REVIEWS

Dermatoscopy: Alternative uses in daily clinical practice

Giuseppe Micali, MD,a Francesco Lacarrubba, MD,a Doriana Massimino, MD,a and Robert A. Schwartz, MD, MPHb Catania, Italy, and Newark, New Jersey
Dermatoscopy, also known as dermoscopy, epiluminescence microscopy, or surface microscopy, is a noninvasive technique allowing rapid and magnied (310) in vivo observation of the skin with the visualization of morphologic features often imperceptible to the naked eye. Videodermatoscopy (VD) represents the evolution of dermatoscopy and is performed with a video camera equipped with lenses providing higher magnication (310 to 31000). Over the past few years, both dermatoscopy and VD have been demonstrated to be useful in a wide variety of cutaneous disorders, including ectoparasitic infestations, cutaneous/mucosal infections, hair and nail abnormalities, psoriasis, and other dermatologic as well as cosmetologic conditions. Depending on the skin disorder, both dermatoscopy and VD may be useful for differential diagnosis, prognostic evaluation, and monitoring response to treatment. Nowadays, it represents an important and relatively simple aid in daily clinical practice. ( J Am Acad Dermatol 2011;64:1135-46.) Key words: dermatoscopy; ectoparasitoses; epiluminescence microscopy; hair disorders; nail diseases; psoriasis; videodermatoscopy.

INTRODUCTION
Dermatoscopy, also known as dermoscopy, epiluminescence microscopy, or surface microscopy, is a noninvasive technique allowing rapid and magnified in vivo observation of the skin with the visualization of morphologic features often imperceptible to the naked eye. It is performed with manual devices which do not require any computer assistance and generally employs 310 magnifications (Table I). Videodermatoscopy (VD) represents the evolution of dermatoscopy and is performed with a video-camera equipped with lenses providing magnification ranging from 310 to 31000.1,2 The images obtained are visualized on a monitor and stored on a personal computer in order to process them and compare any possible changes over time (Table II). Both dermatoscopy and VD have greatly improved the diagnostic accuracy of pigmented skin lesions and, more recently, the evaluation of nonpigmented skin disorders. They are usually performed according
From the Dermatology Clinic, University of Catania,a and the Department of Dermatology, New Jersey Medical School.b Funding sources: None. Conflicts of interest: None declared. Reprint requests: Giuseppe Micali, MD, Dermatology Clinic, University of Catania, A.O.U. Policlinico-Vittorio Emanuele, Via Santa Sofia, 78-95123, Catania, Italy. E-mail: cldermct@nti.it. Published online February 4, 2011. 0190-9622/$36.00 2010 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2010.03.010

Abbreviations used: AGA: HDD: PPD: VD: androgenetic alopecia hair diameter diversity pigmented purpuric dermatoses videodermatoscopy

to an epiluminescence microscopy technique facilitated by the application of a liquid (oil, alcohol, or water) to the skin to eliminate light reection. However, this method has been recently replaced by new systems involving polarized light instead of liquids, with comparable results.2,3 Over the past few years, both dermatoscopy and VD have been demonstrated to be useful in a wide variety of cutaneous disorders, including ectoparasitic infestations, cutaneous/mucosal infections, hair and nail abnormalities, psoriasis, and other dermatological as well as cosmetologic conditions.

ECTOPARASITOSES
Scabies Both dermatoscopy and VD represent promising and useful diagnostic tools for scabies. Their effectiveness has been conrmed by numerous studies.1,4-13 In particular, the accuracy of VD has been demonstrated to be comparable to that of scraping.11 Dermatoscopic examination of active lesions shows, at low magnications (up to 340), the presence of a small dark brown triangular structure, corresponding to the pigmented anterior part of the 1135

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mite, located at the end of a subtle linear segment, the clinical identication of either adult lice the burrow4,14; together, both structures resembled a (Pediculus humanus and Phthirus pubis, respecjet with contrail. At higher magnifications (3100 to tively) or of viable nits through close-up examina3600), VD allows more detailed identification; the tion. Louse combs and the magnifying lens represent oval translucent body of the mite is clearly visible additional diagnostic tools which increase the possi(Fig 1). One can also visualize other anatomic bility to identify live lice.15-18 In pediculosis capitis, dermatoscopy ensures a more detailed evaluation of structures, such as the anterior and posterior legs both mites and eggs, particuand rostrum. In most cases, larly in the presence of postit is possible to detect the CAPSULE SUMMARY treatment residual eggs.19,20 mite moving inside the bur10,11 Moreover, higher Dermatoscopy unequivorows. Dermatoscopy and videodermatoscopy magnifications allow visualically shows the presence of are noninvasive techniques allowing zation of other diagnostic the nits fixed to the hair shaft, magnified in vivo skin observation, features, such as eggs and allowing a rapid differentiawhich have demonstrated to be useful in feces.10,11 tion from empty nits, the lata wide variety of cutaneous disorders VD is an easy, noninvater appearing as translucent (including ectoparasitic infestations, sive, and relatively rapid structures with a plane and cutaneous/mucosal infections, hair and technique, which allows the fissured free ending14,20 or nail abnormalities, psoriasis and other scales of different origin or inspection of the entire skin dermatological as well as some pseudo-nits (hair casts, desurface, particularly with the cosmetological conditions) beyond the bris of hair spray or gel, or use of a zoom-system instrutraditional indication for pigmented seborrheic scales),14,20 with ment, which requires neither lesions of the skin. subsequent remarkable efan additional magnifying lens Dermatoscopy and videodermatoscopy fects on the therapeutic nor the application of any may be useful for differential diagnosis, management. Furthermore, liquid. False-negative results prognostic evaluation, and monitoring dermatoscopy does not reare not common and depend response to treatment. quire hair pulling, so that a on the lack of operator expelarge scalp area can be invesrience or on the presence of a The aim of this article is to advance tigated with minimal discomsupercial secondary bacteknowledge about and update the fort to the patient. Finally, a rial infection. Moreover, the alternative uses of dermatoscopy and close and accurate VD examuse of VD, especially at high videodermatoscopy by reviewing ination may disclose the mormagnications ([ 3100), has existing papers and presenting our phology and physiology of been regarded as highly speexperience. the lice themselves, together cic with no false-positive with proving the pediculociresults10,11 and as better accepted compared to scraping, especially in the dal activity of topical agents.21,22 The diagnostic effectiveness of dermatoscopy case of children and highly emotional patients.10,14 In addition, VD is comfortable, not painful, and has a may be extended to phthiriasis pubis.1,17 Dermatoscopy can be of particular importance in low risk of related infections, especially in those cases children, where eyelashes are the most common site requiring repeated tests to make a final diagnosis. of infestation. Phthiriasis palpebrarum is often misFinally, it may also be used both for the screening of diagnosed as atopic dermatitis or allergic conjunctifamily members and post-therapeutic follow-up.10,11 The use of dermatoscopy at low-magnifications (310 vitis because of the semitransparent and deep to 340) has some limitations, as it does not always burrowing aspect of the parasite at the lid margins.23 In these cases, dermatoscopy can rapidly clarify any allow, especially to non-experienced operators, a doubt by revealing the presence of lice and/or nits. clear differentiation between the jet-shaped strucFinally, VD examination may enhance patient ture and minor excoriations and/or splinters that may compliance to therapy for both head and crab lice, frequently occur in scabies due to repeated scratchshowing the presence, persistence, or resolution of ing. Another deficit is that mite viability cannot be the infestation on a VD monitor.17 assessed at these magnifications, so that posttherapeutic monitoring cannot be performed. Tungiasis The dermatoscopic aspect of tungiasis, an ectoHead and pubic lice parasitosis caused by the ea Tunga penetrans, has The diagnosis of pediculosis capitis (head lice) been described as a brown to black ring with a and phthiriasis pubis (crab lice) is generally based on
d d d

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Table I. Common dermatoscopy devices (cost range: 200-1000 euros)

Product Company Magnification

Delta Dermlite Dermogenius Gima 2000 Ri-derma

Heine (Germany) 3Gen (US) Biocam (Germany) Gima (Italy) Riester (Germany)

310 310 310 310 310

Table II. Common videodermatoscopy devices (cost range: 5000-26,000 euros)

Product Company Magnification

Dermoscope Easyscan Fotofinder dermoscope Hi-scope Medicalscope Molemax Videocap Videoderm

Medicimedical (Italy) 330 to 3300 Business Enterprise 330 to 3150 (Italy) Fotofinder (Germany) 320 to 370 Hirox (Japan) Fastbrain (Italy) Dermamedical (Austria) DS Medica (Italy) 34 to 3100 310 to 3200 330

Fig 1. Scabies. VD shows roundish body of Sarcoptes scabiei (circle) at one end of the burrow (3100).

310 to 31000 Zovam Europe (Italy) 310 to 3300

central pore, corresponding to pigmented chitin surrounding the posterior portion of the parasites exoskeleton.24 Additional dermatoscopic features include a gray-blue blotch, representing either the developing eggs within the abdomen of the flea25 or to the presence of hematin in the gastrointestinal tract of the parasite.26 After sequential and careful shaving of the epidermis and gently compressing the edges of the wound, a jelly-like bag full of ovoid eggs is seen.27,28 A recently identified dermatoscopic feature, characterized as whitish chains, consists of a number of whitish oval structures with a typical chain-like distribution, corresponding to the parasites eggs.28-30 Cutaneous leishmaniasis Some authors have recently proposed dermatoscopy as a valuable tool in the diagnosis of cutaneous leishmaniasis,31 a protozoan skin infection caused by several species of the genus Leishmania. Diffuse erythema and vascular structures, including commashaped vessels, linear or atypical vessels, and arborizing telangiectasia, are the most common findings. In addition, initial lesions may show yellow oval or tear-drop shaped structures (yellow tears) composed of follicular plugs produced by the compression of the follicular openings. Advanced

Fig 2. Molluscum contagiosum. VD shows a central white to yellow amorphous structure with a peripheral crown of reddish, linear or branched vessels, which do not cross the center of the lesion (330).

stages typically display hyperkeratosis, vascular abnormalities (hairpin and dotted vessels), and the so-called white starburstelike pattern adjacent to the peripheral hyperkeratosis surrounding the central erosion. Despite this interesting evidence, further evaluations need to be performed.

CUTANEOUS/MUCOSAL INFECTIONS
Molluscum contagiosum Clinical diagnosis of molluscum contagiosum, a common skin infection caused by a poxvirus, is in general not difcult, although in some doubtful cases dermatoscopic examination may be helpful.14,32-34 Molluscum contagiosum shows a characteristic pattern (Fig 2), consisting of a central polylobular white to yellow amorphous structure with a peripheral crown of reddish, linear or branched vessels, which

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Fig 3. Genital wart. VD shows multiple irregular whitish projections arising from a common base and containing dilated vessels (3100).

Fig 4. Androgenetic alopecia. VD shows presence of both terminal and miniaturized hairs (350).

rows with central dotted or comma-like vessels in each papule.38 Lupus vulgaris Recent observations have suggested the usefulness of dermatoscopy in the diagnosis of lupus vulgaris, a form of cutaneous tuberculosis, since it has revealed peculiar features consisting of linear focused telangiectases on a typical yellow to golden background.14,39 Moreover, some milia-like cysts and whitish reticular streaks have also been detected. Nevertheless, none of the observed features is sufficiently specific alone, while their combination may result in increased sensitivity.14,39 Further confirmation on a larger series is needed.

do not usually cross the center of the lesion (red corona).14,32,33 Human papillomavirus infections Dermatoscopy has been demonstrated to be a valuable tool in human papillomavirus infections both for diagnosis and treatment monitoring.14,35,36 Cutaneous warts are characterized by multiple, densely packed papillae, each containing a central red dot surrounded by a whitish halo; irregularly distributed black dots, corresponding to thrombosed vessels, are also visible.14 Such hemorrhages are prominent in the plantar wart within a well-defined, yellowish papilliform surface in which skin lines are interrupted, allowing dermatoscopic observation to easily distinguish wart from callus.14,35,36 Flat warts are characterized by regularly distributed, tiny, red dots on a light brown to yellow background.14 The dermatoscopic ndings in genital warts have been described as a mosaic pattern consisting of a white reticular network surrounding central small islands of unaffected mucosal skin.14 However, on VD examination (3100), these islands appear to be constituted by dilated vessels that are more evident in papillomatous lesions in which, moreover, multiple irregular whitish projections with tapering ends arise from a common base37 (Fig 3). The use of dermatoscopy may help to differentiate genital warts from vestibular papillae and pearly penile papules, normal features of female and male external genitalia, respectively.37,38 Dermatoscopically, vestibular papillae present as multiple transparent and cylindrical projections, containing irregular vascular structures, whose bases, however, remain separate37; pearly penile papules appear as whitish pink cobblestone or grape-like structures in a few

HAIR DISORDERS
In the past few years VD has been increasingly and successfully employed in the evaluation of different hair disorders either as a diagnostic device or as a useful instrument for a better insight into their pathogenesis. Androgenetic alopecia VD signicantly enhances the diagnosis and the evaluation of response to therapy of androgenetic alopecia (AGA). Typical features of AGA shown by VD include hair diameter diversity (HDD) and peripilar signs.40-44 HDD is considered one of the earliest signs of the disease resulting from the fact that hair miniaturization does not equally affect all the hair follicles of the same area, resulting in the simultaneous presence of terminal, indeterminate, and miniaturized hairs (Fig 4). HHD involving more than 20% of hair is indicative of AGA. A score correlating the severity of the disease to HDD findings has been suggested.45 VD also facilitates investigation of the predominance of single over multiple

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Fig 5. Frontal brosing alopecia. VD of frontotemporal hairline shows reduction of follicular units and presence of hyperkeratotic perifollicular collarettes (350).

(from 2 to 4) follicular hairs in AGA ostia compared with normal subjects.42 Additional features include peripilar signs, such as brown haloes, at the follicular ostium, due to a superficial perifollicular lymphocytic infiltrate in an early stage of the disease,46 and yellow dots, consisting of degenerated follicular keratinocytes plugged with sebum material, which cause a distension of the follicle.41 Alopecia areata VD ndings of alopecia areata include yellow dots, a number of dystrophic hair shaft features, along with hypopigmented vellus hairs shorter than 10 mm.41,47 The evaluation of these findings is important both for diagnostic purposes as well as for posttreatment follow-up. Yellow dots are described as yellow to yellow red, round or polycyclic dots of different size and correspond to dilated follicular openings.41,47 Dystrophic hair shafts are indicative of anagen alterations.42 At VD observation, they can be described as exclamation-mark hair and cadaverized hair (black dots) and indicate strong disease activity.40,43,47,48 Conversely, short hypopigmented vellus hairs are characteristic of remitting disease. In a recent study, yellow dots and short vellus hairs have been regarded as the most sensitive signs of the disease, whereas exclamation-mark hair and cadaverized hair are regarded as the most specific.47 Scarring alopecia VD evaluation of scarring alopecia provides additional information, although scalp biopsy is required to reach a nal diagnosis. In lichen planopilaris, VD shows the reduction to total absence of orices, hyperkeratotic perifollicular scales, and

erythema. In addition, perifollicular arborizing vessels, pigmented networks, and white pale or bluegray dots in dark-skinned individuals, corresponding to focal decrease in melanin content, can also be observed.41,49 Similar findings have been described in frontal fibrosing alopecia (Fig 5), a variant of lichen planopilaris.50 In discoid lupus erythematous scalp atrophy appears as a diffuse whitish area, particularly in dark-skinned patients. Arborizing and tortuous vessels are commonly observed inside lesional skin. In addition, bright to deep red roundish dots, around follicular openings, and hyperkeratotic perifollicular white scales may be detected.41 Folliculitis decalvans features shown by VD include marked and diffuse perifollicular erythema as well as progressive reduction of follicular ostia. Severe scaling and crusting, particularly around follicular units, are detectable, together with capillary abnormalities, such as interfollicular red loops, similar to those of psoriasis.41,51 Finally, VD is useful in diagnosing cicatricial marginal alopecia, a distinctive pattern of alopecia. It is characterized by reduction in hair follicle density (loss of follicular ostia) and absence of signs of inammation or traction.52 Trichostasis spinulosa The use of VD has been suggested to identify the characteristic brownish hair tuft, consisting of multiple hair emerging from a dilated follicle, in trichostasis spinulosa, a follicular disorder involving the centrofacial region, which causes hair to be retained into pores and embedded in sebaceous material.53,54 Trichotillomania VD evaluation improves the diagnosis of trichotillomania and is a useful tool in differentiating this compulsive disorder from other forms of alopecia, limiting the number of skin biopsies.41,55 With VD, hair appears broken at variable lengths with the extremities showing a characteristic frayed aspect derived from the habit of pulling hair out.1 Hair shaft disorders Monilethrix is a rare autosomal disorder of the hair shaft clinically characterized by a diffuse alopecia due to hair fragility.56,57 With the use of VD, the hair shaft typically shows small oval nodes of normal thickness separated by irregular dystrophic constrictions.58 To describe this particular dermatoscopic finding, some authors have suggested the term regularly bended ribbon sign.56 In addition, the presence of this particular feature helps to

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differentiate monilethrix from pseudomonilethrix and other causes of hair loss. Pili torti represents a hair shaft disorder that can be observed as an occasional nding in normal scalp, in association with other hair abnormalities or as part of a more complex genetic syndrome (Menkes syndrome, Bjornstad syndrome).40 Dermatoscopically, pili torti appears as flat twisted shafts.58 Pili trianguli and canaliculi (uncombable hair) is considered a relatively rare disorder of the hair shaft characterized by zzy and unruly hair, which gradually tends to improve with age. By VD, hair shafts appear triangular, with atypical longitudinal grooving.40 Pili annulati is an autosomal hair shaft disorder characterized by light and dark bands in hair shafts that are responsible for a shining appearance of the scalp.59 By VD, light areas correspond to air-filled cavities within the hair shaft.40,58 Trichorrhexis nodosa is a relatively common hair shaft disorder frequently caused by hair weathering. VD evaluation of the hair shaft reveals the presence of diffuse white knots and a brush-pattern due to the hairs higher susceptibility to become fractured consequent to their fragility.40 Trichorrhexis invaginata (bamboo hair) is a hair shaft abnormality that is generally associated with Netherton disease. It is characterized by the presence of multiple nodes along the hairs length caused by the proximal portion of the hair shaft overlapping the distal one, resulting in a bamboo appearance.60 VD observation shows the presence of multiple ballshaped nodes along the hairs, which causes the hairs to break off.58,60

Fig 6. Psoriasis. VD shows dilated, elongated and convoluted capillaries with typical bushy pattern (3100).

Moreover, dermatoscopic observation (340 to 370 magnification) of the hyponychium displays dilated, tortuous, elongated, and irregularly distributed capillaries, the detection of which can be used to assess the severity of the disease.65 Onychomycosis In some cases dermatoscopy may assist physicians in evaluating onychomychosis.61,66,67 Nail infections caused by fungi producing melanin show homogeneous brownish pigmentation devoid of melanin granules and longitudinal streaks. Nail tumors In a case report of onychomatricoma, dermatoscopic evaluation at the nail plate showed longitudinal white lines, indicating channels containing the tumor projections.68

NAIL DISEASES
Dermatoscopic examination has been recently utilized in the study of some nonpigmented lesions and diseases of the nails.61,62 Dermatoscopy can analyze the nail in various anatomic aspects, such as nail plate, hyponychium, distal edge of the nail plate, proximal nailfold, nail bed, and matrix and generally requires the use of immersion gel or oil.61,62 The evaluation of nailfold capillaroscopic abnormalities, widely utilized in the diagnosis of collagen tissue disorders (systemic sclerosis and dermatomyositis), has previously been published63,64 and will not be discussed in this review. Psoriasis Nail matrix psoriasis frequently produces nail plate surface abnormalities, such as pitting, nail crumbling, onycholysis, salmon patches, splinter hemorrhages, and nail bed hyperkeratosis, that may be better dened with the use of dermatoscopy.62

PSORIASIS
Evaluation of microvascular alterations is relevant to investigate the pathogenesis of as well as to enhance the diagnosis of psoriasis.69 Over the years, the role of VD in the study of psoriatic lesions has gained increasing importance because of the identification of a peculiar vascular pattern.70-72 VD at low magnifications (310 to 350) of the psoriatic microcirculation in lesional skin provides a global vision of the vascular configuration characterized by a dotted pattern. Higher magnifications (3100 to 3400) are able to visualize dilated, elongated, and convoluted capillaries showing a typical glomerular or bushy quality (Fig 6).69,70 The vessel caliber at this level has been observed to be larger (12-13 m) than in normal skin (5-6 m).73,74 In perilesional skin, capillary loops assume an elongated disposition, with a hairpin aspect, parallel to the

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cutaneous surface, with a lengthened apex directed toward the marginal zone of the lesion.70,75,76 Identification of bushy capillaries by VD can be helpful in addressing the diagnosis in unusual presentations, such as in palmar and/or plantar psoriasis,77 psoriatic balanitis,78 and scalp psoriasis,79 particularly in those cases in which no other body sites were involved. Finally, the recognition of this pattern assumes a crucial importance in in vivo therapy monitoring, with a number of studies reporting morphological modifications and loop changes after local and systemic treatments.65,73,74,76

in a patchy distribution, a gray-brown diffuse pigmentation, and a pigmented pseudonetwork represent the most remarkable dermatoscopic findings.88,91 Dermatoscopy has been considered to be of help in preoperatory evaluation, in follow-up, and in monitoring the nonsurgical outcome of the disease, in which the disappearance of vascular structures may indicate adequate treatment.88 Pyogenic granuloma Dermatoscopic examination of pyogenic granuloma reveals a typical pattern characterized by a red to dark pink homogeneous area, corresponding to small capillaries or proliferating vessels, surrounded by a white collarette indicating the hyperplastic epithelium.93,94 Additional dermatoscopic findings include white lines intersecting the lesion (white rail lines), histologically corresponding to fibrous septa that surround the capillary tufts or lobules. and ulceration. Dermatoscopy may help to differentiate pyogenic granuloma from benign or malignant lesions showing similar clinical features, but lacking such dermatoscopic findings. Lichen planus Dermatoscopic evaluation of lichen planus provides an easy and rapid recognition of Wickham striae, which is predictive for the disease, along with other deeper structures including gray-blue dots, cysts, or vascular structures generally not visible to the naked eye.95-98 Wickham striae appear as pearly whitish structures, which secondarily develop thin spikes (comb-like projections) or arboriform ramifications departing from the periphery. Longstanding lesions display a decrease in Wickham striae, gradually surrounded by pigmented structures. Dermatoscopy is also of help in monitoring the evolution and postinflammatory hyperpigmentation of lichen planus.96 Urticaria and urticarial vasculitis Dermatoscopy has been proposed for the evaluation and the differential diagnosis of common urticaria and urticarial vasculitis, based on the recognition of vascular and purpuric features.99 The dermatoscopic observation of common urticaria reveals a red, reticular network of linear vessels, occasionally associated with dotted vessels. In addition, nonvascular areas within vascular structures, as a consequence of massive edema, may be detected.100 Unlike common urticaria, urticarial vasculitis displays numerous purpuric dots or globules on an orange-brown pigmentation, the recognition of which is relevant to their differentiation. Both red lines and purpuric globules are nonspecific for

MISCELLANEA
Clear cell acanthoma Dermatoscopy of clear cell acanthoma, a benign epidermal tumor clinically characterized by a wellcircumscribed, pink reddish papule, shows at low magnication (320 to 350) homogeneous, symmetrical, dotted vessels throughout the entire nodule, arranged either in a net-like pattern or as pearls on a line.80-83 At higher magnification (3200), the dotted vessels display a bush-like aspect.82 Thus dermatoscopy can be a useful diagnostic tool. Port-wine stains The use of dermatoscopy has been proposed for port-wine stains, congenital vascular abnormalities characterized by an increased number of ectatic vessels, in order to determine their depth and predict the outcome of treatments.84 With the use of dermatoscopy, port-wine stains have been classified as superficial or papillary (type 1), consisting of roundish, red structures, and deeper or reticular (type 2), represented by prominent, red linear structures, forming irregular networks in the horizontal subepidermal plexus.84,85 Another possible finding includes a gray whitish veil, due to the deep dermal distribution of the lesion.86,87 Two more patterns have been observed. One is characterized by streaks of white linear structures on a variably whitish to blue background. The second is composed of a particular structure consisting of a pale halo surrounding a comedo-like-shaped central area. Both patterns seem to be predictive of poor laser therapy response.87 Bowens disease Dermatoscopy allows a noninvasive evaluation of the entire lesion, compared with incisional biopsy, which provides histologic information only for a limited area.88 At dermatoscopic examination, Bowens disease displays atypical vascular structures, with a preponderance of dotted/glomerular vessels, and a scaly surface occurring in up to 90% of cases.88-92 In pigmented Bowens disease, small brown globules

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Fig 7. Rosacea. VD shows large polygonal net of thickened vessels (3100). Inset: A detail at higher magnification (3200).

Fig 8. Actinic porokeratosis. VD shows presence of a white track (arrows) surrounding a central red whitish, scar-like area (330).

urticaria or urticarial vasculitis, although the presence of purpuric globules is regarded as highly indicative of an underlying vasculitis.100 Based on this, dermatoscopy may be considered a first-line screening tool for a noninvasive and low-cost diagnosis in daily practice. Rosacea VD has been used to assess qualitative and quantitative structural alterations of capillaries in facial rosacea with a pattern distinct from that of facial seborrheic dermatitis.101 In particular, some VD features indicating rosacea include dilated vessels, prominent telangiectasia, and large polygonal vascular net (Fig 7). No alterations have been found in the nailfold region, suggesting that rosacea does not affect microvasculature of the distal extremities.101 Sebaceous hyperplasia Dermatoscopy of sebaceous hyperplasia reveals a central aggregation of white-yellowish globules surrounded by a crown of vessels. The latter represents the most common detectable vascular structures.102-104 Some investigators refer to the central structure as cumulus sign and consider it highly predictive.102 Nevertheless, the cumulus sign is not exclusive to sebaceous hyperplasia.103 Occasionally, the ostium of the gland is visible as a small crater or umbilication in the center of these yellowish structures. In this case, the central umbilication with the peripheral cumulus have been defined as a bonbon toffee sign.105 Pigmented purpuric dermatoses The term pigmented purpuric dermatoses (PPD), which includes lichen aureus, Schamberg

disease, Majocchis disease, Gougerot and Blum syndrome, and eczematid-like purpura of Doucas and Kapetanakis, has overlapping clinical and histopathologic features resulting from the extravasation of hemosiderin within the papillary dermis from erythrocytes originating in dilated capillaries.98,106,107 At dermatoscopy, all PPD share similar features consisting of irregular, round to oval red dots, globules, and patches with a red brownish or red coppery diffuse homogeneous pigmentation on the background.107 This pattern could be useful to distinguish PPD from other diseases, such as angioma serpiginosum and venous stasis dermatitis. Kaposis sarcoma Dermatoscopy has been recently proposed to improve the preoperative diagnostic accuracy of Kaposis sarcoma.108 Most lesions show a homogeneous bluish-reddish pigmentation, which seems to be related to the presence of vascular structures in the deep dermis. Also, a scaly surface was seen in some regions, along with small brown globules.109,110 Some authors have demonstrated the relative specificity of the rainbow pattern compared with the pale delicate pigmentation in differentiating Kaposis sarcoma from other cutaneous vascular and nonvascular tumors. This rainbow pattern histologically corresponds to closely packed back-to-back vascular networks.108 Nevertheless, more experience is needed to confirm these preliminary results. Actinic porokeratosis Dermatoscopic evaluation of porokeratosis reveals a well-dened, whitish yellow peripheral annular structure, with a brownish pigmentation in the inner side.111-113 This structure, which has been

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described as the outlines of a volcanic crater as observed from a high point,111 or as white track,113 surrounds a central whitish or red-whitish, scar-like area, in which scales and dotted or linear vessels may be observed.111-113 In some areas, a double white track may be present (Fig 8).113 Xanthomatous neoplasms At dermatoscopic examination, xanthomas show a uniform yellowish pigmentation with subtle erythematous border; this pattern has been compared with a setting sun.114-116 Moreover, some linear and/or branched vessels may be present. Specific features include brownish globules and dots of dermal hemosiderin in reticulohistiocytoma, peripheral pigmented network with basal hyperpigmentation in xanthomized dermatofibroma, isolated dotted vessels, corresponding to dilated capillaries, and cloud of yellow areas in adult xanthogranuloma.114

COSMETOLOGIC APPLICATIONS
VD can be of value in a variety of cosmetologic disorders. It may enhance the visualization of xerosis, through the identication of lifted keratinocyte edges and skin akes, which cause the skin to appear whitish.54,117 In pseudofolliculitis barbae, VD displays the course of sharp-pointed ingrown hairs on individual papules responsible for extrafollicular and transfollicular penetration. It has also been recommended to evaluate the efcacy of therapy and to enhance its compliance.54,118

CONCLUSIONS
Alternative uses of dermatoscopy and VD have been described in recent years in steadily increasing numbers. Depending on the skin disorder, both dermatoscopy and VD may be useful for differential diagnosis, prognostic evaluation, and monitoring response to treatment. Nowadays, they represent an important and relatively simple aid in daily clinical practice.
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