|Year : 2017 | Volume
| Issue : 2 | Page : 41-51
Dermoscopy of general dermatological conditions in Indian population: A descriptive study
Sunita S Nayak1, Hita H Mehta2, Prachi C Gajjar2, Vivek N Nimbark2
1 Department of Dermatology, Sir T. Hospital, Government Medical College, Bhavnagar, Gujarat, India
2 Department of Dermatology, Government Medical College, Bhavnagar, Gujarat, India
|Date of Web Publication||28-Jul-2017|
Hita H Mehta
Department of Dermatology, Government Medical College, Sir T Hospital, Bhavnagar, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Patients attending the dermatology outpatient department (OPD) come with varied presentations. It is a challenge for a dermatologist to make a right diagnosis in a short time noninvasively. Hence in such conditions, dermoscope provides a rapid handy diagnostic aid. Objectives: The aim is to evaluate and compare the dermoscopic features of common dermatological conditions in an Indian population with brown skin. Materials and Methods: A total of 475 dermatoses including inflammatory, infectious, vesiculobullous, vascular, benign face tumors, hypopigmentary, drug reactions and miscellaneous conditions attending the OPD between March 2011 and January 2013 were enrolled in the study after obtaining informed consent. Detailed history and thorough dermatological examination were conducted to reach the final diagnosis. Dermlite II PRO dermoscope was used for the study. Data collected was analyzed by frequency and percentage. P value for each dermoscopic parameter in three groups was calculated using Chi-square test for independence using graph pad where the value of P < 0.05 was considered statistically significant. Results: Red dotted vessel was a prominent feature in inflammatory conditions (P < 0.0003), which was found to be regular in a pattern in psoriasis (100%). The unique feature of lichen planus was Wickham's striae (P < 0.0001). Collarette scales were observed in 93% of cases of pityriasis rosea. Live nymphs depicting as brown oval structure (46.67%) were observed. Scabies mites head was characterized using “Triangular sign” (93%). Red brown dots and papilla-like structure were observed in most of the cases of warts. Comedo-like opening (P = 0.024) and milia-like cyst (P = 0.0495) are typical features of seborrheic keratosis. Conclusion: Dermoscopy findings provide an extra clue for the diagnosis of common dermatoses and it also helpful in prognostic evaluation and monitoring response to treatment.
Keywords: Dermoscopy, infections, inflammatory conditions, seborrheic keratosis
|How to cite this article:|
Nayak SS, Mehta HH, Gajjar PC, Nimbark VN. Dermoscopy of general dermatological conditions in Indian population: A descriptive study. Clin Dermatol Rev 2017;1:41-51
|How to cite this URL:|
Nayak SS, Mehta HH, Gajjar PC, Nimbark VN. Dermoscopy of general dermatological conditions in Indian population: A descriptive study. Clin Dermatol Rev [serial online] 2017 [cited 2019 Mar 19];1:41-51. Available from: http://www.cdriadvlkn.org/text.asp?2017/1/2/41/211787
| Introduction|| |
Dermoscopy is a simple, rapid, reliable and noninvasive diagnostic tool that helps to visualize morphological features that cannot be seen with naked eyes, thus representing a link between macroscopic clinical dermatology and microscopic dermatopathology. Although earlier, it was introduced to diagnose only pigmented disorders, dermoscopy has now gained wider application in the field of general dermatology. In-depth dermoscopy findings for various nonpigmented diseases were first described by Iris Zalaudek et al.
The term “Dermatoscopy” was introduced in 1921 by Saphier. The first world dermoscopy Congress was held in Rome in 2001, where the definitions of structures seen in benign and malignant pigmented lesions were standardized.
Dermoscopy is of two types – polarized and nonpolarized. Nowadays, the polarized mode is widely used because of better visualization of vascular and pigmented structure. In this study, polarized dermoscope was used and broadly categorized dermoscopic findings for common skin disorders into inflammatory, infectious, vesiculobullous disorders, vascular structure, benign facial tumors, hypopigmented lesions, drug reactions and other miscellaneous cases.
The objective of this study is to evaluate and compare the dermoscopic features of common dermatological conditions in an Indian population with brown skin.
| Materials and Methods|| |
A total of 475 patients including 242 females and 233 males attending the dermatology outpatient department were enrolled randomly in the cross-sectional descriptive study conducted between March 2011 and January 2013. The study was approved by the institutional review board and human ethics committee before patient enrollment. The study was conducted in accordance with the Declaration of Helsinki. All those willing to participate were explained the procedure and the reason for photography before taking their written informed consent.
Before conducting the study, literature search was done using PubMed database with the keywords “Dermoscopy/Dermatoscopy” for general dermatology as well as for each specific disease. We could not gather literature for certain diseases such as pemphigus vulgaris (PV), bullous pemphigoid (BP), chickenpox, herpes zoster herpes simplex, pompholyx, comedone, acne, boil, milia and erythema nodosum leprosum (ENL).
We included clinically diagnosed cases of various diseases (40) of both genders in all ages in our study. In the case of multiple lesions, we selected randomly active lesion for our study. Medical records, demographic and clinical data including patient's age, sex and lesion types were documented. We excluded patients refusing for consent, and those who had undergone topical and systemic treatment for last one and 6 months, respectively. We have included lesions from all sites except those on scalp, nail and hair.
Detailed history and thorough dermatological, physical and systemic examination was conducted. Routine investigations and histopathology were taken wherever necessary to aid the clinical diagnosis. The conditions were categorized into inflammatory, infective, vesicular, vascular, drug reactions, hypopigmented lesions, benign face tumors and miscellaneous skin disorders. Dermoscopic and clinical photographs were taken after informed consent.
All dermoscopic findings were studied using handheld pocket dermoscope Dermlite II Pro (3 Gen, San Juan, Capistrano, CA, USA) with a ×10 magnification keeping a distance of approximately 1 inch from the lesion. Clinical and dermoscopy photographs were also taken and stored. In the case of patient having multiple lesions, only a single active lesion was selected for dermoscopy.
We used few terminologies as dermoscopic criteria by collecting various studies. The preserved images were later reviewed again by two separate observers and the results were collaborated. Variables used for dermoscopic evaluation were divided into vascular and nonvascular features which were further subcategorized into vascular morphology and its arrangement, background color, type of the scales and its pattern, follicular abnormalities and any specific clues. This categorization is mainly helpful in differentiating inflammatory conditions. The characteristics were not graded but simply noted as present or absent.
Data collected was analyzed by frequency and percentage. P value for each dermoscopic parameter in three groups was calculated using Chi-square test for independence using graph pad where the value of P < 0.05 was considered statistically significant.
| Results|| |
In this study, we have randomly enrolled 475 participants with 41 diseases which were categorized as inflammatory disorders, infections, vesiculobullous disorders, vascular lesions, benign facial tumors, hypopigmented lesions, drug reactions and miscellaneous conditions. The disorders were examined based on their common clinical characteristics and evaluated for dermoscopic features. For evaluating dermoscopic features, mainly two parameters had been considered, vascular and nonvascular which were further subcategorized according to the category. Patients with the inflammatory and infectious disease had multiple lesions but we included only single active lesion for our study. As we could not classify dermoscopic features for all the diseases, we have included only a few common diseases in tabular form. The conditions visualized dermoscopically in inflammatory disorders were psoriasis, lichen planus (LP), pityriasis rosea (PR) and dermatitis and discoid lupus erythematosus (DLE). We included 15 cases of each entity. All inflammatory conditions were studied mainly under four dermoscopic criteria – morphology of vascular structure and their arrangement, scale color and their distribution, background color and other specific features. The detail findings of inflammatory conditions are described in [Table 1] and [Figure 1].
In infectious diseases category, we enrolled 30 cases of warts and 15 cases each of pediculosis capitis, scabies, tinea corporis, molluscum contagiosum and furuncles. Due to the wide difference in etiology, pathogenesis and clinical features of the above diseases, we could not categorize dermoscopic features of infectious diseases except warts [Figure 2]. Dermoscopic features and patterns of warts are described in [Table 2] and [Figure 2]. In the clinically confirmed diagnosis of pediculosis, translucent oval structures were seen in 80% of cases, brown oval structures were seen in 47% of cases and lice were seen in 7% of cases. The free end of the translucent oval structure was straight and ragged whereas that of the brown structure was oval and smooth. Triangular structure representing the head of mites were seen in 73% of cases of scabies. “S” shaped presentation of burrow as an interesting finding was noted in 93% of cases and associated brownish patch noted in the field may suggest fecal material of mite. When mite presented dorsally, triangular structure appeared angulated which was observed in 11% of cases. In tinea corporis, striking feature we found was ring-like structure with erythema (79%) and peripheral scaling with central clearing (93%). Erosions were observed in 79% of cases. Lobules and central white amorphous structure were typical presentation of molluscum contagiosum in all cases. Dermoscopy findings of furuncles were erythema and white structureless area in all cases and hazy yellow structures indicating crusts in 33% of cases [Figure 2].
Under vesiculobullous disorders, we studied dermoscopic features of 15 cases of PV, two cases of pemphigus foliaceous (PF), a single case of BP, 15 cases each of chicken pox and herpes zoster, a single case of herpes simplex, nine cases of pompholyx, single case each of insect bite and Kaposi's varicelliform eruption [Figure 3]. Chickenpox, herpes zoster and herpes simplex were considered here because of their clinical resemblance with other conditions of the above group. We described vesiculobullous findings as erythema on base, well defined/ill-defined border, brown dots/patches and erosions. Vesicles were seen as well-defined translucent homogeneous areas in all cases and had erythematosus base in 92% of cases of PV. Older lesions showed whitish discoloration inside the vesicular border. Scaling, white cloud-like patch and erosion was observed in both the cases of PF. In a single case of BP, we observed dermoscopically well-defined structure with brown black dots in the center and eosinophilic infiltrates in histopathology. We found ill-defined white structure with surrounding erythema and peripherally distributed brown dots (100%) in chicken pox whereas in herpes zoster, we observed multiple confluent round cloudy white polylobular structures with central brown dots (53%) and surrounding erythema. Erythema was more marked in herpes zoster. Brown dots may correspond to multinucleate giant cells in Tzanck smear of herpetic lesions. In a case of kaposi's varicelliform eruption, erosion with multiple tiny brown dots and scales were observed. In the case of insect bite, we observed erosion on an erythematous background.
Fifteen cases of urticaria, ten cases of ENL, 15 cases each of purpura and cherry angioma, five cases of pyogenic granuloma and a single interesting case of cutaneous vasculitis associated with livedo reticularis were studied in vascular conditions [Figure 4]. Linear red lines (60%) suggest branching capillaries in urticaria. Erythematous patch (80%) with red dots and red lines (33%) were noted in ENL cases. Ill-define erythematous to purple patches were noted in all cases of purpura. In cherry red angiomas, red lacunae were the classical structure seen in 93% of cases. The well-defined red homogeneous area with interspersed white lines were noted in all cases of pyogenic granuloma. A single case of cutaneous vasculitis associated with livedo reticularis presented with a large erosion surrounded with purple globules and red dots on the outermost side. Lesion of livedo reticularis showed erythematous ring-like lesions with comma-shaped vessel.
In benign facial tumors, we included a total of 45 cases of seborrheic keratosis (SK), 15 cases each of acne and comedones, twelve cases of milia, five cases of syringoma, four cases of sebaceous hyperplasia and a single case of trichoepithelioma [Figure 5]. We included 15 cases of SK with each of common type, stucco keratosis and dermatosis papulosa nigra. Dermoscopic features of all varieties of SK are described in [Table 3] and [Figure 5]. Acne presented as central dark pore (54%) surrounded by white ray-like structure (67%) resembling a star bust and an erythematous background (100%). Seven white and eight black comedones were taken in the study. Hair follicle surrounded by central black ring was typical dermoscopic pattern in all cases of comedones. Ring is small with yellowish surrounding in white comedones. In 12 cases of milia, central white structure and the surrounding brown ring were the typical findings. Glittering yellowish white globules were seen in all five cases of syringoma. We noticed multiple dull yellowish white globules in all four cases of sebaceous hyperplasia and in two cases, we found surrounding vessels. We observed whitish structure surrounded by erythematous halo in a single case of trichoepthelioma studied.
We considered three conditions in hypopigmented lesions including 15 cases each of vitiligo, pityriasis alba and pityriasis versicolor [Figure 6a]. In this study, perifollicular pigmentation was an important finding in vitiligo which was observed in 26% of cases and interfollicular pigmentation in 13% of cases with blotchy white areas in all patients. Red lines suggesting telangiectasia were noted in 20% of patients on long-term corticosteroid treatment. Well circumscribed pinkish patch with the irregular border was observed in all cases. Discrete scales were noted in 80% of cases. We noticed diffuse hypopigmented blotches with satellite lesions (nearby small round white globules) in all cases of pityriasis versicolor.
Dermoscopic differentiation of common dermatoses is described in [Figure 6a] and [Figure 6b]. We have demonstrated unusual presentation of common skin disease-like retroauricular and linear psoriasis and initial lesion of herpes zoster in [Figure 7].
In the category of drug reaction, we have included eight pigmented cases of fixed drug reaction (FDR) which showed brownish pigmentation, erythema, erosions and purple surrounding. A total of seven images of erythema multiforme were studied which showed erythema with a purplish tinge and red dots
In other miscellaneous conditions, three cases of porokeratosis, six cases each of corns and callosity, two cases of granuloma annulare (GA) and a single interesting case of Bowen's disease were enrolled.
The typical pattern of porokeratosis in both cases was brown ring surrounded by white ring. Other features were white dots (100%) and black dots inside the lesion (50%) [Figure 6b]. The concentric ring was a classic picture of corns (100%) whereas all cases of callosity showed homogeneous yellowish structure. Both the cases of GA showed erythematous annular lesions with central yellowish white/red structure and periphery showed few erythematous globules. We could find glomerular-like red structures with scales, brown dots and erosions in a single case of Bowen's disease to confirm our diagnosis [Figure 8].
Dermoscopic features of single cases of few conditions were also included for differential diagnostic purpose and because of their interesting finding.
| Discussion|| |
Dermoscopy is a very potent and simple diagnostic tool. Previously, it was used only to aid the diagnosis of pigmented skin lesions but in the present era, it is continually gaining appreciation in the field of general dermatology. Clinically, inflammatory skin conditions may sometimes look like each other. Here, dermoscopy helps to differentiate them and also helps in identifying lesions with unusual presentations and sites. Besides specific features for each disease, we also found some nonspecific features [Table 1] and [Figure 1].
Red dots or dotted vessels were highly significant for all inflammatory conditions but the pattern was different (P = 0.003). It was in a regular pattern in all cases of psoriasis, patchy in dermatitis and PR, linear in LP and irregular in DLE. The red globules in psoriasis were attributed histopathologically to the tortuous capillaries in the upper dermis., Irregular red lines were seen only in psoriasis and DLE.
Red dots and globules were very sensitive predictors of psoriasis though not very specific as they are also present in several other inflammatory and neoplastic lesions.,, Lallas et al. mentioned that red dots, globules, homogeneous vascular area and light red background aided in the diagnosis of psoriasis with a 99% probability.
White striations or white pearly structures correspond to WS which were exclusively seen in LP (P < 0.0001). WS can be presented as linear, reticular, circular, radial streaming and leaf venation pattern. The latter was described as new criteria by Friedman et al. In this study, all most all pattern of WS were observed [Figure 1]. Interestingly, we also noticed leaf venation pattern in oral LP [Figure 8]. Comedo-like the opening was observed in a case of hypertrophic LP [Figure 6b]. Histopathologically, hypergranulosis of the dilated infundibulum represents the comedone-like opening in dermoscopy whereas dermal melanophage and epidermal melanophage corresponds to greyish and brown dots respectively in hypertrophic LP.
Scales were presented in all cases of inflammatory conditions which were bright white and thick in psoriasis, peripheral in PR, yellow in dermatitis, scanty and irregular in rest of the conditions.
The study by Chuh mentioned peripheral scaling as “collarette scaling” as a typical feature of PR. We also witnessed this type of scale presentation., In dermoscopy of PR, Lallas et al. found peripheral collarette scaling around the central yellowish structure. However, we found pinkish erythema rather than yellowish structure.
Errichetti and Stinco differentiated between exudative lesions in dermatitis and chronic lichenified dermatitis. In the former, he described yellowish crust/scaling as “yellow clod sign” whereas in the latter, he described the patchy arrangement of red dotted vessels. We also observed such yellow crust (67%).
In this study, irregular red lines, white scales and reticular pigmentation were typical features of DLE and in few cases, we also observed perifollicular keratotic lesions and structureless whitish area which were consistent with those observed by Lallas et al. According to the author, follicular keratotic plugs correlated with follicular hyperkeratosis, white scales with hyperkeratosis, structureless whitish area with diffuse dermal fibrosis and follicular red dots with perifollicular red blood cell extravasation. He also mentioned that in early lesions of DLE, perifollicular whitish halos, follicular plugging and white scales were the predominant features while late stage of disease showed telangiectatic vessels, pigmentation structures and whitish structureless areas.
A wide range of diseases can be included in the infectious category but we have included few common conditions such as warts, scabies, pediculosis capitis, tinea corporis, molluscum contagiosum and furuncles [Figure 2].
Papillae/papilliform structures were found to be a highly significant feature for warts (P = 0.0132). Red to brown dots were characteristic features of HPV infection but it represented differently in different types of warts. Common warts displayed as multiple densely packed papillae with central dot giving tadpole appearance whereas plantar warts showed multiple punctate dots within yellowish petal-like structures. Zalaudek et al. also suggested that the dots in plantar warts are caused by the chronically high pressure at plantar sites., Red/brown dots were arranged regularly exclusively in plane warts (P < 0.0001). In the literature on the western skin, red dots were observed whereas we observed brown dots in Indian skin [Table 2].
Dong et al. observed knob-like pattern more frequently in advanced, raised/papillomatous warts and genital warts. Similarly, we also observed such structures in genital warts. One of the genital wart lesions looked similar to seborrheic keratosis but the presence of dots in papilla, knob-like structure and the absence of typical features of seborrheic keratosis-like comedone opening, moth-eaten appearance helped us to diagnose the lesion as genital warts [Figure 6b].
Scabies and pediculosis are ubiquitous, contagious and incapacitating infestations afflicting large populations in our country and hence early diagnosis and treatment is required. Lice are often difficult to search while nits can be confused with dandruff. However, dermoscopically, dandruff can be differentiated easily by structureless scales. As mentioned in the study by Zalaudek et al. in pediculosis capitis, eggs containing nymphs (live) were ovoid and brown whereas empty nymphs were translucent and showed fissured free ending. In this study, we observed both transparent and brown oval structures.
Argenziano et al. first coined the term “triangular sign” for the head of scabies mites. He also correlated the head of the mite and burrow with reminiscent of “delta wing jet with contrail.” Persistence of brown structure in pediculosis and presence of scabetic mites suggest the need for further treatment. Thus, dermoscopy is not only helpful in diagnostic purpose but can also be helpful for therapeutic evaluation.
As Iris Zalaudek et al. in their study described the chaotic direction of scales but in our study along with annular lesion and central clearing, we also observed coarse scales, but in a single case of tinea imbriacata, we observed more chaotic and zigzag pattern of scales.
Molluscum contagiosum can be easily diagnosed clinically but sometimes, it is difficult to diagnose in pediatric age group and in inaccessible lesions. Multiple lobules with white amorphous central structures (umbilication) were a typical feature in molluscum contagiosum which makes its diagnosis easier. Moreover, this was also observed in many studies. We were unable to observe branching vessels in molluscum contagiosum as mentioned in the literature.,
Furuncles showed a central whitish yellow amorphous structure with surrounding erythema in all cases. The study by Zalaudek et al. described a mixed vascular pattern associated with boils.
We failed to gather literature for dermoscopy in vesiculobullous disorder. Dermoscopically, vesicles presented as round structure with well- to ill-defined border [Figure 3]. While considering PV, the classical picture is the markedly well-defined border with erythema in almost all cases making this a very important feature of the disease. We observed hazy white structure, scaling and erosion in PF which may be due to the superficial position of the vesicle in the disease.
Differential diagnosis of herpes zoster, chicken pox and insect bite is shown in [Figure 3]. Even though insect bite clinically mimicked herpes zoster but the dermoscopic absence of brown dots in insect bite easily differentiates these two conditions.
Erythema is a typical feature of vascular lesions [Figure 4]. Urticaria presented as linear redlines and erythematous structureless area and a similar pattern was also observed in other study by Lopez et al. He also claimed that red-lined pattern corresponds histologically with transient ectatic/elongated filled horizontal subpapillary vessels. Lallas et al. in their study differentiated dermoscopic features between urticaria and urticarial vasculitis. He described structureless erythematous area with linear vessels in urticaria and purplered dots/globules on an orange-brown background in urticarial vasculitis. ENL lesions did not show any specific findings except the white structureless area in erythematous background. Lallas et al. described dermoscopic features of purpura as small round, purplish red dots/globules as well as the structureless large purpuric area. He also stated that similar structures can be seen in other infective and inflammatory skin diseases such as pigmented purpuric dermatoses, leukocytoclastic vasculits, arthropod bites, viral infections and drug reactions. In drug reactions, FDR and EM showed vacuolar interface dermatitis and we observed purplish tinge in both of them [Figure 8]. Martín et al. described the lesions of cherry red angioma as a rounded patch with lacunae which are separated by fibrous septa. We also observed similar such findings. Zaballos et al. described the presence of white collarette, vascular structures and red homogeneous area with white rail lines intersecting the pyogenic granuloma in their study. In all our cases, we also observed red homogeneous structure with intersecting white lines. Here, red area corresponds to small capillaries or proliferating vessels and white line to fibrous septa that surrounds the capillary tufts/lobules.
Dermoscopic picture of SK was observed according to clinical variants of SK [Table 3] and [Figure 5]. Classical dermoscopic presentations of SK are comedo-like structure and milia-like cyst as described by Lin et al. in their study. Among all the features of SK, the comedo-like opening is a more significant feature (P = 0.0024). We could not demonstrate hairpin vessels in any of our case which was commented in another Indian study. Fissures and ridges were absent in stucco keratosis. Comedo-like opening is also present in hypertrophic LP but easily differentiated from SK by the presence of brownish black hyperpigmented scales [Figure 6b].
Corazza et al. described dermoscopy of syringoma as multiple glittering yellowish white structure of varying size and shapes arranged singly or in clusters with surrounding vessels. We observed similar picture but without surrounding vascular structure [Figure 5]. [Figure 6a] describes dermoscopic features of hypopigmented dermatoses.
We studied three clinically annular lesions such as tinea corporis, GA and porokeratosis and differentiated them dermoscopically. Beaded appearance in the periphery in GA and white ring in porokeratosis easily differentiates the two conditions from tinea infection [Figure 6b].
We found an interesting case of a 35-year-old female patient presented with smooth tiny papules on the face which can be confused with some common conditions such as acne, syringoma or GA. However, histology showed palisading granuloma and dermoscopy showed ill-defined pink periphery with red central patch which confirmed GA [Figure 8].
We also included few diseases to find some interesting feature. We found glomerular vessels in the lesion of Bowen's disease. Lallas et al. in their study stated that Bowen's disease can be differentiated dermoscopically from chronic plaque psoriasis by the presence of glomerular vessels which are larger in diameter and are clusterly arranged unlike psoriasis [Figure 8].
Due to the lack of literature on boil, PV, PF, BP, herpes zoster, Kaposi's varicelliform eruptions, chickenpox, herpes simplex, pompholyx, ENL, comedone, acne and milia, we could not compare it with other studies. Hence, these observations need further confirmation on large series of patients.
Dermoscopy also has limitations like certain dermoscopic features found in some dermatoses are similar. It should be realized that dermoscopic picture studied in other countries do not entirely match with that carried out in Indian population because of difference in complexity as erythema can be easily demonstrated in western fair skinned population. Hence, more such studies are yet to be carried out in Indian population. Here, we could not correlate each case with histopathologically.
| Conclusion|| |
Dermoscopy helps us to distinguish clinically similar two or more conditions that can be hardly be differentiated with naked eyes. It provides an extra clue which may be missed grossly. It is not only helpful in the differential diagnosis of various diseases but also helpful in prognostic evaluation and monitoring response to treatment. Besides differential diagnosis and early diagnosis, dermoscopy also helps us to decide appropriate lesions and site for histopathology. Thus nowadays, dermoscopy represents an important and relatively simple, easy and noninvasive tool in daily clinical practice.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6a], [Figure 6b], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]