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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 37
| Issue : 4 | Page : 199-204 |
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Dermoscopic profile of pityriasis rosea
Ömer Faruk Elmas1, Asuman Kilitçi2, Emine Müge Acar3
1 Department of Dermatology and Venereology, Faculty of Medicine, Ahi Evran University, Kirsehir, Turkey
2 Department of Pathology, Faculty of Medicine, Ahi Evran University, Kirsehir, Turkey
3 Department of Dermatology, Ahi Evran Research and Training Hospital, Kirsehir, Turkey
| Date of Submission | 05-Dec-2018 |
| Date of Decision | 27-Apr-2019 |
| Date of Acceptance | 03-Jun-2019 |
| Date of Web Publication | 04-Nov-2019 |
Correspondence Address:
Dr. Ömer Faruk Elmas
Faculty of Medicine, Ahi Evran University, Kirsehir 40000
Turkey
 Source of Support: None, Conflict of Interest: None  | 2 |
DOI: 10.4103/ds.ds_14_19
Background: Pityriasis rosea (PR) is a common, self-limited cutaneous disease characterized by wide distributed erythematous scaly lesions. The diagnosis is usually based on the clinical features. Objectives: Here, we aimed to investigate the dermoscopic features of PR which may provide helpful clues to the diagnosis. Methods: Demographic, clinical, and dermoscopic features of the patients with PR were retrospectively reviewed, and the findings identified were recorded. Results: A total of 100 lesions from 25 different patients were included in the study. The most common dermoscopic finding was peripheral collarette scale (84%), followed by central yellow with peripheral reddish background (40%), peripheral dotted vessels with patchy distribution (35%), diffuse reddish background (31%), scattered dotted vessels (30%), and irregular distributed scales and red globules (20%). Conclusion: To the best of our knowledge, this is the most comprehensive study focusing on the dermoscopic features of PR. Here, we identified new dermoscopic findings which were not described previously for PR. These findings were irregular linear vessels, blood spots, brown globules, and brown structureless areas. It can be concluded that dermoscopy may provide remarkable clues to diagnosis, especially in atypical presentations of the entity.
Keywords: Dermatoscopy, inflammoscopy, pityriasis rosea
How to cite this article:
Elmas ÖF, Kilitçi A, Acar EM. Dermoscopic profile of pityriasis rosea. Dermatol Sin 2019;37:199-204 |
| Introduction | |  |
Pityriasis rosea (PR) is a common, self-limited cutaneous disease characterized by wide distributed erythematous scaly lesions with minimal or no constitutional symptoms. Despite its self-limited course, the dramatic appearance of the disease may be a source of anxiety for the patients.[1]
The etiopathogenesis of the disease is clearly unknown, but human herpesviruses 6 and 7 are accused as the possible etiologic agents.[2]
Diagnosis of the entity is usually based on the clinical features. The histopathological examination does not provide specific diagnostic findings.[3] However, for atypical clinical presentations, clinical-histopathological correlation is recommended.[4]
Recently, dermoscopy has become an essential diagnostic tool in many dermatological conditions. However, there is a limited knowledge on the dermoscopic features of cutaneous inflammatory disorders. When reviewing the literature, it seems that there are also very few studies focusing on the dermoscopic aspect of PR.[5],[6]
Here, we aimed to investigate the dermoscopic features of PR which may provide helpful clues to the diagnosis.
| Materials and Methods | | |
This retrospective study was conducted at a university hospital in the Province of Kırşehir in the Central Anatolia Region of Turkey. We included the patients diagnosed with PR those who applied to our outpatient clinic between December 2017 and November 2018. Age, gender, disease durations, symptoms, distribution of the lesions, presence of herald patch, presence of collarette scale, and result of venereal disease research laboratory (VDRL) serology of all the patients were recorded.
Clinical criteria
The diagnosis of PR was made based on the proposed diagnostic criteria for PR in majority of the cases.[3] These criteria were as follows:
- The essential clinical features (the patient should have all of these features)
- Separate circular or oval lesions
- Scaling on majority of the lesions
- Peripheral scaling in collarette morphology with central fading on at least two lesions.
- The optional clinical features (the patient should have at least one of these features)
- The lesions distribute mainly on the trunk and proximal limb with very limited distribution on the distal to mid-upper arm and mid-thigh
- Most of the lesions distribute along Langer's lines
- A herald patch visible at least 2 days before occurring of other lesions (noted by the patient or clinician).
- The exclusional clinical features (the patient should have none of these features)
- Multiple small vesicular lesions at the center of two or more lesions
- Two or more lesions on the palmoplantar region
- Presence of clinical or microbiological evidence of secondary syphilis.
We also excluded a possible secondary syphilis with performing VDRL serology for all the cases.
Histopathological criteria
In cases who did not fully meet the clinical criteria, the diagnosis was made on the basis of the clinical-pathological correlation. In these suspected PR cases, the pathological criteria which accepted to be mandatory for diagnosis were as follows:[7]
- Focal parakeratosis
- Mild-to-moderate focal spongiosis
- Superficial dermal perivascular mononuclear inflammatory infiltration
- Excluding the possible superficial fungal infection with periodic acid–Schiff stain.
Dermoscopic evaluation
Dermoscopic images of a total of four lesions from two different locations (two lesions from the abdomen and two lesions from the back) were examined for each patient. All the vascular and nonvascular features observed were recorded.
Dermoscopic examination performed by a handheld dermoscope with ×10 magnification (DermLite 4, 3GEN Inc., San Juan Capistrano, CA, USA). Capture of dermoscopic images was performed using a high-resolution mobile camera phone attached to the dermoscope (iPhone 7 plus, Apple Inc., CA, USA).
Statistical analysis
Relationship between two categorical independent variables was evaluated using the Chi-square test. Descriptive statistics for numeric variables were represented as mean ± standard deviation and for categorical variables as numbers and percentage values. SPSS Windows version 24.0 package software (SPSS Inc., Chicago, IL, USA) was used for statistical analysis, and P < 0.05 was considered as statistically significant.
Ethic approval
All the procedures followed were in accordance with the Helsinki Declaration, and the study was approved by Ahi Evran University Instutional Review Board, Kırşehir, Turkey (Approval date and number: 2018-21/178) and an informed consent was obtained from all the participants.
| Results | | |
There were a total of 64 patients diagnosed as PR. Thirty-nine patients were excluded due to several factors including insufficient clinical data, insufficient dermoscopic images, low-quality dermoscopic images, and absence of VDRL serology. The patients those who did not fully meet the clinical diagnostic criteria along with lack of histopathological examination were also excluded. Thus, a total of 100 lesions from 25 different patients were included.
The mean age of the patients was 25.7 ± 10.7 years (age range: 10–47 years). Fifteen (60%) patients were female and ten (40%) were male. The mean disease duration was 11.4 ± 8.6 days. Majority of the patients were asymptomatic (n = 16, 64%). Nine (36%) patients were suffering from a mild itching. No patient reported another constitutional symptom. Seventeen (68%) patients had a herald patch [Figure 1]. Moreover, 18 (84%) patients had a peripheral collarette on at least two lesions [Figure 2].
Nineteen (76%) of the patients met the above-mentioned diagnostic clinical criteria for PR. The final diagnosis of 8 (24%) patients was made based on the clinical-pathological correlation according to above-mentioned histopathological criteria.
Three patients were diagnosed as purpuric PR with clinical-pathological correlation in which bleeding diathesis was also excluded.
When it comes to the dermoscopy, the most common dermoscopic feature was collarette scale which was also visible clearly with naked eyes in the overwhelming majority [Figure 3]. In six lesions, collarette scale was visible just on dermoscopic examination [Figure 4]. The most common background color on dermoscopy was central yellow with peripheral reddish [Figure 3]. The most common vascular pattern was peripheral dotted vessels with patchy distribution [Figure 3] and [Figure 5]. Number and frequency of the dermoscopic features observed were detailed in [Table 1]. | Figure 3: Peripheral collarette scaling (black arrow), blood spots (white arrows), and peripheral dotted vessels with patchy distribution (circle)
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 | Figure 4: Clinical (a) and dermoscopic (b) images of the same lesion. Peripheral collarette scaling is visible only on the dermoscopic examination
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 | Figure 5: Peripheral dotted vessels with patchy distribution (black arrow), scattered irregular linear vessels (red arrow), and brown globules (white arrows)
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When the patients were grouped into different age groups (10–18, 19–27, 28–36, and 37–47), there was no statistically significant difference (P < 0.05) between the groups in term of the frequency of any dermoscopic finding. There was also no statistically significant difference (P < 0.05) between genders regarding the frequency of any dermoscopic finding.
When the patients were classified into two groups such as “the patients having a clinical diagnosis of PR” and “the patients having a clinicopathological diagnosis of PR,” there was no statistically significant difference (P < 0.05) between the two groups regarding the frequency of any dermoscopic finding.
There was also no statistically significant difference between herald patches and the subsequent lesions regarding the frequency of any dermoscopic feature.
| Discussion | | |
The role of dermoscopy has been widely investigated for many cutaneous conditions. However, dermoscopy in inflammatory skin disorder, also known as “inflammoscopy,” is a relatively novel diagnostic method. When reviewing the literature, it seems that psoriasis, lichen planus, and lupus are the most common studied inflammatory disorders.[8] PR has very rarely been a subject of dermoscopic studies.[5],[6]
To the best of our knowledge, the only original study describing dermoscopic findings of PR in detail is the study of Lallas et al. in which they identified dermoscopic features of 20 lesions from 20 patients.[5] In this study, yellowish background, peripheral scaling, and vessels distributed in patchy pattern were the major dermoscopic findings. The presence of these findings was statistically significant for PR when comparing with psoriasis, dermatitis, and lichen planus.[5] We also found that collarette scale was present in 84 lesions. Irregularly distributed scale was present in 23 cases. The histological counterparts of scales are hyperkeratosis and parakeratosis which are the common histopathological features of PR.
In the study of Lallas et al., dermoscopic background colors were classified as light red, dull red, and yellowish. They reported that majority of the cases showed yellowish background.[5] In the present study, the background colors were considered in five different groups as follows: central yellow with peripheral reddish structureless [Figure 3], diffuse yellow structureless [Figure 6], central reddish with peripheral yellow structureless [Figure 7], diffuse reddish structureless [Figure 8], and central skin-colored and peripheral reddish structureless [Figure 3]. Unlike the study of Lallas et al., the most common pattern was central yellow with peripheral reddish followed by diffuse reddish. Diffuse yellow background was observed just in 14% of the lesions. We observed that the lesions having reddish background histologically showed more prominent superficial vascular structures than the lesions showing just skin-colored and yellow backgrounds. | Figure 6: Diffuse yellow structureless background and peripheral collarette scaling
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 | Figure 7: Central reddish with peripheral yellow structureless background
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 | Figure 8: Diffuse reddish background with numerous red globules in a case of purpuric pityriasis rosea
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In the study of Lallas et al., the only vessel type observed was dotted vessels, and majority of these vessels had patchy distribution.[5] Unlike their study, we observed four different vessel patterns. The most common vessel pattern was peripheral dotted vessels with patchy distribution followed by scattered dotted vessels [Figure 3] and [Figure 5], scattered irregular linear vessels, and irregular linear vessels with patchy distribution [Figure 3]. We did not observe any histological difference between the lesions showing different dermoscopic patterns of vessels. This situation may be associated with the biopsied part of the lesions.
Here, we described three more findings, to the best of our knowledge, which were not described for PR previously: blood spots [Figure 3], brown dots [Figure 3], and brown structureless [Figure 9]. | Figure 9: Peripheral red globules (circles) and structureless brown background
Click here to view |
Dermoscopic red globules [Figure 9] mean small red oval-to-round structures which were previously described for many dermatological conditions such as psoriasis, seborrheic dermatitis, and pigmented purpuric dermatosis.[9],[10] The presence of red globules in PR may be due to prominent vascular proliferation associated with the inflammatory processes. In purpuric forms of PR, red globules are likely associated with the extravasated red blood cells. We observed that all the lesions of purpuric PR (n = 12, 100%) showed red globules with a statistically significant difference (P < 0.05) when compared to the classical PR, and none of the lesions of purpuric PR showed blood spots. In the present study, the classical form of PR showing numerous red globules histologically demonstrated increased superficial dermal vascularity, but the lesions of purpuric PR showed the prominence of extravasated dermal erythrocytes instead.
Blood spots [Figure 3] are small superficial brown-to-dark red-to-black foci caused by hemorrhage associated with minimal traumatization. The histological counterpart of the blood spots is blood accumulation on the corneal layer of the skin. They can also be seen in psoriasis (Auspitz phenomenon) reflecting papillary tip bleeding.[11] Red globules, in contrast, are purely red structures caused by vascular proliferation and dilatation.
Brown dots and brown structureless are usually associated with melanocytic lesions; however, they can also be seen in nonmelanocytic conditions such as seborrheic keratosis, dermatofibroma, and pigmented purpuric dermatosis.[10],[12] Brown color change in PR may reflect increased melanophages in the superficial dermis. In a histopathological study including 50 patients with PR, 34% of the patients showed dermal melanin.[13] We also notice dermal melanin and some melanophages on the histological examination of the lesions having brown color change. Focal parakeratosis, mild-to-moderate focal spongiosis, and superficial dermal perivascular mononuclear inflammatory infiltration and extravasated red blood cells were the main histopathological features we observed [Figure 10] and [Figure 11]. | Figure 10: Parakeratosis, hypogranulosis, moderate spongiosis, and superficial perivascular lymphocytic infiltration can be clearly seen (H and E, ×200)
Click here to view |
Clinically, PR may have a similar presentation with the other papulosquamous diseases including psoriasis and lichen planus. In this context, dermoscopy can be very useful in differential diagnosis. The main dermoscopic features of psoriasis are regularly distributed and tightly packaged dotted and coiled vessels with an erythematous background.[4] In PR, the vessels almost always have an irregular or scattered distribution. Dermoscopy of lichen planus usually shows thick white lines on a purplish red background allowing the diagnosis in majority of the cases.[4] Nummular dermatitis shows a patchy distribution of dotted and coiled vessels on an erythematous background without a collarette of scale.[4] PR may also show a peripheral patchy arrangement of vessels which was the most common vessel pattern observed in the present study. In such cases, clinical features and the other dermoscopic clues to PR including peripheral collarette scale and yellow background may be considered in favor of PR. Tinea corporis has been reported to have erosions, ring-like structure with erythema, and peripheral scaling with central clearing.[14] The last one can cause a similar appearance to PR, but the presence of other dermoscopic findings along with the clinical presentation may be helpful in differential diagnosis. [Figure 12] shows the typical dermoscopic presentations of PR, psoriasis, lichen planus, and nummular dermatitis. | Figure 12: Typical dermoscopic presentations of pityriasis rosea, lichen planus, psoriasis, and nummular dermatitis. (a) Pityriasis rosea. Peripheral collarette scaling (arrow) and peripheral dotted vessels with patchy distribution. (b) Lichen planus. White thick lines (arrows) also known as Wickham striae forming a network. (c) Psoriasis. Note the regular distribution of the dotted vessels (circle). (d) Nummular dermatitis. Patchy distribution of dotted vessels (circle) on the erythematous background without a collarette of scale
Click here to view |
| Conclusion | | |
To the best of our knowledge, this is the most comprehensive study focusing on the dermoscopic features of PR. Here, we identified many dermoscopic findings which were not described previously for PR. These findings were irregular linear vessels, blood spots, brown globules, and brown structureless. It can be concluded that dermoscopy may provide remarkable clues to diagnosis, especially in atypical presentation of the entity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest
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| 11. | Holubar K, Fatović-Ferencić S. Papillary tip bleeding or the auspitz phenomenon: A hero wrongly credited and a misnomer resolved. J Am Acad Dermatol 2003;48:263-4. |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1]
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