• Users Online: 881
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
SYMPOSIUM: BASICS OF DERMOSCOPY AND DERMOSCOPIC PATTERNS
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 84-91

Dermoscopic approach to hyperpigmented lesions in skin of color


1 Department of Dermatology, S Nijalingappa Medical College, Bagalkot, Karnataka, India
2 Department of Dermatology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India

Date of Submission28-Apr-2020
Date of Decision06-Jul-2020
Date of Acceptance06-Jul-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Balachandra S Ankad
Department of Dermatology, S Nijalingappa Medical College, Navanagar, Bagalkot - 587 102, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_74_20

Rights and Permissions
  Abstract 


Hyperpigmented skin lesions are common presentation of Indian patients. It causes cosmetic disfigurement, as well as has immense psycho social impact. Most of the lesions are diagnosed clinically but some of them are difficult to diagnose because of overlapping features. To form basic dermoscopic guidelines to approach a hyperpigmented lesion. LPP and EDP demonstrate brownish background with bluish gray hue and brown to gray globules, which is also seen in PCD with superimposition of brown globules. Linear cristae cutis and sulci cutis forms a special clue in AN. Frictional melanosis displays bluish gray globules with patulous follicles with plugs and perifollicular scaling. Patulous follicular opening with whitish yellow excrescences on pseudopigment network is seen in seborrheic melanosis. PDL displays peri-follicular brown globules with no vasculature changes or scales. Melasma shows prominent brown background with reticular or reticulo-globular pigment pattern. Exogenous ochronosis demonstrates grayish brown globules with obliteration of follicular openings. Brown polygonal globules with scales along skin lines and over the globules are noted in CRP. Hub and spoke pattern of pigmentation is a feature of macular amyloidosis. Hyperpigmented pityriasis versicolor demonstrates accentuated pigment network with scaling in diffuse or perifollicular or along skin lines seen. Dermoscopic diagnosis should be based on amalgam of all parameters identified in a given lesion and not in isolation. Dermoscopy is of great importance for assessment of hyperpigmentation disorders in dark-skinned patients as they may clinically look similar due to the natural brownish background.

Keywords: Approach, dermoscopy, hyperpigmented diseases


How to cite this article:
Ankad BS, Drago NR, Koti VR, Nikam BP. Dermoscopic approach to hyperpigmented lesions in skin of color. Clin Dermatol Rev 2020;4:84-91

How to cite this URL:
Ankad BS, Drago NR, Koti VR, Nikam BP. Dermoscopic approach to hyperpigmented lesions in skin of color. Clin Dermatol Rev [serial online] 2020 [cited 2020 Oct 25];4:84-91. Available from: https://www.cdriadvlkn.org/text.asp?2020/4/2/84/292486




  Introduction Top


Hyperpigmented skin lesions are common presentation of Indian patients. It causes cosmetic disfigurement with immense psychosocial impact. The most common hyperpigmented lesions in our daily practice are of melasma, lichen planus pigmentosus (LPP), erythema dyschromicum perstans (EDP), Riehl's melanosis, pigmentary demarcation lines (PDL), seborrheic melanosis (SM), and frictional melanosis (FM). Few conditions affect both facial and nonfacial skin whereas some are observed exclusively on the face. Most of these lesions are diagnosed clinically but some of them are difficult to diagnose because of overlapping features.[1]

Dermoscopy, being a noninvasive tool, shows pigmentary variations in the skin layers. The pigmentation is derived primarily from melanin and hemoglobin. The color of melanin depends on the density and the location of melanin in the skin layers.[2] Dermoscopic utility in hyperpigmented lesions is well established in literature. Although it demonstrates classical patterns in few hyperpigmentary lesions, definitive criteria, or guidelines are not described. Added to this, many reports lack of dermoscopic-histopathological correlation.

Here, authors have attempted a basic dermoscopic approach to a hyperpigmented lesion in skin of color based on few dermoscopic parameters. International Dermoscopic Society has recommended basic guidelines for inflammatory conditions and that include; (i) color on background, (ii) vascular structures (including morphology and distribution), (iii) scales (including color and distribution), (iv) follicular structures, and (v) specific clues.[3] Authors have added “globular structures” as an additional parameter to this list and proposed dermoscopic approach to hyperpigmentary lesions.


  Lichen Planus Pigmentosus Top


Dermoscopy in LPP demonstrates pigmented globules, color of which ranges from dark brown and bluish-gray and their color is very intense.[4] Dots and globules are densely arranged in diffuse, dotted [Figure 1]a, annular, hem-like [Figure 1]b, arcuate, speckled [Figure 1]c, perifollicular, peri-eccrine [Figure 1]d, and in cobblestone [Figure 1]e patterns.[5] Annular and arcuate arrangement of globules gives reticular or pseudo reticular patterns [Figure 1]f.[6] The arrangement of globules in a particular pattern depends on the predominant changes in a given lesion. Characteristics of pigment globules are explained on the basis of very active vacuolar dermatitis, heavy melanin incontinence, and focal atrophy of melanized epidermis and widespread follicular involvement.[7]
Figure 1: (a) Dermoscopy of lichen planus pigmentosus shows “dotted” pattern with brown (yellow arrows) and bluish-gray (red arrows) pigment globules. Brown background is well appreciated. (b) Dermoscopy of lichen planus pigmentosus shows “hem-like” pattern (yellow arrows) with predominant bluish-gray globules (red arrows) with lesser brown globules (green arrows). Note the brownish background with bluish-gray hue. (c) Dermoscopy of lichen planus pigmentosus shows irregularly distributed bluish-gray (red arrows) and brown pigment (yellow arrows) globules giving a “speckled” pattern. (d) Dermoscopy of lichen planus pigmentosus reveals perieccrine and perifollicular positioned bluish-gray (red arrows) and brown (yellow arrows) pigment globules. Appreciate the densely packed and intensely colored globules. Note brownish-gray background and red-colored artefacts (green arrows) which appear as dotted vessels. (e) Dermoscopy of lichen planus pigmentosus demonstrates “cobblestone” pattern with bluish-gray (red arrows), brown (yellow arrows), and brownish-gray (green arrows) pigment globules. (f) Dermoscopy of lichen planus pigmentosus reveals bluish-gray (red arrows) and brown (yellow arrows) globules arranged in “pseudo-reticular network” pattern. Note the vascular lesion (yellow circle), not related to lichen planus pigmentosus. Brownish-gray background is well appreciated

Click here to view


Interestingly, hem-like pattern commonly noted in the areas of skin folds such as neck, axillae, and cubital fossae wherein brown and bluish-gray globules are arranged regularly in parallel lines. Perieccrine and perifollicular distribution of globules is the most common pattern. It is observed in facial and nonfacial lesions with densely packed globules sparing the white dots of eccrine and follicular openings. Few lesions show speckled pattern. It is noteworthy that Wickham striae and vascular features are absent unlike classical lichen planus. The background color is brownish but with a hue of bluish-gray.[8],[9]

In accordance with the parameters of basic guidelines, in LPP brownish with bluish-gray hue is background color and brown to gray globules are pigment pattern. No scales or vascular or follicular structures are observed in LPP.


  Erythema Dyschromicum Perstans or Ashy Dermatosis Top


Dermoscopy of EDP or ashy dermatosis shows pigment globules with variegation of color from bluish-gray to brown with variable erythema and linear vessels. Importantly, pigment globules are irregularly organized in linear and circular design. On the account of this pattern, it is called as “speckled” or sprinkled or widespread appearance [Figure 2]a.[10]
Figure 2: (a) Dermoscopy of erythema dyschromicum perstans reveals bluish-gray globules (red arrows) in a bizarre and irregular arrangement referred as “speckled” appearance. Globules are dull as they are situated in deeper dermis. Note the meager amount of brown (yellow arrows) and brownish-gray globules on bluish-gray background. (b) Dermoscopy of erythema dyschromicum perstans reveals brownish-gray with pink hue in background with bluish-gray (red arrows) and brown (yellow arrows) pigment globules. Out of focus vessels are well appreciated (green arrows). (c) Dermoscopy of acanthosis nigricans demonstrates linear crista cutis (yellow arrows) and sulcus cutis (red arrows) with scattered black or dark brown dots and globules (black arrows). Note the irregular size and shape of the pigment dots and globules. (d) Dermoscopy of chronic lesion of acanthosis nigricans demonstrates linear crista cutis (yellow arrows) and sulcus cutis (red arrows) and pigment globules (black arrows). Note the exophytic papillary structures are strikingly present (yellow box). Grayish-brown with pale white color is well appreciated in the background. (e) Dermoscopy of pigmented contact dermatitis shows regular arrangement of brown (yellow arrows) and bluish-gray (red arrows) pigment globules giving a reticular arrangement. Brownish-gray background and superimposition of brown globules over bluish-gray globules are well appreciated. White scales (black arrow) and perifollicular halo (green arrows) are present. (f) Dermoscopy of friction melanosis shows accentuated pseudopigment network with patchy distribution of brown (yellow arrows) and bluish-gray (red arrows) pigmented globules. Patulous follicular openings (yellow circles) are well appreciated. (g) Dermoscopy of seborrheic melanosis shows prominent pseudo network (blue circle) and dilated follicles with whitish-yellow plugs (black arrows). Note the erythematous background and white scales (yellow star)

Click here to view


The characteristics of pigment globules in EDP include granular, smaller, and dull or dim in color. This is in contrast to pigment globules of LPP wherein globules are intense in color and bigger in size.[11],[12] The histopathological basis for dermoscopic patterns are; well preserved and finger like rete ridges, lesser intensity of melanin incontinence, and no active interface dermatitis. These findings result in smaller and granular globules. Moreover, the absence of focal epidermal atrophy produces dull or dim globules. Pseudoreticular or reticular pattern of pigmented globules is not observed in EDP. This is probably due to fact that widespread follicular involvement is missing in EDP unlike in LPP (videsupra).[7]

Hence, characteristics of pigment globules EDP differ for that of LPP. In the nutshell, LPP demonstrates extensive vacuolar degeneration, increased intensity of melanin, follicular involvement, and rete ridges flattening whereas in EDP, above features present are in a lesser extent.[13]

Background color in EDP in skin types I, II, and III is bluish-gray with brown or pink hue due to heavy melanophages in the dermis and occasional melanin in epidermis and linear vessels.[11],[14] However, bluish-gray and brownish color is observed in skin types IV and V with pinkish hue on few occasions, [Figure 2]b. This is possibly because of heavy pigmentation.[15]

In dermoscopic approach to an EDP lesion, clinicians are expected to observe the bluish-gray or brownish background color and “speckled” bluish-gray globules as pigment pattern with linear vessels as vascular elements. No scales and follicular changes are seen in EDP.


  Acanthosis Nigricans Top


Dermoscopy of acanthosis nigricans (AN) usually reveals linear crista cutis and sulcus cutis with scattered black or dark brown dots and globules [Figure 2]c.[16] In chronic lesions with thickened skin, exophytic papillary structures are seen [Figure 2]d.[17]

The background color is alternating darker brown or grayish-brown in the crista cutis region and white (hypopigmented) in sulci cutis.[16] Dots or globules vary in size and take the diverse shapes according to their orientation of pigment in the papillary structures.

In histopathological terms, linear crista cutis represents uplifted and pigmented epidermis by papillomatous projections of the dermis. Sulcus cutis reflects equally pigmented surrounding epidermis. However, it is noteworthy that white color of sulci cutis is due to the basket weave stratum corneum filled in the valley of downwardly progressed epidermis.[18]

In chronic lesions with thickened skin, exophytic papillary structures are seen due to extreme papillomatosis.[17] Darker brown or black dots probably correspond to heavy melanization in the epidermis. Keratin-filled invaginations are darker in skin of color.[19]

Hence, in the line of dermoscopic basics, alternating bands of brown or gray and pale white form the background color and numerous dark brown dots and globules are the pigment pattern. No follicular or vascular or scales patterns seen. Linear cristae cutis and sulci cutis are the special clue in AN.


  Pigmented Contact Dermatitis Top


Dermoscopy pigmented contact dermatitis (PCD) also called as Riehl's Melanosis demonstrates regular array of brown and bluish-gray pigment globules giving a reticular network [Figure 2]e.[20] As compared to LPP, globules are finer and smaller in PCD. Superimposition of brown globules is characteristic of PCD which is not observed in LPP or EDP. Brown and bluish-gray pigment globules correlate with epidermal melanin and melanophages respectively as a result of basal cell degeneration and pigmentary incontinence.[21],[22] Follicular plugs with peri-follicular white halo may be seen respectively due to follicular hyperkeratosis and perifollicular fibrosis. Telangiectatic vessels and mild scales can be noted occasionally.[10] In the perspective of skin of color, grayish hue is predominant and bluish-gray pigment globules are occupied largely in perifollicular area in arcuate and circular form giving the “reticular network” appearance. Vessels are not evident due to dense melanin and for the same reason whitish halo around follicles are not recognized.

Hence, brownish-gray is the background color, brown and grayish globules are pigment pattern, follicular plugs with perifollicular white halo are the follicular changes, telangiectatic vessles are the vascular structures and scales are mild and located in perifollicular area. Superimposition of brown globules is the special clue in PCD.


  Frictional Melanosis Top


FM is an acquired localized pigmentary disorder which develops at sites of repeated friction and commonly detected in darker skin types.[23] Dermoscopy of FM affecting the back is typified by either diffuse brownish structureless area or reticular brownish area. Diffuse or reticular pattern in FM is based on the degree of epidermal pigmentation.[10] Pigmentation is extensive in former and focal in latter. Despite, dermoscopic features of FM in facial lesions is not outlined in skin Types I, II, and III. Accentuated pseudopigment network, irregularly placed pigmented globules and patulous follicular openings with plugs is observed in skin types IV and V.[23]

The color of background is brown with pockets of gray hue. Pigment globules are brown and bluish-gray in shade. Broadly, globules are “patchy” in distribution and primarily located in perifollicular areas. Other patterns comprise diffuse and irregular array [Figure 2]f. Size and shape are irregular. Due to repeated rubbing, broken hairs, dilated follicular openings with follicular plugging are identified. Perifollicular white scales are noted due follicular hyperkeratosis. Close differential include LPP, EDP, and PCD which are discerned by the characteristics of pigment globules. They are dense, bigger, uniform in LPP; smaller and uniform in EDP; smaller and granular in PCD; and smaller and irregular in FM.

Predominant brownish color, randomly located bluish-gray globules with follicular modifications are possibly explained on the ground of histopathological changes in FM that consists of irregular acanthosis of epidermis, antler-like projection of rete ridges, hypermelanosis of basal layer and “patchy” pigment incontinence with follicular dilatation with plugs.[24]

In concordance with the basic approach in FM, background color is brown, bluish-gray globules are the pigment network and follicular changes include patulous follicles with plugs. Vascular elements are not seen. Scales are white in perifollicular area.


  Seborrheic Melanosis Top


The entity of SM is described recently in the literature which probes the localized hyperpigmentation in the areas of face, such of ala grooves, angle of the mouth, and labiomental crease in the patients with Fitzpatrick skin Types III, IV, and V.[25] Three patterns of dermoscopy are reported in SM, namely, pigment, vascular, and mixed patterns. Pigment pattern with prominent pseudonetwork, vascular with linear and arborizing vessels over light pink background and combination of both in mixed pattern are explained. Yellowish scales are seen [Figure 2]g.[25] Whitish yellow excrescences erupting from the vellus hairs with prominent follicular openings are strikingly present in SM. Based on these dermoscopic observations and history, clinical morphology of lesions; authors consummated that localized hyperpigmented areas are largely related to seborrheic dermatitis (SD).

However, histopathological confirmation of dermoscopic features was not executed. This is the major drawback in pervious perceptions. Few points of concern are hyperpigmentation on the face is not be only due to SD, typical sites of SD in face are different and lastly, dermoscopic features are not consistent with SD.[26] Dermoscopy of SD in face shows red dots in clusters, yellow scales and pinkish background with yellowish-white spicules in the follicular openings.[27] Red dots were not described in earlier communiqué.

Hence, it is imperative that further scrutiny is crucial to clarify the dermoscopic features explained in SM by conducting studies encompassing larger samples with clinicodermoscopy-histopathological correlation.

In the view of basic approach,[25] pinkish hue is the background color; pseudonetwork is the pigment pattern, linear vessels are the vascular elements and white scales are present with dilated follicles with plugs.


  Pigmentary Demarcation Lines Top


PDL are hyperpigmented areas with acute change of color from normal skin. PDL over face usually resembles melasma and postinflammatory hyperpigmentation; hence, pose a diagnostic confusion for the clinicians. Dermoscopy shows normal or exaggerated pseudoreticular network [Figure 3]a. Brown globules are unevenly distributed on the background of brownish pigmented areas and around the follicles as well. Brown globules correlate with increase in melanin in the basal layer.[17]
Figure 3: (a) Dermoscopy of pigmentary demarcation lines shows accentuated pseudoreticular pigment network (black arrows). Brown pigment globules are seen arranged around follicular openings (blue arrow) and in irregular diffuse pattern (black circle). (b) Dermoscopy of melasma shows brownish background with pigment globules arranged in reticular pattern (yellow stars). Note the brownish background color. (c) Dermoscopy of melasma reveals reticular netwrok (yellow circles) and brown globules (black arrow) in reticulo-globular pattern. Note the brownish background color. (d) Dermoscopy of melasma reveals brown pigment globules concentrated in perifollicular areas (yellow arrows) with sparing of follicles (black arrows). Note the “out of focus” linear vessels (green arrows) suggestive of vascular element in the etiology of melasma. (e) Dermoscopy of steroid damaged face shows “in focus” vessels (arrows) suggestive of atrophic of skin by the steroid application. (f) Dermoscopy of exogenous ochronosis demonstrates grayish-brown dark structures in curvilinear and “worm like” appearance (yellow arrows), white scales (red arrows) with telangiectasia (black arrows)

Click here to view


Hence, in line of basic guidelines, background color is brown, brown globules are the pigment network with no vasculature or scales.


  Melasma Top


Dermoscopy of melasma reveals a highly variable patterns of pigmentation, i.e., reticular [Figure 3]b, pseudoreticular or reticuloglobular [Figure 3]c, granular, patchy, and diffuse.[28] Regular brownish appearance, irregular bluish-gray, and combination of both are observed in epidermal, dermal, and mixed types.[10] The color of pigment pattern varies from light to dark brown. There is characteristic follicular sparing.[28]

Previously, the classification of melasma was based on clinical, Wood's lamp, and histopathological features. Recent advances in imaging technologies have proven their efficacy in categorizing melasma into epidermal, dermal, or mixed types.[29] Hence, dermoscopy shows brown or dark brown, bluish-gray, or combination of both respectively in epidermal, dermal, or mixed types of melasma.[10] Notwithstanding, the difficulty in observing the bluish-gray hue (suggestive of dermal melasma) exists in skin of color.[17],[30] This is seemingly due to normal melanin in the basal cell layer that acts as a curtain resulting in nonvisualization of dermal melanin. This is largely because of the absence of vacuolar degeneration of basal layer.[31]

Erythema with telangiectasia may be observed in few lesions of untreated cases suggesting a vascular component in etiology [Figure 3]d.[32] It is meaningful to note that vessels in melasma per se are deeper and are not sharply focused where as in steroid damaged face vessels are superficial and sharply focused [Figure 3]e. This is attributed to the epidermal atrophy because of steroid.

Furthermore,in vivo reflectance confocal microscopic analysis revealed hetergeneous presence of melanophages in different locations in a single lesion of melasma. This compounds and confirms that all melasma lesions should be considered as mixed type.[33] Hence, we consider role of dermoscopy in melasma is befitting in observing the features of exogenous ochronosis (EO) (videinfra) in a lesion of melasma especially in skin Types IV, V, VI and to assess the treatment response, until larger research studies highlighting clinico-dermoscopic-histopathological correlation are done to typify nature of melasma.

In view of the basics approach, melasma shows prominent brown as background color, reticular or reticuloglobular changes as pigment pattern, variable degree of erythema, and telangiectasias as vascular structures. No follicular changes and no scales are recognized in melasma.


  Exogenous Ochronosis Top


Dermoscopy in EO demonstrates dark grayish-brown structures or globules that are arranged in annular and arciform pattern giving a curvilinear and “worm like” appearance [Figure 3]f. Although pigment globules are located in the perifollicular region definitely areas of follicular obliteration are appreciated. Importantly, a clear demarcation between melasma and EO is observed.[34],[35] Vascular elements include patchy erythema and linear telangiectasia. Scales are white and minimal.[36]

It is accepted that grayish-brown globules correspond to focal deposition of banana-shaped ochronotic pigment in the dermis. We differ in dermoscopic-histopathological correlation of ochre bodies in previous reports. The characteristic histopathological changes of EO include ochre bodies (superficial reticular dermis) and homogenization of collagen.[37] The ochre bodies are located in the reticular dermis and may not be picked up by the dermoscopy. Reactive epidermal and dermal pigmentary changes might be responsible to grayish-brown globules. Nevertheless, this is our viewpoint which needs further elucidation by doing dermoscopy-guided biopsy to affirm this hypothesis.

In the lines of basic guidelines, EO shows dark brown and pale white color in the background, grayish-brown globules are the pigment network with obliteration of follicular openings and mild scaling are noted. Curvilinear configuration of gray-brown globules is the special clue in EO.


  Confluent Reticulated Papillomatosis Top


Dermoscopy of confluent reticulated papillomatosis (CRP) is typified by fissures and ridges, also called as sulci and gyri, arranged in “cerebriform” pattern. Ridges are composed of polygonal dark brown globules which are separated by white striae giving a “cobblestone” pattern [Figure 4]a.[38] Brown globules represent hypermelanosis in basal layer. Sulci and gyri correlate with pigmented epidermis and dermal papillomatosis. Hence, in CRP, background color is alternating brown and pale white. This is analogous to AN (videsupra).[18]
Figure 4: (a) Dermoscopy of confluent reticulated papillomatosis shows sulci (yellow arrow) and gyri (black arrow) with a result of a “cerebriform” pattern (yellow box). White scales are present along the skin furrow, striae and perifollicular areas (red arrows). Broken and V-like hairs (yellow circles) are well appreciated. (b) Dermoscopy of lichen amyloidosis (to represent macular amyloidosis) shows brown pigmented globules in “hub and spoke” pattern. Note the central white (yellow arrows) or brown (black arrows) and peripheral brown dots (red arrows). (c) Dermoscopy of hyperpigmented pityriasis versicolor shows accentuated pigment network (yellow stars) and well demarcated margins with fine white scales (yellow circles). Perifollicular white areas (red arrows) and widening of skin furrows (yellow arrows) are well appreciated

Click here to view


White scales are situated along the skin furrows.[39] In terms of skin of color, globules are darker brown and white scales are noted along the skin furrows and brown globules. Interestingly, white scales are in perifollicular area arranged in tubular fashion. Vascular structures are not seen. Notably, striking hair changes such as broken hairs, V-like hairs, and reduced density of hairs are observed in lesional skin.[40]

On account of basic guidelines, background is brown and white, polygonal globules are the pigment network, scales are white and present along the globules, lines and in perifollicular area. No vascular elements are observed. Follicular changes include decreased hairs, V-like hairs, and broken hairs.


  Macular Amyloidosis Top


Dermoscopy of macular amyloidosis (MA) shows a distinctive “hub and spoke” pattern which consists of brown clod in the center and radiating brown lines from the central clod [Figure 4]b.[41] Dermoscopic features in lichen amyloidosis are also similar to that of MA in respect with “hub and spoke” pattern. Surrounding brown area takes many configurations such as streaks, leaf-like, or bulbous projections. Central clod is the hub and radiating lines are the spokes and central hub is either brown or white.[42] It should be noted that melanin is present in the tip of papillae which forms the “hub” and the spikes are due to irregularly hyperplastic reactive epidermal basal pigmentation. The white area in the center is because of orthokeratosis and acanthosis.[18]

According to basic dermoscopic parameters, brown is the background color, brown dots, clods, or streaks are the pigment pattern. No scales and no follicular changes and vascular elements are noted in MA.


  Hyperpigmented Pityriasis Versicolor Top


Dermoscopy of hyperpigmented pityriasis versicolor (HPV) shows accentuated pigment network or diffuse brownish pigmentation with fine white scales [Figure 4]c. Margins of the lesions are well demarcated.[10] Although scales are confined mainly to skin furrows they are distributed in patchy, perifollicular, and diffuse patterns.[43]

In an Indian study, employing a dermoscope with higher magnification (×50) in HPV, authors observed accentuated pigment network, white halo surrounding the brownish pigmented area, translucent hair shaft and scales. White halo was referred as “contrast halo sign.” It was suggested that translucent hairs represent follicular invasion by the fungus.[44] However, histopathological documentation was not done to confirm this hypothesis. In our experience, white areas are located in perifollicular position [Figure 4]c. Thus, more rigorous research is warranted to affirm the exact location of white areas. Interestingly, widening of skin furrows is another striking feature in HPV which is analogs to dermoscopic feature observed in hypopigmented pityriasis versicolor.[45]

Hence, in basic approach, background color is brown, accentuated pigment network is the pigment pattern, white scales are diffuse or perifollicular or along the skin furrows with no follicular and vascular changes.

In the summary, dermoscopy definitely delineates epidermal and dermal pigmentation in hyperpigmentary lesions. Melasma, PDL, EO, CRP, AN, MA, and HPA show reliable and conclusive features that are repetitive and reproducible. There is overlap in dermoscopic features in LPP, EDP, PCD and FM. In doubtful lesions, clinico-dermoscopic-histopathological correlation is mandatory. SM is a recently defined entity, thus further speculations are of paramount importance. Different dermoscopic features of all the hyperpigmentary lesions are depicted in [Table 1] and [Table 2].
Table 1: Different dermoscopic parameters in various hyperpigmented conditions

Click here to view
Table 2: Different dermoscopic parameters in various hyperpigmented conditions

Click here to view


To conclude, hyperpigmentary lesions in skin of color demonstrate definitive and characteristic dermoscopic pattern. Pigmented globules play a crucial role in distinguishing different lesions. Pursuing the above-mentioned steps of basic approach in dermoscopy may prove useful in diagnosing or discerning a hyperpigmented lesion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patel AB, Kubba R, Kubba A. Clinicopathological correlation of acquired hyperpigmentary disorders. Indian J Dermatol Venereol Leprol 2013;79:367-75.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Bowling J. Introduction to dermoscopy. In: Bowling J, editor. Diagnostic Dermoscopy: The Illustrated Guide. West Sussex: Wiley-Blackwell; 2012. p. 2-14.  Back to cited text no. 2
    
3.
Errichetti E. Dermoscopy of inflammatory dermatoses (Inflammoscopy): An up-to-date overview. Dermatol Pract Concept 2019;9:169-80.  Back to cited text no. 3
    
4.
Sonthalia S, Errichetti E, Kaliyadan F, Jha AK, Lallas A. Dermoscopy of lichen planus pigmentosus in Indian patients Pitfalls to avoid. Indian J Dermatol Venereol Leprol 2018;84:311-3.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Sharma VK, Gupta V, Pahadiya P, Vedi KK, Arava S, Ramam M. Dermoscopy and patch testing in patients with lichen planus pigmentosus on face: A cross-sectional observational study in fifty Indian patients. Indian J Dermatol Venereol Leprol 2017;83:656-62.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Pirmez R, Duque-Estrada B, Donati A, Campos-do-Carmo G, Valente NS, Romiti R, et al. Clinical and dermoscopic features of lichen planus pigmentosus in 37 patients with frontal fibrosing alopecia. Br J Dermatol 2016;175:1387-90.  Back to cited text no. 6
    
7.
Mobini N, Caire ST, Hu S, Kamino H. Noninfectious erythematous, papular, and squamous diseases. In: Elder DE, Elenitsas R, Rosenbach M, Murphy GF, Rubin AI, Xu X, editors. Lever's Histopathology of the Skin. Philadelphia: Wolters Kluwer; 2015. p. 192-239.  Back to cited text no. 7
    
8.
Neema S, Jha A. Lichen planus pigmentosus. Pigment Int 2017;4:48-9.  Back to cited text no. 8
  [Full text]  
9.
Güngör Ş, Topal IO, Göncü EK. Dermoscopic patterns in active and regressive lichen planus and lichen planus variants: A morphological study. Dermatol Pract Concept 2015;5:45-53.  Back to cited text no. 9
    
10.
Errichetti E, Aimilios Lallas A. Hyperpigmented dermatoses. In: Lallas A, Errichetti E, Ioannides D, editors. Dermoscopy in General Dermatology. London: CRC Press; 2019. p. 106-21.  Back to cited text no. 10
    
11.
Elmas ÖF, Acar EM, Kilitçi A. Dermoscopic diagnosis of ashy dermatosis: A retrospective study. Indian Dermatol Online J 2019;10:639-43.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Mittal J, Kaur S. Lichen planus pigmentosus and ashy dermatosis: A clinical, dermoscopic and histopathological comparison. J Pakistan Assoc Dermatol 2019;29:208-14.  Back to cited text no. 12
    
13.
Vázquez-López F, Vidal AM, Zalaudek I. Dermoscopic subpatterns of ashy dermatosis related to lichen planus. Arch Dermatol 2010;146:110.  Back to cited text no. 13
    
14.
Errichetti E, Angione V, Stinco G. Dermoscopy in assisting the recognition of ashy dermatosis. JAAD Case Rep 2017;3:482-4.  Back to cited text no. 14
    
15.
Leung AKC, Lam JM. Erythema dyschromicum perstans in an 8-year-old Indian Child. Case Rep Dermatol Med 2018;2018:2143089.  Back to cited text no. 15
    
16.
Uchida S, Oiso N, Suzuki T, Kawada A. Dermoscopic features of hyperpigmented dots in crista cutis in two siblings in a Japanese family with inherited acanthosis nigricans. J Cosmetics Dermatol Sci Appl 2012;2:252-53.  Back to cited text no. 16
    
17.
Sonthalia S, Gupta A, Jha AK, Sarkar R. Hyperpigmented disorders (disorders of pigmentation). In: Lallas A, Errichetti E, Ioannides D, editors. Dermoscopy in General Dermatology. London: CRC Press; 2019. p. 257-69.  Back to cited text no. 17
    
18.
Maize JC, Ralston JS. Metabolic diseases of the skin. In: Elder DE, Elenitsas R, Rosenbach M, Murphy GF, Rubin AI, Xu X, editors. Lever's Histopathology of the Skin. Philadelphia: Wolters Kluwer; 2015. p. 502-44.  Back to cited text no. 18
    
19.
Nirmal B. Dermatoscopy image characteristics and differences among commonly used standard dermatoscopes. Indian Dermatol Online J 2017;8:233-4.  Back to cited text no. 19
[PUBMED]  [Full text]  
20.
Wang L, Xu AE. Four views of Riehl's melanosis: Clinical appearance, dermoscopy, confocal microscopy and histopathology. J Eur Acad Dermatol Venereol 2014;28:1199-206.  Back to cited text no. 20
    
21.
Satter EK. Riehl Melanosis (Pigmented Contact Dermatitis). Available from: https://emedicine.medscape.com/article/1119818-overview. [Last accessed on 2020 Apr 28].  Back to cited text no. 21
    
22.
Neema S, Chatterjee M, Mukherjee T, Jha S. Pigmented contact dermatitis resulting from self-medication for postherpetic Neuralgia. Indian J Dermatol 2016;61:340-1.  Back to cited text no. 22
[PUBMED]  [Full text]  
23.
Mutalik SD, Pethe SV, Nikam BP, Rasal YD. Facial frictional melanosis in Indian patients: Defining the entity. Clin Dermatol Rev 2019;3:78-83.  Back to cited text no. 23
  [Full text]  
24.
Sharquie KE, Noaimi AA, Hajji AA. Frictional melanosis of rubbing thighs in Iraqi patients. J Cosmet Dermatol Sci Appl 2014;4:203-11.  Back to cited text no. 24
    
25.
Verma SB, Vasani RJ, Chandrashekar L, Thomas M. Seborrheic melanosis: An entity worthy of mention in dermatological literature. Indian J Dermatol Venereol Leprol 2017;83:285-9.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Arshdeep BM, Sonthalia S, Kaliyadan F, Errichetti E, Jha AK, Lallas A. Seborrheic melanosis and dermoscopy: Lumping better than splitting. Indian J Dermatol Venereol Leprol 2018;84:585-7.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Kim GW, Jung HJ, Ko HC, Kim MB, Lee WJ, Lee SJ, et al. Dermoscopy can be useful in differentiating scalp psoriasis from seborrhoeic dermatitis. Br J Dermatol 2011;164:652-6.  Back to cited text no. 27
    
28.
Sonthalia S, Jha AK, Langar S. Dermoscopy of Melasma. Indian Dermatol Online J 2017;8:525-6.  Back to cited text no. 28
[PUBMED]  [Full text]  
29.
Tamler C, Fonseca RM, Pereira FB, Barcauí CP. Classification of melasma by dermoscopy: Comparative study with Wood's lamp. Surg Cosmet Dermatol 2009;1:115-9.  Back to cited text no. 29
    
30.
Sonthalia S, Jha AK, Bosseila M, Errichetti E. Dermoscopy − Master by analysis and patience, not haste and nonchalance. Pigment Int 2018;5:117-19.  Back to cited text no. 30
  [Full text]  
31.
Fedeles F, Robinson-Bostom L. Pigmentary disorders of the skin. In: Elder DE, Elenitsas R, Rosenbach M, Murphy GF, Rubin AI, Xu X, editors. Lever's Histopathology of the Skin. Philadelphia: Wolters Kluwer; 2015. p. 839-52.  Back to cited text no. 31
    
32.
Sarkar R, Arora P, Garg VK, Sonthalia S, Gokhale N. Melasma update. Indian Dermatol Online J 2014;5:426-35.  Back to cited text no. 32
  [Full text]  
33.
Kang HY, Bahadoran P, Suzuki I, Zugaj D, Khemis A, Passeron T, et al.In vivo reflectance confocal microscopy detects pigmentary changes in melasma at a cellular level resolution. Exp Dermatol 2010;19:e228-33.  Back to cited text no. 33
    
34.
Khunger N, Kandhari R. Dermoscopic criteria for differentiating exogenous ochronosis from melasma. Indian J Dermatol Venereol Leprol 2013;79:819-21.  Back to cited text no. 34
[PUBMED]  [Full text]  
35.
Gil I, Segura S, Martínez-Escala E, Lloreta J, Puig S, Vélez M, et al. Dermoscopic and reflectance confocal microscopic features of exogenous ochronosis. Arch Dermatol 2010;146:1021-5.  Back to cited text no. 35
    
36.
Hermawan M, Simbolon Sitohang IB, Sirait SP. Exogenous ochronosis: Screening by dermoscopy and histopathological confirmation. J Nat Sc Biol Med 2019;10, Suppl S1:163-5.  Back to cited text no. 36
    
37.
Martins VM, Sousa AR, Portela NC, Tigre CA, Gonçalves LM, Castro Filho RJ. Exogenous ochronosis: Case report and literature review. An Bras Dermatol 2012;87:633-6.  Back to cited text no. 37
    
38.
Bernardes Filho F, Quaresma MV, Rezende FC, Kac BK, Nery JA, Azulay-Abulafia L. Confluent and reticulate papillomatosis of Gougerot-Carteaud and obesity: Dermoscopic findings. An Bras Dermatol 2014;89:507-9.  Back to cited text no. 38
    
39.
Errichetti E, Maione V, Stinco G. Dermatoscopy of confluent and reticulated papillomatosis (Gougerot-Carteaud syndrome). J Dtsch Dermatol Ges 2017;15:836-8.  Back to cited text no. 39
    
40.
Ankad BS, Dombale V, Sujana L. Dermoscopic patterns in confluent and reticulated papillomatosis: A case report. Our Dermatol Online 2016;7:323-26.  Back to cited text no. 40
    
41.
Kumar P, Neema S, Pathak N. Macular amyloidosis in a middle-aged woman. Pigment Int 2018;5:57-8.  Back to cited text no. 41
  [Full text]  
42.
Chuang YY, Lee DD, Lin CS, Chang YJ, Tanaka M, Chang YT, et al. Characteristic dermoscopic features of primary cutaneous amyloidosis: A study of 35 cases. Br J Dermatol 2012;167:548-54.  Back to cited text no. 42
    
43.
Mathur M, Acharya P, Karki A, Kc N, Shah J. Dermoscopic pattern of pityriasis versicolor. Clin Cosmet Investig Dermatol 2019;12:303-9.  Back to cited text no. 43
    
44.
Kaur I, Jakhar D, Singal A. Dermoscopy in the evaluation of pityriasis versicolor: A cross sectional study. Indian Dermatol Online J 2019;10:682-5.  Back to cited text no. 44
[PUBMED]  [Full text]  
45.
Ankad BS. Hypopigmented disorders (disorders of pigmentation). In: Lallas A, Errichetti E, Ioannides D, editors. Dermoscopy in General Dermatology. London: CRC Press; 2019. p. 257-69.  Back to cited text no. 45
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Lichen Planus Pi...
Erythema Dyschro...
Acanthosis Nigricans
Pigmented Contac...
Frictional Melanosis
Seborrheic Melanosis
Pigmentary Demar...
Melasma
Exogenous Ochronosis
Confluent Reticu...
Macular Amyloidosis
Hyperpigmented P...
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed694    
    Printed42    
    Emailed0    
    PDF Downloaded79    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]