ArticlePDF AvailableLiterature Review

Dermoscopy in General Dermatology: A Practical Overview

September 2016
Dermatology and Therapy 6(4)

September 2016
6(4)

DOI:10.1007/s13555-016-0141-6

License
CC BY-NC 4.0

Authors:

Enzo Errichetti

University of Udine

Giuseppe Stinco

University of Udine

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).

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)

…

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)

…

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)

…

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)

…

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)

…

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REVIEW

Dermoscopy in General Dermatology: A Practical

Overview

Enzo Errichetti .Giuseppe Stinco

Received: July 12, 2016

The Author(s) 2016. This article is published with open access at Springerlink.com

ABSTRACT

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,

Enhanced content To view enhanced content for this

article go to http://www.medengine.com/Redeem/

2295F06011919714.

E. Errichetti (&)G. Stinco

Department of Experimental and Clinical Medicine,

Institute of Dermatology, University of Udine,

Udine, Italy

e-mail: enzoerri@yahoo.it

Dermatol Ther (Heidelb)

DOI 10.1007/s13555-016-0141-6

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).

Keywords: Dermatitis; Dermatoscopy;

Dermoscopy; Differential diagnosis;

Inﬂammoscopy; Trichoscopy

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

Dermatol Ther (Heidelb)

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, SCRand/or PO) in case the level

V turns out to be the best evidence available.

Tables 1,2,3,4,5and 6provide 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. 1a) [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].

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. 1b) [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

Dermatol Ther (Heidelb)

Table 1 Summary of the dermoscopic clues of all the dermatological disorders considered, divided according to their clinical pattern (Part I)

Clinical

pattern

Dermatoses presenting with

erythematous-desquamative

patches plaques (I)

Dermatoses presenting with

erythematous-desquamative patches

plaques (II)

Papulosquamous—

papulokeratotic dermatoses (I)

Papulosquamous—

papulokeratotic

dermatoses (II)

Dermoscopic

clues of each

dermatosis

Plaque psoriasis:

•White scales

•Symmetrically and regularly

distributed, dotted vessels on a

light or dull red background

Eczematous dermatitis:

•Yellow serocrusts

•Dotted vessels in a patchy

distribution

Pityriasis rosea:

•Peripheral whitish scales

(‘‘collarette’’ sign)

•Irregular or patchy dotted vessels

Mycosis fangoides:

•Orange-yellowish patchy areas

•Linear vessels with or without red dots

forming peculiar ‘‘spermatozoon-like’’

structures

Subacute cutaneous lupus

erythematosus:

•Whitish scale

•Mixed vascular pattern (at least two

types among dotted, linear-irregular,

linear and branching vessels)

Lichen planus:

•Wickham striae

Papulosquamous sarcoidosis:

•See ‘‘Facial inﬂammatory skin

diseases (II)’’

Pityriasis rosea:

•See ‘‘Dermatoses presenting

with

erythematous-desquamative

patches plaques (I)’’

Guttate psoriasis:

•Diffusely distributed

dotted vessels

Pityriasis lichenoides

chronica:

•Nondotted vessels

•Focally distributed

dotted vessels

•Orange-yellowish

structureless areas

Classic pityriasis rubra

pilaris:

•Round/oval yellowish

areas surrounded by

linear dotted vessels

•Central keratin plugs

More common in acute exudative lesions

More common in chronic and licheniﬁed lesions

Dermatol Ther (Heidelb)

Table 2 Summary of the dermoscopic clues of all the dermatological disorders considered, divided according to their

clinical pattern (Part II)

Clinical

pattern

Papulosquamous—

papulokeratotic dermatoses

(III)

Papulosquamous—

papulokeratotic dermatoses

(IV)

Facial

inﬂammatory

skin diseases (I)

Facial

inﬂammatory

skin diseases (II)

Dermoscopic

clues of

each

dermatosis

Disseminated forms of

porokeratosis:

•Peripheral ‘‘cornoid

lamella’’

Lymphomatoid papulosis:

•Diffuse tortuous irregular (or

dotted at low magniﬁcation)

vessels (early lesions)

•Central whitish-yellowish

(hyperkeratotic lesions) or

brown-grey (necrotic lesions)

structureless area

Papulosquamous chronic

GVHD:

•Whitish scales

•Dotted and linear vessels

Poikiloderma vasculare

atrophicans:

•Sparse whitish scales

•Blurred branched vessels on a

reddish/orangish background

Grover disease, Darier disease

and BRAF-inhibitor-

induced acantholytic

dyskeratosis:

•Central star-shaped/branched

polygonal/roundish-oval

brownish area surrounded by

a whitish halo

Rosacea:

•Linear vessels

arranged in a

polygonal

network

Seborrheic

dermatitis:

•Dotted vessels

in a patchy

distribution

•Fine yellowish

scales

Discoid lupus

erythematosus:

•Perifollicular

whitish halo

(early lesions)

•Follicular

keratotic plugs,

red dots (early

lesions)

•White scaling

(early lesions)

•Whitish

structureless

areas (late

lesions)

•Blurred linear

branching (late

lesions)

Sarcoidosis,

cutaneous

leishmaniasis

and lupus

vulgaris:

•Diffuse or

localised,

structureless,

orange yellowish

areas

•Focussed linear

or branching

vessels

Granuloma

faciale:

•Dilated follicular

openings

•Linear branching

vessels

Demodicidosis:

•‘‘Demodex tails’’

•‘‘Demodex

follicular

openings’’

Grover disease (spongiotic variant) may also display whitish scaling over a reddish-yellowish background

‘‘Demodex follicular openings’’ appear as round and coarse follicular openings containing light brown/greyish plugs

surrounded by an erythematous halo, while ‘‘demodex follicular openings’’ appear as round and coarse follicular openings

containing light brown/greyish plugs surrounded by an erythematous halo

Dermatol Ther (Heidelb)

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. 1c) [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

Table 3 Summary of the dermoscopic clues of all the dermatological disorders considered, divided according to their

clinical pattern (Part III)

Clinical

pattern

Acquired

keratodermas (I)

Acquired

keratodermas (II)

Sclero-atrophic dermatoses Hypopigmented

macular diseases

(I)

Dermoscopic

clues of

each

dermatosis

Palmar psoriasis:

•Diffuse white

scaling

Chronic hand

eczema:

•Brownish-orange

dots/globules

•Yellowish scales/

crusts

Keratoderma due

to mycosis

fungoides:

•Relatively large,

amber scales over a

white-to-pinkish

background

Keratoderma due

to pityriasis rubra

pilaris:

•Patchily

distributed,

homogeneous,

structureless,

orange areas

Tinea manuum:

•Whitish scales

mainly localised in

the creases

Palmar lichen

planus:

•Roundish,

yellowish

areas often having

peripheral

projections

Aquagenic palmar

keratoderma:

•Yellowish-whitish

well-deﬁned

globules

•Enlargement of

the sweat duct

pores

Morphea:

•Fibrotic beams

Lichen sclerosus:

•‘‘Comedo-like openings’’

•Whitish patches

Necrobiosis lipoidica:

•Yellowish-orange/whitish-pinkish

background

•Comma-shaped (incipient lesions),

network-shaped/hairpin-like (more

developed lesions), or elongated,

branching and focussed serpentine

(advanced lesions) vessels

Extragenital

guttate lichen

sclerosus:

•See

‘‘Sclero-atrophic

dermatoses’’

Achromic pityriasis

versicolor:

•Fairly demarcated

white area. Fine

scales in the skin

furrows

Guttate vitiligo:

•Well-demarcated,

dense/glowing,

white area

•Perifollicular

hyperpigmentation

Dermatol Ther (Heidelb)

orange-yellowish patchy areas (Fig. 1d) [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

Table 4 Summary of the demioscopic clues of all the dermatological disorders considered, divided according to their clinical

pattern (Part IV)

Clinical

pattern

Hypopigmented

macular diseases (II)

Hyperpigmented

maculopapular diseases

(I)

Hyperpigmented

maculopapular diseases (II)

Hyperpigmented

maculopapular

diseases (III)

Dermoscopic

clues of

each

dermatosis

Idiopathic guttate

hypomelanosis:

•‘‘Cloudy sky-like’’ or

‘‘cloudy’’ pattern

Progressive macular

hypomelanosis:

•Ill-deﬁned whitish

area without scaling

Postinﬂammatory

hypopigmentation:

•Dermoscopic

ﬁndings typical of

the original lesions

Pityriasis versicolor:

•Fine whitish scaling

•Pigmented network

composed of brown

stripes/diffuse brownish

pigmentation

Lichen planus

pigmentosus:

•Diffuse, structureless,

brownish pigmentation

•Fine/coarse, grey-blue/

brown dots/globules

Conﬂuent and

reticulated

papillomatosis

(Gougerot-Carteaud

syndrome):

•Fine whitish scaling

•Brownish areas in a

‘‘cobblestone’’ or ‘‘sulci

and gyri’’ pattern

Dowling-Degos disease:

•Brown star-like area/

irregular brownish

projections with a

hypopigmented centre

Erythema ab igne

(hyperpigmented stage):

•Diffuse brownish

pigmentation

•Telangiectatic vessels

•Whitish scaling

Macular amyloidosis and

lichen amyloidosus:

•White or brown central hub

surrounded by various

conﬁgurations of brownish

pigmentation

Friction melanosis:

•Brownish

structureless areas

arranged in a

reticular fashion

Terra ﬁrma-forme

dermatosis:

•Large polygonal

plate-like brown

scales arranged in a

mosaic pattern

Urticaria

pigmentosa:

•Homogeneous

light-brown blot

and/or pigment

network

Telangiectasia

macularis eruptiva

perstans:

•Reticular vessels on

a erythematous or

brownish base

The ‘‘cloudy sky-like’’ pattern consists of multiple small areas coalescing into irregular/porycyclic macules, with several

white shades and both well- and ill-deﬁned edges, surrounded by patchy hyperpigmented network, while the ‘‘cloudy’’

pattern consists of well or ill-deﬁned roundish homogeneous whitish areas surrounded by patchy hyperpigmented network

In lichen amyloidosus the central hub may be replaced by a scar-like area

Dermatol Ther (Heidelb)

peripherally distributed)andamixedvascular

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].

Table 5 Summary of The dermoscopic clues of all the dermatological disorders considered, divided according to their

clinical pattern (Part V)

Clinical

pattern

Itchy

papulonodular

dermatoses

Erythrodermas (I) Erythrodermas (II) Noninfectious

balanitis—erythroplasia

of Queyrat

Dermoscopic

clues of

each

dermatosis

Hypertrophic

lichen planus:

•Rippled surface

•‘‘Comedo-like’’

structures

•Round corneal

structures

(‘‘corn pearls’’)

Prurigo

nodularis:

•‘‘White

starburst’’

pattern

Nodular

scabies:

•Mites (‘‘hang

glider sign’’)

•Burrows (‘‘jet

with

condensation

trails’’)

Acquired

perforating

dermatosis:

•Three

concentric

areas with

different

aspect/colour

Erythrodermic

psoriasis:

•Diffusely

distributed whitish

scales

•Regularly arranged

dotted/glomerular

vessels

Erythrodermic

atopic dermatitis:

•Yellowish scales/

sero crusts

•Patchily distributed

dotted vessels

Erythrodermic

mycosis fungoides:

•Linear vessels

(including

spermatozoon-like

vessels) and dotted

vessels

Erythrodermic pityriasis rubra

pilaris:

•Orange blotches

•Islands of nonerythematous

(spared) skin displaying reticular

vessels

Erythrodermic scabies:

•Dark-brown triangular structures

located at the end of whitish

structureless wavy lines

(delta-wing jets with contrail)

Zoon’s plasma cell

balanitis:

•Focal/diffuse

orange-yellowish

structureless areas

•Fairly focussed curved

vessels (including

serpentine, convoluted

and chalice-shaped)

Psoriatic balanitis:

•Regularly distributed

dotted/glomerular

vessels

Seborrheic dermatitis

and non-speciﬁc

balanitis:

•Linear irregular

unspeciﬁc blurry vessels

Erythroplasia of

Queyrat:

•Scattered glomerular

vessels

Consists of radially arranged whitish lines or a 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

Dermatol Ther (Heidelb)

Table 6 Summary of the dermoscopic clues of all the dermatological disorders considered, divided according to their clinical pattern (Part VI)

Clinical

pattern

Inﬂammatory cicatricial alopecia Nonscarring alopecias Scaling disorders of the scalp

Dermoscopic

clues of each

dermatosis

Discoid lupus erythematosus:

•Follicular keratonc plugs, thick

arborising vessels and red dots (acute

lesions)

•Thin arborising vessels emerging from

yellow dots (late lesions)

•White areas and branching vessels

(long-lasting lesions)

Lichen planopilaris:

•Perifollicular scales

Frontal ﬁbrosing alopecia:

•Minor perifollicular scaling

•Lonely hair/predominance of

follicular openings with only one hair

at the hair-bearing margin

Folliculitis decalvans:

•Follicular pustules

•Yellow discharge/crusts

•Hair tufts that contain [10 hairs

Shafts

Alopecia areata:

•Black dots, micro-exclamation mark hairs, broken

hairs, tapered hairs, monilethrix-like hairs and

trichorrhexis nodosa (acute forms)

•Regular yellow dots (inactive lesions);

•Circle and/or pigtail hairs (regrowing phases)

Trichotillomania:

•Hairs broken at different lengths

•Short hairs with trichoptilosis (‘‘split ends’’)

•Other: irregular coiled hairs, amorphous hair residues,

black dots, ﬂame-like hairs, tulip-like hairs and

V-sign

Androgenetic alopecia:

•Hair shaft thickness heterogeneity

•Increased proportion of thin and vellus hairs ([10 %

of the hairs)

Telogen efﬂuvium:

•Lack of features typical of other diseases

Tinea capitis:

•‘‘Comma’’ hair, ‘‘corkscrew’’ hair, ‘‘zigzag’’

hair and ‘‘Morse code’’ hair

Scalp psoriasis:

•Red dots/globules

•Signet ring vessels, red loops, white scales,

punctate hemorrhages and hidden hairs

(with a lower speciﬁcity)

Seborrheic dermatitis:

•Arborizing vessels

•Yellowish scaling, structureless red areas,

honeycomb pigment and comma vessels

(with a lower speciﬁcity)

Pityriasis amiantacea:

•Compact white keratotic material adhering

to a tuft of hair (asbestos-like scale)

Two or more hairs emerging from one follicular unit that are broken at the same level

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 (chrome forms). Importantly, 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

Dermatol Ther (Heidelb)

PAPULOSQUAMOUS/

PAPULOKERATOTIC DERMATOSES

Classical Lichen Planus (Level of Evidence:

II)

The dermoscopic hallmark of classical lichen

planus is represented by Wickham striae

(Fig. 2a), 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].

Fig. 1 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 whit-

ish 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)

Dermatol Ther (Heidelb)

Pityriasis Rosea (Level of Evidence: II)

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. 2b).

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. 2c) [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. 2d)

[40]. Interestingly, whitish areas may

Fig. 2 The dermoscopic analysis of classical lichen planus

typically shows the Wickham striae over a purplish

background (a). Dermoscopy of papulosquamous sarcoido-

sis 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 nondot-

ted 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)

Dermatol Ther (Heidelb)

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. 2e); 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. 2e)

[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. 2f) [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

Dermatol Ther (Heidelb)

whitish halo being characteristic of the

Darier-like histological subtype (Fig. 3a) and

whitish scaling over a reddish-yellowish

background being characteristic of the

spongiotic histological subtype (Fig. 3b);

dotted and/or linear/irregular vessels may be

found in both such forms (Fig. 3a, 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. 3c, d) [55–58].

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. 4a).

Additional features include rosettes [60],

follicular plugs, white/yellowish scales,

orange-yellowish areas, pigmentation

Fig. 3 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 examina-

tion 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

surrounded by a thin whitish halo in the latter condition

(d)

Dermatol Ther (Heidelb)

structures, dilated follicles and follicular

pustules (papulopustular rosacea) [26,59].

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. 4b); 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

Fig. 4 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)

Dermatol Ther (Heidelb)

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. 4c)

[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. 4d)

[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. 4e) [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. 4f) [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. 5a) [28,85].

Palmar Psoriasis (Level of Evidence: III)

The main dermoscopic ﬁnding of palmar

psoriasis is represented by the presence of

Dermatol Ther (Heidelb)

white scales typically distributed in a diffuse

pattern (and only infrequently showing

patchily or central distribution) (Fig. 5b)

[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].

Fig. 5 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)

Dermatol Ther (Heidelb)

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. 5c)

(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. 5d) (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

andfocussedserpentine (advanced lesions)

vessels over a yellowish-orange/

whitish-pinkish background (with or without

reddish areas) (Fig. 6a) [89–93]. Additional

ﬁndings include patchy pigmented

reticulum, yellow crusting and ulceration

[89–93].

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. 6b) [94–96]; pigment

network-like structures are also often

evident, while ‘‘comedo-like openings’’ and

whitish patches are less commonly seen

[94–96].

Fig. 6 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)

Dermatol Ther (Heidelb)

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. 6c) [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. 7a), similarly to hyperpigmented lesions

[101].

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. 7b) [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. 7c)

[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.7d), thereby

assisting the retrospective diagnosis

[1,40,106].

Dermatol Ther (Heidelb)

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. 8a) (personal observations).

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. 8b); perifollicular/annular

Fig. 7 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 hypopig-

mentation often presents with some dermoscopic ﬁndings

typical of the original lesions (in this case, the star-like

arrangment typical of prurigo nodularis) (d)

Dermatol Ther (Heidelb)

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. 8c) 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. 8d) [110].

Fig. 8 Dermoscopy of hyperpigmented lesions of pityriasis

versicolor often shows ﬁne whitish scaling localised in the

skin furrows associated with a diffuse brownish pigmen-

tation (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 (Gouger-

ot–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

Dermatol Ther (Heidelb)

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. 8e) [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. 8f), 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].Otherlessfrequentvascularﬁndings

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. 9a)

[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. 9a)

[14,15,35–37,108,122].

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,

Dermatol Ther (Heidelb)

which may surround brown-reddish/

brown-yellowish crust(s), erosion(s) and/or

hyperkeratosis/scales (Fig. 9b) [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. 9c) [1].

Fig. 9 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 exami-

nation 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)

Dermatol Ther (Heidelb)

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. 9d) [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 fungoidesisrepresentedby

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);

Dermatol Ther (Heidelb)

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 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; charac-

teristic (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)

Dermatol Ther (Heidelb)

(Fig. 10a, b) [131–137]; additional ﬁndings

include ﬁne interfollicular scaling, blue-grey

dots, scattered brown discolouration and red

dots (Fig. 10a) [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. 10c)

[131,133–137].

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. 10d) [132,133,136–141,

149,150]; other possible dermoscopic ﬁndings

of active lesions include violaceous or

violet-brown inter- or perifollicular violaceous

areas (Fig. 10d), 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. 10d) 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. 10e)

[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. 10e) [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. 10f), 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. 10f) [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,

Dermatol Ther (Heidelb)

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. 11a)

[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].

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

Fig. 11 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)

Dermatol Ther (Heidelb)

from one follicular unit that are broken at the

same level) (Fig. 11b) [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. 11c)

[131,132,139,164–168]. Thin wavy hair and

honeycomb hyperpigmentation often coexist as

additional, nonspeciﬁc features (Fig. 11c)

[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. 11d) [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. 11d) [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. 12a)

[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. 12b) [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].

Seborrheic Dermatitis (Level of Evidence:

III)

The most characteristic dermoscopic ﬁndings of

seborrheic dermatitis of the scalp consist of

arborising vessels [138,188–190]; additional

Dermatol Ther (Heidelb)

indicative features are yellowish scaling,

featureless areas (structureless red areas),

honeycomb pigment and comma vessels

(Fig. 12c) [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. 12d) [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

Fig. 12 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)

Dermatol Ther (Heidelb)

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,wealsoconsideredstudieslacking

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.

ACKNOWLEDGMENTS

We are extremely grateful to Dr. Angelo

Piccirillo for providing us with Fig. 4d 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.

Disclosures. Enzo Errichetti and Giuseppe

Stinco declare no conﬂict of interest.

Compliance with Ethics Guidelines. 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.

Open Access. This article is distributed

under the terms of the Creative Commons

Attribution-NonCommercial 4.0 International

License (http://creativecommons.org/licenses/

by-nc/4.0/), which permits any noncommercial

use, distribution, and reproduction in any

medium, provided you give appropriate credit

to the original author(s) and the source, provide

a link to the Creative Commons license, and

indicate if changes were made.

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Dermatol Ther (Heidelb)

Clinical and Dermoscopic evaluation of post acne erythema after treatment with topical timolol maleate 0.5%

Article

Full-text available

Jun 2024

Background and objectives: A common consequence of acne inflammation is called post-acne erythema, which describes telangiectasia and erythematous lesions that persist even after acne treatment, although some post-acne erythema lesions may become better with time. For some patients, having prolonged post-acne erythema might not be acceptable. Many studies have assessed the effectiveness of various post-acne erythema therapeutic approaches; however, there is no standard treatment. The aim of this study was to evaluate efficacy and safety of topical timolol maleate 0.5% in the treatment of post-acne erythema clinically and by dermoscopy. Methods: A randomized therapeutic clinical trial conducted in Sulaimanyah city-Kurdistan region over a period from March to September of 2022.Thirty patients (24 female and 6 male) with persistent post-acne erythema were enrolled in this study. Treatments with timolol 0.5% ophthalmic solution: apply 3-5 drops of timolol over the affected area every night at bedtime for 12 weeks. Our objectives were patient satisfaction, dermoscopy-assessed erythema assessment, and physician-reported clinical improvement. Result: After 12 weeks of treatment, there were no patients with severe erythema, clinically and statistically; there was a marked decline in the mean clinician erythema score and its standard deviation from 2.7± 0.98 to 1.0 ± 1.0 Also by dermoscopy-assessed erythema assessment, there was a substantial decrease in the mean erythema score and its standard deviation from 2.0±0.72 to 0.70±0.70, no participants after therapy exhibited severe erythema by dermoscopy.so statistically there is significant reduction in erythema clinically and dermoscopically. Conclusion: The results of this study show that there was very good response of post-acne erythema lesions with no obvious side effects, further therapeutic clinical studies with larger sample size is needed.

Historia de la dermatoscopia. Un viaje a través del tiempo

Article

Full-text available

May 2024

La historia de la dermatoscopia representa un fascinante viaje desde sus primeros pasos hasta su posición actual como una herramienta fundamental en la práctica médica. A lo largo de los años, la dermatoscopia ha experimentado una evolución continua, desde las primeras observaciones con equipos elementales, pasando por el avenimiento del dermatoscopio de mano hasta las sofisticadas tecnologías digitales y de análisis asistido por computadora de hoy en día. Este artículo aborda los orígenes, los hitos clave y las contribuciones significativas que han marcado el curso de la historia de la dermatoscopia, destacando su importancia en el diagnóstico precoz y preciso de una amplia gama de enfermedades cutáneas.

A Preliminary Study Examining the Correlation between EGFRI Treatment, Clinic Dermatoscopy Features, and Serum Levels of Anti-Alpha-Galactosyl IgE in Colorectal Cancer Patients

Article

Full-text available

Jun 2024

The introduction of molecularly targeted therapies, particularly the epidermal growth factor receptor inhibitors (EGFRIs), has had a positive impact by increasing the life expectancy of patients with advanced colorectal cancer (CRC). The most used anti-EGFRIs monoclonal antagonist, Cetuximab, induces skin responses in most patients, leading to a reduction of dosages or even therapy discontinuation, all with devastating effects. Our study aimed to assess the predictive role and the possible correlations of clinical features, imaging aspects (dermatoscopy), and laboratory tests (anti-alpha-galactosyl IgE levels) for early detection of Cetuximab skin toxicity in patients with metastatic CRC. The association of IgE antibodies against goat alpha-1,3-galactose serum levels with various degrees of skin toxicity encountered during the oncologic treatment resulted in higher concentrations in patients with pruritus and hair changes. Incorporating dermatoscopy into the routine dermatological consultation allowed us to perform a severity assessment, dynamically record, and identify even the erupting lesions previously invisible to classical examination. Hence, we were enabled to generate a broad report and to classify various degrees of skin toxicity severity linked to Cetuximab treatment in 19 patients with metastatic CRC. Detecting the emergent lesions and initiating dermatological treatment in the early stages decreased the severity of skin toxicity. As a result, the duration of the antibiotic treatment was much shorter, and the risk of dose reduction or interruption of the cancer treatment was diminished. In conclusion, we emphasize the need for a regular dermatological examination with dermatoscopy of CRC patients undergoing Cetuximab treatment. Skin toxicity is a significant concern for these patients, and healthcare providers should be vigilant in monitoring and managing this side effect in order to optimize patient care. The correlation between anti-alpha-Gal IgE levels and Cetuximab-induced skin toxicities is an emerging area. More extensive studies need to be published in order to establish this relationship directly.

Dermoscopy of Actinic Lichen Planus in Skin of Color

Article

Full-text available

Apr 2024

Introduction: Actinic Lichen Planus (ALP) is a rare photosensitive variant of lichen planus. Four subtypes can be distinguished: pigmented, annular (AALP), plaque-like and dyschromic ALP. Methods: This is a retrospective; descriptive and analytical study investigating the dermoscopic patterns of different subtypes of ALP in skin of color. Results: Sixteen adult patients were included in this study; the majority of them were young females, while five patients with the pigmented subtype of ALP were more than 50 years old. This subtype was more prevalent in patients with phototype IV. AALP was described in men with a very dark phototype.In pigmented melasma-like ALP, dermoscopy showed an annular granular pattern, white reticular and circular Wickham striae (WS) with hypopigmentation lacking skin creases, dots inside circles and an eccentric pigmentation on circles. In ALP, annular, circular WS; and perifollicular white halos with follicular plugs were described. The black hole pattern with dotted vessels was seen in the dyschromic ALP. White-yellow-bluish WS were noticed in plaque-type ALP with circumferential radial lines at the periphery. Conclusions: This descriptive study of dermoscopic patterns of various subtypes of ALP in skin of color highlighted new dermoscopic descriptions that vary according to the clinical variant or the morphology; lesions distribution; and phototype. Also, many epidemiological differences were found between our results and the literature concerning the older age of onset in melasma-like pigmented ALP, and the male predominance in annular ALP.

Laser-mediated Solutions: Breaking Barriers in Transdermal Drug Delivery

Article

Jun 2024
AAPS PHARMSCITECH

Skin diseases pose challenges in treatment due to the skin’s complex structure and protective functions. Topical drug delivery has emerged as a preferred method for treating these conditions, offering localized therapy with minimal systemic side effects. However, the skin’s barrier properties frequently limit topical treatments’ efficacy by preventing drug penetration into deeper skin layers. In recent years, laser-assisted drug delivery (LADD) has gained attention as a promising strategy to overcome these limitations. LADD involves using lasers to create microchannels in the skin, facilitating the deposition of drugs and enhancing their penetration into the target tissue. Several lasers, such as fractional CO2, have been tested to see how well they work at delivering drugs. Despite the promising outcomes demonstrated in preclinical and clinical studies, several challenges persist in implementing LADD, including limited penetration depth, potential tissue damage, and the cost of LADD systems. Furthermore, selecting appropriate laser parameters and drug formulations is crucial to ensuring optimal therapeutic outcomes. Nevertheless, LADD holds significant potential for improving treatment efficacy for various skin conditions, including skin cancers, scars, and dermatological disorders. Future research efforts should focus on optimizing LADD techniques, addressing safety concerns, and exploring novel drug formulations to maximize the therapeutic benefits of this innovative approach. With continued advancements in laser technology and pharmaceutical science, LADD has the potential to revolutionize the field of dermatology and enhance patient care.

Les porokératoses

Article

May 2024

P. Huet

Imaging Approach in the Diagnostics and Evaluation of the Psoriasis Plaque: A Preliminary Study and Literature Review

Article

Full-text available

May 2024

(1) Background: the aim of the study was to demonstrate its usefulness in the field of imaging evaluation of plaque morphology in psoriasis vulgaris, with an emphasis on the use of confocal microscopy and other advanced skin-imaging techniques. (2) Methods: we conducted a prospective study over two years (July 2022–April 2024), on patients diagnosed with moderate or severe psoriasis vulgaris, treated in the dermatology department of our institution. We selected 30 patients, of whom 15 became eligible according to the inclusion and the exclusion criteria. A total of 60 psoriasis plaques were analyzed by dermatoscopy using a Delta 30 dermatoscope and Vidix 4.0 videodermoscope (VD), by cutaneous ultrasound (US) using a high-resolution 20 MHz linear probe, and by confocal microscopy, along with histopathological analysis. (3) Results: the study included fifteen patients with vulgar psoriasis, diagnosed histopathologically, of whom six were women and nine were men, with an average age of 55. Between two and six plaques per patient were selected and a total of sixty psoriasis plaques were analyzed by non-invasive imaging techniques. Twelve lesions were analyzed with ex vivo fluorescence confocal microscopy (FCM), compared to histology. US showed that the hyperechoic band and the lack of damage to the subcutaneous tissue were the most common criteria. The epidermis and dermis were found to be thicker in the area of psoriasis plaques compared to healthy skin. Dermatoscopy showed that the specific aspect of psoriasis plaques localized on the limbs and trunk was a lesion with an erythematous background, with dotted vessels with regular distribution on the surface and covered by white scales with diffuse distribution. The presence of bushy vessels with medium condensation was the most frequently identified pattern on VD. Good correlations were identified between the histological criteria and those obtained through confocal microscopy. (4) Conclusions: the assessment and monitoring of patients with psoriasis vulgaris can be conducted in a more complete and all-encompassing manner by incorporating dermatoscopy, ultrasonography, and confocal microscopy in clinical practice.

Dermoscopy as an auxiliary tool for the diagnosis of acral squamous diseases: palmoplantar psoriasis, tinea pedis/manuum and eczema

Article

Apr 2024

Dermoscopy to differentiate clinically similar inflammatory and neoplastic skin lesions

Article

Apr 2024

Introduction: Over the few last decades, dermoscopy has become an invaluable and popular imaging technique that complements the diagnostic armamentarium of dermatologists, being employed for both tumors and inflammatory diseases. Whereas distinction between neoplastic and inflammatory lesions is often straightforward based on clinical data, there are some scenarios that may be troublesome, e.g., solitary inflammatory lesions or tumors superimposed to a widespread inflammatory condition that may share macroscopic morphological findings. Evidence acquisition: We reviewed the literature to identify dermoscopic clues to support the differential diagnosis of clinically similar inflammatory and neoplastic skin lesions, also providing the histological background of such dermoscopic points of differentiation. Evidence synthesis: Dermoscopic differentiating features were identified for 12 relatively common challenging scenarios, including Bowen's disease and basal cell carcinoma vs. psoriasis and dermatitis, erythroplasia of Queyrat vs. inflammatory balanitis, mammary and extramammary Paget's disease vs. inflammatory mimickers, actinic keratoses vs. discoid lupus erythematosus, squamous cell carcinoma vs. hypertrophic lichen planus and lichen simplex chronicus, actinic cheilitis vs. inflammatory cheilitis, keratoacanthomas vs. prurigo nodularis, nodular lymphomas vs. pseudolymphomas and inflammatory mimickers, mycosis fungoides vs. parapsoriasis and inflammatory mimickers, angiosarcoma vs granuloma faciale, and Kaposi sarcoma vs pseudo-Kaposi. Conclusions: Dermoscopy may be of aid in differentiating clinically similar inflammatory and neoplastic skin lesions.

Dermoscopy of nasal and auricular gouty tophi

Article

Full-text available

Apr 2024

Dermoscopy as a useful supportive tool for the diagnosis of pityriasis amiantacea-like tinea capitis

Article

Full-text available

Jul 2016

Clinical distinction between pityriasis amiantacea-like tinea capitis and pityriasis amiantacea due to noninfectious inflammatory diseases is a troublesome task, with a significant likelihood of diagnostic errors/delays and prescription of inappropriate therapies. We report a case of pityriasis amiantacea-like tinea capitis with its dermoscopic findings in order to highlight the usefulness of dermoscopy in improving the recognition of such a condition.

Terra firma-forme dermatosis: Case Series and dermoscopic features

Article

Jan 2015
Dermatol Online J

Dermoscopy of Lichen Planus

Chapter

Jan 2013

Dermatoscopy of confluent and reticulated papillomatosis (Gougerot-Carteaud syndrome)

Article

May 2017
J DTSCH DERMATOL GES

Zoon's balanitis: Correlation between dermatopathology and dermoscopy

Article

Dec 2016
ANN DERMATOL VENER

Dermoscopy as an auxiliary tool in the differentiation of the main types of erythroderma due to dermatological disorders

Article

Jul 2016

Relevance of trichoscopy in the differential diagnosis of alopecia: A cross-sectional study from North India

Article

Jun 2016
INDIAN J DERMATOL VE

Background: Trichoscopy is an office tool used in the diagnosis of alopecia but its utility has not been assessed. Objectives: To compare the trichoscopic characteristics of different types of alopecia, identify features of diagnostic value, and to determine the utility of trichoscopy in the diagnosis of alopecia. Methods: A descriptive cross-sectional study was performed in patients with alopecia. After clinical assessment and relevant investigations, trichoscopy was performed using a non-polarized trichoscope (×10). The utility of trichoscopy in difficult cases of alopecia was assessed statistically. Results: One hundred and twenty patients of alopecia (90 non-cicatricial, 30 cicatricial) were recruited. The diagnosis was made on the basis of a detailed history and clinical examination, and confirmed by biopsy and relevant investigations in difficult cases. Yellow dots (63.3%) were the most common trichoscopic feature followed by thin hair (40.8%). Among the 21 difficult cases of alopecia, trichoscopy was diagnostic in 19 (90.5%). Statistically significant features on intergroup comparison included black dots (Fischer's exact test, P< 0.001), cadaverized hair (P = 0.024), exclamation mark hair (P < 0.001) in alopecia areata; diameter diversity more than 20% (P < 0.001) and thin hair (P < 0.001) in androgenetic alopecia; broken hair of different lengths (P < 0.001), frayed hair (P < 0.001), split ends (P < 0.001) in trichotillomania; comma hair (P < 0.001) in tinea capitis and arborizing blood vessels in discoid lupus erythematosus (P = 0.012). Limitations: The small number of patients in some types of alopecia was a limiting factor. Conclusions: Trichoscopy is useful in the differential diagnosis of alopecia. Among the various trichoscopic findings, those of diagnostic value were identified.

Dermoscopy of subacute cutaneous lupus erythematosus

Article

Jun 2016

Trichotillomania and Traction Alopecia

Chapter

Oct 2012

Trichoscopy of trichotillomania is characterized by a chaotic pattern of diverse features related to hair fracturing. The most characteristic features are hairs broken at different lengths, short hairs with trichoptilosis (“split ends”), irregular coiled hairs, amorphous hair residues, and black dots. Micro–exclamation mark hairs are rare in trichotillomania, but they may be a diagnostic pitfall and lead to misdiagnosis of alopecia areata. Trichoscopic features of traction alopecia and traumatic cicatricial marginal alopecia are described briefly in this chapter.

Telogen Effluvium

Chapter

Oct 2012

Trichoscopy has limited value in diagnosing telogen effluvium. Frequent, but not specific, findings include the presence of empty hair follicles, a predominance of follicular units with only one hair, perifollicular discoloration (the peripilar sign), and upright regrowing hairs. There is no significant difference between the findings in the frontal area and those of the occipital area, which differentiates telogen effluvium from androgenetic alopecia. However, clinicians should be aware of the frequent coexistence of both diseases.

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