[Dermatology Reports 2019; 11:7916] [page 1]

Dermoscopy is a new diagnostictool in diagnosis of commonhypopigmented macular disease:A descriptive studyKhitam Al-RefuFaculty of Medicine, Mutah University,Jordan

AbstractOne of the most frequent complaints in

dermatology clinics is the eruption ofhypopigmented patchy skin lesions. Theaim of the study was to investigate the util-ity of dermoscopy in common hypopig-mented macular diseases. Patients with thefollowings diseases were examined by der-moscopy: vitiligo, pityriasis alba, nevusdepigmentosus, achromic pityriasis versi-color, idiopathic guttate hypomelanosis, andextragenital guttate lichen sclerosus.

This study showed that these hypopig-mented macular diseases might display spe-cific dermoscopic features. In vitiligo, themean dermoscopic features were the pres-ence of a diffuse white glow with perifollic-ular pigment, perilesional hyperpigmenta-tion, leukotrichia and the pigmentary net-work. In idiopathic guttate hypomelanosis,the characteristic features were the presenceof multiple, shiny, scaly macules with well-and ill-defined edges borders that coalescedinto polycyclic macules. For nevus depig-mentosus, the mean features were hypopig-mented patches with irregular border with afaint reticular network. For pityriasis alba,the fairly ill-demarcated hypopigmentedmacules with fine scales were the mean fea-ture. In lichen sclerosus, there were whitestructureless areas, perilesional erythema-tous halo, follicular plugging and whitechrysalis like structures. Dermoscopy ofachromic pityriasis versicolor showed afairly demarcated white area with finescales localized in the skin creases.

IntroductionOver the last few years, dermoscopy

has been shown to be a helpful tool in thediagnosis of many general dermatologicaldisorders.1-7 In addition to its well-docu-mented value in the diagnosis of skintumors and pigmentary melanocyticlesions, dermoscopy is very helpful inassisting the diagnosis of various generaldermatological disorders, includingscalp/hair diseases,8 nail/ nail-fold abnor-malities,9 and inflammatory dermatoses.1

One of the commonest complaints in der-matology clinics is the eruption of macularor patchy hypopigmented skin lesions. Thiscomplaint may be very disturbing to thepatient, especially for those with dark skin.Some of important hypopigmented maculardiseases1 are vitiligo, pityriasis alba, extra-genital lichen sclerosus, achromic pityriasisversicolor, idiopathic guttate hypome-lanosis and nevus depigmentosus.Generally, these disorders share the samepatient’s complaint which is characterizedby the presence of hypo or depigmentedpatches or macules. In this study, the aimwas to provide an overview on the use ofdermoscopy in dermatology by analyzingthe dermoscopic features of some of impor-tant hypopigmented macular diseases. Newstudies have documented dermoscopic fea-tures in vitiligo.10-19 Very few reports docu-mented these changes in idiopathic guttatehypomelanosis20,21 nevus depigmentosus,22-24achromic pityriasis versicolor25 and extra-genital lichen sclerosus.26-28 This studyinvestigated 108 patients presented at der-matology clinics during the last three yearscomplaining of hypopigmented and depig-mented cutaneous lesions. This currentstudy contained a larger number of cases,aiming to describe the common and uncom-mon dermoscopic features for the hypopig-mented macular disease; comparing thefindings with the previous reports and doc-umenting the frequency of them.

Materials and MethodsA total of 108 patients were seen at the

dermatology clinics (Mutah UniversityMedical Center) during January 2015 toOctober 2017 complaining of patchy ormacular hypopigmented lesions. Detailedand informed consent was taken from thepatients. The sample collection was notconsecutive, as the intention was to investi-gate the patients who were diagnosed withspecific hypopigmented skin diseases. Thefollowing skin diseases were included in theresearch: vitiligo, pityriasis alba, nevusdepigmentosus, achromic pityriasis versi-color, idiopathic guttate hypomelanosis, andextragenital guttate lichen sclerosus. All ofthe cases which were on treatment wereexcluded from the study. This was of partic-ular concern for the cases of vitiligo; thepatients were on no treatment for threemonths prior investigations. A detailed his-tory was taken, and dermatological exami-nation was done. A histopathological exam-ination was done for all cases of idiopathicguttate hypomelanosis and lichen sclerosuset atrophicus to confirm the diagnosis of thedisease. The histology was not performed

for other hypopigmented skin diseases asthe diagnosis was based on clinical back-ground combined with Wood’s light exami-nation and potassium hydroxide (KOH)scrapping. All of the cases were underwentWood’s light examination. This was a verycrucial method to confirm the diagnosis ofsome cases such as vitiligo and pityriasisversicolor. All of the scaly macules andpatches were examined with potassiumhydroxide scrapping. This is a very impor-tant test to confirm the diagnosis of all sus-pected cases of pityriasis versicolor. Thegently scrapped skin scales were placeddirectly onto a microscope slide and arecovered with 10% potassium hydroxide,and were left to stand until clear and gentlyheated to speed up the action of KOH. Adermoscopic examination of all cases wasperformed using a hand-held dermoscope(Dermlite DL3, Gen, USA) application(10× magnification) with both polarizedand non-polarized lights. iPhone camerawas attached to capture images. The datesand times of capturing photos were auto-matically stored. The dermoscopic exami-nation was done for all cases looking forspecific diagnostic finding for each case.The dermoscopic examination was doneblindly without referring to the clinical orhistological information. The followingparameters were taken into considerationwhen applying dermoscopy in these dis-eases: i) presence of altered pigmentationwithin the patch or macule; ii) The edge ofthe macules or patch; whether it is fairlydemarcated or ill-defined; iii) Presence of

Dermatology Reports 2019; volume 11:7916

Correspondence: Khitam Al-Refu, Faculty ofMedicine, Mutah University, Jordan.Tel.: 00962797401149.E-mail: alrefukhi@yahoo.com -alrefukhi@mutah.edu.jo

Key words: Dermoscopy; Diagnosis;Hypopigmented macules; Vitiligo.

Conflict of interest: the author declares nopotential conflict of interest.

Funding: none.

Received for publication: 26 October 2018.Revision received: 28 November 2018.Accepted for publication: 29 November 2018.

This work is licensed under a CreativeCommons Attribution-NonCommercial 4.0International License (CC BY-NC 4.0).

©Copyright K. Al-Refu, 2018Licensee PAGEPress, ItalyDermatology Reports 2019; 11:7916doi:10.4081/dr.2018.7916

the scales within the lesion or surroundingskin; iv) Presence of perifollicular pigmen-tation; v) Presence of perilesional reticulat-ed hyperpigmentation or telangiectasia; vi)The color of the hair within the hypopig-mented lesions; vii) The morphology/arrangement of vascular structures.Regarding the pattern or the shape of mac-ules in dermoscopy, there were differentpatterns described included:10 trichromepattern, nebulous pattern, polka dot pattern(several depigmented macules), comet tail-ing of the lesion, amoeboid pattern, andpetaloid pattern.

ResultsIn this study, 108 patients with the fol-

lowings diseases were enrolled in the study:vitiligo (48 cases), pityriasis alba (16cases), nevus depigmentosus (8 cases),achromic pityriasis versicolor (16 cases),idiopathic guttate hypomelanosis (11cases), and extragenital guttate lichen scle-rosus (9 cases). Out of 48 patients withvitiligo included in the study, 25 werefemales, and 23 were males. The duration ofthe disease ranged from 8 months to 2years; with an average duration of 4months. The mean age of onset was 24years. Among the patterns of vitiligo, 23patients had vitiligo vulgaris, acral distribu-tion in 11 cases, a focal variant in 10 casesand 4 had segmental distribution. The mostcommon site was extremities followed bytrunk and face. All cases demonstratedbright white (depigmented) areas withWood’s light illumination with bright blue-white fluorescence. The dermoscopic analy-sis was done for established, progressive, orregimenting vitiligo. All of the casesshowed different activity of the diseaseeven within the same patient. Regarding thepattern of pigmentation dermoscopy, a dif-fuse white glow was seen in 78% of cases,perilesional hyperpigmentation was presentin 30% of cases, perifollicular hyperpig-mentation was present in 75% of cases,interfollicular pigmentation was seen in40% of cases, white villus and terminal hairin 70% of cases, the pigmentary networkwithin the lesions in 23% of cases, lesionaland perilesional telangiectasia were presentin 8% of cases. All of the lesions were notscaly in this study. Regarding the pattern indermoscopy, there were different patternsseen in this study in order of frequency asfollows: nebulous pattern (72% of lesions),amoeboid pattern (63% of lesions),trichrome pattern (58% of lesions), petaloidpattern (51% of lesions), polka dot pattern(46% of lesions) and comet tailing of the

lesion (28% of lesions). Figure 1 demon-strates some of these dermoscopic featuresin vitiligo patients.

Patients with idiopathic guttatehypomelanosis were 11 cases (7 males, fourfemales). The Average age of the patientswas 55.3 years with a range of 35 years to80 years. On physical examination, therewere multiple circular hypopigmented mac-ules of various sizes ranging from 1 to 3mm in diameter. The skin was scaly andshowed some features of sun-damage.Average disease duration was 6 years. Thehistopathological findings for skin biopsiesfrom these lesions demonstrated basket-wave hyperkeratosis, epidermal atrophy,and flattened rete ridges, and reduction ofmelanin pigment and numbers ofmelanocytes. Dermoscopic features (Figure2A) for these cases were nearly similar inall cases and was characterized by the pres-ence of multiple, shiny, porcelain-whitemacules with well- and ill-defined edgesborders. These macules may coalesce intopolycyclic macules. Hyperpigmented net-works may be seen within the lesions or sur-rounding skin giving the appearance of thecloudy-sky pattern. The surrounding skinwas scaly. The hair was pigmented with noperi-follicular hyperpigmentation. In addi-tion, as has been described in vitiligo, it wascommon to see the petaloid, amoeboid, andnebuloid and polka dot appearance in somecases (even in the same patient and in thesame dermoscopic view) as has beendescribed in Figure 2A.

Nevus depigmentosus was one of thecommon differential diagnosis of vitiligo.All of the presented cases in this researchwere children. Eight cases presented withan asymptomatic light patches that had beenfirst noted in the neonatal period. Thepatches had been stable in shape, texture,but increasing in size with age. The meanage of presentation was 3 years with a range(1.5-12 years). Physical examination foreach patient revealed a single, well-defined,hypopigmented patch, with a serrated bor-der. The surrounding skin was normal.Wood’s light examination of the patchshowed an off-white accentuation withoutfluorescence. On dermoscopy (Figure 2B),the hypopigmented patch with an irregularand serrated boarder was the prominent fea-ture. Some of patches showed faint reticularnetwork within them. The borders alsoshowed pseudopods pattern protruding intothe normal skin. Hairs within the patcheswas of normal colors, and there was noperipheral hyperpigmentation.

Sixteen patients with pityriasis albawere examined with dermoscopy. The meanage of presentation was 8.2 years. The meanduration of the patches was 12 weeks, andno treatment was prescribed. KOH scrapingwas negative for all cases and similarly wasthe Wood’s light examination. On dermo-scopic examination (Figure 3A), thehypopigmented macules were fairly ill-demarcated white area with fine scales thatare commonly distributed within and out-side the macules. The hair inside the patch-

Article

Figure 1. (A) Dermoscopic view for vitiligo show depigmented patch, perilesional hyper-pigmentation (blue arrows) and depigmented hair (leukotrichia) (red arrow). It is promi-nent in the same view that the lower margin of the depigmented patch with ill-definedmargins that merge indistinctly into the surrounding (Nebulous pattern) (blue stars). (B)Dermoscopic view for vitiligo show Polka dot appearance with several depigmented mac-ules within a hyperpigmented background. Few macules show perifollicular repigmenta-tion and leukotrichia as well.

A B

[page 2] [Dermatology Reports 2019; 11:7916]

es was of normal color. There is no sharpmargin to differentiate the hypopigmentedpatch from the surrounding skin. These fea-tures were seen in all cases of pityriasisalba. In addition, 30 % of cases demonstrat-ed erythematous changes within and sur-rounding the macules and patches.

All of 16 patients with pityriasis versi-color were 12 males and four females.Mean age was 23 years. They did not havetreatment prior to presentation. The meanduration of disease was 9 weeks. All caseshad the lesions on their necks and uppertrunk. The patients were asymptomatic. Thediagnosis was confirmed based on clinicalassessment, KOH scrapping, and Wood’slight illumination. The characteristic der-moscopic feature (Figure 3B) in 85% ofcases was diffuse hypopigmented blotches(fairly defined) with fine scales that werecommonly localized in the skin furrows. Inaddition, some of the cases (65%) demon-strate satellite lesions (nearby small roundwhite globules). In 22% of cases, thehypopigmented blotches were ill-defined,but with prominent white, scaly globules.None of the cases demonstrated perilesionalhyperpigmentation or perifollicular hyper-pigmentation. The hair inside these maculeswas of normal color but covered by scalesin some cases.

In this study, 9 cases with extragenitallichen sclerosus were examined with der-moscopy. Seven females with mean age 11years, with a range 7-18 years. Two casesare males, of age 28 and 34 years. The meanduration of the disease 1, 8 years (with arange from 1,2 to 2,3 years). The presenta-tion of these cases was white macules overthe trunk and extremities. It started as ery-thema, expanding gradually, and finallyturned out to be a white patch. Examinationrevealed a well-demarcated, mild atrophicporcelain-white macules. The diagnosis forthis cases was confirmed by histopathology(Figure 4) which showed hyperkeratosis,epidermal atrophy, squamatization of thebasal cell layer and homogenization andhyalinosis of the upper dermis.

The predominant dermoscopic featureof lichen sclerosus (Figure 5) was white-yellowish structureless areas and whitechrysalis like structures. This whitish coloris glowing white and surrounded by an ery-thematous halo (as delicate linear branchingvessels with different lengths and calibers)especially in active lesions. Fine whitishscales were prominent. Follicular pluggingwas seen in new lesions of lichen sclerosuset atrophicus and was not started on treat-ment yet. Table 1 summarized all the previ-ous dermoscopic features in all examinedhypopigmented macular diseases.

DiscussionHypomelanosis of the skin encompass-

es a wide spectrum of congenital andacquired alterations in melanin pigmenta-tion. They pose a diagnostic challenge forthe clinician; many of these hypopigmentedskin lesions appear similar. Vitiligo is oneof the most common forms of acquiredhypomelanosis of the skin which can betreated in a guideline-oriented manner. Butit carries tremendous social implications associal stigma, especially in Arab countriesand one of these Jordan (this research hasbeen done). The eruption of hypopigmentedskin lesions is of particular concern espe-cially in darker skin patients. The commonskin type in Arab countries is the type IIIand IV Fitzpatrick skin types. Therefore,

Article

A B

Figure 3. (A) Dermoscopic feature for a child with pityriasis alba. The hypopigmentedmacules were fairly ill-demarcated white area with fine scales that are commonly distrib-uted within and outside the macules. The hair inside the patches was of normal color.There is no sharp margin to differentiate the hypopigmented patch from the surroundingskin. (B) Dermoscopic view for achromic pityriasis versicolor showed a fairly demarcatedwhite area with fine scales that are commonly localized in the skin creases.

Figure 4. Histopathology of a lesion ofextragenital lichen sclerosus showed hyper-keratosis, epidermal atrophy, squamatiza-tion of the basal cell layer and homogeniza-tion and hyalinization of the upper dermis.

Figure 2. (A) Dermoscopy of a lesion of idiopathic guttate hypomelanosis shows multiple,roundish, homogenous, white-porcelain macules, and two were well defined (amoeboidpattern) (red arrows) and with irregular cloudy whitish pattern (nebuloid) (blue arrow).Several white shades present within the field represents the scales. In addition, thesewhitish areas were surrounded by a patchy hyperpigmented network (cloudy- sky pat-tern) (blue stars). (B) The hypopigmented patches of nevus depigmentosus with irregularborder (serrated) and with a faint reticular network within the patch.

A B

[Dermatology Reports 2019; 11:7916] [page 3]

there is a need for standardized criteria todifferentiate this disease from otherhypopigmented macular diseases. The der-moscopy may be a helpful as a non-invasivetool in assisting the differential diagnosis ofseveral hypopigmented macular lesions andhas the potential to improve the diagnosticaccuracy.

Vitiligo is an acquired, autoimmune dis-order characterized by well-demarcateddepigmented macules and patches with orwithout leukotrichia. Evolving new lesionsof vitiligo are difficult to be distinguishedclinically from other causes of hypopig-mentation and depigmentation. The dermo-scopic examination can detect subtlechanges which may be useful in the earlydiagnosis of vitiligo from other differentialdiagnoses of vitiligo. Some workers havestudied the utility of dermoscopy in thediagnosis of vitiligo. A pattern of depigmen-tation with residual reservoirs of perifollic-ular pigment have been noted, and this wassignifying focally active or regimentingvitiligo.15 This residual perifollicular pig-mentation had been observed in (91.9%) ofpatients with progressing vitiligo and(62.9%) of those with stable vitiligo,16 andthis can be considered as characteristic forvitiligo lesions as it was absent in the non-vitiligo depigmented skin.16 In this study, 48cases of vitiligo had been examined by der-moscopy. A diffuse white glow was seen in78% of cases, perilesional hyperpigmenta-tion was present in 30% of cases, and peri-follicular hyperpigmentation was present in75% of cases. In this study, the dermoscopicanalysis was done for established, progres-sive, or regimenting vitiligo, and this mayexplain the difference in frequency from the

previous study. In addition, interfollicularpigmentation was seen in 40% of cases,white villus and terminal hair in 70% ofcases, the pigmentary network within thelesions in 23% of cases and lesional andperilesional telangiectasia were present in8% of cases. The presence of telangiectasiamay be related to the history of treatment ofpatients by topical steroids. This marginaland perifollicular marginal and perifollicu-lar hyperpigmentation, reticular pigmenta-tion and marginal reticular pigmentationmay be associated with stability and repig-mentation of vitiligo.17 Since the progres-sive lesions of vitiligo display perifollicularpigmentation and stable/remitting lesionsdisplay perifollicular depigmentation.18Regarding the pattern, there were differentpatterns seen in order of frequency as fol-lows: nebulous pattern (72% of lesions),amoeboid pattern (63% of lesions),trichrome pattern (58% of lesions), petal-loid pattern (51% of lesions), polka dot pat-tern (46% of lesions) and comet tailing ofthe lesion (28% of lesions). A similar pat-tern has been reported before.10

ConclusionsIn conclusion, this study confirmed the

findings in previous studies; the glowingwhite color was characteristic for vitiligo.In addition, this perifollicular pigmentationwas seen in all stable and progressive casesof vitiligo. There was a different pattern forthe depigmented patch of vitiligo, and thismay reflect the activity and the progressionof the disease.

Idiopathic guttate hypomelanosis isanother disease characteristically presented

with such depigmented macules. It is com-monly seen in elderly patients and charac-terized by hypopigmented macules. Thediagnosis of idiopathic guttate hypome-lanosis is usually simple and can beassessed clinically, but sometimes, especial-ly in atypical sites, the distinction fromother macular hypopigmented dermatoses19especially vitiligo may be challenging. Thisstudy reported the dermoscopic features of11 cases with idiopathic guttate hypome-lanosis. These cases were complaining ofthe presence of multiple tiny white spots onshins and forearms resembling teardrops.There are two reports prior to this studydemonstrating dermoscopic features in thisdisease.20,21 The first one showed four pat-terns (amoeboid, feathery, petaloid and neb-uloid patterns). The other study showed thetypical features as cloudy sky-like pattern(multiple small areas coalescing into poly-cyclic macules, with several white shadesand both well- and ill-defined edges, sur-rounded by a patchy hyperpigmented net-work) and the cloudy pattern (well or ill-defined roundish homogeneous whitishareas surrounded by a patchy hyperpig-mented network. This study which wasdone in 11 cases, were nearly similar to thefindings of the second study. Dermoscopicfeatures for these cases were nearly similarin all cases which characterized by the pres-ence of multiple, shiny, white macules withwell- and ill-defined edges borders. Thesemacules coalesce into polycyclic macules.The surrounding skin was scaly. The hairwas pigmented as the surrounding skin withno follicular hyperpigmentation. In addi-tion, it was common to see the petaloid,amoeboid, and nebuloid in all cases. Thesedermoscopic features were observed in thisstudy may be useful to support the clinicaldiagnosis of idiopathic guttate hypome-lanosis, distinguishing it from otherhypopigmented macular lesions.

For nevus depigmentosus, 8 cases pre-sented with an asymptomatic light patchthat had been first noted in the neonatalperiod. Generally, the diagnosis of thesecases was clinical. The commonly usedclinical criteria proposed by Coupe22 fornevus depigmentosus are as follows: leuko-derma present at birth or of an early onset;no alteration in the distribution of leukoder-ma throughout life; no alteration in textureor change of sensation; and absence of ahyperpigmented border. Nevus depigmen-tosus should be differentiated from vitiligo,as both showed off-white accentuation. Indermoscopy, depigmented patches appearedwith irregular and serrated border. Therewas a faint reticular network within thehypopigmented patch. The borders alsoshowed pseudopods pattern protruding into

Article

A B

Figure 5. The dermoscopic features of new lichen sclerosus et atrophicus (A) and an oldLSE lesions (B). Dermoscopy showing white structureless areas (blue stars) and comedo-like openings (yellow arrows) with telangiectasia of different lengths and calibers (redarrows).

[page 4] [Dermatology Reports 2019; 11:7916]

[Dermatology Reports 2019; 11:7916] [page 5]

Article

Tablle 1. D

ermoscopic features of hypopigm

ented macular disease.

The

dise

ase

T

he n

atur

e of

T

he e

dge

The

pre

senc

e

T

he p

rese

nce

of

T

he p

rese

nce

of

Th

e co

lor

of h

air

pig

men

tati

on

of

lesi

ons

of s

cale

s

per

ifol

licul

ar

te

lang

iect

asia

and

arr

ange

men

t

p

igm

enta

tion

of v

ascu

lar

stru

ctur

e

Vitiligo (48 cases)

A

diffuse wh

ite glow

The edge wa

s we

ll A

ll of th

e lesions A perifollicular L

esional and perilesional W

hite villus and

was seen in 78%

of cases. dem

arcated in all lesions w

ere non-scaly. h

yperpigm

entatio

n telangiectasia terminal hair in 70%

In

terfollicular pigmentatio

n w

ith perilesional was present in 75%

of cases. we

re present in 8% of cases.

was seen in 40%

of cases. hyperpigm

entatio

n in

The pigmentary netwo

rk 30% of cases.

with

in th

e lesions in

23

% of cases.

Idiopathic Guttate Presence of m

ultip

le, shiny, The edges of these macules

The surrounding skin There wa

s no perifo

llicular N

o specific changes. T

he hair w

asHypomelanosis porcelain-white macules. w

ere either well-d

efined wa

s scaly. hyperpigm

entatio

n. pigm

ented.

(11 cases)

H

yperpigm

ented networks or ill-defined even within

with

in th

e lesions or the sam

e lesion.

su

rrounding

(c

loudy-sky p

attern).

Nevus Som

e of th

e patches show

ed Serrated border of the

A

ll of th

e lesions There wa

s no peripheral N

o specific changes. H

airs with

in th

eDe

pigm

entosus faint re

ticular netwo

rk p

atches was th

e prom

inent w

ere non-scaly. hyperpigmentatio

n. patches was of n

ormal

(8 cases) within th

em. fe

ature.

colors.

The borders also show

ed

pseudopods patte

rn

protruding into th

e norm

al skin.

Pityria

sis Alba

T

he hypopigmented macules

There is no sharp margin Fine scales th

at are There was no perip

heral 30%

of cases dem

onstrated The hair inside the

(16 cases)

were fairly ill-demarcated to diffe

rentiate th

e co

mmonly

hyperpigmentatio

n. erythem

atous changes within patches was of n

ormal color.

white area. h

ypopigmented patch from

distributed with

in an

d surrounding the

th

e surrounding skin. and outside the macules. m

acules and patches.

Achrom

ic Diffu

se hypopigmented In 22% of cases th

e Presence of fine scales There wa

s no peripheral N

o specific changes. T

he hair inside these

Pityria

sis b

lotches (fairly defined) hypopigmented blotches

that were commonly

hyperpigm

entatio

n. m

acules was of n

ormal

Versicolor in 85%

of cases. we

re ill-d

efined, but with

localize

d in th

e c

olor, but covered

(16 cases)

Satellite lesions (nearby

prom

inent w

hite, s

kin furrow

s. b

y scales

sm

all round white globules)

s

caly globules. in som

e cases.

in (65%).

Extragenital Lichen White-yellowish

There is no sharp Fine whitish scales There was no perip

heral Presence of te

langiectasia The hair inside th

e patches

Sclerosus (9 cases) structureless areas.

margin to differentiate w

ere prom

inent. hyperpigm

entatio

n. with

different lengths was of n

ormal color.

White chrysalis like

the hypopigm

ented patch and calibers. Presence of an

structures. from th

e surrounding skin. erythematous halo (as

d

elicate linear b

ranching

vessels with

different

lengths and calibers)

e

specially in active

lesions.

[page 6] [Dermatology Reports 2019; 11:7916]

the normal skin. Hair within the patcheswas of normal colors, and there was noperipheral hyperpigmentation. In addition,there was a normal colored peri-lesionalskin. This feature was described before.23,24

Pityriasis alba is a common benign skincondition causing hypopigmented facialpatches in children. Parents and patients areoften concerned about the cosmetic appear-ance and the similarity to the lesions ofvitiligo (from the community view). Buthere, the patches tend to be ill-defined. Inaddition, Wood’s light has little effect on thehypopigmentation of pityriasis alba.Sixteen cases with pityriasis alba wereexamined with dermoscopy. One previousreport investigated this disease by der-moscopy.25 On dermoscopic examination,the hypopigmented macules were fairly ill-demarcated white area with fine scales thatare commonly distributed within and out-side the macules. The hair inside the patch-es was of normal color. There is no sharpmargin to differentiate the hypopigmentedpatch from the surrounded skin. These fea-tures were seen in all cases of pityriasisalba. In addition, 30% of cases demonstrat-ed erythematous changes within and sur-rounding the macules and patches.

In this study, all of 16 patients withpityriasis versicolor were examined by der-moscopy. The characteristic dermoscopicfeature in 78% of cases was diffusehypopigmented blotches (fairly defined)with fine scales that were commonly local-ized in the skin furrows. In addition, most ofthe cases (85%) demonstrate satellitelesions (nearby small round white glob-ules). In 22% of cases, the hypopigmentedblotches were ill-defined, but with promi-nent white, scaly globules. Actually, thisdermoscopic feature of presence of scalesthat were localized in the skin furrows wascharacteristic to pityriasis versicolor andwas not seen in other diseases that havebeen studied here.

Extra-genital lichen sclerosus et-atroph-icus is a chronic inflammatory dermatosisof unknown etiology. The presentation ofthese cases was with white macules over thetrunk and extremities. It started as erythe-ma, expanding gradually, and finally turnedout to be a white patch. Examinationrevealed a well-demarcated, mild atrophicporcelain-white macules. These cases wereexamined with dermoscopy, the predomi-nant dermoscopic feature of lichen sclero-sus is white-yellowish structureless areas,this whitish color is glowing white, and sur-rounded by an erythematous halo especiallyin active lesions. In addition, these activelesions showed follicular plugging whichwas absent from old lesions, and this was incorrelation with a previous studies.26,27 Fine

whitish scales were prominent. In additionto the presence of shiny, fibrotic, whitebeams radiating from the center of thelesions toward the periphery, they aredescribed as white chrysalis like structuresin previous reports.26,27 They are parallel ororthogonal or disordered linear streaks andusually seen in dermatofibroma, basal cellcarcinoma, Spitz nevus and melanoma.28Although the diagnosis of lichen sclerosusis mainly clinically and by histopathology,in early stages of the disease, both areuncharacteristic.29,30 It has been reportedthat histopathological changes were non-specific in one-third of men with character-istic clinical signs of lichen sclerosus. Thisdisease is a scarring disease, and promptdiagnosis is mandatory. These dermoscopicfeatures were highly characteristic and notdemonstrated in other hypopigmented mac-ular lesions.

This study showed that these hypopig-mented macular diseases might display spe-cific and characteristic dermoscopic fea-tures. As described in this research, some ofthe dermoscopic findings in these hypopig-mented macular diseases were non-specific.So, these dermoscopic findings shouldalways be interpreted within the overallclinical context of the patient history, inte-grated with information from the historyand the macroscopic examination.2,3Dermoscopy may scores over routinehistopathology in the diagnosis of someskin disease in which skin biopsy may betraumatic as in case of nevus depigmento-sus and pityriasis alba. It’s an additive testto confirm the diagnosis of pityriasis versi-color, lichen sclerosus et atrophicus andidiopathic guttate hypomelanosis.

References1. Errichetti E, Stinco G. The practicalusefulness of dermoscopy in generaldermatology. J Ital Dermatol Venereol2015;150:533-46.

2. Lallas A, Giacomel J, Argenziano G, etal. Dermoscopy in general dermatol-ogy: practical tips for the clinician. Br JDermatol 2014;170:514-26.

3. Lallas A, Zalaudek I, Argenziano G, etal. Dermoscopy in general dermatology.Dermatol Clin 2013;31:679-94.

4. Errichetti E, Stinco G. Dermoscopy ingeneral dermatology: a practicaloverview. Dermatol Ther (Heidelb)2016;6:471-507.

5. Zalaudek I, Argenziano G, Di Stefani A,Ferrara G, et al. Dermoscopy in generaldermatology. Dermatology 2006;212:7-18.

6. Micali G, Lacarrubba F, Massimino D,

Schwartz RA. Dermatoscopy: alterna-tive uses in daily clinical practice. J AmAcad Dermatol 2011;64:1135-46.

7. Zalaudek I, Lallas A, Moscarella E, etal. The dermatologist’s stethoscope-tra-ditional and new applications of der-moscopy. Dermatol Pract Concept2013;3:67-71.

8. Miteva M, Tosti A. Hair and scalp der-matoscopy. J Am Acad Dermatol2012;67:1040-8.

9. Lencastre A, Lamas A, Sa D, Tosti A.Onychoscopy. Clin Dermatol 2013;31:587-93.

10. Gandhi S, Shamanur M, ShashikiranAR, et al. Study of clinico-epidemiolog-ical and dermoscopic patterns of vitiligoin pediatric age group. Ind J PaediatrDermatol 2017;18:292-8.

11. Alghamdi KM, Kumar A, Taïeb A,Ezzedine K. Assessment methods forthe evaluation of vitiligo. J Eur AcadDermatol Venereol 2012;26:1463-71.

12. Sosa JJ, Currimbhoy SD, Ukoha U, etal. Confetti-like depigmentation: Apotential sign of rapidly progressingvitiligo. J Am Acad Dermatol2015;73:272-5.

13. Benzekri L, Gauthier Y. Clinical mark-ers of vitiligo activity. J Am AcadDermatol 2017;76:856-62.

14. Thatte SS, Khopkar US. The utility ofdermoscopy in the diagnosis of evolv-ing lesions of vitiligo. Ind J Der VL2014;80:505-8.

15. Chuh AA, Zawar V. Demonstration ofresidual perifollicular pigmentation inlocalized vitiligo-a reverse and novelapplication of digital epiluminescencedermoscopy. Comput Med ImagingGraph 2004;28:213-7.

16. Meng R, Zhao G, Cai RK, et al.Application of polarized light der-moscopy in the early diagnosis of vitili-go and its differential diagnosis fromother depigmented diseases. Chin JDermatol 2009;42:810-3.

17. Chandrashekhar L. Dermoscopy: A toolto assess stability in Vitiligo. In:Khopkar U, ed. Dermoscopy and tri-choscopy in diseases of the brown skin:atlas and short text. New Delhi, India:Jaypee Brothers Medical Publishers;2012. pp 112-113.

18. Kumar Jha A, Sonthalia S, Lallas A,Chaudhary RKP. Dermoscopy in vitili-go: diagnosis and beyond. Int JDermatol 2017;26.

19. Jackson SM, Nesbitt LT. The diagnosis.In: Jackson SM, Nesbitt LT, eds.Differential diagnosis for the dermatol-ogist, 2nd ed. New York, NY: Springer;2012. pp 767-768.

20. Ankad BS, Beergouder SL.

Article

[Dermatology Reports 2019; 11:7916] [page 7]

Dermoscopic evaluation of idiopathicguttate hypomelanosis: a preliminaryobservation. Indian Dermatol Online J2015;6:164-7.

21. Errichetti E, Stinco G. Dermoscopy ofidiopathic guttate hypomelanosis. JDermatol 2015;42:1118-9.

22. Coupe RL. Unilateral systematizedachromic naevus. Dermatologica1967;134:19-35.

23. Ankad BS, Shah S. Dermoscopy ofnevus depigmentosus. Pigment Int2017;4:121-3.

24. Sarma N, Akkad BS. Dermoscopy innevoid disorders: dermoscopy in darkerskins. New Delhi, India: Japee

Brothers; 2017. pp 127-128.25. Nayak SS, Mehta HH, Gajjar PC,

Nimbark VN. Dermoscopy of generaldermatological conditions in Indianpopulation: A descriptive study. ClinDerm Rev 2017;1:41-51.

26. Ankad BS, Beergouder BL.Dermoscopic patterns in lichen sclero-sus: A report of three cases. Ind D J2015;6:237-40.

27. Errichetti E, Lallas A, Apalla Z, et al.Dermoscopy of morphea and cutaneouslichen sclerosus: clinicopathologicalcorrelation study and comparativeanalysis. Dermatology 2017;233:462-70.

28. Marghoob AA, Cowell L, Kopf AW,Scope A. Observation of chrysalisstructures with polarized dermoscopy.Arch Dermatol 2009;145:618.

29. Carlson JA, Lamb P, Malfetano J, et al.Clinicopathologic comparison of vulvarand extragenital lichen sclerosus:Histologic variants, evolving lesions,and etiology of 141 cases. Mod Pathol1998;11:844-54.

30. Edmonds EV, Oyama N, Chan I, et al.Extracellular matrix protein 1 autoanti-bodies in male genital lichen sclerosus.Br J Dermatol 2011;165:218-9.

Article