Enzo Errichetti

Dermoscopy in General Dermatology: A Practical Overview.

Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides and subacute cutaneous lupus erythematosus), papulosquamous/papulokeratotic dermatoses (lichen planus, pityriasis rosea, papulosquamous sarcoidosis, guttate psoriasis, pityriasis lichenoides chronica, classical pityriasis rubra pilaris, porokeratosis, lymphomatoid papulosis, papulosquamous chronic GVHD, parakeratosis variegata, Grover disease, Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis), facial inflammatory skin diseases (rosacea, seborrheic dermatitis, discoid lupus erythematosus, sarcoidosis, cutaneous leishmaniasis, lupus vulgaris, granuloma faciale and demodicidosis), acquired keratodermas (chronic hand eczema, palmar psoriasis, keratoderma due to mycosis fungoides, keratoderma resulting from pityriasis rubra pilaris, tinea manuum, palmar lichen planus and aquagenic palmar keratoderma), sclero-atrophic dermatoses (necrobiosis lipoidica, morphea and cutaneous lichen sclerosus), hypopigmented macular diseases (extragenital guttate lichen sclerosus, achromic pityriasis versicolor, guttate vitiligo, idiopathic guttate hypomelanosis, progressive macular hypomelanosis and postinflammatory hypopigmentations), hyperpigmented maculopapular diseases (pityriasis versicolor, lichen planus pigmentosus, Gougerot-Carteaud syndrome, Dowling-Degos disease, erythema ab igne, macular amyloidosis, lichen amyloidosus, friction melanosis, terra firma-forme dermatosis, urticaria pigmentosa and telangiectasia macularis eruptiva perstans), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), erythrodermas (due to psoriasis, atopic dermatitis, mycosis fungoides, pityriasis rubra pilaris and scabies), noninfectious balanitis (Zoon’s plasma cell balanitis, psoriatic balanitis, seborrheic dermatitis and non-specific balanitis) and erythroplasia of Queyrat, inflammatory cicatricial alopecias (scalp discoid lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans), nonscarring alopecias (alopecia areata, trichotillomania, androgenetic alopecia and telogen effluvium) and scaling disorders of the scalp (tinea capitis, scalp psoriasis, seborrheic dermatitis and pityriasis amiantacea).

Differentiation of pityriasis lichenoides chronica from guttate psoriasis by dermoscopy

Clinical differentiation between pityriasis lichenoides chronica (PLC) and guttate psoriasis (GP) may sometimes be a difficult task, which often requires histological analysis to reach a definitive diagnosis. In this study, PLC and GP lesions were examined using dermoscopy, and the significance of specific dermoscopic findings was investigated in order to facilitate their differentiation and decrease the number of cases requiring biopsy. We found that the incidence of orange–yellowish structureless areas, focal dotted vessels and nondotted vessels was statistically significant in PLC, while the incidence of diffuse dotted vessels was statistically significant in GP.

Dermoscopy in differential diagnosis of palmar psoriasis and chronic hand eczema.

Clinical differentiation between palmar psoriasis and chronic hand eczema may sometimes be a diagnostic challenge; in such cases histopathological analysis helps to differentiate the two conditions. In the present study, palmar psoriasis and chronic hand eczema were investigated using dermoscopy and the significance of specific dermoscopic features was assessed in order to improve their non‐invasive differentiation. Ten patients with biopsy‐proven palmar psoriasis and 11 patients with biopsy‐proven chronic hand eczema were included in the study. We found that the presence of diffuse white scales was significant in palmar psoriasis whereas the presence of yellowish scales, brownish‐orange dots/globules and yellowish‐orange crusts was significant in chronic hand eczema.

Dermoscopy of Darier's disease

1 Parisi R, Symmons DP, Griffiths CE et al. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol 2013; 133: 377–385. 2 Mah e E, Gnossike P, Sigal ML. Le psoriasis de l’enfant. Arch Pediatr 2014; 21: 778–786. 3 Morris A, Rogers M, Fischer G et al. Childhood psoriasis: a clinical review of 1262 cases. Pediatr Dermatol 2001; 18: 188–198. 4 Seyhan M, Cos kun BK, Sa glam H et al. Psoriasis in childhood and adolescence: evaluation of demographic and clinical features. Pediat Int 2006; 48: 525–530. 5 Kumar B, Jain R, Sandhu K et al. Epidemiology of childhood psoriasis: a study of 419 patients from northern India. Int J Dermatol 2004; 43: 654– 658. 6 Mah e E, Beauchet A, Bodemer C et al. Psoriasis and obesity in French children: a case-control, multicentre study. Br J Dermatol 2014; 172: 1593–1600. 7 Kumar B, Saraswat A, Kaur I. Palmoplantar lesions in psoriasis: a study of 3065 patients. Acta Derm Venereol 2002; 82: 192–195. 8 Brunasso AM, Puntoni M, Aberer W et al. Clinical and epidemiological comparison of patients affected by palmoplantar plaque psoriasis and palmoplantar pustulosis: a case series study. Br J Dermatol 2013; 168: 1243– 1251. 9 Pettey AA, Balkrishnan R, Rapp SR et al. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice. J Am Acad Dermatol 2003; 49: 271–275.

Dermoscopy of idiopathic guttate hypomelanosis

arms (Fig. 1a). Darier’s sign was negative. There was no significant family or medical history. Histopathological analysis of the lesional skin revealed capillary proliferation and telangiectasia in the upper dermis and increased pigmentation in the basal layer of the epidermis (Fig. 1b–e). Immunohistochemical stainings were performed by 3,30-diaminobenzidinetetrachloride immunohistochemistry using monoclonal antibodies to factor VIII-antigen related antigen, vascular endothelial growth factor (VEGF) and CD117. VEGF was higher in the keratinocytes obtained from the lesions than perilesional skin. The VEGF staining pattern and intensity in the dermis demonstrated no significant differences between the perilesional and lesional skin (Fig. 1d). The number of CD117 mast cells per vessel unit was slightly higher in comparison with the perilesional normal skin (Fig. 1f). The results of our image analyses for Fontana–Masson, VEGF, factor VIIIa-related antigen and CD117 are detailed in the supporting information section. We diagnosed our patient with acquired bilateral TMEP on the upper arms. After the 6month follow-up examination, his skin lesions were still persistent. Telangiectasia macularis eruptiva perstans on the upper arm may be caused by mast cell activation due to chronic UV exposure, and it has been speculated that VEGF is a major contributing factor to the pigmentation of this disease because it exerts paracrine effects on the melanocytes and activates the arachidonic acid pathway, increasing melanogenesis. We suggest that acquired bilateral TMEP on the arms of Asian men is a common, unrecognized and distinct photoaging-associated disorder. CONFLICT OF INTEREST: The authors have no conflicts of interest to declare.

Dermoscopy of Zoon's plasma cell balanitis

References 1 Goodall JW, Richmond QM. A case of Darier’s disease. Br J Clin Pract 1965; 19: 475–476. 2 Rowley MJ, Nesbitt LT, Carrington PR, Espinoza CG. Hypopigmented macules in acantholytic disorders. Int J Dermatol 1995; 34: 390–392. 3 Cattano AN. An unusual case of keratosis follicularis. Arch Dermatol 1968; 98: 168–174. 4 Berth-Jones J, Hutchinson PE. Darier’s disease with peri-follicular depigmentation. Br J Dermatol 1989; 120: 827–830. 5 Sakuntabhai A, Ruiz-Perez V, Carter S et al.Mutations in ATP2A2, encoding a Ca2 + pump, cause Darier disease. Nat Genet 1999; 21: 271–277. 6 Kippenberger S, Bernd A, Bereiter-Hahn J, Ramirez-Bosca A, Kaufmann R. The mechanism of melanocyte dendrite formation: the impact of differentiating keratinocytes. Pigment Cell Res 1998; 11: 34–37. 7 Hakuno M, Shimizu H, Akiyama M et al. Dissociation of intraand extracellular domains of desmosomal cadherins and E-cadherin in Hailey-Hailey disease and Darier’s disease. Br J Dermatol 2000; 142: 702–711. 8 Goh BK, Kumarasinghe SPW, Ng SK. Two Singaporean cases of guttate leukoderma in Darier’s disease. Clin Exp Dermatol 2004; 29: 313–314. 9 Goh B, Kumarasinghe P, Lee Y. Loss of melanosome transfer accounts for guttate leukoderma in Darier’s disease: electron microscopic findings. Pigment Cell Res 2005; 18: 48. 10 Eytan O, Morice-Picard F, Sarig O et al. Cole disease results from mutations in ENPP1. Am J Hum Genet 2013; 93: 752–757.

Dermoscopy of prurigo nodularis.

The diagnosis of prurigo nodularis is mainly clinical, based on its distinctive features. However, in some cases it may be difficult to differentiate it from other nodular dermatoses only on the clinical basis, thus requiring histopathological examination to reach a definitive diagnosis. The aim of this study was to describe for the first time the dermoscopic features of prurigo nodularis and the useful contribution of dermoscopy in the differential diagnosis of such dermatoses. Fourteen patients with histopathologically proven prurigo nodularis were included in the study. The results of our study suggest that the detection of a “white starburst pattern” surrounding brown‐reddish/brown‐yellowish crust(s), erosion(s) and/or hyperkeratosis/scales is a useful clue to support the clinical diagnosis of prurigo nodularis, distinguishing it from the other main differential diagnoses.

Dermoscopy of subacute cutaneous lupus erythematosus

pruritus on quality of life: the skin equivalent of pain. Arch Dermatol 2011; 147: 1153–1156. 3 Reich A, Heisig M, Phan NQ, et al. Visual analogue scale: evaluation of the instrument for the assessment of pruritus. Acta Derm Venereol 2012; 92: 497–501. 4 Armstrong AW, Kwong MW, Ledo L, et al. Practice models and challenges in teledermatology: a study of collective experiences from teledermatologists. PLoS ONE 2011; 6: e28687. 5 Centers for Medicare and Medicaid Services. Physician Quality Reporting System (PQRS). https://www.cms.gov/ Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html?redirect=/pqri/. [Accessed February 10, 2016.]

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

Dermoscopy as an auxiliary tool in the differentiation of the main types of erythroderma due to dermatological disorders Most cases of erythroderma are due to inflammatory and lymphoproliferative skin disorders, mainly including psoriasis, eczematous diseases, pityriasis rubra pilaris, and mycosis fungoides. Even though the clinical history or presence of specific cutaneous/nail lesions may be useful in assisting the differential diagnosis of erythrodermas caused by the aforementioned dermatoses, their distinction is often challenging for both dermatologists and pathologists. We here report the dermoscopic pattern of four instances of chronic erythroderma in patients with a definitive diagnosis of the above-mentioned dermatological conditions (dermoscopy was always carried out with DermLite DL3; 3Gen, San Juan Capistrano, CA, USA). Case 1 (erythroderma due to psoriasis; Fig. 1a) has a monomorphous pattern with diffusely distributed whitish scales and regularly arranged dotted vessels on a fairly homogeneous reddish background (Fig. 2a). Case 2 (erythroderma due to atopic dermatitis; Fig. 1b) has yellowish scales/serocrusts, sparse whitish scales, and patchily distributed dotted vessels on a pinkish background (Fig. 2b). Case 3 (erythroderma due to mycosis fungoides; Fig. 1c) has a monomorphous aspect consisting of sparse whitish scales ass.ociated with widespread dotted vessels and some peculiar

Latent tuberculosis reactivation in a patient with erythrodermic psoriasis under treatment with ustekinumab and a low dose steroid, despite isoniazid chemoprophylaxis

A 36-year-old healthy man (weight: 78 kg; BMI: 24.6), with a 7-year history of moderate to severe psoriasis, poorly responsive to conventional systemic treatments, was admitted to our clinic for a significant worsening of the disease. Physical examination showed an erythrodermic status with a PASI (psoriasis area severity index) of 44. We started cyclosporine treatment at the dose of 4 mg/kg daily, without any significant results after 6 weeks of therapy. Therefore, we added a systemic steroid (oral [...]