|Year : 2021 | Volume
| Issue : 1 | Page : 65-70
Dermatoscopy and clinicopathological correlation in different spectrum of leprosy
Amrit Singh Bhatia1, Ambresh Badad1, Ashok S Hogade1, M Spoorthy2
1 Department of Dermatology, Venereology, Leprology, Mahadevappa Rampure Medical College, Kalaburagi, Karnataka, India
2 Department of Pathology, Mahadevappa Rampure Medical College, Kalaburagi, Karnataka, India
|Date of Submission||20-Feb-2020|
|Date of Decision||03-Jun-2020|
|Date of Acceptance||26-Jun-2020|
|Date of Web Publication||19-Feb-2021|
Dr Badad's Skin Eye and Laser Care Centre, H No 10-105, 16 A and B, Sharan Nagar, Tank Bund Road, Brahmpur, Kalalburagi - 585 103, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Leprosy is a chronic granulomatous infection with varied clinical presentations. Dermatoscopy is a noninvasive technique that allows rapid and magnified in vivo observation of the skin with the visualization of morphologic features that are invisible to the naked eye. In our study, we aim to describe the dermatoscopic features of all types of leprosy and correlate with clinical and histopathological findings. Materials and Methods: A prospective observational study was done on all the leprosy patients attending OPD over a period of 1 year. The study patients were categorized as per Ridley–Jopling classification. The lesions of different types of leprosy were photographed and evaluated by dermatoscopy and biopsied. Results: A total of 60 patients (34 males and 26 females) were taken under the study. Of 60 patients, 6 cases of tuberculoid leprosy, 22 cases of borderline tuberculoid (3 with Type 1 reaction), 16 cases of borderline lepromatous, 12 cases of lepromatous leprosy (5 with Type 2 reaction), and 4 cases of Histoid leprosy. The dermatoscopic features seen are yellowish-orange areas and vascular structures such as linear branching vessels and crown vessels. Broken pigment network and white chrysalis like areas are also seen. Absence or diminished hair follicles and eccrine duct openings are seen in tuberculoid spectrum. Scaling and follicular plugs are seen in type 1 reaction. Conclusion: Yellowish-orange areas and vascular structures are the common dermatoscopic features seen in leprosy. Broken pigment network and paucity of appendageal structures are other features seen.
Keywords: Dermatoscopy, granulomatous infection, leprosy
|How to cite this article:|
Bhatia AS, Badad A, Hogade AS, Spoorthy M. Dermatoscopy and clinicopathological correlation in different spectrum of leprosy. Clin Dermatol Rev 2021;5:65-70
|How to cite this URL:|
Bhatia AS, Badad A, Hogade AS, Spoorthy M. Dermatoscopy and clinicopathological correlation in different spectrum of leprosy. Clin Dermatol Rev [serial online] 2021 [cited 2021 Jul 25];5:65-70. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/65/309771
| Introduction|| |
Leprosy, also known as Hansen's disease, is a chronic granulomatous infection caused by the bacterium Mycobacterium leprae. It primarily infects the skin and the nerves. The diagnosis of the disease is based on the cardinal features of hypoesthetic light colored-skin lesions, thickened peripheral nerves, and presence of acid-fast lepra bacilli in slit skin smear. It has varied clinical presentations spanning from the paucibacillary tuberculoid spectrum to the multibacillary lepromatous spectrum. The variety of clinical presentations makes leprosy a diagnostic challenge and thus has to be differentiated from other infective and noninfective granulomatous dermatoses.
Dermatoscopy being a noninvasive, repeatable, recordable bedside investigation is a valuable tool in clinical dermatology for diagnosis and monitoring of skin diseases. Its utility has now been extended to pigmentary and inflammatory disorders including granulomatous diseases., This study was performed with an aim to highlight the various dermatoscopic features of the entire spectrum of leprosy and to correlate with clinical and histopathological findings.
| Materials and Methods|| |
This is a prospective observational study in which all the spectrum of leprosy from tuberculoid to lepromatous pole were included and dermatoscopy was done. The study was done in the Leprosy clinic of a tertiary care hospital in South India for 1 year from January 2019 to December 2019 after obtaining Institutional Ethics Committee approval. Patients attending the leprosy clinic and admitted patients for institutional therapy were enrolled in the study. All the study patients were categorized as per Ridley–Jopling classification based on clinical, slit skin smear, and histopathological findings. The clinical and histopathological findings were correlated with the characteristic dermoscopic findings. The patient consent was taken for clinical photographs, dermoscopic evaluation, and histopathological examination. Dermatoscopic evaluation was done by a dermatologist using a hand held Dermlite II hybrid M dermatoscope at ×10 magnification in polarized contact mode, and photographs were captured using an Apple phone. The same lesion was also biopsied and sent for histopathological examination.
| Results|| |
A total of 60 patients of leprosy (34 males and 26 females) attending the leprosy clinic during the study period were enrolled. The study patients were of Indian ethnicity with skin phototype IV to VI. The average age was 30–38 years and the mean duration of the disease was 12 months. As per the Ridley–Jopling classification, there were 6 cases of tuberculoid leprosy (TT), 22 cases of borderline tuberculoid (BT), 16 cases of borderline lepromatous (BL), 12 cases of lepromatous leprosy (LL), and 4 cases of histoid leprosy included in the study. Among the cases of BT, 3 patients had type 1 reaction and 5 patients with LL had type 2 reaction. All skin lesions were biopsied and hematoxylin and eosin stains were used to stain. Dermatoscopic patterns were observed for different spectrums and then clinical correlation was drawn based on the clinical diagnosis and histopathological and dermatoscopic findings.
Patients with Hansen (TT) clinically presented with a well defined, erythematous annular plaque with central clearing and loss of sensation over the right forearm [Figure 1]a. Dermatoscopy performed over the annular lesion demonstrated yellowish-orange areas, broken pigmentary network, decreased number of white dots depicting decreased number of sweat glands, loss of hair follicles, and eccrine gland openings are shown in [Figure 1]b. Erythema was seen in the surrounding area [Figure 1]b. Another dermatoscopic picture taken from the center of the lesion showing broken pigmentary network and white dots [Figure 1]c. Histopathology reveals Langhans type of giant cells with epithelioid cells and lymphoplasmacytic infiltrate [Figure 1]d. Compact granulomas beneath the epidermis along with neurovascular bundle are also seen [Figure 1]d.
|Figure 1: Tuberculoid leprosy (a) clinical picture showing well defined, erythematous annular plaque with central clearing and loss of sensation over the right forearm, (b) dermatoscopic picture showing yellowish-orange areas (star), broken pigmentary network (arrow), decreased number of white dots (circle), (c) dermatoscopic picture taken from the center of the lesion showing broken pigmentary network (arrow) and white dots (circle), (d) histopathology reveals Langhans type of giant cells with epithelioid cells and lymphoplasmacytic infiltrate (H&E x10)|
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In BT leprosy, the patient clinically presented with a well-defined hypopigmented plaque present over the face [Figure 2]a and over the right thigh [Figure 2]b. Satellite lesion is also seen. Dermatoscopy shows structureless yellowish-orange areas along with branching and anastomosing vessels. Yellow globules were seen which are suggestive of sebaceous units in the absence of hair follicles. Diminished pigment network and white areas depicting eccrine gland openings could also be appreciated [Figure 2]c. Histopathology reveals giant cells and ill formed granuloma [Figure 2]d.
|Figure 2: Borderline tuberculoid leprosy; clinical picture showing hypopigmented plaque present over the face (a) and over right thigh (b) alongwith satellite lesions, (c) dermatoscopic picture showing structureless yellowish-orange areas (star) and yellow globules (arrow), (d) Histopathology reveals giant cells and ill formed granuloma (H&Ex10)|
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In BL leprosy, the patient clinically presented with numerous hypopigmented plaques all over the body mainly over the trunk [Figure 3]a and chest [Figure 3]b with loss of sensation more in the center than in the periphery. Dermatoscopy shows prominent pigmentary changes in the form of broken and loss of pigmentary network. Another dermatoscopic picture showing decreased hair follicles in the center [Figure 3]d. Reduction of sebaceous glands is seen. In addition, linear white chrysalis like structures is also shown in [Figure 3]c. Histopathology reveals clear Grenz zone with collection of lymphocytes. Collection of epithelioid cells without formation of well-defined granulomas is also shown in [Figure 3]e.
|Figure 3: Borderline lepromatous leprosy; clinical picture showing numerous hypopigmented plaques over the trunk (a) and chest (b) with loss of sensation more in the center than in the periphery, (c) dermatoscopic picture showing loss of pigmentary network (arrow) and linear white chrysalis like structures (circle), (d) dermatoscopic picture showing decreased hair follicles in the center (arrow), (e) histopathology reveals clear Grenz zone with collection of lymphocytes (H&Ex10)|
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The patient of LL clinically presented with multiple, erythematous lesions present over the trunk [Figure 4]a and [Figure 4]b and arms [Figure 4]a distributed symmetrically. Glove and stocking anaesthesia and nerve enlargement present. Dermatoscopy showed yellowish orange areas with decreased pigmentation. Partial loss of hair follicles, dry xerotic skin, and white characteristic scaling was also seen over the lesion [Figure 4]c. Histopathology reveals clear Grenz zone with macrophages in the dermis [Figure 4]d. Acid-fast bacilli in bundles are seen on Fite Ferraco stain.
|Figure 4: Lepromatous leprosy; clinical picture showing multiple, erythematous lesions over trunk (a and b) and arms (a) distributed symmetrically with glove and stocking anaesthesia and nerve enlargement, (c) dermatoscopic picture showing dry xerotic skin and white characteristic scaling (arrows), (d) histopathology reveals clear Grenz zone with macrophages in the dermis (H&Ex40)|
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Patient with Type 1 lepra reaction clinically presented with multiple, erythematous, and edematous plaques present over the trunk [Figure 5]a. Ear lobe infiltration is also seen [Figure 5]b. Dermatoscopy showed yellowish-orange areas with characteristic diffuse erythematous background along with sparse hair follicles and scaling [Figure 5]c. Histopathology reveals loose and disorganized granuloma in the upper and mid-dermis, dermal edema, and cellular contents comprising epithelioid cells, lymphocytes, giant cells, and macrophages [Figure 5]d.
|Figure 5: Type 1 lepra reaction; clinical picture showing multiple, erythematous and oedematous plaques over the trunk (a) and ear lobe infiltration (b), (c) dermatoscopic picture showing yellowish-orange areas with characteristic diffuse erythematous background showing increased vascularity (star) along with sparse hair follicles and scaling (arrows), (d) Histopathology reveals loose and disorganized granuloma in the upper and mid-dermis, dermal edema, and cellular contents comprising epithelioid cells, lymphocytes, giant cells, and macrophages (H&Ex40)|
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Type 2 lepra reaction or erythema nodosum leprosum patient clinically presented with erythematous, swollen, tender nodules present over the body mainly on the right forearm [Figure 6]a and over the mammary area [Figure 6]b. Dermatoscopy showed dilated blood vessels, increased erythema and white characteristic scaling over the lesion [Figure 6]c. Another dermatoscopic picture shows yellowish-orange area in the center surrounded by erythema [Figure 6]d. Histopathology reveals foamy macrophages with polymorphonuclear cell infiltrate containing acid fast bacilli [Figure 6]e.
|Figure 6: Type 2 lepra reaction (erythema nodosum leprosum); clinical picture showing erythematous, swollen, tender nodules present over the right forearm (a) and mammary area (b), (c) dermatoscopic picture showing dilated blood vessels, increased erythema (star) and white characteristic scaling (arrow) over the lesion, (d) dermatoscopic picture shows yellowish-orange area in the center surrounded by erythema, (e) histopathology reveals foamy macrophages with polymorphonuclear cell infiltrate containing acid fast bacilli (H&Ex10)|
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Histoid leprosy patient clinically presented with multiple, skin colored, shiny papules, and nodules present over the trunk [Figure 7]a and right forearm [Figure 7]b. Dermatoscopy showed well circumscribed yellowish-orange dome-shaped areas with few crown vessels in the center and margins of each area and scaling. A whitish-yellow structureless area and peripheral brownish pigmentation is also shown in [Figure 7]c. Another dermatoscopic picture showing grayish-brown pigmentation with scaling [Figure 7]d. Histopathology reveals thinned out epidermis and spindle-shaped cells arranged in storiform pattern [Figure 7]e.
|Figure 7: Histoid leprosy; clinical picture showing multiple, skin colored, shiny papules and nodules over trunk (a) and right forearm (b), (c) dermatoscopic picture showing well circumscribed yellowish-orange dome-shaped areas (star) with few crown vessels (line arrow) in the center and margins of each area. A whitish-yellow structureless area and peripheral brownish pigmentation (block arrow) is also seen, (d) dermatoscopic picture showing grayish-brown pigmentation with scaling (arrow), (e) histopathology reveals thinned out epidermis and spindle-shaped cells arranged in storiform pattern (H&ExScanner)|
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| Discussion|| |
Dermatoscopy helps in the diagnosis of infections and inflammatory conditions by demonstrating a characteristic pattern. In our study, we have covered the entire spectrum of leprosy from tuberculoid pole to the lepromatous pole, including reactions so that it becomes easy to differentiate it from other diseases having similar dermatoscopic findings.
Dermatoscopic features of various granulomatous disorders have been described previously, showing translucent, round/oval orange yellow patches as the main dermatoscopic finding which is not predictive for a specific disease but is highly suggestive of an underlying dermal granuloma. Linear or branching vessels are common additional dermatoscopic findings that may obscure yellow patches. Necrobiosis lipoidica is typified by a prominent network of branching arborizing vessels within a yellow background color either alone or in combination with white or red areas.,, Ulcerations and yellow crusts represent the most common additional features. Vessels of granuloma annulare are generally dotted or short linear and rarely linear arborizing. Cutaneous leishmaniasis may show a wider range of changes (including follicular plugs, “yellow tears,” hyperkeratosis, erosion/ulceration, “white starburst-like pattern,” salmon-colored ovoid structures) and variable vessels (comma-shaped, linear, dotted, polymorphous, hairpin, arborizing, corkscrew, and glomerular-like vessels).,, The findings of our study shows yellowish-orange structureless areas, vascular structures and altered/loss of pigment network as the prominent dermatoscopic finding in lesions of TT, BT, LL. In Histoid Leprosy, a whitish-yellow structureless area and peripheral brownish pigmentation were new dermoscopic observations along with characteristic patterns of a granulomatous skin condition. In our study we observed linear branching vessels regardless of the disease duration. Unlike other granulomatous diseases, loss of pigmentary network, and paucity of dermal appendages appear to be the dermatoscopic findings toward leprosy.
Dermatoscopic patterns in BT leprosy have been shown to be useful in adding the diagnosis, based on the characteristic findings. White areas were noted in all the lesions of leprosy not in reaction, which correspond to a decreased number of melanocytes in BT leprosy. White areas were not described previously in granulomatous conditions, and this is understandably due to presence of melanocytes. Here, white areas represent the mere reduced number of melanocytes, not hyperkeratosis, acanthosis, or fibrosis.
Vitiligo and leprosy are the two diseases which can present with hypopigmented lesions. Dermatoscopy may be used for aiding clinical diagnosis. In a study, dermatoscopy differentiating Vitiligo from a hypopigmented patch of leprosy was done. Dermatoscopy in hypopigmented patches of leprosy revealed altered pigment network. White globules appeared to be slightly decreased in number and flattened over the patches of leprosy. Some of the patches show microscales. There are neither hypo/depigmented islands in leprosy patches, nor is there any perifollicular hypopigmentation. On the other hand, hypopigmented patches of vitiligo show multiple areas of depigmentation with loss of pigment network over them, forming variably, sized islands of depigmentation. No scaling is seen over the patches of early vitiligo. Perifollicular depigmentation is seen in many patches of evolving vitiligo.
Type 1 leprosy reactions are episodes of immune activation predominantly affecting the borderline spectrum of the disease. The presence of scaling and follicular plugs were the dermatoscopic features of reversal reactions. Dermatoscopic monitoring for these features would help in early detection of reversal reactions. Erythema nodosum leprosum (ENL) represents type 3 hypersensitivity reaction, which commonly affects the extensors of the limbs. Dermatoscopy of ENL showed increased erythema and dilated blood vessels representing features of acute inflammation.
| Conclusion|| |
Dermoscopy is a useful, noninvasive bed side test for diagnosis of various dermatological diseases. Dermoscopy and its clinicohistopathological correlation of various spectrum of leprosy were done in this study as shown in [Table 1]. Dermoscopy will be useful tool for diagnosis and to differentiate from other close mimicking conditions.
|Table 1: Clinical, dermatoscopic and histopathological correlation of the entire spectrum of leprosy|
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The informed consent was obtained for participation in the study and publication of data and images for research and educational purposes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]