (level of evidence: ii).

The dermoscopic hallmark of classical lichen planus is represented by Wickham striae (Fig.  2 a), which may appear as pearly-whitish (and less commonly yellow or blue-white) structures possibly displaying several morphological patterns, including reticular (the most common), linear, “radial streaming”, annular, round, “leaf venation” (delicate secondary striae branching from the centred whitish venation, linked together at either end, mimicking the crystal structure of snow) and “starry sky” (clustered, follicular white dots) aspect [ 13 – 15 , 35 – 39 ]. Dotted, globular and/or linear vessels, mainly localised at the periphery of the lesion (and less commonly showing a perifollicular or diffuse pattern), violet, reddish, pink, brown or yellow background, white/yellow dots and some pigmented structures (dots, globules and/or reticular or cloud-like areas) are other additional dermoscopic findings of active lesions [ 13 – 15 , 35 – 39 ].

The dermoscopic analysis of classical lichen planus typically shows the Wickham striae over a purplish background ( a ). Dermoscopy of papulosquamous sarcoidosis shows the characteristic orange-yellowish background, in combination with in-focus fine linear vessels (black arrowhead); whitish lines and white scales are also evident in the centre ( b ). Guttate psoriasis lesions typically show a distinctive monomorphic dermoscopic picture, with dotted vessels distributed in a diffuse pattern ( c ). Dermoscopy of pityriasis lichenoides chronica frequently displays nondotted vessels, e.g. linear irregular vessels (black arrowhead), focally distributed dotted vessels (black circle) and orange-yellowish structureless areas ( d ). Dermoscopic examination of a case of disseminated superficial actinic porokeratosis displays the peculiar “cornoid lamella” at the periphery of the lesion ( e ). Dermoscopy of a necrotic lesion of lymphomatoid papulosis shows a central brown-grey structureless area ( f )

See the section “ Dermatoses presenting with erythematous-desquamative patches/plaques ”.

Papulosquamous Sarcoidosis (Level of Evidence: II)

See the section “ Common facial inflammatory skin diseases ” (Fig.  2 b).

Guttate Psoriasis (Level of Evidence: III)

Guttate psoriasis classically displays a distinctive monomorphic dermoscopic aspect consisting of dotted vessels regularly distributed all over the lesion, which are often associated with whitish scales (Fig.  2 c) [ 1 , 40 ], similarly to that seen in plaque-type psoriasis [ 1 – 6 , 41 ]; orange-yellowish structureless areas may also be present, but they are quite uncommon [ 40 ].

Pityriasis Lichenoides Chronica (Level of Evidence: III)

The most peculiar dermoscopic findings of pityriasis lichenoides chronica include nondotted vessels (i.e. milky red areas/globules, linear irregular and branching vessels), focally distributed dotted vessels and orange-yellowish structureless areas (Fig.  2 d) [ 40 ]. Interestingly, whitish areas may sometimes be present in the context of clinically active lesions as a result of focal post-inflammatory hypopigmentation [ 1 , 40 ].

Classical Pityriasis Rubra Pilaris (Level of Evidence: V—CSS, CR)

Dermoscopy of classical pityriasis rubra pilaris papules may show round/oval yellowish areas surrounded by vessels of mixed morphology, namely linear and dotted [ 1 , 16 ]. Additionally, central keratin plugs may also be observed [ 1 ].

Disseminated Forms of Porokeratosis (Level of Evidence: V—CSS, CR)

The most peculiar dermoscopic feature of all variants of porokeratosis is the “cornoid lamella”, which appears as a well-defined, thin, white-yellowish, annular peripheral hyperkeratotic structure (“white track”) similar to the outlines of a volcanic crater as observed from a high point, which may be hyperpigmented in disseminated superficial actinic porokeratosis (Fig.  2 e); the centre of the lesions is usually whitish or brownish and may exhibit circular and/or linear whitish and/or hyperpigmented tracks, blue-grey dots and dotted, linear or globular vessels (Fig.  2 e) [ 17 , 42 – 49 ].

Lymphomatoid Papulosis (Level of Evidence: V—CSS)

Dermoscopic pattern of lymphomatoid papulosis varies according to the disease stage. The initial inflammatory papules usually display a vascular pattern of tortuous irregular (or dotted at low magnification) vessels, surrounded by white structureless areas, radiating from the centre to the periphery of the lesion, while in more mature papules, such a vascular pattern is less evident and generally detectable only at the periphery of the lesion as the centre is occupied by a whitish-yellowish (hyperkeratotic lesions) or brown-grey (necrotic lesions) structureless area (Fig.  2 f) [ 50 ].

Papulosquamous Chronic GVHD (Level of Evidence: V—CSS)

The dermoscopic aspect of papulosquamous chronic GVHD consists of whitish scales associated with vessels of mixed morphology, namely dotted and linear [ 1 ]. Although such a pattern is quite unspecific, it might be useful in assisting the clinical differential diagnosis with the other above-mentioned papulosquamous disorders as they typically show a different appearance [ 1 ].

Poikiloderma Vasculare Atrophicans/Parakeratosis Variegata (Level of Evidence: V—CSS)

This condition typically shows a monomorphic pattern consisting of relatively blurred branched vessels on a reddish or orangish-brown background, associated with sparse whitish scales [ 51 ].

Acantholytic and Dyskeratotic Papular Disorders (Grover Disease, Darier Disease and BRAF-Inhibitor-Induced Acantholytic Dyskeratosis; Level of Evidence: V—CSS, CR)

Grover disease may display different features according to the histological subtype, with a central star-shaped/branched polygonal/roundish-oval brownish area surrounded by a whitish halo being characteristic of the Darier-like histological subtype (Fig.  3 a) and whitish scaling over a reddish-yellowish background being characteristic of the spongiotic histological subtype (Fig.  3 b); dotted and/or linear/irregular vessels may be found in both such forms (Fig.  3 a, b) [ 52 – 55 ]. Importantly, the dermoscopic pattern of Darier-like Grover disease overlaps with that detectable in both Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis (Fig.  3 c, d) [ 55 – 58 ].

Dermoscopy of Darier-like Grover disease displays a central branched polygonal brownish area surrounded by a thin whitish halo with peripheral dotted vessels (black circle) ( a ), while spongiotic Grover disease presents with whitish scaling over a reddish-yellowish background and irregular vessels (black circle) ( b ). Dermoscopic examination of Darier disease ( c ) and BRAF-inhibitor-induced acantholytic dyskeratosis ( d ) shows a pattern similar to that observed in Darier-like Grover disease, with a centrally located polygonal brownish area surrounded by a whitish halo and linear vessels (black arrow) in Darier disease ( c ) and a central branched polygonal brownish area surrounded by a thin whitish halo in the latter condition ( d )

Common Facial Inflammatory Skin Diseases

Rosacea (level of evidence: iii).

The dermoscopic hallmark of rosacea is represented by the presence of linear vessels characteristically arranged in a polygonal network (vascular polygons) [ 26 , 59 ] (Fig.  4 a). Additional features include rosettes [ 60 ], follicular plugs, white/yellowish scales, orange-yellowish areas, pigmentation structures, dilated follicles and follicular pustules (papulopustular rosacea) [ 26 , 59 ].

The main dermoscopic feature of rosacea is the presence of linear vessels, which are characteristically arranged in a polygonal network ( a ). The most typical dermoscopic finding of seborrheic dermatitis is represented by the presence of dotted vessels in a patchy distribution (black circle) and yellowish scales (black arrows); blurry linear branching vessels (black arrowheads) and whitish scales are also not uncommonly present ( b ). Dermoscopy of an intermediate-stage lesion of facial discoid lupus erythematosus reveals follicular white/yellowish rings/keratotic plugs, whitish scaling and blurred branching vessels (black arrow) over a reddish background ( c ). Dermoscopic examination of facial sarcoidosis displays a structureless orange-yellowish background with focussed linear vessels ( d ), while granuloma faciale features dilated follicular openings (black arrows) associated with linear/branching vessels (black circles) over a pinkish background ( e ). Dermoscopy of demodicidosis shows the so-called "Demodex tails", which are visualised as creamy/whitish gelatinous threads protruding out of follicular openings (black arrow), and “Demodex follicular openings”, which appear as round and coarse follicular openings containing light brown/greyish plugs surrounded by an erythematous halo (black arrowhead) ( f )

Seborrheic Dermatitis (Level of Evidence: III)

The most typical dermoscopic findings of seborrheic dermatitis include dotted vessels in a patchy distribution and fine yellowish scales (in combination or not with white scales) (Fig.  4 b); follicular plugs, orange-yellowish areas, whitish structureless areas and linear branching vessels are less common features [ 26 ].

Discoid Lupus erythematosus (Level of Evidence: III)

Dermoscopy of facial (and extra-scalp in general) discoid lupus erythematosus shows different features according to the stage of disease, with erythema, perifollicular whitish halo, follicular keratotic plugs, red dots and white scaling being the most common/characteristic features of early lesions, and whitish structureless areas, hyperpigmentation (honeycomb network, perifollicular pigmentation, radial pigment streaks or pigmentation arranged in unspecified pattern) and blurred telangiectasias (mainly linear branching vessels and less commonly dotted/polymorphous vessels) representing the most frequent findings of late phases [ 26 , 61 – 65 ]; intermediate-stage lesions may display a mixture of the aforementioned features (Fig.  4 c) [ 26 , 61 – 65 ]. Less common dermoscopic findings include diffuse hyperkeratosis (hypertrophic discoid lupus erythematosus) [ 65 ], dilated follicles and yellowish scales [ 26 , 61 – 65 ].

Granulomatous Skin Diseases (Sarcoidosis, Cutaneous Leishmaniasis and Lupus Vulgaris; Level of Evidence: III)

The dermoscopic signature of all these granulomatous facial dermatoses consists of structureless orange-yellowish areas (diffuse or localised—often described as “grains of sand” in lupus vulgaris and teardrop-like areas in leishmaniasis), commonly associated with focussed linear or branching vessels (Fig.  4 d) [ 26 , 66 – 80 ]. Other possible findings include milia-like cysts, erythema, whitish lines or structureless areas, follicular plugs, dilated follicles, pigmentation structures, and white and/or yellow scales [ 26 , 66 – 80 ]. Additionally, leishmaniasis has been reported to show hyperkeratosis, further vascular features (hairpin, comma-shaped, glomerular-like and/or corkscrew vessels), central ulcerations and white peripheral projections (white starburst pattern) [ 73 – 80 ]. Nevertheless, dermoscopy may not be considered as a reliable tool in differentiating such granulomatous diseases and therefore histological assessment is needed to reach a definitive diagnosis [ 26 , 66 – 80 ].

Granuloma Faciale (Level of Evidence: III)

The dermoscopic hallmark of granuloma faciale is represented by the presence of dilated follicular openings associated with linear branching vessels (which sometimes appear as focussed elongated telangiectasias) over a pinkish background (Fig.  4 e) [ 26 , 81 – 83 ]; additional findings include perifollicular whitish halo, whitish streaks, follicular plugs, yellowish scales and pigmentation structures [ 26 , 81 – 83 ].

Demodicidosis (Level of Evidence: V—CSS)

The most indicative dermoscopic features of all types of demodicidosis are the so-called "Demodex tails", which are creamy/whitish gelatinous threads (representing the presence of the mite itself under magnification) protruding out of follicular openings, and “Demodex follicular openings”, which appear as round and coarse follicular openings containing light brown/greyish plugs surrounded by an erythematous halo (Fig.  4 f) [ 84 ]. Other unspecific dermoscopic findings (whose prevalence varies according to the subtypes of demodicidosis) include diffuse erythema, scaling, pustules and reticular dilated vessels [ 84 ].

Acquired Keratodermas

Chronic hand eczema (level of evidence: iii).

The most specific dermoscopic features of chronic hand eczema include brownish-orange dots/globules (corresponding to tiny spongiotic vesicles), yellowish scales and yellowish-orange crusts [ 28 , 85 ]; other less common findings are focally distributed whitish scaling and dotted vessels (Fig.  5 a) [ 28 , 85 ].

Dermoscopy of chronic hand eczema typically reveals sparse whitish scales, yellowish scaling (black circles) and orangish dots/globules (black arrowheads), while palmar psoriasis and tinea manuum respectively display diffuse white scaling ( b ) and white scales mainly localised in the skin furrows ( c ). Dermoscopic examination of a case of palmar lichen planus shows roundish yellowish areas, some of which display peripheral projections in a star-like appearance (black arrowheads) over a purplish background ( d )

Palmar Psoriasis (Level of Evidence: III)

The main dermoscopic finding of palmar psoriasis is represented by the presence of white scales typically distributed in a diffuse pattern (and only infrequently showing patchily or central distribution) (Fig.  5 b) [ 23 , 28 , 85 ]. Dotted vessels, which are regularly distributed (and only rarely in rings or patchy-distributed), may also be visible quite commonly when using a fluid interface (which reduce the scaling) [ 23 ]; focal yellowish scales are an additional but very rare finding [ 23 , 28 ].

Keratoderma due to Mycosis Fungoides (Level of Evidence: V—CR)

The most characteristic dermoscopic finding of keratoderma due to mycosis fungoides consists of relatively large amber scales over a white-to-pinkish background; sparse whitish scales and several non-specific reddish fissures are also visible [ 85 ].

Keratoderma due to Pityriasis Rubra Pilaris (Level of Evidence: V—CR)

The dermoscopic hallmark of keratoderma resulting from pityriasis rubra pilaris is the presence of patchily distributed, homogeneous, structureless orange areas presenting different sizes; unspecific whitish scaling may also be observed [ 85 ].

Tinea Manuum (Level of Evidence: V—PO)

From a dermoscopic point of view, tinea manuum displays whitish scaling distributed in a characteristic pattern, i.e. mainly localised in the physiologic palmar creases (Fig.  5 c) (personal observations).

Palmar Lichen Planus (Level of Evidence: V—PO)

Palmar lichen planus is typically characterised by roundish yellowish areas often having peripheral projections that may create a star-like appearance; a purplish background is sometimes visible (Fig.  5 d) (personal observations).

Aquagenic Palmar Keratoderma (Level of Evidence: V—CR)

Dermoscopy of aquagenic palmar keratoderma shows large yellow well-defined globules not affecting dermatoglyphs [ 86 ] or simply enlargement of the sweat duct pores when compared with a normal-looking palmar skin area [ 87 , 88 ].

Sclero-atrophic Dermatoses

Necrobiosis lipoidica (level of evidence: iii).

Dermoscopy of necrobiosis lipoidica lesions typically shows comma-shaped (incipient lesions), network-shaped/hairpin-like (more developed lesions) or elongated, branching and focussed serpentine (advanced lesions) vessels over a yellowish-orange/whitish-pinkish background (with or without reddish areas) (Fig.  6 a) [ 89 – 93 ]. Additional findings include patchy pigmented reticulum, yellow crusting and ulceration [ 89 – 93 ].

Dermoscopic examination of an advanced lesion of necrobiosis lipoidica reveals elongated, branching and focussed serpentine vessels over a yellowish-orange/whitish background ( a ). Dermoscopy of morphea shows the typical fibrotic beams (black arrows) associated with linear branching vessels ( b ), while cutaneous lichen sclerosus displays several “comedo-like openings” (follicular keratotic plugs), whitish patches, dotted vessels (black circle) and delicate linear branching vessels ( c )

Morphea (Level of Evidence: IV)

The most specific dermoscopic feature of morphea consists of whitish fibrotic beams, which are frequently crossed by linear branching vessels (Fig.  6 b) [ 94 – 96 ]; pigment network-like structures are also often evident, while “comedo-like openings” and whitish patches are less commonly seen [ 94 – 96 ].

Cutaneous Lichen Sclerosus (Level of Evidence: IV)

The dermoscopic hallmarks of cutaneous lichen sclerosus include “comedo-like openings” (follicular keratotic plugs) and whitish patches (Fig.  6 c) [ 94 , 95 , 97 – 100 ]; less common/less specific findings are represented by delicate linear branching vessels, fibrotic beams, grey dots, purpuric spots, pigment network-like structures, non-branching vessels (comma-like, hairpin and/or dotted), fine whitish scaling and chrysalis structures [ 94 , 95 , 97 – 100 ].

Hypopigmented Macular Diseases

Extragenital guttate lichen sclerosus (level of evidence: iv).

See the section “ Sclero-atrophic dermatoses ”.

Achromic Pityriasis Versicolor (Level of Evidence: V—PO)

Dermoscopy of achromic/hypochromic lesions of pityriasis versicolor usually shows a fairly demarcated white area with fine scales that are commonly localised in the skin furrows (Fig.  7 a), similarly to hyperpigmented lesions [ 101 ].

Dermoscopy of achromic/hypochromic lesions of pityriasis versicolor usually shows a fairly demarcated white area with fine scales that are commonly localised in the skin furrows ( a ), while active lesions of guttate vitiligo typically display a well-demarcated, dense/glowing, often associated with perifollicular hyperpigmentation (black arrowheads) ( b ). Dermoscopic examination of idiopathic guttate hypomelanosis may show multiple small areas coalescing into irregular/polycyclic macules, with several white shades and both well- and ill-defined edges, surrounded by patchy hyperpigmented network (“cloudy sky-like” pattern) ( c ), whilst postinflammatory hypopigmentation often presents with some dermoscopic findings typical of the original lesions (in this case, the star-like arrangment typical of prurigo nodularis) ( d )

Guttate Vitiligo (Level of Evidence: V—CSS)

The most common/typical dermoscopic features of guttate vitiligo include a well-demarcated, dense/glowing, white area and perifollicular hyperpigmentation (which is more frequently seen in repigmenting or progressing lesions than stable lesions) (Fig.  7 b) [ 102 – 104 ]. Other possible findings include perilesional hyperpigmentation, a reversed pigmentary network, reticular pigmentation and telangiectasias [ 102 – 104 ].

Idiopathic Guttate Hypomelanosis (Level of Evidence: V—CSS)

Dermoscopic examination of idiopathic guttate hypomelanosis displays two main aspects, i.e. the “cloudy sky-like” pattern (multiple small areas coalescing into irregular/polycyclic macules, with several white shades and both well- and ill-defined edges, surrounded by patchy hyperpigmented network) and the “cloudy” pattern (well or ill-defined roundish homogeneous whitish areas surrounded by patchy hyperpigmented network) (Fig.  7 c) [ 101 , 105 ].

Progressive Macular Hypomelanosis (Level of Evidence: V—PO)

Progressive macular hypomelanosis is dermoscopically characterised by an ill-defined whitish area without scaling [ 101 ].

Postinflammatory Hypopigmentation (Level of Evidence: V—CSS, PO)

Postinflammatory macular hypopigmentations often present some dermoscopic findings typical of the original lesions, e.g. non-dotted vessels/orangish structureless areas in pityriasis lichenoides [ 1 , 40 ], dotted vessels in guttate psoriasis [ 1 , 40 ] and star-like depigmentation in prurigo nodularis [ 103 ] (Fig.  7 d), thereby assisting the retrospective diagnosis [ 1 , 40 , 106 ].

Hyperpigmented Maculopapular Diseases

Pityriasis versicolor (level of evidence: v—cr, po).

Dermoscopy of hyperpigmented lesions of pityriasis versicolor shows fine whitish scaling (often localised in the skin furrows) associated with a pigmented network composed of brown stripes [ 107 ] or a diffuse, more or less homogeneous, brownish pigmentation (Fig.  8 a) (personal observations).

Dermoscopy of hyperpigmented lesions of pityriasis versicolor often shows fine whitish scaling localised in the skin furrows associated with a diffuse brownish pigmentation ( a ). The most common dermoscopic finding of lichen planus pigmentosus is represented by fine/coarse, grey-blue/brown dots over a brownish background ( b ), while confluent and reticulated papillomatosis (Gougerot–Carteaud syndrome) displays fine whitish scaling and brownish, homogeneous, more or less defined, polygonal, flat globules separated by whitish/pale striae creating a cobblestone pattern ( c ). Dermoscopic examination of pigmented lesions of erythema ab igne may reveal diffuse brownish pigmentation with telangiectatic vessels/fine whitish scaling, while friction melanosis and urticaria pigmentosa typically display brownish structureless areas arranged in a reticular fashion ( e ) and a homogeneous light-brown blot with a pigment network ( f ), respectively

Lichen Planus Pigmentosus (Level of Evidence: V—CSS)

The main dermoscopic patterns of lichen planus pigmentosus are represented by a diffuse, structureless, brownish pigmentation and/or fine/coarse, grey-blue/brown dots/globules (Fig.  8 b); perifollicular/annular pigmentation and white dots are other less common findings [ 38 , 39 , 108 , 109 ].

Confluent and Reticulated Papillomatosis (Gougerot-Carteaud Syndrome; Level of Evidence: V—CSS, CR)

Confluent and reticulated papillomatosis typically displays fine whitish scaling associated with brownish, homogeneous, more or less defined, polygonal, flat globules separated by whitish/pale striae creating a cobblestone appearance [ 110 ] (Fig.  8 c) or brownish areas presenting a “sulci and gyri” pattern [ 111 ].

Dowling-Degos Disease (Level of Evidence: V—CR)

The dermoscopic aspect of Dowling-Degos disease consists of a brown star-like area/irregular brownish projections with a hypopigmented centre over a brownish/reddish-brown background [ 112 – 114 ].

Erythema Ab Igne (Hyperpigmented Stage; Level of Evidence: V—PO)

The pigmentary stage of erythema ab igne is typically characterised by diffuse brownish pigmentation with or without telangiectatic vessels/whitish scaling (Fig.  8 d) [ 110 ].

Primary Cutaneous Amyloidosis (Macular Amyloidosis and Lichen Amyloidosus; Level of Evidence: V—CSS)

The most common dermoscopic finding of both macular amyloidosis and lichen amyloidosus is a central hub (which is either white or brown in the former and white in the latter) surrounded by various configurations of brownish pigmentation, including fine radiating streaks, dots, leaf-like projections and bulbous projections [ 115 ]. Additionally, in lichen amyloidosus the central hub may be replaced by a scar-like area (which may be the only feature in larger and thicker lesions) and a rim of white collarette (resembling a volcanic crater) may sometimes be appreciated [ 115 ].

Friction Melanosis (Level of Evidence: V—CR)

The dermoscopic examination of friction melanosis typically reveals brownish structureless areas arranged in a reticular fashion (Fig.  8 e) [ 115 ].

Terra Firma-Forme Dermatosis (Level of Evidence: V—CSS)

Dermoscopy of terra firma-forme dermatosis classically shows large polygonal plate-like brown scales arranged in a mosaic pattern [ 116 ].

Maculopapular Cutaneous Mastocytosis (Urticaria Pigmentosa, UP, and Telangiectasia Macularis Eruptiva Perstans, TMEP; Level of Evidence: V—CSS, CR)

The most common dermoscopic features of UP consist of a homogeneous light-brown blot and/or pigment network (Fig.  8 f), while TMEP is mainly characterised by reticular vessels on an erythematous/brownish base (“reticular vascular” pattern), sometimes associated with a brownish network [ 117 – 121 ]. However, dermoscopy cannot guarantee a reliable distinction of such conditions as, albeit uncommonly, UP may display the reticular vascular pattern as well [ 117 ]. Other less frequent vascular findings visible in both UP and TMEP include sparse dotted vessels and thin and tortuous linear vessels [ 117 – 121 ].

Itchy Papulonodular Dermatoses

Hypertrophic lichen planus (level of evidence: v—cr).

Dermoscopic examination of hypertrophic lichen planus lesions displays a characteristic pattern consisting of a rippled surface with comedo-like structures filled with yellow keratinous plugs and/or round corneal structures (“corn pearls”) (Fig.  9 a) [ 14 , 15 , 35 – 37 , 108 , 122 ]; less common features include Wickham striae, unspecific vascular findings (red globules, linear and dotted vessels), chalk-white structureless areas, scaling and central hyperpigmentation (Fig.  9 a) [ 14 , 15 , 35 – 37 , 108 , 122 ].

Dermoscopy of hypertrophic lichen planus shows a peculiar pattern characterised by a rippled surface with comedo-like structures filled with yellow keratinous plugs (black arrows) and/or round corneal structures (“corn pearls”) (black arrowheads); some irregular dotted vessels (black circle), scaling and central hyperpigmentation are also present in this picture ( a ). Dermoscopy of a prurigo nodularis lesion displays the typical “white starburst pattern”, with radially arranged whitish lines (black arrows) on a brownish and/or reddish background; central erosion and scales are also present in this case ( b ). Although dermoscopy of nodular scabies may often show the presence of mites (“hang glider sign”) and/or burrows (“jet with condensation trails”), it is not uncommon that the only detectable findings are nonspecific vascular features (mainly dotted vessels) ( c ). Dermoscopic examination of a case of reactive perforating collagenosis reveals the typical “three concentric areas” pattern, with a central round brownish-greenish/yellowish-brown structureless area, surrounded by a white keratotic collarette and an erythematous halo ( d )

Prurigo Nodularis (Level of Evidence: V—CSS)

The dermoscopic hallmark of prurigo nodularis (both hyperkeratotic and excoriated lesions) is represented by the presence of the so-called “white starburst pattern”, consisting of radially arranged whitish lines or peripheral whitish halo with some centrifugal coarse projections on a brownish and/or reddish background, which may surround brown-reddish/brown-yellowish crust(s), erosion(s) and/or hyperkeratosis/scales (Fig.  9 b) [ 106 ].

Nodular Scabies (Level of Evidence: V—CSS)

The distinctive dermoscopic sign of nodular lesions of scabies is the presence of mites (“hang glider sign”) and/or burrows (“jet with condensation trails”) [ 123 ]. According to a recent study on ten patients with nodular scabies, the latter dermoscopic finding would be constantly present in such a type of scabies [ 123 ], but in our experience it may be missing (especially in extragenital sites) and unspecific vascular features (mainly dotted vessels) may be the only detectable findings (Fig.  9 c) [ 1 ].

Acquired Perforating Dermatosis (Level of Evidence: V—CR)

The dermoscopic pattern of acquired perforating dermatosis is characterised by the presence of three concentric areas [ 1 , 106 , 124 , 125 ], namely a central round brownish-greenish/yellowish-brown structureless area (I), surrounded by a white keratotic collarette (II) and an erythematous halo with or without dotted vessels (III) (“reactive perforating collagenosis” histological subtype) (Fig.  9 d) [ 1 , 106 , 124 ] or bright white clods (I), centred in a structureless grey area (II), surrounded by reticular brown lines (III) (“perforating folliculitis” histological subtype) [ 125 ].

Erythrodermas

Erythrodermic psoriasis (level of evidence: v—cr).

Dermoscopy of erythrodermic psoriasis reveals a monomorphous pattern with diffusely distributed whitish scales and regularly arranged dotted/glomerular vessels on a fairly homogeneous reddish background [ 29 , 126 ].

Erythrodermic Atopic Dermatitis (Level of Evidence: V—CR)

As for other types of eczematous dermatitis, the most important dermoscopic features of erythrodermic atopic dermatitis consist of yellowish scales/serocrusts and patchily distributed dotted vessels on a pinkish background; unspecific sparse whitish scales may also be seen [ 29 ].

Erythrodermic Mycosis Fungoides (Level of Evidence: V—CR)

The most characteristic dermoscopic finding of erythrodermic mycosis fungoides is represented by the combination of linear vessels (some of them having a spermatozoon-like shape) and dotted vessels over a whitish-pinkish background; unspecific sparse whitish scales are also visible [ 29 ].

Erythrodermic Pityriasis Rubra Pilaris (Level of Evidence: V—CR)

Dermoscopy of erythrodermic pityriasis rubra pilaris typically displays peculiar orange blotches and islands of nonerythematous (spared) skin displaying reticular vessels; additional features include diffuse whitish scaling and scattered dotted vessels over a reddish background [ 29 ].

Erythrodermic Scabies (Level of Evidence: V—CR)

The main dermoscopic findings of erythrodermic scabies include whitish scales and thousands of characteristic dark-brown triangular structures located at the end of whitish structureless wavy lines (delta-wing jets with contrail) over a reddish background [ 127 ].

Common Forms of Noninfectious Balanitis and Erythroplasia of Queyrat

Zoon’s plasma cell balanitis (level of evidence: v—css).

The dermoscopic hallmark of Zoon’s plasma cell balanitis is the presence of focal/diffuse orange-yellowish structureless areas and/or fairly focussed curved vessels (including serpentine, convoluted and chalice-shaped); other possible findings include linear irregular blurry vessels and dotted vessels [ 128 ].

Psoriatic Balanitis

From a dermoscopic point of view, psoriatic balanitis is characterised by the presence of regularly distributed dotted/glomerular vessels [ 23 , 129 ].

Seborrheic Dermatitis and Non-Specific Balanitis (Level of Evidence: V—PO)

Seborrheic dermatitis and non-specific balanitis usually show only linear irregular unspecific blurry vessels [ 128 ].

Erythroplasia of Queyrat (Level of Evidence: V—CR)

Erythroplasia of Queyrat has been reported to show scattered glomerular vessels [ 130 ].

Common Inflammatory Cicatricial Alopecia

Discoid lupus erythematosus (level of evidence: ii).

The dermoscopic hallmarks of active discoid lupus erythematosus of the scalp are represented by follicular keratotic plugs (quite large yellowish/whitish dots) and thick arborising vessels (Fig.  10 a, b) [ 131 – 137 ]; additional findings include fine interfollicular scaling, blue-grey dots, scattered brown discolouration and red dots (Fig.  10 a) [ 131 – 137 ]. Thin arborising vessels emerging from the yellow dots (“red spider in a yellow dot”) are considered peculiar of late, prefibrotic lesions [ 133 ], while pink areas, loss of follicular openings, white areas and branching vessels are typical of long-lasting lesions (Fig.  10 c) [ 131 , 133 – 137 ].

Dermoscopy of discoid lupus erythematosus of the scalp varies according to the disease stage: active lesions may be mainly characterised by red dots ( a ) or follicular keratotic plugs (quite large yellowish/whitish dots) and thick arborising vessels ( b ), while long-lasting lesions commonly display loss of follicular openings, white areas and thin vessels ( c ). The main dermoscopic hallmarks of active lichen planopilaris are perifollicular scales; characteristic (but not pathognomonic) white dots (fibrotic white dots) (black arrowheads) and a reddish background are also present in less active areas in this case ( d ). Dermoscopic examination of a case of frontal fibrosing alopecia reveals minor perifollicular scaling with an aflegmasic (ivory white to ivory beige) surrounding background; follicular openings with only one hair at the hair-bearing margin (black arrows) and lonely hair (black arrowhead) are also visible ( e ). Classic dermoscopic appearance of active folliculitis decalvans showing follicular pustules, yellow discharge, crusts and characteristic hair tufts that contain >10 hair shafts (white arrowhead); unspecific vessels and erythema are also evident in the picture ( f )

Lichen Planopilaris (Level of Evidence: II)

The main dermoscopic features of active lichen planopilaris are perifollicular scales, which typically migrate along the hair shaft and form a tubular structure covering the proximal portion of the emerging hair shaft (“collar-like” or “tubular” perifollicular hyperkeratosis) (Fig.  10 d) [ 132 , 133 , 136 – 141 , 149 , 150 ]; other possible dermoscopic findings of active lesions include violaceous or violet-brown inter- or perifollicular violaceous areas (Fig.  10 d), perifollicular inflammation, elongated linear blood vessels in concentric arrangement and target “blue-grey dots” [ 132 , 133 , 136 – 141 , 149 , 150 ]. Inactive/late lesions may show characteristic (but not pathognomonic) irregular, large white dots (fibrotic white dots) (Fig.  10 d) as well as less specific findings such as acquired pili torti, loss of follicular openings, white areas, honeycomb/scattered hyperpigmentation, milky red areas (strawberry ice cream colour) and small hair tufts of 5–9 hairs [ 132 , 133 , 136 – 141 , 149 , 150 ].

Frontal Fibrosing Alopecia (Level of Evidence: II)

The most common dermoscopic findings in frontal fibrosing alopecia include a lack of follicular openings and minor perifollicular scaling [ 131 , 132 , 137 , 140 – 144 ]; additionally, perifollicular erythema may be seen but the surrounding background is usually aflegmasic (ivory white to ivory beige) (Fig.  10 e) [ 131 , 132 , 137 , 140 – 144 ]. Interestingly, there is often a strong predominance of follicular openings with only one hair at the hair-bearing margin and lonely hair may be observed (Fig.  10 e) [ 131 , 132 , 137 , 140 – 144 ]. Fine arborising vessels and perifollicular brown or brown-violet areas may sometimes be visible [ 131 , 132 , 137 , 140 – 144 ].

Folliculitis Decalvans (Level of Evidence: II)

The most characteristic dermoscopic feature of folliculitis decalvans is the presence of hair tufts that contain >10 hair shafts (Fig.  10 f), which are often surrounded by a band of yellowish scales (yellowish tubular scaling) and by perifollicular epidermal hyperplasia (which may be arranged in a starburst pattern) at their base [ 132 , 133 , 137 , 145 – 148 ]; other peculiar findings in active folliculitis decalvans include follicular pustules and yellow discharge and crusts (Fig.  10 f) [ 132 , 133 , 137 , 145 – 149 ]. A perifollicular concentration of blood vessels (elongated loops/coiled vessels) and a perifollicular erythema arranged in a starburst pattern may also be visible [ 132 , 133 , 137 , 145 – 147 , 149 ]. In long-lasting lesions, ivory-white and milky-red areas without follicular orifices predominate [ 145 ].

Common Nonscarring Alopecias

Alopecia areata (level of evidence: ii).

The most characteristic findings of active alopecia areata include black dots, micro-exclamation mark hairs, broken hairs, tapered hairs, monilethrix-like hairs and trichorrhexis nodosa, while long-standing inactive disease is mainly characterised by yellow dots and vellus hairs (Fig.  11 a) [ 131 , 139 , 151 – 158 ]. The main signs of regrowing consist of upright and regularly coiled (circle and/or pigtail) hairs [ 131 , 139 , 151 – 158 ]. Less specific/less common features of active stages include tulip hairs and zigzag hairs [ 151 , 152 ].

Dermoscopic examination of a case of active alopecia areata shows black dots and micro-exclamation mark hairs; regular yellow dots are also evident ( a ), while dermoscopy of trichotillomania reveals a chaotic pattern of diverse findings related to hair fracturing, including (in this case) hairs broken at different lengths, black dots, flame-like hairs (white arrow), tulip-like hairs (short hairs with darker, tulip-shaped ends white arrowhead) and V-sign (two or more hairs emerging from one follicular unit that are broken at the same level black arrowhead) ( b ). Dermoscopy of androgenetic alopecia typically shows hair shaft thickness heterogeneity, a large number of follicular units with only one emerging hair shaft, and an increased proportion of thin and vellus hairs (>10% of the hairs); wavy hairs are also visible (black arrowhead) ( c ). The most indicative dermoscopic clue of telogen effluvium is the lack of features typical of other diseases; empty hair follicles and follicular units with only one hair are also evident in this case of chronic telogen effluvium ( d )

Trichotillomania (Level of Evidence: II)

Dermoscopy of trichotillomania often reveals a chaotic pattern of diverse findings related to hair fracturing [ 151 , 159 ]. The most peculiar features include hairs broken at different lengths, short hairs with trichoptilosis (“split ends”), irregular coiled hairs, amorphous hair residues, black dots, flame-like hairs, tulip-like hairs (short hairs with darker, tulip-shaped ends) and V-sign (two or more hairs emerging from one follicular unit that are broken at the same level) (Fig.  11 b) [ 131 , 139 , 151 , 156 , 159 – 163 ]. Less common/less specific findings are tapered hairs, follicular microhemorrhages, micro-exclamation mark hairs and upright regrowing hairs [ 151 , 159 – 163 ].

Androgenetic Alopecia (Level of Evidence: IV)

The main dermoscopic features of androgenetic alopecia include hair shaft thickness heterogeneity, yellow dots (irregularly distributed and with a remarkable variability in size and shape), perifollicular discolouration (the peripilar sign), an increased proportion of thin and vellus hairs (>10 % of the hairs) and a large number of follicular units with only one emerging hair shaft (Fig.  11 c) [ 131 , 132 , 139 , 164 – 168 ]. Thin wavy hair and honeycomb hyperpigmentation often coexist as additional, nonspecific features (Fig.  11 c) [ 131 , 132 , 139 , 164 – 168 ].

Telogen Effluvium (Level of Evidence: IV)

The most indicative dermoscopic clue of telogen effluvium is the lack of features typical of other diseases (Fig.  11 d) [ 131 , 139 , 169 ]; common, but nonspecific, findings include the presence of empty hair follicles, a predominance of follicular units with only one hair, perifollicular discolouration (the peripilar sign), upright regrowing hairs (mainly acute forms) and progressive uniform hair thinning (chronic forms) (Fig.  11 d) [ 131 , 139 , 169 ]. There is no significant difference between the findings in the frontal area and those in the occipital area, which differentiates telogen effluvium from androgenetic alopecia; however, it is important to underline that both disorders may coexist [ 131 , 139 , 169 ].

Common Scaling Disorders of the Scalp

Tinea capitis (level of evidence: ii).

The main dermatoscopic features of tinea capitis are represented by “comma” hair (c-shaped hair shaft with a sharp, slanting end and homogeneous thickness), “corkscrew” hair (twisted or coiled, short, broken hair fragments), “zigzag” hair (hair shaft bent at multiple points) and “Morse code” hair [presence of multiple transverse bands (gaps) throughout the hair shaft] (Fig.  12 a) [ 151 , 170 – 187 ]. Other nonspecific trichoscopic findings in TC include broken and dystrophic hairs, i-hair, black dots, yellowish dots, erythema, scaling, pustules, elongated blood vessels, tufted hair and large yellowish wax-coloured perifollicular areas (favus) [ 151 , 170 – 187 ].

Scalp Psoriasis (Level of Evidence: III)

The most indicative dermoscopic features of psoriasis of the scalp are represented by red dots and red globules as well as (with a lower specificity) signet ring vessels, red loops, white scales, punctate haemorrhages and hidden hairs (Fig.  12 b) [ 138 , 188 – 190 ]. Additional (but unspecific) findings include other vascular structures, pigmentations (perifollicular pigmentation, honeycomb pigment pattern and brown dots) and white/yellow dots [ 138 , 188 – 190 ] .

Dermoscopic examination of a case of tinea capitis displays scaling and the peculiar “comma” hair (white arrow), “corkscrew” hair (white circle), “zigzag” hair (black arrow) and “Morse code” hair (black arrowhead) ( a ). Dermoscopy of scalp psoriasis reveals the typical dotted vessels (magnified in the upper-right box) and white scales; a haemorrhagic spot is also evident ( b ). Differently from psoriasis, scalp seborrhoeic dermatitis shows yellowish scales and the characteristic arborising vessels (white circle) ( c ). Dermoscopic examination of pityriasis amiantacea displays diffuse white scaling and the characteristic compact white keratotic material adhering to a tuft of hair (asbestos-like scale) ( d )

The most characteristic dermoscopic findings of seborrheic dermatitis of the scalp consist of arborising vessels [ 138 , 188 – 190 ]; additional indicative features are yellowish scaling, featureless areas (structureless red areas), honeycomb pigment and comma vessels (Fig.  12 c) [ 138 , 188 – 190 ]. Less specific finding include other vascular structures, pigmentations (perifollicular pigmentation, honeycomb pigment pattern and brown dots) and white/yellow dots [ 138 , 188 – 190 ].

Pityriasis Amiantacea (Level of Evidence: V—CR)

Dermoscopy of pityriasis amiantacea typically displays diffuse white scaling and the characteristic compact white keratotic material adhering to a tuft of hair (asbestos-like scale) (Fig.  12 d) [ 191 ].

Conclusions

Dermoscopy may be a helpful auxiliary tool in assisting the the noninvasive recognition/differential diagnosis of several “general” dermatoses by magnifying both surface structures and subsurface features that are invisible to the unaided eye and reflect the different histopathological background of each condition. Importantly, this article should be read with a critical eye as it presents three limitations: (1) the comparative analysis of several dermatoses is not the result of direct comparative studies but has been made merely considering the dermoscopic appearance of each condition; (2) the dermoscopic description of some considered diseases is based on limited observations; (3) the level of evidence assigned to each dermatosis is based on the study/studies showing the best evidence available, so some of the reported dermoscopic findings might come from works with a lower level of evidence. Of note, in this analysis, we also considered studies lacking strong evidence as there is a growing recognition that observational studies (even case series, case reports and anecdotes) may provide worthy information, especially if they are properly supported by mechanism-based reasoning (e.g. dermoscopic-pathological correlations) [ 192 – 194 ]. Anyway, further high-quality, prospective, blinded, controlled investigations are needed to better characterise the use of dermoscopy in general dermatology.

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Acknowledgments

We are extremely grateful to Dr. Angelo Piccirillo for providing us with Fig.  4 d and Prof. Pasquale Patrone for the outstanding encouragement to write this article. No funding or sponsorship was received for this study or publication of this article. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole and have given final approval for the version to be published.

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Enzo Errichetti and Giuseppe Stinco declare no conflict of interest.

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Errichetti, E., Stinco, G. Dermoscopy in General Dermatology: A Practical Overview. Dermatol Ther (Heidelb) 6 , 471–507 (2016). https://doi.org/10.1007/s13555-016-0141-6

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Unmasking Dermoscopic Evaluation of Melasma

Findings of a cross-sectional study in central india.

Sreenath, Sahana; Phulari, Yoganand J; Hiremath, Ravishekar N 1 ; Ghodke, Sandhya 2 ; Raj, Rishi 3

Department of Dermatology and STD, D. Y. Patil Medical College, Kolhapur, Maharashtra, India

1 Department of Community Medicine, AFMS, New Delhi, India

2 Department of Consultant Anaesthesiology, Rainbow Children Hospital, Bangalore, Karnataka, India

3 Department of Medical Informatics, AFMS, New Delhi, India

Address for correspondence: Dr. Yoganand J Phulari, Department of Dermatology and STD, D. Y. Patil Medical College, Kadamwadi, Kolhapur, Maharashtra, India. E-mail: [email protected]

Received March 01, 2022

Received in revised form May 05, 2022

Accepted May 07, 2022

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Background: 

There exists a wide range of variations in skin tone around the world, with Asian and Indian subjects showing a greater susceptibility toward pigmentation disorder.

Objective: 

This study was carried out with the objective to assess the clinical and dermoscopic findings among different types of melasma in a single center of Central India.

Materials and Methods: 

A cross-sectional study was carried out among patients with clinical features of melasma attending the outpatient department at multispecialty hospital with a sample size of 100. A prestructured pro forma was used to collect the baseline data. Clinical and dermatological examination was done after taking a detailed history. Clinical pattern of melasma such as centrofacial, malar, and mandibular was noted. The areas of melasma were examined using a contact polarized Dermlite DL4 3 rd Gen Dermoscope attached to an iPhone.

Results: 

The mean age of study participants was 38.15 years with a standard deviation of 6.93. Seventeen percentage were of male gender. Thirty-one percentage of the female patients had a history of oral contraceptive pill (OCP) usage, and 22% of the female patients had a history of menstrual abnormalities. Fitzpatrick skin Type IV was the most commonly affected skin type. Centrofacial type of melasma is the most common clinical type and reticuloglobular pattern is the commonly seen pattern on dermoscopy. The color of dermoscopy was predominantly brown in malar (52.2%) and mandibular (57.1%) and mixed in Centrofacial (45.7%), which was followed by 26.1%–28.6% mixed color in malar and andibular types and 41.4% brown color in centrofacial type. The difference in the color of dermoscopy ( P = 0.48), presence of telangiectasia on dermoscopy ( P = 0.23), pattern of dermoscopy ( P = 0.15), and mean Melasma Severity Index scores with different clinical types was not statistically significant. Similarly, the association between different clinical types of melasma with duration of sun exposure ( P = 0.33) and topical photo protection ( P = 0.34) was also not statistically significant.

Conclusion: 

Our study findings concluded that melasma is common in women in the age group of 27–56 years range. Exposure to sunlight and the hormonal changes (due to OCP usage) were those among the various factors influencing the development of melasma. Centrofacial melasma was the most common pattern seen in our study group. Epidermal melasma features on dermoscopy were reticuloglobular patterns with a brownish hue, while the features of dermal melasma were irregular patterns with a bluish hue and mixed melasma had irregular patchy brown pigmentation. Perifollicular globules and telangiectasia were also seen.

Introduction

There exist a wide range of variations in skin tone around the world, with Asian and Indian subjects showing a greater susceptibility toward pigmentation disorder.[ 1 2 ] Facial pigmentation is a major cosmetic and psychological concern. Indian society has shown an increasing demand toward fairness. This is evident from the fact that India comprises one of the largest global markets for fairness skin products.[ 3 ] Facial hyperpigmentary disorders include a common group of conditions that are characterized by hyperpigmented lesions on the face. The causes mainly comprise melasma, exogenous ochronosis, lichen planus pigmentosus, Riehl's melanosis, and various miscellaneous conditions. 20%–30% of middle-aged women present with melasma in India. The prevalence of postinflammatory hyperpigmentation is more than 70% in both men and women aged <35 years; this percentage was found to decrease to <10% after the age of 50 years.[ 4 ] Conditions such as lichen planus pigmentosus, cosmetic dermatosis, ashy dermatosis, and lesions of benign and malignant skin tumors are difficult to differentiate clinically. This poses a significant diagnostic and therapeutic challenge for dermatologists. This led to the advent of a new diagnostic technique, dermatoscopy.

Melasma is a chronic acquired hypermelanotic disorder of the skin characterized by brown macules which are irregular in shape and symmetrically distributed on sun-exposed areas of the body, particularly on the face. It is a common cause of demand for dermatological attention that affects mainly women (especially during the period of menarche). It affects mainly the pigmented phenotypes – Fitzpatrick skin Types III–V. Melasma impacts the quality of life of patients due to its frequent facial involvement[ 5 ] affecting their psychological and emotional well-being, which makes them to search for a dermatologist. As it has a very significant impact on appearance, it leads to emotional and psychosocial distress, thus reducing the quality of life of the affected patients.[ 6 ] Melasma is diagnosed mainly on a clinical basis. Melasma should be differentiated from other causes of facial hypermelanosis.[ 6 ] Biopsy is not routinely performed for the diagnosis of facial melanosis due to the risk of development of pigmentation or scar at the biopsy site and also the reluctance on the part of the patient.[ 7 ] Dermatoscopy is a noninvasive and reliable technique used for direct visualization of skin pigmentation and is increasingly being used for the diagnosis of pigmentary disorders. The characteristic dermoscopic patterns visualized on dermoscopy allow early diagnosis of melasma and help to differentiate it from other facial hypermelanoses. In view of the above, we carried out this study to assess the clinical and dermoscopic findings among different types of melasma.

Materials and Methods

A cross-sectional study was carried out among patients with clinical features of melasma attending the outpatient department at multispecialty hospital. The sample size was calculated based on the average yearly number of new patients diagnosed with melasma over the last 3 years in the hospital, adjusted to fulfill the inclusion and exclusion criteria which came out to be 100. Institutional ethical committee clearance was obtained and written informed consent was obtained from all the patients enrolled in the study. Patients on clinical examination showing melasma of postpubertal age and both the sexes were included in the study. Patients who did not give consent and those who had already received topical therapy for melasma and prepubertal age group were excluded. A prestructured pro forma was used to collect the baseline data. Clinical and dermatological examination was done after taking a detailed history. The areas of melasma were examined using a contact polarized Dermlite DL4 3 rd Gen Dermoscope attached to an iPhone. Statistical Package for the Social Sciences (SPSS) for Windows Version 22.0 Released 2013. Armonk, NY, USA: IBM Corp., was used to perform statistical analyses.

The mean age of study participants was 38.15 years with a standard deviation of 6.93. Seventeen percentage were of male gender. Thirty-one percentage of the female patients had a history of oral contraceptive pill (OCP) usage, and 22% of the female patients had a history of menstrual abnormalities. Fitzpatrick skin Type IV was the most commonly affected skin type, followed by Type V and Type III [ Table 1 ]. Centrofacial type of melasma is the most common clinical type followed by malar and mandibular types. Reticuloglobular pattern is the commonly seen pattern on dermoscopy, followed by irregular and perifollicular patterns. The color of dermoscopy was predominantly brown in malar (52.2%) and mandibular (57.1%) and mixed in centrofacial (45.7%), which was followed by 26.1% to 28.6% mixed color in malar and mandibular types and 41.4% brown color in centrofacial type. This difference in the color of dermoscopy between clinical types was not statistically significant ( P = 0.48) [ Table 2 ].

Telangiectasia was more predominantly seen in centrofacial type (42.9%), followed by malar type with 30.4% and relatively less in mandibular type (14.3%). However, this difference in the presence of telangiectasia on dermoscopy between different clinical types was not statistically significant ( P = 0.23). Reticuloglobular pattern was more predominant in malar (52.2%) and centrofacial type (58.6%) as compared to perifollicular pattern in mandibular clinical type (42.9%). However, this difference in the pattern of dermoscopy based on the clinical types of melasma was not statistically significant ( P = 0.15). Reticuloglobular pattern was more predominant in malar (52.2%) and centrofacial type (58.6%) as compared to perifollicular pattern in mandibular clinical type (42.9%). However, this difference in the pattern of dermoscopy based on the clinical types of melasma was not statistically significant ( P = 0.15). The mean Melasma Severity Index score for malar type was 20.52 ± 9.36, for mandibular type was 15.86 ± 9.82, and centrofacial type was 22.03 ± 9.78. This difference in the mean Melasma Severity Index scores was not statistically significant ( P = 0.24) [ Table 3 ]. The association between occurrence of different types of melasma with age, gender groups was not statistically significant ( P = 0.70) [ Table 4 ]. Centrofacial type was more predominantly expressed (55%–75%) irrespective of the duration of sun exposure. This was followed by malar type with 20%–30% occurrence and less seen with mandibular type (3.3%–15%). This association between different clinical types of melasma and duration of sun exposure was not statistically significant ( P = 0.33). Centrofacial type was more predominantly seen (67.9% to 77.3%) irrespective of the use of topical photoprotection, which was followed by malar type (22.7%–23.1%) and the mandibular type was not present (0%) with use of topical photoprotection as compared to those who did not use of topical photoprotection (9.0%). However, this association between the use of topical photoprotection and clinical types of melasma was not statistically significant ( P = 0.34) [ Table 5 ].

Hyperpigmented lesions on the face have always been a distressing symptom to the patient. In the present era, the people have been showing a growing interest in the physical appearance and especially toward fairness in our Indian population. Hence, the number of patients seeking dermatologist care for facial hypermelanosis has been increasing day by day. The field of dermatoscopy has been evolving mainly for the past one decade. In the earlier days, this technique was mainly used by developed countries in order to diagnose and monitor cases of melanoma. But now, the application of this office tool has been extended to developing countries as well. A number of studies and researches are going on regarding the use of dermatoscopy in various inflammatory, noninflammatory, and pigmentary conditions. Our study was an observational which mainly aimed at studying the importance of dermatoscopy in melasma. Melasma was classified into epidermal dermal and mixed based on the depth of melanin in the skin, which was initially examined on Wood's lamp and later confirmed on dermoscopy. Homogeneous reticular network of pigmentation was noticed in majority of the epidermal type of melasma. Dermal type of melasma on dermoscopy showed uniform skin involvement and no areas of sparing with dark brown to gray hyperpigmented lesions were observed. Mixed pattern of melasma on dermoscopy observed reticuloglobular pattern, exaggerated pseudo network with granular pigmentation, arciform structures, exogenous ochronosis, atrophy, and telangiectasias [ Figures 1 2 3 4 5 6 ]. The dermatoscopic features thus helped to classify melasma into epidermal, dermal, or mixed types and also observed additional features like telangiectasia which aids in designing of optimal treatment for the patients.

In our study involving 100 patients, the most common age group with melasma was between 31 and 40 years with a mean age of 38.15 years. The youngest patient was 27 years of age and the oldest was 56 years of age. Many of the previous studies reported similar age distribution although Jagannathan et al .[ 8 ] in their study found the patients belonging to the age range 20–30 as the most commonly affected. In another study on 140 patients, Yalamanchili et al .,[ 9 ] reported the mean age to be 37.13 years and the age range between 31 and 40 years. The test results showed that centrofacial type was more predominantly seen in patients with <40 (70.2%) and >40 years (69.8%), which was followed by malar type with 24.6% and 20.9% and relatively lesser occurrence of mandibular type with 5.3% and 9.3% in <40 and >40 years, respectively.

As in all the previous studies, females were more commonly affected with melasma than men in our present study with a male-to-female ratio of 1:3. In our study, 83% of females were affected and 17% of males were affected. This further substantiates the hormonal etiology of melasma. The test results demonstrated that centrofacial type was more predominantly present in both males (64.7%) and females (71.1%), which was followed by malar and mandibular types in males with 17.6% and in females with malar type with 24.1% and relatively lesser with mandibular type (4.8%).

Sunlight exposure

Exposure to sunlight is one of the important factors for the development of melasma. All the patients in our study had a history of sun exposure prior to the development of melasma. Seventy-one percentage of patients resided in an urban area and 29% of patients belonged to a rural area. Twenty percentage of the total patients had sunlight exposure of <1 h/day, 20% of the patients had 1–2 h of sun exposure, and 60% of them had more than 2 h of sun exposure every day. The test results demonstrated that centrofacial type was more predominantly expressed (55%–75%) irrespective of the duration of sun exposure. This was followed by malar type with 20–30% occurrence and less seen with mandibular type (3.3%–15%). The test results showed that centrofacial type was more predominantly seen (67.9% to 77.3%) irrespective of the use of topical photoprotection, which was followed by malar type (22.7%–23.1) and the mandibular type was not present (0%) with the use of topical photoprotection as compared to those who did not use of topical photoprotection (9.0%).

Our study results are consistent with a study by Pawar et al . who in their study found a 100% history of sun exposure.[ 10 ] However, Moin et al . in their study found a contrasting result with only 9.80% of their patients having a history of significant sun exposure.[ 11 ] The enormous difference between the findings among the studies may be explained probably by the geographical, cultural, and clothing differences in the studies.

Menstrual abnormalities in female patients

Out of 83 female patients in our study, 18 patients, i.e., 22% of females had menstrual abnormalities which are different as compared to observations made by Suthanther et al . where they found only 10.9% of the female patients with menstrual abnormalities in their study.[ 12 ]

Oral contraceptive pill usage

Thirty-one percentage of the females gave a history of OCP use prior to the development of melasma as compared to a study done by Jagannathan et al .[ 8 ] and Pawar et al .,[ 10 ] where only 13.75% and 16.30% of the females had a history of OCP usage, respectively.

Fitzpatrick skin type

Our study was done in the western part of India where most of the patients had Fitzpatrick skin Types 4 and 5. 45% of the patients belonged to Fitzpatrick skin Type 4, 42% of the patients belonged to skin Type 5, and 13% of the patients belonged to skin Type 3, as compared to the study done by Pawar et al .,[ 10 ] where 6.67% belonged to Type 3, 83.33% belonged to Type 4, and only 10% belonged to Type 5. The test results showed that centrofacial type was more predominantly expressed with all forms of Fitzpatrick skin types, i.e., Type III, IV, and V (61.5%–76.2%), which was followed by malar type ranging between 16.7 and 38.5% and least expressive in mandibular type with 0.0%–8.9%. However, this association between Fitzpatrick skin types and clinical types of melasma was not statistically significant ( P = 0.45).

Distribution of melasma

In our study, the prevalence of centrofacial melasma was 70%, malar Type 23%, and mandibular type being 7% as compared to Yalamanchili et al ., (2014),[ 9 ] where centrofacial type was 25%, malar type 68%, and mandibular Type 7.1%. In our study, centrofacial melasma was the most common type.

Color of dermoscopic findings

In our study, brown color was the most common color – 45%, followed by mixed (brown and bluish gray) type 40% and bluish gray color being 15%. The test results demonstrated that the color of dermoscopy was predominantly brown in malar (52.2%) and mandibular (57.1%) and mixed in centrofacial (45.7%), which was followed by 26.1% to 28.6% mixed color in malar and mandibular types and 41.4% brown color in centrofacial type.

Pattern on dermoscopy

In the present study, reticuloglobular pattern was the commonly found – 55%, followed by irregular pattern – 30% and perifollicular pattern – 15% as compared to Yalamanchili et al ., (2014),[ 9 ] where 95% was reticuloglobular pattern and 97% was perifollicular pattern. The test results showed that reticuloglobular pattern was more predominant in malar (52.2%) and centrofacial type (58.6%) as compared to perifollicular pattern in mandibular clinical type (42.9%). However, this difference in the pattern of dermoscopy based on the clinical types of melasma was not statistically significant ( P = 0.15). Thirty-eight percentage of the patients had telangiectasia in this study. The test results showed that telangiectasia was more predominantly seen in centrofacial type (42.9%), followed by malar type with 30.4% and relatively less in mandibular type (14.3%).

Mean melasma area and severity index score

The test results showed that the mean Melasma Severity Index score for malar type was 20.52 ± 9.36, for mandibular type was 15.86 ± 9.82, and centrofacial type was 22.03 ± 9.78. This difference in the mean Melasma Severity Index scores was not statistically significant ( P = 0.24), as compared to Yalamanchili et al ., (2014),[ 9 ] where the mean melasma area and severity index score was found to be 5.7.

As per the case report discussion by Sonthalia et al .,[ 13 ] in most of the extensively described literature, melasma dermoscopic features have mostly been mentioned in comparison to other facial melanoses. Reticular or pseudoreticular as common in deeper melasmas is the basic pattern[ 9 ] and the pigment suggests mainly of depth of melasma[ 14 ] although there are articles contesting it.[ 15 ] Dermoscopic pictures apart from being more treatment compliant is also a valuable tool in follow-up of melasma treatment.[ 16 ]

Nanjundaswamy et al .[ 17 ] in their findings showed characteristic wave-like pattern with dermal type presenting as gray color, epidermal type presenting with light brown color, and mixed type presented with dark brown color in middle-aged people and had statistical significance association. The explanation given by the authors is that during the initial stage, only epidermis had pigment deposition because of external factors, and age progression and various other factors such as multiple treatment regimens with hormonal influences led to the finally mixed type of melisma.

Our study findings concluded that melasma is common in women in the age group of 27–56 years range. Exposure to sunlight and the hormonal changes (due to OCP usage) were those among the various factors influencing the development of melasma. Centrofacial melasma was the most common pattern seen in our study group. Epidermal melasma features on dermoscopy were reticuloglobular pattern with a brownish hue, while the features of dermal melasma were irregular pattern with a bluish hue and mixed melasma had irregular patchy brown pigmentation. Perifollicular globules and telangiectasia were also seen. Our study recommends to carry out studies at multiple centers and with a large sample size to see the association of various variables with different clinical types which were not statistically significant in our study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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What’s in a Name—Dermoscopy vs Dermatoscopy

• 1 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York
• 2 Yale School of Medicine, New Haven, Connecticut

Dermoscopy improves diagnostic accuracy by uncovering dimensions of skin morphologic characteristics imperceptible to the naked eye. While the practice of dermoscopy has become common among dermatologists only in recent years, microscopic examination of the skin is actually a centuries-old practice.

Skin surface microscopy was first used in the mid-17th century by Peter Borelus and Johan Christophorus Kolhaus, primarily for examination of nailfold capillaries. In the early 20th century, Otfried Müller built portable monocular and binocular microscopes more easily used for clinical practice. A German dermatologist, Johann Saphier, first coined the term dermatoscopy in 1920 and outlined the possible clinical applications of skin surface microscopy. While Saphier used this practice primarily for the investigation of small skin vessels, he broadened its use to melanocytic nevi and introduced the term globules . 1

Read More About

Berk-Krauss J , Laird ME. What’s in a Name—Dermoscopy vs Dermatoscopy. JAMA Dermatol. 2017;153(12):1235. doi:10.1001/jamadermatol.2017.3905

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• v.11(1); 2021 Jan

Research in Dermoscopy: The Best Is Yet to Come!

Aimilios lallas.

1 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece

Giuseppe Argenziano

2 Dermatology Unit, University of Campania, Naples, Italy

It is not easy to precisely define when dermoscopy was “invented.” The first description of the idea of in-vivo direct skin microscopy goes back to 1950 when Leon Goldman applied it to detect cutaneous filariae [ 1 ]. As he extended his research to the in-vivo microscopic examination of nevi, he provided the first pieces of evidence on the potential of this method to uncover clinically invisible morphologic structures of skin tumors [ 2 ].

Twenty years later, in 1970, Rona MacKie provided the first description of the microscopic surface patterns of nevi, melanoma, basal cell carcinoma, and angioma [ 3 ]. In 1980, Fritsch and Pechlaner improved the technique and suggested that it had the potential of improving the clinical discrimination between benign and malignant skin neoplasms [ 4 ].

In the late 1980s the first efforts of systematically categorizing the observed features of lesions and assessing their diagnostic significance were published. Parameters to be evaluated would include patterns, colors, intensity of pigmentation, configuration, regularity, and other characteristics of the surface and the margin of the lesion [ 5 ]. This was, in fact, the introduction of pattern analysis in dermoscopy.

A deluge of publications by several research groups followed in the last decade of the twentieth century. Today, most of what is considered basic dermoscopy knowledge sprang from a plethora of publications within that short period. The modified pattern analysis, the ABCD rule of dermoscopy, the Menzies method, and the 7-point checklist were published between 1994 and 1998 [ 6 – 9 ]. Almost simultaneously, large studies on basal cell carcinoma and melanoma on specific locations (eg, acral, face) came to light [ 10 – 12 ].

At the beginning of the new millennium, when the first consensus meeting among dermoscopy experts was held, it seemed that all dermoscopy knowledge had been discovered [13]. It is true that most of the information included in the publication that summarized the consensus meeting of 2000 is still considered valid; but what followed in the increased amount of research, was totally unpredictable.

We used the Scopus database to retrieve data on publications on dermoscopy, using the following search terms: “dermoscopy” OR “dermatoscopy” OR “epiluminescence microscopy.” Our search revealed a total of 17,213 items. Of them, 392 items had been published in the years leading up to and including 2000 and 16,821 items have been published since 2001. Of the latter group, 3,426 were published between 2001 and 2010 and 13,395 between 2011 and 2020. The graphs below illustrate the number of publications per year, highlighting the almost exponential increase ( Figures 1 , ​ ,2, 2 , ​ ,3 3 ).

Several factors might be driving this impressive trend. Improved understanding of dermoscopic morphology generated the need for more profound investigations. The expansion of the use of dermoscopy in the field of inflammatory and infectious dermatoses opened a new horizon for scientific research. Above all, a new generation of young passionate researchers in the field has surfaced. Up to the year 2000, worldwide only 14 authors had published 10 or more papers on dermoscopy. Today, 145 authors have published more than 30 articles each.

The annual rate of published dermoscopy articles continued to increase steadily during the last decade. The 10 top authors of dermoscopy papers from 2011 to date are listed in Figure 4 and a list of the top 50 authors in Table 1 .

In the year 2020, which was dominated by the COVID pandemic, the number of published dermoscopy papers reached a historic high of 2,253 items, with 118 different authors publishing more than 5 papers each. The top 10 are listed in Figure 5 .

Several journals have published dermoscopy articles throughout the last decades, including all the top-ranking dermatology journals. The largest number has been published in the Journal of the American Academy of Dermatology (788), followed by the Journal of the European Academy of Dermatology and Venereology (571) ( Figure 6 ). The fact that the official journals of the 2 largest dermatologic societies in the world published so many papers on the topic highlights their popularity among reader-clinicians. Dermatology Practical and Conceptual is not included in this list because it is a new journal that only recently has been indexed by Scopus. Being the official journal of the International Dermoscopy Society and given us the considerable space we need to devote to dermoscopy papers, and we are confident that our journal will one day appear high up in this list.

Predicting the future is a difficult task, and we cannot know if this trend will continue in the forthcoming years or if it will stabilize. What we believe to be true of the future is that dermoscopy will continue to be an invaluable tool for clinicians, inspire research, and unite the medical community. These are the ideals to which we aspire.

Aimilios Lallas, MD

Deputy Editor

Giuseppe Argenziano, MD

Editor-in-Chief

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

Authorship: Both authors have contributed significantly to this publication.

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Dermoscopy of Inflammatory Conditions: The Journey So Far

Rajiv Gandhi University of Health Sciences, Bengaluru, India *Correspondence to [email protected]

The authors have declared no conflicts of interest.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License .

The use of dermoscopy in general dermatological practice has recently increased. Its non-invasive nature means it is being practiced frequently by dermatologists to diagnose various skin conditions. Dermoscopy, also known as dermatoscopy, allows dermatologists to quickly visualise skin structures up to the papillary dermis level. The skin patterns seen under dermoscopy are usually due to pigment and vascular structures; melanin and haemoglobin play major roles and give different patterns depending on the skin condition and pathological changes. Many inflammatory diseases are encountered by clinicians in daily practice; at times they are indistinguishable to the naked eye and a biopsy is required to confirm the diagnosis. Dermoscopy is a useful tool in the diagnosis and differentiation of inflammatory skin conditions and is aptly termed inflammoscopy when used in these situations. Inflammoscopy demonstrates the distinct characteristic patterns of many conditions and aids accurate diagnoses. In this article, the importance of dermoscopy in the diagnosis of relatively common inflammatory conditions, such as eczema, psoriasis, lichen planus, pityriasis rosea, pityriasis lichenoides et varioliformis acuta, pityriasis lichenoides chronica, and discoid lupus erythematosus, is highlighted. Here, an overview of dermoscopic patterns in each of these conditions is emphasised.

INTRODUCTION

Dermoscopy is a non-invasive diagnostic method that aids in the visualisation of surface and subsurface skin structures, leading to accurate diagnoses. In the past, it was used for pigmented lesions to differentiate melanoma from benign melanocytic lesions. 1 Recently, awareness and knowledge of dermoscopy have increased tremendously in many countries. Dermoscopy has expanded its applications not only to inflammatory but also to infectious conditions, with inflammoscopy being the term used for dermoscopic examination of inflammatory conditions. 2 Different names are given to dermoscopy based on the site as well as disease condition; trichoscopy is used for scalp and hair disorders, inflammoscopy for inflammatory conditions, and entomodermoscopy when infestation and infectious conditions are examined under dermoscopy. 3

Dermoscopy demonstrates the characteristic and often specific patterns of a skin condition, enabling physicians to diagnose the skin disease accurately. All patterns visualised using dermoscopy depend on the location and distribution of melanin and haemoglobin pigment in the skin layers. 4 This paper emphasises the utility of dermoscopy in the diagnosis of inflammatory conditions. In this review, the dermoscopic patterns of psoriasis, lichen planus (LP), pityriasis rosea (PR), prurigo nodularis (PN), eczema, pityriasis lichenoides et varioliformis acuta (PLEVA), pityriasis lichenoides chronica (PLC), and discoid lupus erythematosus (DLE) are described and their importance is highlighted. In inflammoscopy, accurate diagnosis can be made by considering criteria such as scale, lesion colour, type of vessels, and vessel arrangement and background colour. 5

STUDY AND DATA SELECTION

Articles and chapters were screened in journals and textbooks, respectively, for information on dermoscopy of inflammatory conditions. Both original and review articles were included. Articles describing the dermoscopic patterns of inflammatory skin conditions were selected. MEDLINE, PUBMED, and EMBASE were screened up to 2017.

The Basics of Dermoscopy

Normally, unaided eyes cannot visualise subsurface structures because incident light is reflected and some of this light gets absorbed. This is due to the differences in the refractive indices of the stratum corneum (1.55) and air (1.00), a phenomenon known as specular reflectance or glare. This is prevented by using an interface medium, which is applied onto the skin before a dermoscopic examination. Isopropyl alcohol, water, liquid paraffin, and ultrasound gel are all used as interface media fluids. This type of dermoscopy, wherein the dermoscope comes into contact with skin lesions, is known as non-polarised dermoscopy. Many authors state that contact with the skin surface results in nosocomial infections; this is avoided by using non-contact dermoscopy with polarised lights. The non-polarised method of dermoscopy assists in the recognition of superficial structures such as scales, milia-like cysts, and comedo-like openings, whereas the polarised mode helps in the visualisation of vessels and their arrangement, pigmentation, and dermal collagenous elements. Newer, hand-held dermoscopes have an inbuilt mode that changes from the polarised to the non-polarised technique with a click of a button. This is referred to as a blink sign. 4,6

Psoriasis is a common, chronic, disfiguring, inflammatory, and proliferative condition of the skin, characterised by red, scaly, sharply demarcated, indurated plaques, present particularly over extensor surfaces and the scalp. 7 Lallas et al. 8 studied dermoscopy of psoriasis and described dotted or coiled (glomerular) vessels arranged regularly. Though dotted vessels can be seen in other inflammatory dermatosis, the uniformity and homogenous distribution is characteristic of psoriasis ( Figure 1 ). In histopathology studies, the presence of red dots corresponds with the loops of vertically arranged vessels within the elongated dermal papillae. 8 Errichetti et al. 9 differentiated PLC from guttate psoriasis dermoscopically and stated that orange-yellow structureless areas and dotted and no-dotted vessels are characteristic in PLC, whereas diffuse dotted vessels are specific to psoriasis.

Figure 1: Dermoscopy of psoriasis shows scaling and regular red dots (orange arrows), which are regular and uniform on the dull red background. Few glomerular vessels (white circle) are noted (A). A red background is not prominent on the scalp (B). Lichen planus reveals annular white ring (Wickham striae); red areas (orange star), and linear vessels (black circle) are present at the periphery (C). Corn pearls (black stars), blue-grey areas, red globules, and peripheral brownish striations are present in hypertrophic lichen planus (D). In prurigo nodularis yellowish areas (red star), white areas, red dots, and clods (black arrows) are present in excoriated lesions (E) as well as bright white areas in a starburst pattern with red dots and clods in late lesions. Note the peripheral brownish striations (F).

Vázquez-López and Manjón-Haces 7 described the dermoscopic subpatterns of psoriasis as round capillaries (red globules) arranged in irregular circles or rings with a beaded, lacelike capillary appearance, termed red globular rings. These patterns are infrequently observed in a minimal number of cases of plaque psoriasis and are considered diagnostic. Two important additional findings, along with vascular pattern, are the presence of white scales and a light red background. Kibar et al. 10 observed two new dermoscopic signs that are specific to scalp psoriasis, namely signet ring vessels and hidden hairs. Apart from diagnosis, dermoscopy plays an important role in monitoring the disease. The number of twisted vessels visualised using high magnification represents the activity of the disease and the number of these vessels reduces in response to treatment. 11 Errichetti et al. 12 described the dermoscopic patterns in erythrodermic psoriasis, which revealed a monomorphous pattern, with diffusely distributed white-coloured scales and regularly arranged dotted/glomerular vessels on a fairly homogeneous red-coloured background. Although dermoscopy of psoriasis shows dotted vessels, in palmar psoriasis only diffuse scales are visible due to the thickness of these scales. Scales should be scraped in order to see the dotted vessels. 13 Clinical diagnosis of psoriasis is straightforward if the presentation is typical, consisting of silvery-white scales on an erythematous background. Atypical clinical presentations require a biopsy, which is invasive. However, this limitation is overcome by using dermoscopy, because of its non-invasive nature; the role of dermoscopy in the diagnosis of psoriasis is well established.

Lichen Planus

LP is an inflammatory dermatosis of the mucocutaneous surfaces that can present with a variety of clinical manifestations. Classical lesions of LP present as polygonal, flat-topped, violaceous papules and plaques, superimposed with reticulated white scale, termed Wickham striae (WS). Visualisation of this subtle but specific finding in LP can be enhanced by the application of water or oil to the affected area. Dermoscopy enables the visualisation of WS, which has been assessed as a highly sensitive and specific criterion for the diagnosis of LP ( Figure 1 ). WS correspond to compact orthokeratosis above zones of wedge-shaped hypergranulosis and acanthosis, centred on acrosyringia and acrotrichia. 8,14 WS is classically seen as white crossing lines on dermoscopic evaluation and defined as ‘reticular pattern WS’. Güngör et al. 15 described various other patterns of WS, including leaf veination, circular, radial streaming, linear, globular, annular, perpendicular, veil-like structureless, and a combination of these patterns. Reticular pattern is the most common pattern of WS.

The evolution of LP lesions can be monitored using dermoscopy. Early active lesions show WS arranged in a starburst pattern with a central thick white structure that expands into radial striations towards the periphery. The WS border shows projections of varying sizes, from thin spikes (comb-like appearance) to broad arboriform ramifications that may come together in networks. Prominent linear vessels are usually intermingled with the WS border projections (radial capillaries). 16

In matured lesions of LP, the arrangement of WS is usually seen as a reticular pattern and vascular structures are well established, appearing as red globules, dots, and linear striations. The pigment pattern appears at this stage as pigmented dots or globules scattered in the lesion. 15 In regressing lesions of LP, WS disappears and the pigmented network becomes more prominent. The pigment pattern at this stage appears as radiating streaks at the periphery of the lesion, grey-black structureless areas, grey-black linear streaks, or grey-black pigment dots. The distribution pattern of grey-black streaks and dots suggests that they represent a previous location of WS. 15 In hypertrophic LP (HLP), corn pearls or comedo-like openings and yellow areas are observed in addition to the aforementioned patterns. 17 Dermoscopy of LP gives many characteristic patterns that differentiate LP from other conditions, and it is particularly helpful in visualising unusual manifestations and LP coexisting with other conditions.

Prurigo Nodularis

PN is a chronic neurodermatitis that presents with intensely pruritic nodules that are secondary to an intense itch-scratch cycle. 18 Errichetti et al. 19 have noted pearly white areas in the centre, extending peripherally in a starburst pattern in PN. The patterns differ with respect to duration and type of lesion. Early and excoriated lesions show white areas, white scale, yellow erosion/crust, dotted or glomerular vessels, and haemorrhagic spots. Late and hyperkeratotic lesions demonstrate similar patterns in variable frequencies except for yellow erosion ( Figure 1 ). 19 Follicular plugging is an additional feature present in late lesions of PN. 19

Dermoscopically, nodular scabies, multiple keratoacanthoma, and HLP can be differentiated. Nodules in scabies that indicate mites or burrows appear as a hang glider sign, or show a jet with contrails. 20 Keratoacanthoma presents with a central white crust with peripheral hair pin and linear vessels. 21 HLP shows pearly white areas in the centre that differ from the white area seen in PN. In HLP, white areas do not cover the entire lesion; instead, they extend peripherally and are less prominent. Comedo-like openings are characteristically seen in HLP irrespective of the duration of lesions. Grey-blue globules that correspond to melanin in the dermis are seen in HLP but not in PN. 17

Peripheral brownish striations extending from white areas are also described as characteristic features of PN. These represent melanin deposited in elongated rete ridges as a result of inflammation. White areas correspond to dermal fibrosis. In the author’s experience, yellowish areas (representing discharge), brown and black dots, and globules (representing post inflammatory pigmentation) are new dermoscopic observations in PN. Hence, patterns of dermoscopy in PN vary according to the duration and evolutionary stage of the lesions. Early lesions demonstrate erosion, yellow areas, and ‘crusts’ and in late lesions, black or brown dots and follicular plugs are visualised. The white, starburst pattern is seen in all lesions irrespective of the lesion duration.

Discoid Lupus Erythematosus

DLE presents as erythematous patches and plaques with adherent scale and hyperpigmented borders. Photo-exposed areas are most commonly affected, but shaded sites such as the trunk and back are involved in generalised DLE. 22 The patterns of dermoscopy in DLE vary according to the stage of disease. Erythema, perifollicular whitish halo, follicular keratotic plugs, red dots, branching telangiectasia, and white scaling are the most characteristic features of early lesions ( Figure 2 ). These patterns correspond to inflammation, follicular pathology, and vessel involvement. 23 Late lesions demonstrate white-coloured structureless areas, hyperpigmentation in the form of a honeycomb network, perifollicular pigmentation, and a sprinkled pattern with blurred telangiectasias. The white areas represent fibrosis and the pigmentation is due to melanophages. 24 Diffuse hyperkeratosis, dilated follicles, and yellowish scales are examples of less commonly encountered dermoscopic patterns. 25

Figure 2: Dermoscopy of pityriasis lichenoides et varioliformis acuta shows white-yellow, structureless areas with crust, grey-blue radiating strands (black stars), red dots, and globules (black arrows) (A). Amorphous brownish area (orange arrow) and red dots (black arrows) at the periphery are noted (B). Pityriasis lichenoides chronica shows brownish structureless areas and red dots with a micaceous scale (C) and white-coloured areas (red stars) surrounding brown areas are noted (D). Discoid lupus erythematosus shows erythema, dilated follicles (black circles), telangiectasia (white arrows), and scaling (E), as well as the loss of follicular ostia, white areas (orange stars), and telangiectasia (white arrows) (F).

Pityriasis Lichenoides et Varioliformis Acuta

PLEVA is an acute inflammatory condition characterised by follicle-oriented pustules and crusts. 26 PLEVA can mimic various skin conditions such as chicken pox, lymphomatoid papulosis, guttate psoriasis, LP, and PR. Dermoscopic patterns give clues to the diagnosis: white-coloured, structureless areas, a central crust, red globules, blue-grey areas, yellow globules, and scaling are described in the literature as features of PLEVA ( Figure 2 ). 27 Authors described dermoscopic patterns in PLEVA that differ between early and late lesions. In the former, an amorphous brownish area around the hair follicles, within a rim of white scale and dotted vessels at the periphery, are noted; white-coloured, structureless areas and a central crust-plug surrounded by a rim of white scale, red dots and haemorrhages are observed in late phase lesions. 26 Vascular patterns vary from dots, to linear, to haemorrhages and are arranged either in a targetoid or dotted pattern. 26,27 Ankadand Beergouder 26 described new findings that correlated with histopathological changes, including focal blue-grey areas and yellow globules that represent melanin in the dermis and spongiosis and basal cell degeneration, respectively. Dermoscopic patterns correlate well with histopathological changes. Hence, by recognising clinical features and using dermoscopy, the diagnosis of PLEVA can be assumed.

Pityriasis Lichenoides Chronica

PLC clinically presents as purpuric macules and papules with micaceous scales on the surface that are adherent. Lesions heal with hypopigmented areas especially in skin Type 4, 5, and 6. PLC can be confused with guttate psoriasis and therefore dermoscopy plays an important supportive role in the diagnosis of PLC. The most peculiar dermoscopic findings in PLC include orange-yellowish structureless areas, focally distributed dotted vessels and milky-red globules, and linear irregular and branching vessels ( Figure 2 ). 3 Errichetti et al. 9 described dermoscopic differentiation of guttate psoriasis and PLC. Guttate psoriasis demonstrates regularly arranged red dots on a dull red background, whereas an orange-yellowish background with linear and dotted vessels is characteristic of PLC.

However, in the authors’ experience, brown structureless areas and white scaling in the centre, with dotted vessels and hypopigmented areas in the periphery are common, characteristic findings in PLC of melanin-rich skin. Linear vessels are not usually seen. We believe that differences in skin colour are contributing to the different background colours seen in PLC. A brownish background is likely due to haemosiderin deposition (due to extravasated erythrocytes), melanophages (focal basal cell degeneration), and lymphocytic infiltration.

Pityriasis Rosea

PR is a papulosquamous disease characterised by erythematous papules and plaques with peripheral scaling that is classically described as collarette scaling. Clinical differentiation of PR from dermatophytosis and psoriasis is difficult in unusual presentations. 28 Dermoscopy of PR is well established and both herald and daughter patches demonstrate typical patterns under dermoscopy. It shows diffuse and structureless yellow-orange areas, and characteristic focal white-coloured peripheral scaling ( Figure 3 ). Red dots, different from those seen in psoriasis, may be seen at the periphery but are less evident. 8,28

Figure 3: Dermoscopy of eczema reveals a yellow-orange crust, (A: asteatotic), yellow serocrusts (black arrow), and curvilinear white globules on a white background (B: subacute). Red dots are arranged in a regular (black circle) and cluster pattern (orange circle) (A, B, C, D). Nummular eczema shows focal white scales, a yellow-orange crust, red dots (C), diffuse white areas, and patchily arranged red dots (D: lichen simplex chronicus). Pityriasis rosea is shown by brown dots (red arrows), collarette scales on a yellow-brown background (E: late lesion), scale, and a brown globule (black star); milky pink dots and globules (white arrow) are noted in early lesions (F: early lesion).

These findings ensure dermoscopic differentiation of PR from other papulosquamous conditions. In psoriasis, red dots in regular patterns and scales are seen on a red background. A yellow or brown colour under dermoscopy is a negative factor for psoriasis; 29 however, the authors have observed brownish yellow backgrounds and brown dots in these patients, corresponding to the spongiotic tissue reaction plus haemosiderin deposits from extravasated red blood cells and lymphocytic infiltrate. A pronounced brownish hue on the background is related to the colour of the skin. This peculiar finding is frequently seen in late lesions of PR. Similarly, in early lesions, where pathological changes are not well formed, dermoscopy shows milky-red globules, indicating extravasated red blood cell in the dermis. Brown areas are very minimal suggesting early deposition of haemosiderin in the dermis. It is proven beyond doubt that dermoscopy demonstrates characteristic patterns in PR. Thus, patterns of PR seen under dermoscopy are accurate.

Eczema presents with patches and plaques on the extremities. Clinically, it mimics psoriasis, dermatophytic infection, and LP. Dermoscopy of eczema shows a yellow coloured serocrust and clusters of red dots and white scales ( Figure 3 ). Lallas et al. 8 evaluated the dermoscopic patterns of eczema and opined that patterns may change depending on the stage of the eczema. In the acute stage, yellowish crusts, dotted vessels in a patchy distribution, and focal white scales are seen. In the chronic and lichenification stages, white scales and clusters of red dots are noted. 8

In one study, dermoscopic patterns of hand eczema and palmar psoriasis were studied extensively. Eczema showed clusters of red dots, whereas psoriasis was characterised by diffusely arranged red dots. Yellow findings were specific to eczema. 13 In all types of eczema, vascular patterns are repetitive and the patchy distribution of red dots is very specific. However, focal white scales, yellowish serocrusts, and white areas are predominantly seen in acute and chronic stages of eczema, respectively. 13 Yellowish serocrusts correspond to spongiosis and serous discharge and white areas correspond to hyperkeratosis and acanthosis. A yellowish hue is characteristic of acute eczema and is referred to as ‘yellow clod’ sign. 30

However, with 10x magnification, the authors have noticed a presence of red dots and globules, especially in asteatotic and subacute eczema, in the same way as that of psoriasis. They are of different sizes and shapes, unlike in psoriasis where they are the same size, both uniform and regular. This dermoscopic finding is explained by the  fact that chronic scratching and rubbing result in psoriasiform hyperplasia. This results in diffusely arranged red dots over the entire lesion. This is a preliminary finding; further elucidation is required for this observation. Dermoscopy of erythrodermic atopic dermatitis consists of yellowish scales/serocrusts and clusters of dotted vessels on a pinkish background. Non-specific, sparse white-coloured scales may be observed. 12 These findings help clinicians to differentiate inflammatory conditions that present with erythroderma.

Dermoscopy is an in vivo method of diagnostic technique that enables the clinician to visualise the skin structures not seen by the naked eye. By supplying higher magnification of a lesion, dermoscopy provides a detailed analysis of the lesion, allowing the accurate diagnosis and treatment. Hence, dermoscopy is considered the stethoscope of dermatologists. Thus, the authors recommend dermoscopic examination of skin lesions in daily practice.

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Dermoscopy use in primary care: a qualitative study with general practitioners

Affiliations.

• 1 Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast (QUB), Belfast, Northern Ireland, UK. [email protected].
• 2 Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast (QUB), Belfast, Northern Ireland, UK.
• PMID: 35291937
• PMCID: PMC8925058
• DOI: 10.1186/s12875-022-01653-7

Background: Skin assessments constitute a significant proportion of consultations with family physicians (commonly called general practitioners or GPs in the UK), and referrals to hospital dermatology departments have risen significantly in recent years. Research has shown that dermoscopy use may help GPs to assess and triage skin lesions, including suspected skin cancers, more accurately. However, dermoscopy is used by a small minority of GPs in the UK. Previous questionnaire studies have aimed to establish in a limited way some perceptions of dermoscopy among GPs: this study aimed to explore more deeply the factors influencing the use of dermoscopy among GPs.

Methods: This was a qualitative interview study set in UK general practice. A purposive sample was taken of GPs who were established dermoscopy users, GPs who had recently adopted dermoscopy, and those who did not use dermoscopy. A total of twelve semi-structured interviews were conducted. Audio-recordings were transcribed verbatim and analysed using a thematic analysis (Braun and Clarke).

Results: GPs' capability to use dermoscopy necessitated receiving adequate training, while previous dermatology experience and support from colleagues were also considered factors that enabled dermoscopy use. The impact of dermoscopy on patient consultations about skin complaints was generally considered to be positive, as was having an 'in-house' dermoscopy user within a GP practice to refer patients to. However, training in dermoscopy was not considered a priority for many GPs either due to other more pressing concerns within their practices or the perceived complexity of dermoscopy, alongside barriers such as equipment costs. Significant ethical concerns with posting patient photographs online for training and teaching purposes were also highlighted.

Conclusions: Both GPs who use dermoscopy, and those who do not, consider it to have an important role in improving skin assessments within primary care. However the need for adequate training in dermoscopy and dermatology more generally was highlighted as a key barrier to its wider use. The development of competency standards for the use of dermoscopy could allow the adequacy of training to be assessed and developed.

Keywords: Dermatology; Dermoscopy; Family Practice; General Practice; Melanoma; Qualitative research.

© 2022. The Author(s).

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Conflict of interest statement

Since the conclusion of this study, F.M. has developed a course on skin lesion recognition in primary care that includes the use of dermoscopy. The other authors have no competing interests to declare.

A pigmented skin lesion shown…

A pigmented skin lesion shown as A a clinical image; and B a…

Overview of themes derived from…

Overview of themes derived from thematic analysis

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Thesis Topic

Iadvl postgraduate thesis topic bank proposed by sigs (iadvl academy) - (2022).

PG Thesis Protocol Template

SIG Aesthetics

• MNRF with PRP vs MNRF in striae – A comparative, clinico- histopathological study.
• The efficacy of PRF or Biofiller in Acne scars – A clinicohistopathological study with grading of scars.
• Dermal threads vs 5% minoxidil in androgenetic alopecia
• Botulinum toxin vs Microneedle Radiofrequency in axillary hyperhidrosis – A comparative assessment
• PRP vs tranexamic acid mesotherapy – A split face comparative study
• Scar revision outcome analysis with and without botulinum toxin
• DLQI of patients attending aesthetics clinic

SIG Dermatology Clinical Research

• Randomized controlled trial comparing the efficacy and safety of intralesional vitamin D versus cryotherapy in the treatment of verruca vulgaris
• A randomized controlled trial comparing the efficacy and safety of intradermal MMR versus 10% KOH in the treatment of molluscum contagiosum in children
• A randomized controlled trial comparing the efficacy and safety of topical timolol versus oral propranolol in the treatment of infantile hemangioma
• A randomized controlled trial comparing the efficacy and safety of oral cochicine versus oral isotretinoin in the treatment of lichen planus pigmentosus
• A randomized controlled trial comparing the efficacy and safety of oral Cyclosporine versus oral corticosteroids in the treatment of atopic eczema
• A randomized controlled trial comparing the efficacy and safety of daily oral corticosteroids versus mini-pulse in the treatment of rapidly progressive non-segmental vitiligo
• Risk factors for STI in CSWs/ MSM/ STI clinic attendees
• Prevalence of acquired ichthyosis in diabetes and its relationship with systemic complications
• Costing of care in pemphigus
• Comparison of quality of life / expenses in various treatments in psoriasis.
• Prevalence and outcome of telogen effluvium in primi gravida
• Quality of life outcomes in acne vulgaris
• Assessment of insulin resistance and metabolic panel in psoriasis, acne, acne inversa, AGA, vitiligo.
• RCT comparing the efficacy and safety of excimer vs targeted broad band UV B in the treatment of focal, non-segmental vitiligo
• Dermoscopy in topical steroid damaged face
• Validating a severity score in TSDF
• RCT – microneedling vs MNRF for acne scars
• RCT – microneedling vs MNRF for striae
• RCT single wavelength vs combination lasers in hair removal
• Risk factors for development of infantile hemangioma
• Assessment of neuropsychatric manifestations in atopic eczema
• Quality of life in patients with alopecia areata
• ACE receptors in hair roots- Could that explain severe hair loss post Covid?
• Sexual problems in patients suffering from genital psoriasis.
• Topical tofacitinib for acral vitiligo
• Compliance of treatment in acne patients - clinical factors
• Efficacy and safety of DPCP in AA
• Dermoscopy in follicular disorders
• Oral minoxidil for AGA

SIG Dermatopathology

• Dermoscopic and histopathologic correlation in lichen planus
• Clinical, histopathological and immunohistochemical study of CD4 and CD8 T lymphocyte subsets in lichen planus
• Role of plasmacytoid dendritic cells in differentiating conditions with interface dermatitis
• Histopathological features of lichen sclerosus et atrophicus
• Clinicopathological correlation in connective tissue diseases and correlation with ANA titer
• Study of clinical and histological features of pityriasis rosea, pityriasis lichenoides, guttate psoriasis: a comparative study
• Clinical, histopathologic and immunofluorescence study in cutaneous amyloidosis
• Clinico-dermoscopic-histopathological correlation of cicatricial alopecias
• Clinico-immunopathological correlation in vasculitis
• Study of T lymphocytes (CD4, CD8, regulatory cells), B lymphocytes, natural killer cells, FOXP3, TGF-β1 AND IL-10 mRNA levels in blood using real time PCR and expression of CD4, CD8, granzyme B, TGF- β1 and IL-10 in skin biopsy using IHC in vasculitis and their comparison post treatment
• Invisible dermatoses: a histological spectrum (clinically invisible)/ True invisible dermatoses (clinical and histological), can CPC help?
• Neutrophils in stratum corneum on an acanthotic epidermis: a spectrum
• Dermoscopic-histologic correlation in vitiligo activity
• Histopathological spectrum of cutaneous reactions to novel targeted chemotherapeutic agents
• Clinico-histopathologic study of erythrodermas
• Clinico-histopathological study of porokeratosis
• Clinico-histopathological spectrum of panniculitis
• Clinico-histopathological spectrum of allergic contact dermatitis
• Clinico-histopathological correlation in prurigo nodularis
• Clinico-histopathologic study of reactions to tattoos
• Eosinophilic dermatoses: A clinical and histopathological spectrum
• Correlation of BI in slit skin smears (SSS) versus histopathology
• Sensitivity of earlobe SSS in patients with no clinical ear lobe thickening
• Sensitivity of SSS vis a vis type of leprosy
• Clinicopathological and radiological correlation in Hansen’s disease
• Dermoscopic and histopathological correlation in various poles of leprosy: a prospective study
• Macrophage differentiation (M1/M2) in different types of leprosy and correlation with treatment outcome
• Role of B cells and plasma cells in leprosy
• Role of regulatory T cells in leprosy and correlation with treatment outcome
• Study of different types of granulomas in common granulomatous disorders
• Clinico-histopathologic study of rash in secondary syphilis
• Clinico-pathological correlation of subcutaneous/ deep fungal infections
• Necrobiotic granulomas: A clinical and histopathological spectrum
• IHC vs. DIF in immunobullous disorders
• Clinico-histopathologic study of epidermolysis bullosa
• Clinico-histopathologic and immunofluorescence study in dermatitis herpetiformis
• Role of DIF in sub-epidermal bullous diseases
• Dermoscopic-histologic correlation in skin tumors
• Immunohistochemistry as an aid in the diagnosis of adnexal tumors
• Comparative immune-histochemical studies for mycosis fungoides and parapsoriasis
• Benign vs. malignant cutaneous lymphoid infiltrates: role of histopathology and immune-histochemical studies

SIG Dermoscopy

• Dermoscopic in monitoring treatment of warts.
• Dermoscopic and histological comparison of palmoplantar eczema and palmoplantar psoriasis.
• Dermoscopy in noninfective granulomatous disorders.
• Dermoscopic prognostic factors of alopecia areata in relation to intralesional triamcinolone actonide monotherapy.
• A cross-sectional study of clinicodermoscopic features of various causes of pigmentation of the face of middle-aged individuals (acanthosis/ postinflammatory hyperpigmentation/amyloidosis/melasma/ maturational hyperpigmentation).
• Comparative dermoscopic study of alopecia areata and trichotillomania.
• Dermoscopic features of cutaneous T cell lymphoma - a cross-sectional study.
• Clinico-dermoscopic and histopathological correlation in nail tumors.
• Therapeutic monitoring of scabies treatment by dermoscopy.
• Clinical and dermoscopic features of palmoplantar keratodermas.
• A clinical and dermoscopic study of inflammatory follicular disorders.
• Onychoscopy to evaluate treatment response in onychomycosis.
• Dermoscopy to evaluate treatment response in rosacea/ demodicosis.
• Clinico-dermoscopic study of topical steroid damaged facies (TSDF).
• Clinicodermoscopic assessment of facial aging - a comparison between males and females.
• Role of dermoscopy in assessing therapeutic response to tacrolimus or topical clobetasol in limited alopecia areata.
• Role of dermoscopy in differentiating guttate vitiligo, idiopathic guttate hypomelanosis and guttate lichen sclerosus.
• A longitudnal study to delineate specific signs of alopecia areata across the subtypes - Acute, chronic, patchy, total. (histological correlation if feasible)
• Dermatoscopic features of macular amyloidosis.

SIG Dermatosurgery

• Surgical intervention in keloids and relapse rates
• Dermaroller vs Fractional CO2 laser with/without PRP in acne scars (split face study)
• Nail biopsy success rate in diagnosis
• Radio frequency subcision vs subcision in acne scars
• Platelet rich fibrin efficacy in periorbital wrinkles
• Intralesional triamcinolone with or without dermaroller in alopecia areata
• Dermaroller with or without PRP in split scalp trials for AGA
• Comparative study of different vitiligo surgeries on bilateral lesions
• Comparison of PRP preparation with different techniques to assess platelet counts
• Potential scarification of scalp with multiple PRP sessions and its effect on results of hair transplant

SIG Female Genital Dermatoses

• Study on Psychological morbidity in vulvar pruritus
• Study of sexual dysfunction in cases of painful genital conditions
• Pediatric vulvar dermatoses- etiopathogenic and clinical study
• Clinical and etiological study of vulvovaginal itching
• Clinical and etiological study of inflammatory vulvar dermatoses
• Assessment of female sexual dysfunction and quality of life in females with chronic vulvar dermatoses
• Clinical and etiopathogenic study of vulvovaginal discharge
• Questionnaire based study on genital hygiene practices in women with and without chronic vulvar dermatoses
• Combined effect of MNRF and Fractional CO2 Laser in moderate to severe acne scars
• Effect of fractional CO2 in hypertrophic scar
• Fractional CO2 or erbium YAG laser in Tentative cuts
• Comparative study of effect of nail lacquer versus fractional CO2 laser in onychomycosis
• Q switched versus LP Nd YAG laser in onychomycosis
• MNRF in Androgenetic alopecia
• Q switched and YAG for the treatment of Xanthelesma palpebrum.
• Ultra pulse co2 laser versus Q switched Nd YAG for mole removal comparative study
• Efficacy of fractional co2 laser (vaginal probe ) for vaginal tightening
• Combination of Fractional CO2 and PRP in stable non-segmental vitiligo.
• Combined fractional and q switched Nd Yag lasers for tattoo removal
• Combination of Q switched Nd Yag and long pulse Nd Yag for Beckers nevus
• Fractional Mnrf Vs co2 laser split face study
• Q switched nd yag laser vs co2 and q switched combined for tattoos
• Co2 laser efficacy in keloids
• CO2 laser plus PRP efficacy in striae
• Laser hair reduction in skin of colour.
• Treatment of Spider Veins Using 810 nm Diode Laser
• Difficult to treat scars management with combination therapy.
• A comparative study of q switched ndYag + fractional CO2 versus Q switched ndyag alone for tattoo removal
• Comparative study of triple wavelength hair removal laser low fluence multiple pass to high fluence single pass
• Treatment of hidradenitis suppurative with lasers
• Laser treatment of Acne keloidalis nuchae
• Treatment of hidradenitis suppurativa with lasers
• Laser treatment for periorbital melanosis
• Laser treatment for Lip pigmentation
• Comparative study of Fractional CO2 laser v/s LP/QSw Nd:YAG laser for for the treatment of Onycomycosis.
• Comparative study of Fractional CO2 v/s MNRF for striae.
• Q SW Nd:YAG v/s combination of Fractional CO2 + Q Sw NdYAG for Nevus if Ota
• Comparative study of pin point CO2 laser v/s intralesional RF for papular acne scars.
• Efficiency of Gold Toning + topical Clindamycin for acne v/s only Gold toning.
• Fractional Nd:YAG for melasma
• Q SW Nd:YAG v/s arginine peel for periorbital hypermelanosis

SIG Leprosy

• Assessing effectiveness of alternative drug regimes in Leprosy
• High frequency ultrasound to study the changes in nerve pre and post treatment
• Comparative histopathology of skin and nerve in leprosy patients
• Study of oxidative stress in lepra reaction
• Observational study on ocular changes in leprosy in the post elimination era
• Assessing effectiveness of prophylactic prednisolone vs therapeutic prednisolone for leprosy neuropathy
• Use of Immunofluorescence microscopy (Rhodamine-O) staining Vs Slit skin smear for Acid fast bacilli
• Efficacy of alternative antimicrobials in the treatment of leprosy
• Assessing efficacy of chemoprophylaxis/immunoprophylaxis in leprosy
• Psychosocial burden in leprosy
• Social stigma and leprosy
• Dermatoscopic evaluation of cutaneous lesions of leprosy
• Nutritional assessment of patients with leprosy
• Clinical and histopathological evaluation of safety, efficacy, tolerability of current three drug MDT PB regimen vs the two-drug regime in paucibacillary Hansen's disease
• Plantar arch assessment in patients with plantar hypoesthesia and trophic ulcers in Leprosy
• An exploratory study of Microbiomes in plantar ulcers
• Study of Grade 2 disabilities in new leprosy patients
• Study of grade 2 disabilities in childhood leprosy
• Study of childhood leprosy in a Dermatology OPD over 1 year period
• Study of leprosy in elderly leprosy patients > 60 years of age
• Study of residual deformities and disabilities in Released From Treatment (RFT) patients
• A study of benefits of use of EMLA cream before performing slit skin smears in suspected leprosy patients
• Clinical and histological study of BB leprosy and its annular / ring shaped lesions
• Use of different regimens/ schedules of prednisolone in type 1 reactions in leprosy patients
• Study of use of thalidomide in type 2 reactions, its dosage, tolerability and adverse effects
• Slit skin smear examination in MB leprosy: inter-site variations
• Use of MiP vaccine as adjuvant in MB leprosy- clinico-histologial study
• Dermatoscopic study of clofazimine induced pigmentation
• Study of facial lesions in leprosy patients
• Study of use of SW filaments in sensory assessment in young v/s older leprosy patients
• Use of cosmetic camouflage in facial leprosy patches for improving Life quality index

SIG Neglected tropical diseases

• Study on type of cutaneous tuberculosis and its dermoscopic features
• Comparative study on oral ivermectin + topical ivermectin and oral ivermectin + topical permethrin in scabies and ivermectin alone
• Secondary bacterial infection in scabies patients and its determinants
• Incidence and clinical characteristics of childhood leprosy. Observational study in tertiary care hospital
• Histopathological patterns of cutaneous tuberculosis
• Histopathological study of Cutaneous leishmaniasis
• Dermatological manifestations in lymphatic filariasis and their management
• Clinical, microbiological (smears and culture) and histopathological characteristics of subcutaneous mycosis and mycetoma
• Positivity rate of LD bodies in cutaneous leishmaniasis tissue smear and factors modifying it
• To study the patterns of treatment response and multi-drug resistance in late / non-responders to first line anti-tubercular treatment in cutaneous tuberculosis
• Molecular identification and antifungal susceptibility testing in subcutaneous mycoses
• Comparison of tissue culture and polymerase chain reaction in the diagnosis of atypical mycobacterial infections
• Apremilast in type 2 Lepra reaction
• Azathioprine in type 2 lepra reaction
• Factors affecting Grade 2 disability in leprosy
• Comparison of IL-17 levels among leprosy patients with and without reaction

SIG Pediatric Dermatology

• Comparative study of efficacy of topical Ozenoxacin versus Mupirocin in Impetigo Contagiosa
• Efficacy and Safety of Apremilast in childhood Alopecia Areata
• Spectrum of Ocular changes in Pediatric Atopic Dermatitis : A Observational study
• Comparative study on PRP versus ILS in pediatric Alopecia Areata
• RCT on the safety and efficacy of Bilastine vs Levocetrizine in Chronic spontaneous Urticaria
• RCT on JAK inhibitor Tofacitinib vs conventional OMP in the management of Childhood Vitiligo
• Clinico epidemiological profile of Psychocutaneous Disorders in Adolescence
• Dermoscopic and Histopathological correlation in Pediatric Psoriasis
• Clinical, dermoscopic and epidemiological study of alopecia in pediatric age group.
• Spectrum of nutritional dermatoses in pediatric age group
• Spectrum of SCAR - severe cutaneous ADR in pediatric group
• Clinical and investigative study of Autoimmune Connective Tissue Disorders in pediatric age group
• PPD verses Vit D3 injections in warts in peadiatric pts, comparitive study

SIG Pigmentary diseases

• Suction blister graft versus excimer for acro facial lip vitiligo
• Dermascopy in ADMH
• A clinico-histopathologic and dermoscopic correlation of facial melanosis
• Patch test in facial melanosis
• Endocrinal profile of progressive vitiligo

SIG Pruritus

• To evaluate the burden of chronic pruritus in cancer patients in an oncology center
• Clinical and immune-pathological study of chronic pruritus in geriatric population
• Study of genital itch in patients attending dermatology and gynecology outpatient department in a tertiary care center
• Clinico epidemiological study of scalp pruritus
• Clinical and immune-pathological study of chronic prurigo
• Post herpetic itch - A clinico epidemiological study
• To evaluate association of hematological parameters with severity of itch in chronic pruritus of non dermatological origin
• Pruritus ani: A clinico-investigative study

SIG Psoriasis

• Lipid Accumulation Product Index as Visceral Obesity Indicator in Psoriasis
• Prevalence of Metabolic Syndrome in Psoriasis Patients and its Relation to Disease Duration
• Atherogenic index of plasma in psoriasis patients
• C-reactive protein and cardiovascular risk in patients with psoriasis.
• Dyslipidaemia & oxidative stress in patients of psoriasis
• Comprehensive lipid tetrad index as a marker for increased cardiovascular risk in psoriasis
• Methotrexate vs Apremilast in treatment of palmoplantar psoriasis
• Erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti- cyclic citrullinated peptide antibodies in nail psoriasis
• Coexistence of onychomycosis in psoriatic nails
• Alcoholism in psoriasis
• Comorbidities in childhood psoriasis
• Renal dysfunction in chronic plaque psoriasis
• USG evaluation of enthesial thickness in psoriasis patients
• Mometasone Vs Mometasone + Tazarotene in management of limited lesions of plaque psoriasis
• Incidence of Co-morbidities in patients having moderate psoriasis (PASI>5)
• Comparative study of therapeutic response with oral systemic drugs in patients with moderate psoriasis ( metho, Acetretin, cyclosporine, alert,tofacitinib) 10-15 patients in each group
• Correlation between histopathologic and dermoscopic findings in various types of psoriasis
• Comparison of NBUVB VS NBUVB plus Apremilast in moderate to severe psoriasis- an observational study
• Evaluation of serum “THYMIC STROMAL LYMPHOPOIETIN (TSLP) in Psoriasis patients in comparison to controls- a case-control study
• Correlation of CXCL 10 and PEST (Psoriasis Epidemiology Screening Tool ) in patients of Psoriasis-A prospective study
• Study of health-related Quality of life in moderate to severe psoriasis pediatric age group
• Evaluating the efficacy and safety of Apremilast in refractory scalp psoriasis-A prospective study

SIG Recalcitrant Dermatophytoses

• Correlation of MIC levels, mutations with clinical response to Antifungals
• Role of immunity  in extensive,  atypical and aggressive  Dermatophytosis
• Intra familial cases
• Clinico-mycological study of the association of onychomycosis with chronic dermatophytosis versus naive cases of dermatophytosis
• Clinical, dermoscopic and mycological study of tinea pseudo imbricata
• Clinical epidemiological and mycological study of dermatophytosis in children
• Clinical epidemiological and mycological study of dermatophytosis in pregnancy
• Adverse drug reactions to oral antifungal drugs
• Prevalence of atopy in chronic dermatophytosis
• The sensitivity of oral antifungals in immunocompetent versus immunosuppressed individuals
• Treatment response when oral terbinafine is combined with topical terbinafine versus oral terbinafine with azole topical
• Resistance studies vis a vis species of dermatophyte

SIG Trichology & hair transplant

• Comparison of PRP VS IPRF -split scalp prospective study
• Finasteride vs Dutasteride in patterned hair loss
• Tofacitinib in alopecia areata, comparative analysis of 5mg vs 10mg vs 20mg
• Comparative study of Topical minoxidil with finasteride vs dutasteride lotion

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