BJD

British Journal of Dermatology

C L I N I C A L A N D L A B O R A T O R Y I N V E S TI G A T I O N S

Accuracy of dermoscopic criteria for the diagnosis of

psoriasis, dermatitis, lichen planus and pityriasis rosea
A. Lallas, A. Kyrgidis,* T.G. Tzellos, Z. Apalla, E. Karakyriou, A. Karatolias, I. Lefaki, E. Sotiriou,
D. Ioannides, G. Argenziano and I. Zalaudek
State Clinic of Dermatology, Hospital of Skin and Venereal Diseases, Delfon 124, 54643 Thessaloniki, Greece
*Department of OtolaryngologyHead & Neck Surgery and First Dermatologic Department, Medical School, Aristotle University, Thessaloniki, Greece
Dermatology Unit, Medical Department, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
Department of Dermatology, Medical University of Graz, Graz, Austria
Division of Evidence Based Dermatology, Departments of Dermatology, Venerology, Allergology and Immunology, Dessau Medical Center, Dessau, Germany

Summary
Correspondence
Aimilios Lallas.
E-mail: emlallas@gmail.com

Accepted for publication

Conicts of interest
None declared.
A.L. and A.K. contributed equally in the writing
of this manuscript and share first authorship
equally.

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DOI 10.1111/j.1365-2133.2012.10868.x

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None.

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Funding sources

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24 January 2012

Background Dermoscopy is useful in evaluating skin tumours, but its applicability

extends also to the field of inflammatory skin disorders. Plaque psoriasis (PP),
dermatitis, lichen planus (LP) and pityriasis rosea (PR) are common inflammatory skin diseases, but little is currently known about their dermoscopic features.
Objectives To determine and compare the dermoscopic patterns associated with PP,
dermatitis, LP and PR and to assess the validity of certain dermoscopic criteria in
the diagnosis of PP.
Methods Patients with PP, dermatitis, LP and PR were prospectively enrolled. The
single most recently developed lesion was examined dermoscopically and histopathologically. Variables included vascular morphology, vascular arrangement,
background colour, scale colour, scale distribution and presence of Wickham
striae. Univariate and adjusted odds ratios were calculated. Discriminant functions
were used to plot receiver-operator characteristic curves.
Results Eighty-three patients with PP and 86 patients with either dermatitis, LP or
PR were included in the study. Dotted vessels in a regular arrangement over a
light red background and white scales were highly predictive for the diagnosis of
PP, whereas dermatitis more commonly showed yellow scales and dotted vessels
in a patchy arrangement. PR was characterized by yellowish background, dotted
vessels and peripheral scales; whitish lines (Wickham striae) were seen exclusively in LP.
Conclusions PP, LP, PR and dermatitis show specific dermoscopic patterns that may
aid their clinical diagnosis. Certain combinations of dermoscopic features can
reliably predict the diagnosis of PP.

Plaque psoriasis (PP), dermatitis, pityriasis rosea (PR) and

lichen planus (LP) are common inflammatory skin diseases.
Their characteristic appearance allows a clinical diagnosis in a
high proportion of patients.14 However, unusual presentations
at times do exist and may cause difficulties in the differentiation among these entities.14 In those cases, histopathology
contributes significantly to the accurate diagnosis.5
Dermoscopy as a noninvasive tool has become standard in the
preoperative evaluation of skin tumours.6 Thereby dermoscopy
offers the benefit to assess pigmented and vascular structures
that are not visible clinically.
Particularly the improved visualization of vessels, but also
colour variegations that are difficult to recognize with the

naked eye, explain why dermoscopy is gaining increasing

importance in the diagnosis of skin lesions in general dermatology: today dermoscopy is used in the realm of skin infections and infestations (entomodermoscopy), hair and scalp
disorders (trichoscopy), nailfold capillary abnormalities (capillaroscopy) and inflammatory skin disorders.7
Dermoscopic patterns of red dots or globules arranged in a
homogeneous, regular or ring-like fashion have been
described as common findings in PP.810 However, there are
limited data available concerning the dermoscopic pattern of
dermatitis, PR and LP; moreover, sporadic cases of dermatitis
reportedly show dermoscopic patterns similar to those in PP,
namely predominantly red dots.11
 2012 The Authors

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BJD  2012 British Association of Dermatologists 2012 166, pp11981205

Dermoscopy of inammatory skin diseases, A. Lallas et al. 1199

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This was a prospective study approved by the relevant authorities and the Human Ethics Review Committee of the School of
Medicine of Aristotle University prior to patient enrolment. It
was conducted in accordance with the Declaration of Helsinki
and all patients provided written informed consent after the
study was explained and their questions answered and before
study procedures were initiated.
The study was conducted at the Hospital of Skin and Venereal Diseases in Thessaloniki, Greece between January and May
2011. Consecutive patients presenting at the outpatient clinic
were screened for eligibility to participate in the study.
Inclusion criteria for study participation were a clinical diagnosis of PP, dermatitis (exogenous and endogenous types), LP
and PR affecting the trunk and or upper or lower extremities.
A large proportion of dermatitis cases belonged to the spectrum of nummular eczema, which is commonly included in
the differential diagnosis of PP.1 Additionally, more generalized forms of dermatitis were included in the study.
Exclusion criteria were topical or systemic treatment (ciclosporin, biologics, methotrexate, retinoids, corticosteroids)
performed less than 1 and 6 months, respectively, before
recruitment. Lesions located on the scalp, palms, soles, intertriginal and genital areas were excluded from the study.
Patient demographics were recorded and the single most recently developed lesion was examined dermoscopically and
histopathologically. Dermoscopy preceded histology, and no
treatment was allowed in the interim. Patients received appropriate treatment after the histological report.
Capture of dermoscopic images was performed using a digital dermoscopy system (Ecoscan II V099021, Canon 1000D,
original magnification 10; Canon, Tokyo, Japan). Minimal
pressure was applied and ultrasound gel was used in order to
preserve vessel morphology and ensure the best available projection. Dermoscopy image capturing was performed by a
single practitioner to avoid diversification during the procedure.
Dermoscopic evaluation was performed by two independent
dermoscopists (A.L., E.K.), who were unaware of the histopathological diagnosis. Variables included in the dermoscopic
evaluation were: (i) vascular morphology (dotted, linear, dotted + linear); (ii) vascular arrangement (regular, in clusters,
patchy, peripheral, in rings); (iii) background colour (dull
red, i.e. intense red colour, light red, i.e. fading red colour,
yellowish); (iv) scale colour (white, yellow, white + yellow);
(v) scale distribution (patchy, peripheral, diffuse, central); and
(vi) presence of white crossing streaks (i.e. Wickham striae).

Patients and methods

Selection of the dermoscopic variables included in the

evaluation process was based on the available literature data,
expertise and a pilot study (data not shown).
Arrangement of the vessels was judged as regular when
vessels were distributed uniformly throughout the lesion,
clustered when they were aggregated in small groups and
seen only in some areas of the lesion, patchy when they were
arranged in an asymmetrical distribution which could not be
classified as clustered, peripheral when they were observed
predominantly at the periphery of the lesion, and in rings
when they were arranged in irregular circles or rings
(Fig. 1).
Scale distribution was considered as an independent variable and was classified as diffuse when scales were arranged
in a homogeneous pattern all over the lesion, patchy when
scales covered a portion of the lesion asymmetrically, and
central and peripheral when they were mainly arranged at the
centre and periphery, respectively. Representative examples of
criteria and colour variegations are shown in Figures 1 and 2,
respectively.
Similarly to the dermoscopic assessment, histopathological
evaluation was also performed by two independent dermatopathologists (Z.A., I.L.), who were blinded to the dermoscopic
diagnosis.
Histological diagnosis of PP, dermatitis, PR and LP was
based on the identification of the hallmarks of each disease
under microscopic examination. Analytically, psoriasiform
epidermal hyperplasia accompanied by tortuous, dilated capillaries in the superficial papillary dermis and a perivascular
mononuclear cell infiltrate were the criteria for the histopathological diagnosis of PP.5
Criteria for dermatitis included presence of acanthosis,
spongiosis and exocytosis of the epidermis, plus a mixed
inflammatory cell infiltrate surrounding the superficial vascular
plexus, composed of lymphocytes, histiocytes and eosinophils.5
Characteristic histopathological features of LP included
wedge-shaped hypergranulosis, saw-toothed acanthosis, liquefaction degeneration of the basal layer and a lymphohistiocytic
band-like infiltrate occupying the upper dermis.12
Histopathological criteria for diagnosis of PR included focal
hyperkeratosis and angulated parakeratosis, hypogranulosis
beneath the foci of parakeratosis, slight spongiosis and a lymphohistiocytic infiltrate surrounding the superficial vascular
plexus.5 A negative periodic acidSchiff stain to exclude superficial dermatophytosis was a prerequisite for the final histopathological diagnosis of the above-mentioned dermatoses.
Discrepancies in the assessment of morphological criteria
and diagnosis between the two dermoscopists or pathologists
were resolved by consensus. All evaluators were unaware of
patient clinical information.

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Given that PP and other inflammatory skin diseases may

sometimes be difficult to differentiate clinically, a more
detailed determination of specific dermoscopic patterns of
inflammatory skin diseases could be a valuable addition for
the clinical assessment.
The aim of this study was to determine the dermoscopic patterns associated with PP, dermatitis, LP and PR and to assess the
validity of certain dermoscopic criteria in the diagnosis of PP.

 2012 The Authors

BJD  2012 British Association of Dermatologists 2012 166, pp11981205

Statistical analysis
The outcome dichotomous variable was set to definite
histological diagnosis of psoriasis. All separate dermoscopic
variables were included in the analysis.

1200 Dermoscopy of inammatory skin diseases, A. Lallas et al.

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(a)

(b)

(c)

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(a)

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Fig 1. Representative dermoscopic examples of vessel arrangements: (a) regular (psoriasis), (b) in clusters (dermatitis), (c) patchy (dermatitis),
(d) in rings (psoriasis) and (e) peripheral (lichen planus); and scale distribution: (f) central (psoriasis), (g) peripheral (pityriasis rosea),
(h) diffuse (lichen planus) and (i) patchy (psoriasis).

Colinearity was assessed via a correlation matrix, using

Spearmans rho correlation coefficient. Relative risks were calculated for all dichotomous variables; for categorical variables
relative risks were approximated by odds ratios (ORs). Crude
ORs, adjusted ORs and corresponding 95% confidence intervals (CIs) were calculated by univariate and conditional multivariate logistic regression, respectively. Forward inclusion with
likelihood ratio criteria proved more parsimonious. Alpha level
was set at 005 while an alpha level of 010 was used as cutoff for variable removal in the automated model selection for
multivariate logistic regression.
Logistic regression models were determined to account for
outcome better than would be expected by chance

Fig 2. Representative examples of colour

variegations: (a) dull red (dermatitis),
(b) light red (psoriasis) and (c) yellow
(pityriasis rosea).

(P < 0001) via Wald test and v2 likelihood ratio test. Goodness of fit was examined by adjusted R2. Tests for interactions
were automatically commenced by the statistical package
through the fitting procedure. We then used the logistic
regression derived model to predict the event probability for a
dichotomous outcome variable. Given the sets of independent
variables produced by multivariate logistic regression, attempts
to find linear combinations of those variables that best separate
the groups of cases were made (discriminant analysis). Specificity and sensitivity were extracted from classification tables.
Discriminant functions were saved and we then used receiveroperator characteristic (ROC) curves to choose between
competing classification schemes.
 2012 The Authors
BJD  2012 British Association of Dermatologists 2012 166, pp11981205

Dermoscopy of inammatory skin diseases, A. Lallas et al. 1201

Table 1 Frequency of dermoscopic variables

in psoriasis, dermatitis, lichen planus and
pityriasis rosea

Dermatitis
(n = 41),
n (%)

Lichen
planus
(n = 25),
n (%)

Pityriasis
rosea
(n = 20),
n (%)

34 (41)
48 (58)
1 (1)

6 (15)
27 (66)
7 (17)

3 (12)
16 (64)
6 (24)

2 (10)
5 (25)
13 (65)

< 0001

83 (100)
0
0

39 (95)
0
2 (5)

9 (36)
3 (12)
13 (52)

20 (100)
0
0

< 0001
< 0001

73
1
2
0
7

14 (34)
3 (7)
24 (59)
0
0

0
0
10 (40)
15 (60)
0

4 (20)
1 (5)
15 (75)
0
0

< 0001
< 0001
< 0025

58 (70)
0
2 (2)

10 (24)
8 (20)
17 (41)

2 (8)
3 (12)
0

17 (85)
1 (5)
0

< 0005
< 0005
< 0001

11
2
37
10
0

27 (66)
0
7 (17)
1 (24)
0

2 (8)
0
0
3 (12)
24 (96)

0
14 (70)
3 (15)
1 (5)
0

< 0001
< 0001
< 0001

Psoriasis
(n = 83),
n (%)

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Dermoscopic
variables

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During the 4 months of study enrolment, 275 patients were

screened for eligibility of study participation. Of those, 106
(385%) patients were excluded because of concurrent treatment (n = 72) or disease involvement exclusively on body
sites excluded in the study design (n = 18), withdrew from
study participation (n = 5) or lacked a definitive histopathological diagnosis (n = 11) resulting in a total of 169 (615%)
patients included in the study.
Of those, 83 (491%) patients had PP, 41 (243%) had
dermatitis, 25 (148%) had LP and 20 (119%) had PR.

Results

Descriptive results of the dermoscopic analysis are quoted

in Table 1. Dotted vessels were seen in all cases of PP and PR,
in 39 41 (95%) cases of dermatitis and in 9 25 (36%) cases
of LP. Even though dotted vessels were common among all
entities, their arrangement and other associated criteria
differed significantly between PP, dermatitis, LP and PR.
Dotted vessels in PP were most commonly arranged in a regular distribution (73 83; 88%) and were associated with white
scales (58 83; 70%) (Fig. 3a); in contrast, vessels in dermatitis
appeared more commonly in a patchy distribution (24 41;
59%) and in association with yellow scales (25 41; 61%)
(Fig. 3b). In PR, dotted vessels were mostly associated with a
yellowish background colour (13 20; 65%) and a peripheral
arrangement of scales (14 20; 70%) (Fig. 3c). Instead, white
crossing lines (Wickham striae) were seen exclusively in LP
(24 25; 96%) and occurred together with a dull red background colour and peripheral arrangement of vessels in 64%
(16 25) and 60% (15 25), respectively (Fig. 3d).
For the further statistical analysis to assess criteria predictive
for PP, patients with dermatitis, LP and PR were matched as
controls. Mean age of patients with PP was 478 years,
and 443 years for the controls. Male to female ratio for PP
and control group was 12 : 1 and 1 : 1, respectively. Table 2
summarizes the descriptive results of the univariate analysis.

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Eighty-three patients with PP and 86 control subjects with

dermatitis, LP or PR were recruited in this diagnostic accuracy
study. Both false positives and false negatives would be classified as failures. Assuming 10% failures among controls and
28% failures among patients, we would be able to reject the
null hypothesis that the failure rates for experimental and control subjects are equal with probability (power) 0804. A corrected v2 statistic was used to evaluate this null hypothesis.
The type I error probability associated with all tests in this
study was set to 005. All statistical calculations were made
with SPSS 170 (SPSS Inc., Chicago, IL, U.S.A.).

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Background colour
Light red
Dull red
Yellowish
Type of vessels
Dotted
Linear
Dotted + linear
Pattern of vessels
Regular
In clusters
Patchy
Peripheral
In rings
Scale colour
White
Yellow
White + yellow
Scale distribution
Patchy
Peripheral
Diffuse
Central
Wickham striae

(88)
(1)
(2)
(8)

(13)
(2)
(45)
(12)

P-value
< 0001

< 0001

< 0001

Bold values denote positive significant correlation using v2 in comparison with the other
diseases.

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BJD  2012 British Association of Dermatologists 2012 166, pp11981205

1202 Dermoscopy of inammatory skin diseases, A. Lallas et al.

(a)

(b)

(c)

(d)

Fig 3. Representative dermoscopic images of

(a) psoriasis exhibiting regularly distributed
dotted vessels over a light red background and
white scales, (b) dermatitis revealing dotted
vessels associated with yellow scales, (c)
pityriasis rosea exhibiting yellowish
background colour, peripheral arrangement of
the scales and patchy distribution of loosely
arranged dotted vessels, and (d) lichen planus
showing Wickham striae.

34 (41)
48 (58)
1 (1)

11 (13)
48 (56)
26 (30)

83 (100)
0
0

68 (79)
3 (3)
15 (17)

(8)

58 (70)
0
2 (2)

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(88)
(1)
(2)

11
2
37
10
0

(13)
(2)
(45)
(12)

P-value
< 0001
0791
0001
0998
0999
0998

RR
4731
1086
0028
0
0
0

95% CI
219210211
05911996
00040213

(21)
(5)
(57)
(17)

< 0001
0439
< 0001
0998
0999

27578
0506
0019
0
0

1189863921
00902841
00040081

29 (34)
12 (14)
17 (20)

< 0001
0999
0003

4560
0
0100

23868716

00220449

29
14
10
5
24

0002
0008
< 0001
0163
0998

0300
0127
6113
2219
0

01380653
00280578
277813452
07256796

18
4
49
15
0

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73
1
2
0
7

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Controls
nonpsoriasis
(n = 86), n (%)

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Predictor
Background colour
Light red
Dull red
Yellowish
Type of vessels
Dotted
Linear
Dotted + linear
Pattern of vessels
Regular
In clusters
Patchy
Peripheral
In rings
Scale colour
White
Yellow
White + yellow
Scale distribution
Patchy
Peripheral
Diffuse
Central
Wickham striae

Patients with
psoriasis
(n = 83), n (%)

Table 2 Univariate analysis: dermoscopy predictors of psoriasis from 169 patients

(34)
(16)
(12)
(6)
(28)

RR, relative risk; CI, confidence interval. Statistically significant values are shown in bold.

Univariate analysis yielded no statistical significance with

regard to the types of vessels. However, PP was found to correlate significantly with a regular arrangement of dotted vessels (rho = 0672, P < 0001), a light red background colour
(rho = 0319, P < 0001) and a diffuse distribution

(rho = 0368, P < 0001) of white scales (rho = 0362,

P < 0001).
Based on the univariate logistic regression analysis, regular
vascular arrangement yielded a 27-fold higher probability of
being PP (relative risk 2758, 95% CI 11906392) compared
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Dermoscopy of inammatory skin diseases, A. Lallas et al. 1203

Table 3 Multivariate analysis with all dermoscopic variables entered:
adjusted dermoscopy predictors for psoriasis from 169 patients

Background colour
Light red
Dull red
Pattern of vessels
Regular
In rings
Scale colour
White + yellow

P-value

RR

95% CI

< 0001
0008

182535
22107

117852827343
2255216688

< 0001
0999

143511
0

27517748450

0002

0050

Predictor
Background colour
Light red
Yellowish
Pattern of vessels
Regular
Patchy
Scale colour
White + yellow

00080322

Variables entered in model were background colour: light red,

dull red, yellowish; type of vessels: dotted, linear, dotted +
linear; pattern of vessels: regular, in clusters, patchy, in rings,
peripheral; scale colour: white, yellow, white + yellow; scale
distribution: patchy, peripheral, diffuse, central; Wickham striae.
Relative risks (RRs) approximated by odds ratios, 95% confidence intervals (CIs) and P-values were calculated with conditional multivariate logistic regression backward elimination
model according to likelihood ratio criteria. RRs mutually adjusted for variables in the model. Logit for outcome variable psoriasis is estimated for psoriasis = no. Logit for all other
independent dichotomous variables = no. Alpha level set to
P < 005. Cut-off value set to 010. Statistically significant values
are shown in bold.

P-value

RR

95% CI

0001
0015

11340
0060

260349403
00060578

< 0001
0017

17188
0099

455164916
00150665

0002

0051

00080338

Variables entered in model were background colour: light red,

yellowish; type of vessels: dotted vessels, linear vessels, dotted + linear; pattern of vessels: regular, patchy; scale colour:
white, white + yellow; scale distribution: patchy, peripheral,
diffuse; Wickham striae. Relative risks (RRs) approximated by
odds ratios, 95% confidence intervals (CIs) and P-values were
calculated with conditional multivariate logistic regression backward elimination model according to likelihood ratio criteria.
RRs mutually adjusted for variables in the model. Logit for outcome variable psoriasis is estimated for psoriasis = no. Logit
for all other independent dichotomous variables = no. Alpha
level set to P < 005. Cut-off value set to 010. Statistically
significant values are shown in bold.

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with controls. Light red background colour, white or diffuse

scales increased the likelihood for PP by 4-fold, 4-fold and 6fold, respectively (see Table 2).

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Predictor

Table 4 Multivariate analysis with only variables with significant

prognostic value in the univariate analysis included: adjusted
dermoscopy predictors for psoriasis from 169 patients

Multivariate analysis

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Two multivariate logistic regression models were performed.

In the first, we entered as dichotomous independent variables
all dermoscopic variables. Forward inclusion with likelihood
criteria was utilized. This model yielded a specificity of 964%
and sensitivity of 860% for the diagnosis of PP. Results are
presented in Table 3.
In the second model, only those variables with significant
prognostic value in the univariate analysis were included
(Table 4). Of note, both models yielded the same variables, a
fact that signifies the independent prognostic value of the
models. The specificity achieved was 880% while sensitivity
was 849%. The ROC curve for this second model is presented
in Figure 4.

Discussion
Our study suggests significant differences in the dermoscopic
patterns of PP, dermatitis, LP and PR, which may assist the
clinical diagnosis in selected cases (Figs 5 and 6).
Dotted vessels are a well-recognized criterion for the diagnosis of PP,811 and were effectively seen in all our cases of
PP. However, our and previous studies showed that dotted
vessels are not limited to PP but occur at variable frequency in
 2012 The Authors
BJD  2012 British Association of Dermatologists 2012 166, pp11981205

Fig 4. Receiver-operator characteristic (ROC) curve. Backward

elimination according to likelihood ratio criteria. Area under curve
(AUC) = 0935, 95% confidence interval 08960974 (P < 0001).

several other inflammatory and neoplastic lesions.7,11,13

Accordingly, dotted vessels as the only dermoscopic criterion
are insufficient to distinguish between these different entities
accurately.
Besides the vascular morphology, the vascular arrangement
and specific dermoscopic clues have been judged to be of
equal importance in the differential diagnosis of nonpigmented skin lesions.9 This is further supported by our study,
which revealed significant differences with respect to the distribution of vessels or additional criteria among PP, dermatitis,
LP and PR.

1204 Dermoscopy of inammatory skin diseases, A. Lallas et al.

(c)

(d)

Fig 5. Side-by-side comparison of clinical

images of plaque psoriasis (PP) (a) and
nummular eczema (b). In both cases, a biopsy
was required for the diagnosis. Squares in (a)
and (b) indicate the corresponding
dermoscopic image. Upon dermoscopic
examination, PP shows regularly arranged
dotted vessels and white scales (c); in
contrast, nummular eczema reveals yellow
diffuse scales and some dotted vessels (d).

value of this pattern in the diagnosis of PP remains to be elucidated further.

Our study furthermore confirms preliminary observations
on the dermoscopic patterns of PR and LP.10,11,15 As such, PR
was typified by peripheral scaling (so-called collarette scales)
around a diffuse and structureless yellowish centre; although
dotted vessels were seen in all our cases of PR, they were generally much less evident and fewer in number compared with
PP or dermatitis (Fig. 6c). By contrast, Wickham striae were
seen exclusively in LP and observed in all but one case
(Fig. 6d); thus our findings highlight the importance of Wickham striae in the diagnosis of LP.
It still remains to be determined how much dermoscopy
may aid the differential diagnosis of tumours from PP; this
question seems particularly important when facing patients
with diffuse PP, who received past psoralen plus ultraviolet A
therapy and are at increased risk for nonmelanoma skin cancer.16,17 With regard to this, Pan et al.18 introduced a dermo-

(b)

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(a)

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In detail, the combination of regularly distributed dotted

vessels over a light red background associated with diffuse
white scales was highly predictive of PP and allowed a correct
diagnosis with 880% specificity and 849% sensitivity; conversely, yellow scales, a patchy arrangement of vessels or yellow background colour decreased significantly the likelihood
for PP by 20-fold, 10-fold and 17-fold, respectively.
Yellow serocrusts have very recently been described as
dermoscopic finding in two cases of nummular eczema.14
This, along with our findings, suggests that white vs. yellow
scales along with regular vs. patchy distribution of dotted vessels may represent a valuable clue in the differential diagnosis
of PP and nummular eczema, respectively (Fig. 5c, d).
On the other hand, although red globular rings (i.e. red
globules arranged in irregular circles or rings) as described
previously by Vazquez-Lopez et al.10 represented a highly
specific feature for PP in our study, this pattern was seen in
only a minority of cases (8%) in our series. Therefore, the

(b)

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(a)

(c)

(d)

Fig 6. Side-by-side comparison of clinical

images of pityriasis rosea (a) and lichen
planus (b). Squares in (a) and (b) indicate the
corresponding dermoscopic image.
(c) Dermoscopically, pityriasis rosea reveals
peripheral scales over a yellowish background
along with some loosely arranged dotted
vessels. (d) Dermoscopy of lichen planus
shows white crossing lines (Wickham striae)
and dotted vessels.
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Dermoscopy of inammatory skin diseases, A. Lallas et al. 1205

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spectrum of nontumoral skin lesions. Br J Dermatol 2004; 150:226
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Louis: Elsevier Mosby, 2005; 21760.
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skin tumors: a dermoscopy study. Arch Dermatol 2004; 140:14859.
14 Navarini AA, Feldmeyer L, Tondury B et al. The yellow clod sign.
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scopic diagnostic model for differentiating solitary psoriatic

plaques from intraepidermal carcinoma (IEC) and superficial
basal cell carcinoma (sBCC). They concluded that red dots,
homogeneous vascular pattern and light red background were
significant dermoscopic features for psoriasis, yielding a diagnostic probability of 99% if all three features were present. In
contrast, clustered vessels, glomerular vessels and hyperkeratosis yield a 98% probability for the diagnosis of IEC, whereas
four of six described criteria (i.e. scattered vascular pattern,
arborizing microvessels, telangiectatic or atypical vessels,
milky-pink background, and brown dots globules) achieved a
diagnostic probability of 99% for sBCC.
As our dataset did not include tumours, the impact of dermoscopy in differentiating PP from skin tumours such as IEC
and sBCC cannot be assessed by our study.
Our study has some limitations: first, we included only
white patients from a Mediterranean area. Given that distribution studies stress the significance of geographical and ethnic
background in the clinical presentation of psoriasis,19 our
results are limited to this population. Second, although recent
studies suggest significant differences in the dermoscopic patterns between scalp psoriasis and seborrhoeic dermatitis,20 our
study excluded lesions from the scalp, and acral, intertriginal
and genital areas. Therefore, no conclusions about the impact
of dermoscopy in the differential diagnosis of psoriasis at
these sites from other erythematosquamous diseases can be
drawn. Finally, our study design does not allow any conclusions about the impact of dermoscopy in the differential diagnosis of PP and nonmelanoma skin cancer; however, the data
of Pan et al.18 point towards such a role.
In conclusion, PP, dermatitis, LP and PR reveal specific
dermoscopic patterns that may aid the clinical diagnosis.
Besides its diagnostic purposes, dermoscopy might provide a
useful tool for the evaluation of treatment outcome in patients
with PP such as early detection of treatment response or
unwarranted side-effects of long-term topical treatment (for
example, the corticosteroid-induced atrophy in patients with
psoriasis).21 The feasibility of our observations in clinical practice, as well as in studying the course of PP, warrants, however, further clinical studies.

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Whats already known about this topic?

Plaque psoriasis, dermatitis, lichen planus and pityriasis

rosea are common inflammatory skin diseases, but little
is currently known about their dermoscopic features.
Applicability of dermoscopy is gradually expanding in
evaluation of inflammatory skin disorders.

What does this study add?

Each of the above-mentioned diseases exhibits a characteristic dermoscopic pattern.
A certain combination of dermoscopic features is more
predictive of the diagnosis of plaque psoriasis.

 2012 The Authors

BJD  2012 British Association of Dermatologists 2012 166, pp11981205

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